The implications of health sector reform for human resources development
Abstract The authors argue that "health for all" is not achievable in most countries without health sector reform that incorporates a process of coordinated health and human resources development. They examine the situation in countries in the Eastern Mediterranean Region of the World Health Organization. Though advances have been made, further progress is inhibited by the limited adaptation of traditional health service structures and processes in many of these countries. National reform strategies are needed. These require the active participation of health professional associations and academic training institutions as well as health service managers. The paper indicates some of the initiatives required and suggests that the starting point for many countries should be a rigorous appraisal of the current state of human resources development in health.
Key words Health care reform; Health for All; Health manpower/organization and administration; Health personnel/education; Health services administration; Eastern Mediterranean (source: MeSH, NLM).
Mots clés Réforme domaine santé; Santé pour tous; Personnel santé/organisation et administration; Personnel sanitaire/enseignement; Administration services de soins; Méditerranée orientale (source: MeSH, INSERM).
Spanish MeSH: Reforma en atención de la salud; Salud para todos; Recursos humanos en salud/organización y administración; Personal de salud/educación; Administración de los servicios de salud; Mediterráneo Oriental (fuente: DeCS, BIREME).
Introduction
Health sector reform became a worldwide phenomenon in the 1990s. While the processes vary from country to country, there is an underlying recognition that radical changes are necessary in the provision of health care if the worldwide potential for health improvement is to be realized. This recognition has emerged and is growing because of mounting political pressure. Governments are under pressure to deliver improved health care, but are at the same time facing financial constraints on their publicly funded health services. Their perceived failure arises from: rising expectations across the world for health and health care; the existence of a rapidly growing variety of technical interventions for the prevention, control and treatment of diseases; and an inability in many countries to employ these new interventions through traditional approaches to the provision of health care, which are seen to be dominated by bureaucracy.
It became obvious during the 1980s and early 1990s that the strategy "health for all by the year 2000", adopted at the 1977 World Health Assembly (1), would not succeed without fundamental changes in the prevailing culture in public health services and related education and training institutions. In 1995, therefore, the Health Assembly adopted a resolution (resolution WHA 48.8) urging the World Health Organization (WHO) and its Member States to undertake coordinated reform in health care, focusing on making better use of resources, especially human resources. This recommendation applies not only to the utilization of health care workers but also to their education and training (2).
From this imperative has come increasing recognition of the need for a process of coordinated health and human resources development, which can be achieved only through the application of the following three fundamental principles. First, the means of planning, production and management must be brought together through tighter coordination. Second, the preparation and use of human resources must be focused on serving the needs of the health system. And third, health systems (public and private sectors together) must serve the needs of the people. All this will require much greater flexibility in health care provision than has existed to date.
This paper explores the current situation in countries in the WHO Eastern Mediterranean Region and identifies their options and opportunities for moving towards health for all through appropriate health sector reforms. Particular attention is paid to educational institutions and professional associations, which so far have not usually played a significant role in the reform process. It is hoped that the proposals and conclusions will also be relevant to other developing countries around the world that have characteristics and difficulties similar to those in the countries of the Eastern Mediterranean Region.
Health care services in the Eastern Mediterranean Region
In many countries in the Eastern Mediterranean Region, health care is still characterized by the following defects: uneven coverage and quality of services; inaccessibility of services, particularly for the under-privileged and rural communities; inefficient use of scarce resources, with public funds often directed to services of limited cost-effectiveness and with disproportionate financing of secondary and tertiary care at the cost of care at the primary level; inadequate responses to public expectations regarding type of care and service provision.
In the public sector, people frequently face unmotivated and inadequately trained staff, with long waiting times, inadequate supplies and drugs, and lack of confidentiality or privacy. At the same time, the private sector now growing rapidly in strength in many countries is often inadequately monitored, with little regulation of its activities. As a result, the public is at risk of financial exploitation through excessive diagnostic assessments and inappropriate interventions.
Despite the considerable achievements made by the health sector over the last few decades, health care in many of these countries faces major constraints. Health services are threatened by mounting social, political and economic pressures and there is an urgent need to increase the cost-effectiveness of interventions. Continued progress will be contingent upon radical changes in the approach to health care provision to increase its relevance, quality, effectiveness and efficiency. The reforms necessary to achieve these improvements have major implications for the orientation and organization of health care (3).
Human resource development in the Eastern Mediterranean Region
There has been a significant expansion in human resources for health in the Eastern Mediterranean Region. The ratio of physicians per 10 000 of the population rose from 5.4 in 1985 to 8.2 in 1996. Even more substantial growth has been achieved for dentists, with ratios increasing from 0.7 to 1.2, and for nursing and midwifery personnel, with increases from 9.2 in 1985 to 14.4 in 1996 (4). However, in most countries there continue to be significant imbalances in the distribution of the different types of health workers. The third evaluation of health-for-all strategies in the Region clearly illustrates this problem, indicating that, despite the strong expansion in some important health professions, the rates of physicians and nurses who work in primary health care are less encouraging. Primary health care nurses show a slight increase, from 2.4 to 2.7 per 10 000 of the population, while physicians working at this level actually show a decline, from 1.8 to 1.5 (4). Other types of imbalance include inappropriate ratios between physicians and nursing/midwifery personnel and low intakes of women.
In the health services of a range of countries across the Region, there is evidence of considerable investment in facilities and services but often with limited attention to the need for supporting management infrastructure and capacity. In other words, the development of human resources has not always kept pace with the physical development of the service, leading to a steady increase in inefficiency and ineffectiveness in the provision of health care. The problems listed in Box 1 may be seen in many countries (57). They are typical of conventional health systems, with roles continued from one generation of health professionals to the next and administration focused mostly, if not exclusively, on ensuring that regulatory processes are adhered to. There is little evidence of internal adaptation to the changing environment or to the principles of coordinated health and human resource development identified earlier.
The increasing pressures for change to a tightly managed, goal-oriented health service include: changes in the patterns of disease; rapid advances in technology; increasing demands from and expectations of the public for accessible and effective health care; rising health care costs requiring renewed attention to the cost-effectiveness of medical interventions; and the growth of an increasingly significant private sector.
Implications of health sector reform for the health workforce
Health-for-all strategies and health sector reform, while taking many different forms, should probably always have these four aims:
to improve the responsiveness of the health sector to the needs of the population;
to increase access to health and health care;
to improve the quality of health care;
to reduce costs while improving efficiency and effectiveness.
Governments have to tread a fine line to ensure, on the one hand, that there is an equitable distribution of publicly funded health care and, on the other, that the resources at their disposal are both used and seen to be used as well as possible in terms of health gains and costs for the range of services provided. Increasingly, the focus for change is the health workforce itself. Health personnel generally account for 6070% of total ministry of health budgets (5). Moreover, it is their expertise, motivation and organization that will determine both the quality and the efficiency of the services provided. A key strategy is therefore the formulation of plans to reorganize and reorient the health workforce, moving away from traditional structures. This effort must be seen not simply as a priority activity but as a foundation stone for health sector reform.
The health services must move from existing processes of administration to a proactive management of the workforce. This will require individuals with skills and capabilities beyond those expected of administrators, and may also require the introduction of new categories of staff with management skills. Building management capacity within the health system will be indispensable for reform. It is only with such capacity that the central units of ministries of health can shift from a traditional regulation of inputs and processes to the more strategic role required to manage outputs and outcomes.
As well as initiatives to improve health service performance, the shifts in emphasis implied by health sector reform require appropriate mechanisms for the measurement of performance, which can be used to provide comparisons between different health providers in the health system, at the individual and institutional levels (8). It will also be necessary to introduce different incentive schemes that encourage and reward individual and corporate performance. These rewards should go beyond simple financial bonuses and may necessitate changes in career opportunities and new approaches to stimulate motivation and commitment.
This process will involve change not only in orientation of the workforce and in the culture of the health system as a whole. There will have to be changes in attitude, not just among managers and senior staff but also among other health professionals, particularly doctors, who are often in a leadership role. These changes must focus on enabling all staff to see that they themelves, as individuals, have responsibility for quality, cost, efficiency, and effectiveness. In this new environment, health care workers will have to become increasingly involved in striking a balance between individual and community health care and between curative and preventive care, with increased attention to the adoption of appropriate technologies. While the reform process may initially be directed at leaders and physicians, it will need eventually to encompass the whole of the health workforce.
All categories of health professionals must understand and accept that health development is not an isolated activity but part of the overall national development. As a consequence, decision-making about health and health care should be regarded as a multidisciplinary, multiprofessional process. Health professionals will require new attitudes and skills that enable them to work with other sectors to ensure comprehensive, high-quality, continuous and personalized care which meets the actual needs of the community.
Finally, improvement in the overall performance of the health sector and of the health workforce will require much more local decision-making than is currently the case in many countries of the Region. This will entail some decentralization of authority, with individual institutions having a much greater degree of autonomy than in the past.
Developing a national strategy for human resources
It will be clear from Box 2 and the preceding sections that a national strategy for health sector reform and development of human resources for health (HRH) must incorporate multiple strands of development within the ministry of health and in related organizations. These developments are interconnected and so need to proceed simultaneously. The first requirement is a core of nationals who are well-trained and experienced in HRH policy development, planning and management, with direct access to national decision-makers in the health sector. In the short term, this will mean a major investment in training and the possible importation of expertise in these fields from outside the country.
For these individuals to function effectively, a plan for health must be formulated with well-defined targets, together with a linked plan for human resources, with clear objectives for the development, deployment and utilization of health service staff. This will need to be supported by a relevant and reliable HRH information system, which will enable planners and managers to monitor progress in terms of individual and corporate performance. Basic and post-basic training should be linked to these objectives, with some form of institutional licensing to ensure that the necessary staff quality is achieved and maintained.
More rigorous attention should be paid to admissions policies for educational institutions to ensure that learning and training meet the requirements of the service. A shift in educational activities is needed to increase the focus on community problems and priorities, using problem-solving techniques to provide health workers with the necessary skills to engage directly at this level.
HRH development as a whole will require continuing close cooperation between the ministry of health, other health care providers, universities and educational institutions and, importantly, professional associations. The individual strengths and capacities of each group must be mobilized so that HRH issues can be tackled jointly.
Medical schools and academic institutions could play an important role in improving general health services, as they currently do for specialized services. They also have great potential for establishing, participating in and maintaining effective programmes of continuing education for health professionals. New policies are needed to break down some of the barriers between these various institutions and ensure that their roles are mutually supportive.
The involvement of professional associations in health-related fields should be enhanced. Mechanisms are needed to ensure their active collaboration with health authorities and medical schools. These associations must have well-defined roles that enable them to share in the design and implementation of new patterns of practice, so that practitioners can more easily see and respond to health needs. Professional associations can also make a valuable contribution to strengthening the continuing education of health professionals and medical audit and monitoring systems, and should include these activities in their mandates. With their concern for good standards of practice and professional competence, these associations have great potential for strengthening the reform process.
Conclusions
Reforms of the health sector are being undertaken by many countries of the Eastern Mediterranean Region. Health financing, cost-effectiveness, and access to quality services are the components of reform receiving the most attention. These and everything else that can contribute to improving the performance of the health services will require enhanced human resources, which need to be defined and developed accordingly (9). The efficient use of human resources and institutional capability must be seen as an essential part of any reform process and a basic challenge for all countries. This includes refocusing the education, training and practice of health professionals, and finding ways to retain and strengthen their capabilities over time.
There is no ideal operational model for health sector reform for countries to follow. Those involved in the reform process can learn from the experience of other countries (10) but at the same time they have to develop sufficient analytical ability within the service to examine and select the strategies that can solve current and future problems.
Health sector reform is driven in most countries by issues of financing, but it is also possible to achieve beneficial outcomes within existing financial realities. A start can and must be made by making a rigorous appraisal of the current state of human resources development in terms of capacity, planning, personnel policy, training, and the management of data and performance (11). This should reveal the needs and opportunities for change and provide the basis for a well-coordinated process of improvement. 
Conflicts of interest: none declared.
Résumé
Réforme du secteur de la santé et développement des ressources humaines
D'après les auteurs, la <<santé pour tous>> est irréalisable dans la plupart des pays sans une réforme du secteur de la santé intégrant un processus de développement coordonné des ressources consacrées à la santé et des ressources humaines. Ils examinent la situation dans les pays de la Région OMS de la Méditerranée orientale. Malgré les progrès réalisés, il est difficile d'aller plus loin en raison de l'adaptation limitée des structures et du fonctionnement traditionnels des services de santé dans nombre de ces pays. Des stratégies nationales de réforme sont nécessaires. Elles exigent la participation active des associations de professionnels de la santé et des établissements de formation ainsi que des responsables des services de santé. L'article mentionne quelques initiatives indispensables et suggère que les pays commencent par une évaluation rigoureuse de l'état actuel du développement des ressources humaines dans le domaine de la santé.
Resumen
Repercusiones de la reforma del sector sanitario para el desarrollo de recursos humanos
Los autores sostienen que la mayoría de los países no podrán alcanzar el objetivo de "salud para todos" sin una reforma del sector sanitario que incluya un proceso de desarrollo coordinado de los recursos sanitarios y humanos. Se examina la situación de países de la Región del Mediterráneo Oriental de la Organización Mundial de la Salud. Pese a los progresos realizados, la limitada capacidad de adaptación de las estructuras y los mecanismos tradicionales de los servicios de salud de muchos de estos países frena cualquier nuevo avance. Se necesitan estrategias nacionales de reforma, y para ello se requiere la participación activa de asociaciones de profesionales de la salud, instituciones de formación académica y administradores de servicios de salud. El artículo señala algunas de las iniciativas necesarias, y sugiere que como punto de partida muchos países deberían efectuar una evaluación rigurosa de la situación actual del desarrollo de recursos humanos en el sector sanitario.
References
1. Formulating strategies for Health for All by the year 2000. Geneva: World Health Organization; 1979 (Health for All Series, No. 2).
2. Reorienting medical education and medical practice for health for all. Geneva: World Health Organization; 1995 (resolution WHA48.8).
3. Martineau T, Martinez J. Human resources and health sector reform: priorities for analysis. Workshop on Human Resources and Health Sector Reform, International Health Division, Liverpool School of Tropical Medicine, Liverpool, England. August 1996.
4. Third report on regional evaluation of Health for All strategies. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 1997. Unpublished document EM/RC44/9.
5. Report of the meeting on the follow up of World Health Assembly resolution WHA48.8 and the recommendations of the Ministerial Consultation on medical education and health services, held in Abu Dhabi, United Arab Emirates, 810 March 1997. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 1997.
6. Report of the first regional meeting for focal points of paramedical resources development, held in Cairo, Egypt, 811 June 1996. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 1996.
7. WHO Regional Office for the Eastern Mediterranean. Role of academia and professional associations in support of HFA. A paper submitted to the WHO/EMR Regional Committee, 44th session, October 1997. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 1997.
8. Hornby P, Forte P. Management indicators for health human resources. Geneva: World Health Organization; in press.
9. Kolehmainen-Aitken R-L, editor. Myths and realities about the decentralisation of health systems. Boston (MA): Management Sciences for Health; 1999.
10. Ham C. Innovations in organisation of health service delivery: country case study. The United Kingdom. Unpublished paper prepared for World Bank by C. Ham, HSMC, University of Birmingham, England, 1999.
11. Management Sciences for Health. HRD Assessment Instrument for non- governmental organizations and public sector health organisations. Boston (MA): Management Sciences for Health; 1998.
1 Director, Management of Noncommunicable Diseases, World Health Organization, 1211 Geneva 27, Switzerland (email alwana@who.int). Correspondence should be addressed to this author.
2 Senior Fellow, Centre for Health Planning and Management, Keele University, England.
Ref. No. 99-0389