Human Resources for Health: an introduction and overview

1. Human Resources for Health: an introduction and overview Barbara McPake, Institute for International Health and Development, Queen Margaret University, Edinburgh

2. Structure of session • Numbers of workers in the health sector • Distribution of workers in the health sector • Performance and incentives

3. Numbers

4. Source: Global Health Observatory http://apps.who.int/ghodata/, accessed 14th July 2011.

5. What is the difference between a doctor and a nurse? • Can define in terms of training • Can define in terms of skills • Can define in terms of activities

6. Nurse practitioners in the US “A nurse practitioner is a health care provider that can diagnose, treat, and monitor various disease processes. In some states, they can prescribe narcotics as well. So far, there are only four states that still won't allow this component of practice. In some states, a NP must have a collaborative agreement with a MD, some may require direct supervision. Some NPs may have their own private practices without physician oversight at all. NPs can obtain privileges at hospitals so that they can round. Some states allow NPs to admit their own patients to hospitals.” http://arnp.blogspot.com/2007/07/what-does-nurse-practitioner-do.html

7. Source: Global Health Observatory http://apps.who.int/ghodata/, accessed 14th July 2011.

8. Maternal mortality ratio and skilled birth attendance: African countries South Africa Gabon Namibia Malawi Tanzania Skilled birth attendance (most recent year available) Kenya Uganda Guinea Bissau Somalia Niger Chad Maternal Mortality Ratio (2008) Source: Global Health Observatory http://apps.who.int/ghodata/, accessed 14th July 2011.

10. Worker density and health outcomes Mowafi et al. Prehospital and Disaster Medicine, 2007 based on analysis of Anand and Barnighausen

11. How many health workers do we need? • The answer is 2.28/1,000 population! (22.8/10,000 population) • How has that been worked out?

12. Source: WHR 2006

13. Source: The World Health Report (2006) Working Together for Health, WHO, Geneva, 2006

15. What are the factors that are resulting in such critical shortages of HRH in Africa? • What can be done about it?

16. Total number of nurses verified to apply for foreign registration from January 1993 to December 2006, Kenya Source: Nursing Council of Kenya, 2007

17. Malawi Emergency Human Resources Programme • 5 year investment of US$95.6m from international partners • 36% of budget for 52% salary top-up for 11 cadres of professional health workers • Expanded training capacity • Used international volunteer doctors, especially for training • Doctor numbers increased 460% from 43 to 241 • Nurse numbers increased 36%

18. Distribution

19. Estimates of geographical workforce imbalance from a range of settings Dussault, G. and Franceschini, M.C. (2006) Human Resources for Health, 4

20. Health service provider densities in Zambia Source: WHR 2006

21. Distribution of health workers by district in Tanzania Source: Munga and Maested, Human Resources for Health, 2009, 7: 4

22. Distribution of health workers by district and cadre, Tanzania Source: Munga and Maested, Human Resources for Health, 2009, 7: 4

23. Source: Munga and Maested, Human Resources for Health, 2009, 7: 4

24. The Kenyan Emergency Hire Programme • Many unemployed health workers in Kenya • Severe maldistribution – health workers posted to rural and underserved areas tend to succeed in relocating their posts to urban centres • Emergency hire programme offered post specific contracts using extra civil-service recruitment process • 830 health workers recruited and posted • Kenyan government aims to integrate these workers to the civil service

25. Distribution of emergency hires in the Kenya emergency hire programme Source: Capacity Project, 2009

26. Performance and incentives

27. ‘That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done.And the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrowing toe-nail receives a few shillings: he who cuts your inside out receives hundreds of guineas, except when he does it to a poor person for practice.’ George Bernard Shaw, 1909 www.qmu.ac.uk/iihd

28. “The problem with salary is the lack of economic incentives to provide care efficiently. A physician who is lazy may provide little care, and one that is not dedicated may provide poor care” • Andrew Jones The Elgar Companion to Health Economics

29. What is an incentive? • Economic incentives are defined as allowing ‘individuals to behave in accordance with expected material rewards or favours that can be traded for such rewards, including leisure’ • Social norms: people behave in accordance with social rewards such as approval of disapproval of others www.qmu.ac.uk/iihd

30. Institutional structures and incentives • Simple framework: incentives for efficiency strengthen as institutions more private and subject to market forces www.qmu.ac.uk/iihd

31. PUBLIC SECTOR? PRIVATE SECTOR? Effort Less effort? ‘Low powered incentives’ Satisfaction in a job well done Prestige Vague relationship to specific types of output ‘High powered incentives’ More money for specific units of activity www.qmu.ac.uk/iihd

32. Over-simplification • Suggests all non-financial incentives are ‘low-powered’ • Few cases correspond to the extremes; real incentive regime requires analysis everywhere • Even small businesses taxed/sometimes subsidised – investments and rewards shared • Well tuned to performance promotion systems with steep pay structures arise in public sector www.qmu.ac.uk/iihd

33. Incentives can be ‘perverse’ as well as induce effort • ‘Opportunism’ (self-interest seeking with guile) also responds to financial incentives • A scheme in India pays public midwives a bonus if they deliver at night. The number of night deliveries increased more than expected. • Hospital league tables in the UK ‘named and shamed’ hospitals with low bed occupancy. Bed occupancy increased but discharges did not. • Scope for opportunism increases with problems of measurement • Lots of measurement problems in the health sector www.qmu.ac.uk/iihd

34. Think about a work situation you experienced • Was it in a public or private institution? • What motivated you to work hard (think about financial and non financial incentives)? • What made you feel like your efforts would be wasted? • Did you encounter incentives to do things you knew were pointless or even harmful? • Think of one measure that would have improved the incentive environment www.qmu.ac.uk/iihd

35. Comparative Analysis of Financial Incentive Strategies to Motivate and Retain Health Workers in South Africa, Tanzania and Malawi Steve Thomas1, Charles Normand1, Prudence Ditlopo2, Maureen Chirwa3, Aziza Mwisongo4, Duane Blaauw2, Cameron Bowie3, Fresier Maseko3 and Posy Bidwell1 1. Trinity College Dublin, 2.University of the Witwatersrand, 3. University of Malawi, 4. National Institute for Medical Research, Tanzania

36. Case study 1: South Africa

37. Have the incentives worked?(South Africa)

38. Case study 2: Tanzania

39. Have the incentives worked?(Tanzania)

40. Case study 3: Malawi

41. Have the incentives worked? (Malawi)

42. Lessons from across the case studies • Financial incentives produce losers as well as winners • Boost to morale and motivation may be short lived if there isn’t a long term plan (but greivances endure!) • Once you start paying for something, it’s difficult to stop • In incentivising something (like quantity of service), do you disincentives something else (like quality of service?) • Discretion and decentralisation allow for flexibility but create disparities

43. Summary • Huge shortages of health workers in Africa • Problems of maldistribution within countries are as important as they are globally • There are examples of successful internationally supported programmes to improve both of these • Incentive management is complex – it’s not always best to strengthen incentives