Résumé

Parvenir à la couverture sanitaire universelle (CSU) implique la répartition des ressources, et en particulier des ressources humaines pour la santé (RHS), afin de répondre aux besoins de la population. Cet article étudie les leçons politiques sur les RHS de quatre pays ayant accompli des progrès durables en matière de CSU: le Brésil, le Ghana, le Mexique et la Thaïlande. Son but est d'informer sur les politiques globales et les engagements financiers dans les RHS visant à promouvoir la CSU.

L'article décrit les expériences des pays à l'aide d'un cadre analytique examinant la couverture efficace par rapport à la disponibilité, l'accessibilité, l'acceptabilité et la qualité (DAAQ) des RHS. Les dimensions DAAQ permettent de réaliser une analyse de traçage des actions politiques en RHS depuis 1990 dans les quatre pays étudiés, par rapport aux tendances nationales des statistiques de main-d'oeuvre et des taux de mortalité de la population.

Les résultats indiquent quels sont les principes clés pour la prise de décisions basées sur les faits sur les RHS visant à promouvoir la CSU. Premièrement, les RHS sont essentielles à l'expansion de la couverture des services de santé et de l'ensemble des avantages; deuxièmement, des stratégies RHS pour chacune des dimensions DAAQ favorisent collectivement les progrès vers une couverture efficace; et troisièmement, le succès est atteint à travers des partenariats impliquant des acteurs tant médicaux que non médicaux.

Répondre aux défis sans précédent dans les domaines de la santé et du développement, qui concernent tous les pays, et transformer les faits RHS en politiques et en pratiques doivent être à la base du programme de CSU et de l'agenda de développement post-2015. C'est un impératif politique qui exige un engagement et un leadership nationaux pour optimiser l'impact des ressources financières et humaines disponibles et accroître l'espérance de vie en bonne santé, avec la reconnaissance que les progrès dans le domaine des soins de santé ne sont possibles qu'avec une main-d'oeuvre de santé adéquate.

Resumen

Lograr una cobertura sanitaria universal implica una distribución de los recursos, en particular, de los recursos humanos para la salud (RHS), a fin de satisfacer las necesidades de la población. Este documento examina las lecciones sobre políticas relacionadas con los RHS de cuatro países que han conseguido avances ininterrumpidos en materia de cobertura sanitaria universal: Brasil, Ghana, México y Tailandia. Su objetivo consiste en exponer la política mundial y los compromisos financieros sobre RHS como ayuda para una cobertura sanitaria universal.

El documento explica las experiencias de los países mencionados por medio de un marco de trabajo analítico que examina la eficacia de una cobertura en función de la disponibilidad, accesibilidad, aceptabilidad y calidad (DAAC) de los RHS. Los aspectos DAAC permiten llevar a cabo análisis de seguimiento sobre las acciones políticas relativas a los RHS desde 1990 en los cuatro países de interés en relación con las tendencias nacionales en el número de trabajadores y las tasas de mortalidad de la población.

Los resultados muestran los principios fundamentales para la toma de decisiones basadas en pruebas científicas sobre los RHS como apoyo a una cobertura sanitaria universal. En primer lugar, los RHS son esenciales para expandir la cobertura de los servicios sanitarios y el conjunto de prestaciones. En segundo lugar, las estrategias RHS en cada uno de los aspectos DAAC respaldan de forma colectiva los logros en la eficacia de la cobertura y, en tercer lugar, los buenos resultados solo pueden conseguirse a través de la asociación de actores sanitarios y no sanitarios.

Hacer frente a los desafíos sanitarios y de desarrollo sin precedentes que afectan a todos los países y traducir las pruebas científicas sobre RHS en políticas y prácticas deben convertirse en los puntos centrales de la cobertura sanitaria universal y de la agenda de desarrollo a partir del año 2015. Se trata de un imperativo político que requiere un compromiso y liderazgo nacionales para potenciar el impacto de los recursos financieros y humanos disponibles, y así mejorar la esperanza de vida saludable, sin olvidar que las mejoras en materia de asistencia sanitaria son posibles gracias a un personal sanitario apto para tal propósito.

ملخص

يتضمن تحقيق التغطية الصحية الشاملة توزيع الموارد، لاسيما الموارد البشرية الصحية، لتلبية احتياجات السكان. وتستكشف هذه الورقة الدروس السياسية المعنية بالموارد البشرية الصحية المستفادة من أربعة بلدان حققت تحسينات مستدامة في التغطية الصحية الشاملة، هي: البرازيل وغانا والمكسيك وتايلند. وتهدف هذه الورقة إلى توفير المعلومات اللازمة للسياسة العالمية والالتزامات المالية للموارد البشرية الصحية دعماً للتغطية الصحية الشاملة.

تقدم هذه الورقة تقارير عن خبرات البلدان باستخدام إطار تحليلي يدرس التغطية الفعالة فيما يتصل بتوافر وإتاحة ومقبولية وجودة الموارد البشرية الصحية. وتتيح أبعاد التوافر والإتاحة والمقبولية والجودة تنفيذ تتبع التحليل المعني بإجراءات سياسة الموارد البشرية الصحية منذ عام 1990 في البلدان الأربع محل الاهتمام فيما يتصل بالاتجاهات الوطنية في أعداد القوى العاملة ومعدلات وفيات السكان.

توفر النتائج المعلومات اللازمة حول المبادئ الرئيسية لاتخاذ القرار المستند على البيّنات المعني بالموارد البشرية الصحية دعماً للتغطية الصحية الشاملة. أولاً، الموارد البشرية الصحية بالغة الأهمية في توسيع تغطية الخدمات الصحية وحزمة المزايا؛ ثانياً، تدعم استراتيجيات الموارد البشرية الصحية في كل بعد من أبعاد التوافر والإتاحة والمقبولية والجودة في مجموعها الإنجازات في التغطية الفعالة؛ ثالثاً، يتحقق النجاح من خلال الشراكات التي تضم جهات فاعلة في المجال الصحي وغير الصحي.

يجب أن تكون مواجهة التحديات الصحية والإنمائية غير المسبوقة التي تؤثر على كل البلدان وتحويل بينّات الموارد البشرية الصحية إلى سياسة وممارسة محور التغطية الصحية الشاملة وجدول أعمال التنمية بعد عام 2015. وتمثل زيادة أثر الموارد المالية والبشرية المتاحة إلى أقصى قدر ممكن، وتحسين متوسط العمر المأمول لدى الأصحاء مع الإقرار بتمكين القوى العاملة الصحية المناسبة للغرض من إدخال تحسينات في الرعاية الصحية واجباً سياسياً يتطلب التزاماً وقيادة على الصعيد الوطني.

摘要

实现全民医保（UHC）涉及满足人们需求的资源分配，尤其是卫生人力资源（HRH）的分配。文本探讨了巴西、加纳、墨西哥和泰国四国HRH相关政策的经验教训，这四个国家在UHC方面取得了持续改进。本文旨在为HRH的相关全球政策和财务规划提供信息，用以支持UHC。

本文使用考查HRH可用性、可及性、可接受性和质量（AAAQ）相关有效覆盖的分析框架来报告国家经验。采用AAAQ维度可以对四个受关注国家执行1990 年以来有关劳动力数量和人口死亡率国家趋势的HRH政策行为跟踪分析。

研究结果可以为基于证据的相关HRH决策的基本原则提供参考信息，对UHC加以支持。首先，HRH对于扩大卫生服务覆盖和福利制度非常关键；其次，每个AAAQ维度中的HRH战略对实现有效覆盖共同起支持作用；第三，成功通过合作关系实现，这种合作关系涉及卫生工作者，也牵涉到非卫生行动者。

面对影响所有国家的前所未有的卫生和发展挑战，将HRH证据转化为政策和实践必须居于UHC和2015 年后发展议程的核心。一个需要国家承诺和领导的政治要务就是，通过认识到专业对口的卫生劳动力能实现医疗卫生事业的改善，将可用财政和人力资源的效力最大化，并改善健康预期寿命。

Резюме

Достижение всеобщего охвата медико-санитарной помощью (ВОМСП) подразумевает распределение ресурсов, особенно кадровых ресурсов здравоохранения (КРЗ), в соответствии с потребностями населения. В данной статье исследуются результаты проведения политики в области КРЗ в четырех странах, добившихся устойчивых улучшений в области ВОМСП: Бразилии, Ганы, Мексики и Таиланда. Целью статьи является информирование о глобальной политике и финансовых обязательствах по КРЗ в целях обеспечения ВОМСП.

В статье сообщается об опыте стран с применением аналитической основы, когда эффективность охвата медицинскими услугами рассматривается на основе таких параметров КРЗ, как наличие, доступность, приемлемость и качество (НДПК). Использование параметров НДПК дало возможность выполнить исторический анализ политики КРЗ в этих четырех странах с 1990 года с учетом национальных тенденций численности рабочей силы и смертности населения.

В результате были выделены основные принципы научно обоснованных решений по КРЗ для поддержки ВОМСП. Во-первых, КРЗ имеет решающее значение для расширения охвата медицинским обслуживанием и связанных с ним комплексных улучшений; во-вторых, стратегии КРЗ по каждому параметру НДПК совместно обеспечивают более эффективный охват услугами; и в-третьих, успех достигается благодаря партнерским отношениям с организациями, как связанными со здравоохранением, так и работающими вне этой области.

Эффективное преодоление беспрецедентных трудностей в области здравоохранения и развития, затрагивающих все страны, и воплощение результатов, полученных в ходе исследования КРЗ, в политику и практику, должно стать основой стратегии ВОМСП и сформировать повестку дня в целях развития после 2015 года. Политическим императивом сегодня является национальная заинтересованность и обеспечение руководства развитием здравоохранения, что позволит оптимально использовать имеющиеся финансовые и людские ресурсы и увеличить ожидаемую продолжительность здоровой жизни. При этом необходимо признание того, что улучшения в области медицинского обслуживания возможны только при наличии кадров работников здравоохранения, соответствующих данным целям.

Introduction

In December 2012, the United Nations General Assembly called upon all governments to “urgently and significantly scale up efforts to accelerate the transition towards universal access to affordable and quality healthcare services”.¹1 A/67/L.36. Agenda item 123: global health and foreign policy. In: General Assembly of the United Nations [Internet]. Sixty-seventh United Nations General Assembly, New York, 3–11 September 2012, official documents. Geneva: UNGA; 2013. Available from: http://daccess-dds-ny.un.org/doc/UNDOC/LTD/N12/630/51/PDF/N1263051.pdf?OpenElement [accessed 10 September 2013].
http://daccess-dds-ny.un.org/doc/UNDOC/L... The evolving momentum for universal health coverage (UHC), with its principles of equity and social justice, aims to ensure that all members of a society can access the health-care services they need without incurring financial hardship.²2 Ooms G, Brolan C, Eggermont N, Eide A, Flores W, Forman L et al. Universal health coverage anchored in the right to health. Bull World Health Organ 2013;91:2–2A. doi: http://dx.doi.org/10.2471/BLT.12.115808 PMID:23397341
https://doi.org/10.2471/BLT.12.115808... ^,33 Savedoff WD, de Ferranti D, Smith AL, Fan V. Political and economic aspects of the transition to universal health coverage. Lancet 2012;380:924–32. doi: http://dx.doi.org/10.1016/S0140-6736(12)61083-6 PMID:22959389
https://doi.org/10.1016/S0140-6736(12)61... UHC encompasses the three dimensions of who is covered (population coverage), what is covered (health-care benefits) and how much of the cost is covered (financial protection), all of which may expand over time.⁴4 The world health report: health systems financing: the path to universal coverage. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/whr/2010/9789241564021_eng.pdf [accessed 10 September 2013].
http://whqlibdoc.who.int/whr/2010/978924...

Addressing these three dimensions of UHC⁵5 Social health protection: an ILO strategy towards universal access to health care. Geneva: International Labour Office; 2008 (Social Security Policy Briefings). Available from: http://www.ilo.org/secsoc/information-resources/publications-and-tools/policy-briefings/WCMS_SECSOC_5956/lang--en/index.htm [accessed 10 September 2013].
http://www.ilo.org/secsoc/information-re... ^–77 Giedion U, Alfonso EA, Díaz Y. The impact of universal coverage schemes in the developing world: a review of the existing evidence. Washington: The World Bank; 2013. Available from: http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Images/IMPACTofUHCSchemesinDevelopingCountries-AReviewofExistingEvidence.pdf [accessed 20 September 2013].
http://siteresources.worldbank.org/HEALT... within the boundaries of fiscal space⁸8 Tandon A, Cashin C. Assessing public expenditure on health from a fiscal space perspective. Washington: The World Bank; 2010 (HNP Discussion Paper). is challenging for all countries. It requires continuing political commitment and leadership to distribute available resources, especially human resources for health (HRH),⁹9 Jimba M, Cometto G, Yamamoto T, Shiao L, Huicho L, Sheikh M. Health workforce: the critical pathway to universal health coverage. Montreux: First Global Symposium on Health Systems Research; 2010. Available from: http://www.hrhresourcecenter.org/node/3459 [accessed 10 September 2013].
http://www.hrhresourcecenter.org/node/34... in an efficient, equitable and sustainable manner to match population needs. Overcoming the inequitable distribution of services is particularly critical.¹⁰10 Victora CG, Hanson K, Bryce J, Vaughan JP. Achieving universal coverage with health interventions. Lancet 2004;364:1541–8. doi: http://dx.doi.org/10.1016/S0140-6736(04)17279-6 PMID:15500901
https://doi.org/10.1016/S0140-6736(04)17...

High-, middle- and low-income countries alike are facing fundamental health challenges stemming from demographic changes, ageing populations, the growing burden of noncommunicable diseases and emerging public health threats such as drug-resistant malaria, tuberculosis and pandemics. Several countries of the Organisation for Economic Co-operation and Development (OECD), hit by the global financial crisis, are revisiting health benefits, coverage and protection – either to reaffirm commitments or cut services.¹¹11 Mladovsky P, Srivastava D, Cylus J, Karanikolos M, Evetovits T, Thomson S, et al. Health policy responses to the financial crisis in Europe. Geneva: World Health Organization, European Observatory on Health Systems and Policies; 2012 (Policy Summary 5). Available from: http://www.euro.who.int/__data/assets/pdf_file/0009/170865/e96643.pdf [accessed 10 September 2013].
http://www.euro.who.int/__data/assets/pd... In low- and middle-income countries, other evolving dynamics will shape efforts to achieve UHC, including epidemiological transitions,¹²12 Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2095–128. doi: http://dx.doi.org/10.1016/S0140-6736(12)61728-0 PMID:23245604
https://doi.org/10.1016/S0140-6736(12)61... economic growth, increased health expenditure and diminishing international health aid – or its reprioritization.¹³13 Pitt C, Lawn JE, Ranganathan M, Mills A, Hanson K. Donor funding for newborn survival: an analysis of donor-reported data, 2002–2010. PLoS Med 2012;9:e1001332. doi: http://dx.doi.org/10.1371/journal.pmed.1001332 PMID:23118619
https://doi.org/10.1371/journal.pmed.100... ^–1515 Ravishankar N, Gubbins P, Cooley RJ, Leach-Kemon K, Michaud CM, Jamison DT et al. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet 2009;373:2113–24. doi: http://dx.doi.org/10.1016/S0140-6736(09)60881-3 PMID:19541038
https://doi.org/10.1016/S0140-6736(09)60... In the next decade, an increasing number of African and Asian countries will become able to finance essential health services from domestic resources and will then face critical decisions on how to invest these funds most effectively to accelerate progress towards UHC.¹⁶16 Brandford DeLong J. Contours of the world economy 1−2030 AD: essays in macro-economic history. New York: Oxford University Press; 2007.

The health workforce is central to a country's response to these challenges. Reaching a greater percentage of the population, extending the benefit package and improving the quality of the care provided requires commensurate attention to the governance and management of the health-care workforce, including its stock, skill mix, distribution, productivity and quality. Matching population health needs with a supply of competent and motivated health workers that are both fit for purpose and fit to practise in the country context is therefore the foundation for accelerating the attainment of UHC.

Case studies: methods and findings

This paper explores the HRH policy lessons from four countries – Brazil, Ghana, Mexico and Thailand (Table 1) – purposefully selected for having achieved sustained improvements in accelerating progress towards UHC since 1990.⁷7 Giedion U, Alfonso EA, Díaz Y. The impact of universal coverage schemes in the developing world: a review of the existing evidence. Washington: The World Bank; 2013. Available from: http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Images/IMPACTofUHCSchemesinDevelopingCountries-AReviewofExistingEvidence.pdf [accessed 20 September 2013].
http://siteresources.worldbank.org/HEALT... Part of their success lies in the policy focus on the health workforce to expand population coverage and the health benefits package. The paper reviews the available literature on the impact of HRH policy to identify the key actions and lessons that support accelerated progress towards UHC, with special attention to “effective coverage” and equity. By effective coverage we mean the proportion of people who have received satisfactory health services relative to the number needing such services.¹⁹19 Tanahashi T. Health service coverage and its evaluation. Bull World Health Organ 1978;56:295–303. PMID:96953^,2020 Shengelia B, Tandon A, Adams OB, Murray CJL. Access, utilization, quality, and effective coverage: an integrated conceptual framework and measurement strategy. Soc Sci Med 2005;61:97–109. doi: http://dx.doi.org/10.1016/j.socscimed.2004.11.055 PMID:15847965
https://doi.org/10.1016/j.socscimed.2004... We focus on maternal and neonatal health – areas in which comparative data are widely available, given that measuring effective coverage of UHC within and across countries is feasible by establishing “tracers” or a subset of activities indicative of overall service quality and quantity.²¹21 The world health report 2013: research for universal health coverage. Geneva: World Health Organization; 2013. Available from: http://apps.who.int/iris/bitstream/10665/85761/2/9789240690837_eng.pdf [accessed 10 September 2013].
http://apps.who.int/iris/bitstream/10665...

We use an analytical framework (Fig. 1) specifically adapted from the UHC “cube”⁴4 The world health report: health systems financing: the path to universal coverage. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/whr/2010/9789241564021_eng.pdf [accessed 10 September 2013].
http://whqlibdoc.who.int/whr/2010/978924... – integrating Tanahashi's health coverage model and the right to health ²2 Ooms G, Brolan C, Eggermont N, Eide A, Flores W, Forman L et al. Universal health coverage anchored in the right to health. Bull World Health Organ 2013;91:2–2A. doi: http://dx.doi.org/10.2471/BLT.12.115808 PMID:23397341
https://doi.org/10.2471/BLT.12.115808... ^,1919 Tanahashi T. Health service coverage and its evaluation. Bull World Health Organ 1978;56:295–303. PMID:96953^,2222 UN Economic and Social Council. General comment no. 14: the right to the highest attainable standard of health (Art. 12 of the Covenant). Geneva: UN Committee on Economic, Social and Cultural Rights; 2000 (Document E/C.12/2000/4). Available from: http://www.unhcr.org/refworld/pdfid/4538838d0.pdf [accessed 10 September 2013].
http://www.unhcr.org/refworld/pdfid/4538... – to characterize the dimensions of effective coverage: availability, accessibility, acceptability, utilization and quality. The paper focuses on these four dimensions as they apply specifically to the health workforce: availability (e.g. stock and production); accessibility (e.g. spatial, temporal and financial dimensions); acceptability (e.g. gender and sociocultural); and quality (e.g. competencies and regulation).

The framework shifts the focus beyond the current monitoring of access to and contact with a health worker – i.e. skilled attendance at birth, or density of health professionals per 1000 population – and turns the AAAQ dimensions of the workforce into the key determining factors of the quality of care,²³23 Graham WJ, McCaw-Binns A, Munjanja S. Translating coverage gains into health gains for all women and children: the quality care opportunity. PLoS Med 2013;10:e1001368. doi: http://dx.doi.org/10.1371/journal.pmed.1001368 PMID:23335862
https://doi.org/10.1371/journal.pmed.100... represented in Fig. 1 as the “effective coverage gap”.

We apply the four workforce dimensions to guide a process-tracing analysis of HRH policy actions since 1990. Process tracing is an analytical tool for exploring causal mechanisms and contributory steps in the chain of events that collectively support a desired outcome.²⁴24 Van Evera S. Guide to methods for students of political science. Cornell University; 1997.^–2626 Collier D. Understanding process tracing. PS: Political Science & Politics 2011;44:823–30. doi: http://dx.doi.org/10.1017/S1049096511001429
https://doi.org/10.1017/S104909651100142... We collated historical data (Fig. 2, Fig. 3, Fig. 4 and Fig. 5) on national trends in the number of skilled birth attendants (midwives, nurses and physicians) employed in the public sector. Subject to data availability, the figures also show the rates for maternal mortality, under-five mortality and either infant or neonatal mortality. We have disaggregated the national policy and governance steps on HRH by their respective AAAQ dimensions (Table 2).²⁷27 The Kampala declaration and agenda for global action. Geneva: World Health Organization, Global Health workforce Alliance; 2008. Available from: http://www.who.int/workforcealliance/Kampala%20Declaration%20and%20Agenda%20web%20file.%20FINAL.pdf [accessed 10 September 2013].
http://www.who.int/workforcealliance/Kam... The respective policies are captured chronologically to explore their linkages to national trends in the health workforce and maternal, neonatal and child health outcomes.

We recognize the limitations inherent in an ex post analysis such as this. The complexity of decision-making and the confounders influencing improved health outcomes are not discussed here. Hence, while the paper explores causal mechanisms, it is beyond its scope to express causal conclusions. Instead, we use the case studies and wider published literature to identify what appears to have worked and where and draw examples of good practice from this evidence base.

Brazil

Since the adoption of its current constitution in 1988, Brazil has worked progressively to achieve UHC by setting up the Sistema Único de Saúde (SUS) [Unified Health System], an integrated health service system based on the provision of community care and improved access for underserved populations. The SUS revealed the need to expand the health workforce, both in terms of adding staff and rationalizing roles and responsibilities, especially in relation to developing new skills and building management capacity at the municipal level – the locus of health service delivery.

The government implemented several steps to produce more staff, improve their training, enhance working conditions and strengthen management capacity. The first major effort in the 1980s was the Programa Larga Escala [Long-term Programme], designed to qualify staff who had not received formal training. In 1987, before the SUS was created, the Capacitação em Desenvolvimento de Recursos Humanos initiative was launched to build capacity in HRH training and management. This was followed in 2006 by the establishment of the Programa de Qualificação e Estruturação da Gestão do Trabalho e da Educação no SUS (ProgeSUS) [Programme of Qualification and Structuring of the Management of Work and Education in the Unified Health System], a programme for strengthening HRH and, more generally, health service management.²⁸28 Buchan J, Fronteira I, Dussault G. Continuity and change in human resources policies for health: lessons from Brazil. Hum Resour Health 2011;9:17. doi: http://dx.doi.org/10.1186/1478-4491-9-17 PMID:21729318
https://doi.org/10.1186/1478-4491-9-17... Other programmes, such as the 2003 Programa de Incentivo a Mudanças Curriculares nos Cursos de Medicina (PROMED) and the 2009 Programa de Educação pelo Trabalho para a Saúde (PET-Saúde) [Programme of Incentives for Curricular Changes in Medical Schools], have sought to improve service acceptability and quality and to bridge the gaps between HRH availability and need in the area of primary care. The family health team model, based on a multidisciplinary team of health workers oriented towards primary care, entails a re-orientation of the values and practices of health professionals towards the community²⁹29 Peres EM, Andrade AM, Dal Poz MR, Grande NR. The practice of physicians and nurses in the Brazilian Family Health Programme - evidences of change in the delivery health care model. Hum Resour Health 2006;4:25. doi: http://dx.doi.org/10.1186/1478-4491-4-25 PMID:17107622
https://doi.org/10.1186/1478-4491-4-25... and improvements in population health and, indirectly, in labour supply.³⁰30 Rocha R, Soares RR. Evaluating the impact of community based health interventions: evidence from Brazil's Family Health Program. New Delhi: Global Development Network; 2009 (GDN Working Paper No. 1). Available from: http://depot.gdnet.org/newkb/submissions/Health project_Brazil_Rocha & Soares_1.pdf [accessed 10 September 2013].
http://depot.gdnet.org/newkb/submissions... The successes of these HRH policies have been made possible by strong political commitment and a sustained policy focus.

Through the implementation of these policies and programmes, between 1990 and 2009 Brazil managed to increase the number of health workers – nurses by 500% and physicians by 66% – well above the 31% in population growth. Between 2002 and 2012 the number of family health teams doubled – from 15 000 to 30 000 – and in 2013 access to basic health units reached 57% of the population (i.e. 108 million people).³¹31 Sala de Apoio á Gestão Estrategica [Internet]. Indicadores de saúde a um clique. Brasilia: Ministério de Saúde; 2013. Portugese. Available from: http://189.28.128.178/sage/ [accessed 10 September 2013].
http://189.28.128.178/sage/... Over the same period neonatal mortality decreased from 26.8 to 9.7 per 1000 live births and under-five mortality from 58 to 15.6 per 1000 live births, respectively.

Ghana

A 1992 constitutional amendment to ensure the right to health enhanced the political and financial commitment to a supply-driven expansion of the health workforce in Ghana. In 1996 new regulation, accompanied by administrative decentralization and the definition of HRH staffing norms, paved the way for Ghana's Patient's Rights Charter of 2002. The improved availability and accessibility of health workers since the turn of the millennium enabled the development of the High-Impact Rapid Delivery strategy (2005), aimed at expanding the package of essential interventions for maternal and child health and extending population coverage. The Human Resources for Health Strategic Plan (2007–2011), which integrated the accessibility, acceptability and quality dimensions, was instituted to improve deployment and retention strategies, accreditation, regulation and licensing and continuous professional development for staff.

In 1990–2009, Ghana witnessed a rapid increase in its supply of professional health workers: 185% more midwives, 260% more nurses and 1300% more physicians. Approximately 14 000 additional professional health workers were trained and employed, a number representing four times the increase in population growth (240% versus 59%) over the same period. In the case of physicians, the growth in each 5-year period is fairly uniform, but in the case of midwives and nurses such growth dropped sharply towards the end of the period (2005–2009). The reduction has since been corrected, however, with the addition of more workers in 2010–12.

Achieving equity in access to and use of essential services continues to be challenging.³²32 Countdown to 2015: building a future for women and children – the 2012 report. Geneva: World Health Organization & United Nations Children’s Fund; 2012. Available from: http://www.countdown2015mnch.org/documents/2012Report/2012-Complete.pdf [accessed 10 September 2013].
http://www.countdown2015mnch.org/documen... A large share of national health expenditure – approximately 85% – is committed to health workforce salaries and incentives, but the steps taken in 1990–2009 have reduced workforce attrition, increased the capacity of health training institutions – Ghana is now one of the largest producers of physicians in sub-Saharan Africa – and improved the number and distribution of health workers.

Mexico

Policies and programmes have generated large increases in the health workforce,³³33 Frenk J, Gómez-Dantés O, Knaul FM. The democratization of heath in Mexico financial innovations for universal coverage. Bull World Health Organ 2009;87:542–8. beginning with the 1995 Health Sector Reform (1995–2000), which established agreements with educational institutions for the training of human resources and increased the number of health workers nationwide.³⁴34 Nigenda G, Ruiz JA. El caso de México: factores restrictivos para la descentralización en recursos humanos. Washington: Pan American Health Organization; 1999 (Serie Desarrollo de Recursos Humanos 16). Spanish. The coverage expansion programme (PAC) initiated in 1996 to address accessibility employed thousands of workers to support health activities in underserved areas. Staff remuneration was initially covered by loans from the Inter-American Development Bank, but the health ministry committed to paying wages in subsequent phases of the programme. In 2002 the PAC was integrated into the new Programa de Calidad, Equidad y Desarrollo en Salud (PROCEDES) [Programme for Quality, Equity and Development in Health].³⁵35 Secretaría de Salud, Programa de Ampliación de Cobertura 1996-2000: recuento y testimonio de un esfuerzo de equidad y extensión de servicios de salud en México. Mexico City: 2000. Spanish.^,3636 Nigenda G, Ruiz-Larios JA, Aguilar-Martínez ME, Bejarano-Arias R. Regularización laboral de trabajadores de la salud pagados con recursos del Seguro Popular en México. Salud Publica Mex 2012;54:616–23. Spanish doi: http://dx.doi.org/10.1590/S0036-36342012000600010 PMID:23318898
https://doi.org/10.1590/S0036-3634201200... The Sistema de Protección Social en Salud (SPSS) [System for Social Protection in Health] and the Seguro Popular de Salud (SPS) [Popular Health Insurance] were created in 2003 to pursue the goal of UHC, with encouraging results across all AAAQ domains.³⁷37 Frenk J. Bridging the divide: global lessons from evidence-based health policy in Mexico. Lancet 2006;368:954–61. doi: http://dx.doi.org/10.1016/S0140-6736(06)69376-8 PMID:16962886
https://doi.org/10.1016/S0140-6736(06)69...

The number of nurses and physicians increased over 1990–2009. More than 250 000 additional professionals were trained and the 80% increase in nurses and the 170% increase in physicians outstripped the population growth of 30%. In the same period, infant mortality and under-five mortality more than halved: from 32.6 to 14.6 per 1000 live births and from 41 to 17.8 per 1000 live births, respectively.³⁸38 Secretaría de Salud. Vol. I. Recursos físicos, materiales y humanos 2000 al 2011. In: Boletín de Información Estadística. Mexico City: Sistema Nacional de Información en Salud. Spanish. Available from: http://www.sinais.salud.gob.mx/publicaciones/index.html [accessed 15 September 2013].
http://www.sinais.salud.gob.mx/publicaci... ^–4141 Alcalde-Rabanal JE, Barnighausen T, Nigenda-Lopez G, Velazco–Mondragón HE, Sosa-Rubi SG. Human resources needed to after health prevention and promotion to adults in primary care. Salud Publica Mex 2013;55:301–9. Maternal mortality fluctuated over the period but was reduced by more than 50% overall, according to data from 2011.⁴²42 Observatorio de Mortalidad Materna en México [Internet]. Indicadores 2011: Objetivo de Desarrollo del Milenio 5: avances en México. Mexico City: OMMM; 2013. Spanish. Available from: http://omm.org.mx/images/stories/Documentos%20grandes/Indicadores%202011%20%2829%20de%20julio%29.pdf [accessed 15 September 2013].
http://omm.org.mx/images/stories/Documen...

Attrition between education and employment is an important workforce problem that remains to be addressed. According to an analysis of the 2008 Encuesta Nacional de Ocupación y Empleo (ENOE) [National Survey of Occupation and Employment], 87% of physicians are employed, but of those who are, approximately 10% work outside the health sector. Thus, nearly one in every five physicians is not participating in the health labour market, a rate that requires further scrutiny in light of the growing private sector for medical education. In 1990, only 7% of medical students were in private schools, but by 2010 the proportion had risen to 20%. Of the 27 new medical schools established during this period, five are publicly funded and the other 22 are funded by private investments.⁴³43 Anuario estadístico 2004: población escolar de posgrado. Mexico City: Asociación Nacional de Universidades e Instituciones de Educación Superior; 2004. Spanish.^–4545 Anuario estadístico 2010: población escolar y personal docente en la educacion media superior y superior, ciclo escolar 2009–2010. Mexico City: Asociación Nacional de Universidades e Instituciones de Educación Superior; 2011. Spanish.

Thailand

Although the HRH policy and governance milestones of 1990–2009 were clearly influential in Thailand's success, critical decisions were also made in the 1970s. Such decisions continue to exert an influence 40 years later.⁴⁶46 Rohde J, Cousens S, Chopra M, Tangcharoensathien V, Black R, Bhutta ZA et al. 30 years after Alma-Ata: has primary health care worked in countries? Lancet 2008;372:950–61. doi: http://dx.doi.org/10.1016/S0140-6736(08)61405-1 PMID:18790318
https://doi.org/10.1016/S0140-6736(08)61... ^,4747 Patcharanarumol W, Tangcharoensathien V, Limwattananon S, Panichkriangkrai W, Pachanee K, Poungkantha W, et al. Chapter 7: Why and how did Thailand achieve good health at low cost? In: Balabanova D, McKee M, Mills A, editors. ‘Good health at low cost’ 25 years on: what makes a successful health system? London: London School of Hygiene and Tropical Medicine; 2011. pp. 193-223. Policies on the provision and financing of health services are pro-poor.⁴⁸48 Evans TG, Chowdhury AM, Evans DB, Fidler AH, Lindelow M, Mills A, et al. Thailand’s universal coverage scheme: achievements and challenges: an independent assessment of the first 10 years (2001–2010). Nonthaburi: Health Insurance System Research Office; 2012. Primary health care at the district level was made possible through a comprehensive health workforce policy developed in 1995 that centred on retention and professional satisfaction to encourage rural deployment,⁴⁹49 Tangcharoensathien V, Prakongsai P, Limwattananon S. Achieving universal coverage in Thailand: what lessons do we learn? A case study commissioned by the Health Systems Knowledge Network of the WHO Commission on Social Determinants of Health. Geneva: World Health Organization; 2007. as well as through policy revisions introduced in 1997 and 2005. Several policies adopted from 1994 to 2009, emphasizing continuous reflection and improvement, have aimed to improve quality: development and strengthening of professional councils, regulation over curriculum standards and quality of training institutes, worker licensing and re-licensing. The establishment of the Healthcare Accreditation Institute in 2009 has consolidated these quality efforts. Post-service training in advanced practice for nursing cadres, such as nurse practitioners, intensive care unit nurses and anaesthesiology nurses, plays a significant task shifting role. Policy has centred on strengthening local and district health systems as a strategy to translate policy into practice and improve equity.

The attention to equity is particularly important. Although in 1991–2009 the overall increase in nurses (210%) and physicians (186%) outstripped population growth (13%), the accessibility dimension improved even more. For example, the ratio of nurses to people increased from 1:7.2 to 1:3.4 in 1991–2009. Regional variations in workforce deployment between the least affluent north-eastern region and affluent areas such as Bangkok have also been substantially reduced.

Case study overview

All governments have an obligation to support the highest attainable standard of health for their citizens, and many are expressing this through a commitment to the progressive realization of UHC. Our analysis provides several messages that can inform evidence-based decision-making on HRH in support of UHC.

First, success in awarding adequate priority to HRH depends on political leadership and commitment that is multisectoral, legislated and regulated through governance instruments and that remains coherent and consistent over electoral cycles. Second, strategies and actions in each of the AAAQ dimensions of HRH have brought about improvements in quality of care and effective coverage and these have resulted in better health outcomes. The focus on HRH goes beyond merely expanding the supply of workers. Each country aims for a workforce that is fit for purpose and fit to practise – made possible by whole-of-government approaches prioritizing equitable, efficient and effective health services. Third, the successes seen in the four countries examined in this paper reflect achievements made possible through partnerships in and outside the health sector: public and private entities; education, labour and finance; government and development partners; federal, state and district governments; health workers and consumers; providers, professional associations and health workers.

Discussion

In the past 10 years there has been increasing recognition that HRH are central to improving health.⁵⁰50 Joint Learning Initiative. Human resources for health: overcoming the crisis. Cambridge: The President and Fellows of Harvard College; 2004.^,5151 The world health report 2006: working together for health. Geneva: World Health Organization; 2006. However, in the initial years of the “decade of action on HRH”, the policy discourse tended to focus on two issues: the “crisis” in the availability of health workers in low- and middle-income countries and the international migration of health workers. While these were critical issues then and remain so today, there is now a growing recognition of the multifaceted nature of HRH-related challenges and of the need for HRH governance and management within dynamic, local health systems.⁵²52 van Olmen J, Criel B, Van Damme W, Marchal B, Van Belle S, Van Dormael M, et al. Analysing health system dynamics: a framework. Antwerp: ITG Press; 2012.

Since 2006, several United Nations agencies, the Global Health Workforce Alliance, regional HRH networks, development agencies, academic institutions, civil society groups and HRH observatories⁵³53 Evidence-informed human resources for health policies: the contribution of HRH observatories. Geneva: World Health Organization; 2011. Available from: http://www.who.int/hrh/resources/observatories_meeting_report.pdf [accessed 10 September 2013].
http://www.who.int/hrh/resources/observa... have greatly expanded the HRH evidence base and analysis, planning and management tools and have led to policy recommendations.⁵²52 van Olmen J, Criel B, Van Damme W, Marchal B, Van Belle S, Van Dormael M, et al. Analysing health system dynamics: a framework. Antwerp: ITG Press; 2012.^,5353 Evidence-informed human resources for health policies: the contribution of HRH observatories. Geneva: World Health Organization; 2011. Available from: http://www.who.int/hrh/resources/observatories_meeting_report.pdf [accessed 10 September 2013].
http://www.who.int/hrh/resources/observa... This strategic workforce intelligence now needs to inform contemporary commitments, policy and actions beyond 2015. The key messages can be synthesized as follows:

First, training more staff is necessary in many countries, given that more than 100 countries lack enough professional health workers if the ILO's access deficit indicator⁵5 Social health protection: an ILO strategy towards universal access to health care. Geneva: International Labour Office; 2008 (Social Security Policy Briefings). Available from: http://www.ilo.org/secsoc/information-resources/publications-and-tools/policy-briefings/WCMS_SECSOC_5956/lang--en/index.htm [accessed 10 September 2013].
http://www.ilo.org/secsoc/information-re... is used to set the threshold for density per 1000 population. However, increasing the numbers is not in itself sufficient to provide culturally appropriate, acceptable care to communities and to address the effective coverage gap. Expanding the supply, participation and availability of health workers also involves making informed decisions about the selection of trainees, the location, content and mode of training, and the development of appropriate skills for individual staff and effective skill mix across multidisciplinary teams. “More staff” only becomes “better staff” when there is sufficient and targeted funding to secure the correct investment in competencies and skills' development over the longer term.⁵⁴54 Task Force for Scaling Up Education and Training for Health Workers [Internet]. Scaling up, saving lives. Geneva: World Health Organization; 2008. Available from: http://www.who.int/workforcealliance/documents/Global_Health FINAL REPORT.pdf [accessed 11 September 2013].
http://www.who.int/workforcealliance/doc... ^,5555 Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923–58. doi: http://dx.doi.org/10.1016/S0140-6736(10)61854-5 PMID:21112623
https://doi.org/10.1016/S0140-6736(10)61...

Second, employing more staff is often necessary but not sufficient to improve access for underserved communities. Ensuring availability also requires planning to improve the accessibility, acceptability and quality dimensions – ensuring appropriate geographic and sector distribution combined with the right bundle of financial and non-financial incentives to direct and retain staff where they are most required and to motivate them to be responsive and productive.⁵⁶56 Huicho L, Dieleman M, Campbell J, Codjia L, Balabanova D, Dussault G et al. Increasing access to health workers in underserved areas: a conceptual framework for measuring results. Bull World Health Organ 2010;88:357–63. doi: http://dx.doi.org/10.2471/BLT.09.070920 PMID:20461135
https://doi.org/10.2471/BLT.09.070920... ”More staff” only becomes “better care” when effective local management and an enabling, “positive practice” environment⁵⁷57 Bhutta ZA, Lassi ZS, Mansoor N. Systematic review on human resources for health interventions to improve maternal health outcomes: evidence from developing countries. Karachi: The Aga Khan University; 2010. are supported by context specific, evidence-based, responsive and fully funded HRH policies that are informed by labour market analysis and relate to defined community needs.

Third, only by addressing deep-seated health system bottlenecks – health workforce constraints being prominent among them – will countries be able to achieve their health objectives.⁵⁸58 Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet 2004;364:900–6. doi: http://dx.doi.org/10.1016/S0140-6736(04)16987-0 PMID:15351199
https://doi.org/10.1016/S0140-6736(04)16... Doing so will require sustained investments, including consideration of recurrent cost budgets for staffing, education, and incentives, and a policy focus over a longer period. There is a risk, however, that systemic HRH challenges will take second place to “quick wins” or “vertical” programmes (e.g. immunization or single-disease control initiatives). This is a governance issue for global health; it requires international solidarity to recognize and act on the available evidence.⁵⁹59 Ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal and Thailand. Why we need a commission on global governance for health. Lancet 2012;379:1470–1. PMID:22169106 There are no effective shortcuts for decision-makers: without adequate policies and funding to achieve a skilled and motivated workforce, other investments in the health system will not yield the expected returns or may even be wasted. Investment in other key elements of the health system will also be necessary, as even the most motivated and skilled health worker needs essential supplies, equipment, infrastructure and financing mechanisms to provide quality care.

Conclusion

The key messages from the process-tracing analysis are consistent with the wider evidence.⁶⁰60 Kaplan AD, Dominis S, Palen JG, Quain EE. Human resource governance: what does governance mean for the health workforce in low- and middle-income countries? Hum Resour Health 2013;11:6. doi: http://dx.doi.org/10.1186/1478-4491-11-6 PMID:23414237
https://doi.org/10.1186/1478-4491-11-6... ^–6363 Witter S, Cometto G, Zaman RU, Sheikh MR, Wibulpolprasert S. Implementing the Agenda for Global Action on human resources for health: analysis from an international tracking survey. J Hosp Admin 2012;2:77–87. doi: http://dx.doi.org/10.5430/jha.v2n1p77
https://doi.org/10.5430/jha.v2n1p77... There is therefore a body of knowledge that can guide HRH policy, actions and commitments in relation to UHC. But evidence is not always transformed into policy and practice. A short-term horizon or wavering policy attention at the national or international level can hinder progress. Sustained improvements in HRH that enable the delivery of acceptable, quality care require consistent policies and long-term predictable funding, fully aligned with national needs, strategies and accountability mechanisms.

This debate should not be confined to HRH; it lays out the logic of how to maximize the accountability, transparency and impact of financial and human resources to keep global promises, measure results and improve health. It is a political imperative to face the unprecedented health and development challenges that transcend all country income groups and to shape discussion on the post-2015 development agenda for health and on the central role of HRH. Political commitment by national and global leaders is needed to build a global health workforce that is responsive to the challenges of the 21st century: one that is fit for purpose and fit to practise. While some argue that health care is labour intensive, it is worth remembering that UHC and improvements in health care are workforce enabled.

Competing interests:

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