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Global Workforce in Crisis: What Crisis?

Author(s): B. Marchal*1, M. Van Dormael1, G. Kegels1
Affiliation(s): 1Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
Keywords: Health workforce, crisis, complexity, context

Human Resources for Health advocates were successful in putting the African health workforce issue on the agenda by framing it as a crisis. The notion of ‘crisis’ usually evokes shortages of staff, and as a consequence, solutions are sought predominantly in the realm of increased manpower production and limitation of brain drain.

Summary/Objectives: We argue that today, there is not one single workforce crisis, and that many African countries do not even face serious shortages. Lumping together all African countries within a single analysis, without taking into consideration the diversity of contexts and the complexity of the problems they face, is likely to lead to inappropriate answers.

1. The challenge of diversity: While some southern African countries have to cope with an undeniable shortage in numbers of health workers (due to HIV/AIDS, brain drain and/or armed conflicts), other sub-Saharan African countries face chronic human resource problems of different kinds: decreased attraction of caring professions, urban/rural misdistribution, skewed skill mix, ineffective regulation mechanisms of health professionals and inadequate (para-)medical education systems. 2. The challenge of performance: Increasing numbers is a necessity in most countries, but will be insufficient on its own to increase performance of health workers. The latter relates to their competencies and their willingness to apply these competencies to the benefit of patient and community. Achievement is the product of three elements: availability of staff, competence and motivation. 3. The challenge of complexity: Management of health workers is dealing with the complexity resulting from the great variety of professional and non-professional cadres, the nature of the work (from very technical tasks to tasks that require strong interpersonal skills), and the diversity of societies to which they belong and of contexts in which they work.

Lessons learned:

In the light of these challenges, we propose a few guiding principles for health workforce management and policy:
1 – Comprehensive problem analysis: Open systems theory offers powerful tools to examine the root causes of health workforce problems, which are often interlinked and acting on different levels.
2 – Comprehensive solution analysis: In clinical settings, balanced bundles of human resource management (HRM) practices including training, supervision, shared decision-making and teamwork, are more effective in eliciting staff commitment than isolated interventions. Furthermore, not only micro issues at organisational level, but also the external conditions that affect health service managers and their staff (decentralisation, labour market conditions, etc.) need to be taken into account.
3 – Implementation scale matters: Small sized organisations cannot always offer comprehensive interventions on their own, because this requires decisions about external conditions outside their scope of decision making. In such cases, federations, associations and networking make much sense.
4 – Supportive policy environment: policies need to provide health service managers with the autonomy and the means to develop responsive HRM practices. They should institute a solid administrative framework, but also need to provide leeway to managers to develop commitment-eliciting management practices.
Focusing only on the numbers limits the search for solutions to a narrow crisis management perspective. Instead of reactive policies that seek solutions in the short-term, we need to take time to develop pro-active, long-term HR policies. Context-sensitive HRM policies and practices are the key to a more stable and better performing health workforce.

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