View online version (complete paper):
http://www.equinetafrica.org/Resources/downloads/HRH%20Review.pdf
Executive Summary
Without a foundation of skilled human resources, healthcare systems cannot function
adequately or effectively, particularly in the public sector and at the primary level of care.
However, health systems in southern Africa face a variety of health personnel problems,
including overall scarcity and an inequitable distribution of health personnel.
EQUINET commissioned this review of the literature as a discussion paper to inform its
future work in this area. This work aims, in cooperation with an international network of
public health organisations, to confront the negative impacts of the maldistribution of and
loss of health personnel from health sectors in southern Africa and to support equitable
policy development and implementation. The programme seeks to explore, review and
harmonise, where relevant, policy tools for enhancing health equity in personnel
distribution in southern Africa; strengthen mechanisms for managing the policy
interactions between health professional associations and health unions and state
authorities on health personnel issues; and facilitate and inform dialogue on policy
options for dealing with the attrition of health personnel from southern Africa to selected
high-income countries, including the United Kingdom, Australia and Canada.
The report provides evidence of inadequate ratios of personnel to population for key
skilled health personnel, and a maldistribution of personnel along three different axes,
between:
- public and private health sectors
- urban and rural areas
- tertiary and primary levels of the health system.
The report describes the exodus of healthcare workers from areas of poverty and low
socio-economic development, to more highly developed areas. The flows follow a
hierarchy of ‘wealth’ and result in a global conveyor belt of health personnel moving
from the bottom to the top, increasing inequity. The report describes personnel flows and
migration from rural to urban areas, from public to private sectors, from lower to higher
income countries within southern Africa and from African countries to industrialised
countries. International migration further increases and exacerbates inequities that exist
between the public and private sector and between urban and rural areas. The knowledge
and skills loss from the poorer to the richer countries is considered as a form of reverse
(poor to rich) subsidy.
There are a variety of push and pull factors that impact on the movement of healthcare
workers, arising both within and beyond the health system. Factors endogenous to the
health care system are low remuneration levels, work associated risks including of
diseases like HIV/AIDS and TB, inadequate human resource planning with consequent
unrealistic work loads, poor infrastructure and sub-optimal conditions of work.
Exogenous push factors are also noted, including political insecurity, crime, taxation
levels, repressive political environments and falling service standards. Movement is also
influenced by pull factors, including aggressive recruitment by recipient countries,
improved quality of life, study and specialisation opportunities and improved pay.
These push and pull factors are mitigated by ‘stick’ factors in source countries, which
lead to greater personnel retention, including family ties, psychological links with home,
migration costs, language and other social and cultural factors. ‘Stay’ factors influence
decisions to remain in recipient countries and influence rates of return of personnel.
These include reluctance to disrupt family life and schooling, lack of employment
opportunities in host country and a higher standard of living in the recipient country.
These factors are presented in the context of current approaches to training and retention
of health personnel in southern Africa. They are analysed for their costs and benefits to
source and recipient areas and countries, and for their impact on equity in health
personnel distribution.
This initial review of the literature indicates that a new policy momentum exists in
relation to human resources for health. This draws from a number of political, economic,
trade and labour rights trends, but also from the extent to which personnel scarcities have
become a critical limiting factor in health interventions. Policy initiatives are being taken
at regional, international and global level by government, private and health professional
actors. On the other, hand millions of health workers are ‘acting with their feet’,
demonstrating their own response to weaknesses in the system by securing the personal
‘best options’ for themselves. While this responds to individual demands for security and
wellbeing, it has costs to the health workers, the primary and district level of health
systems, the poorest populations and public health sectors in the south.
The literature review highlights constraints to designing policies that neither punish
workers nor leave poor communities unfairly underserved. These include the availability
of timely and accurate information on health personnel distribution and movements, and
the paper presents a conceptual framework for approaching and further developing a
wider mapping of determinants of health personnel distribution and flows. It is also
argued that while a host of factors influencing personnel flows are identified, there is
inadequate specific assessment of the relative impact of these factors in different settings
with different mixes of personnel; and of how different policy measures have impacted
on them, objectively and from the view of stakeholders relevant to the issue. This is
suggested to call for more country specific analysis, given the range and variability across
countries of health sector and exogenous (non-health sector) conditions that influence
human resource outcomes. It is also argued that systematic evidence is needed on the size
and characteristics of the brain drain and its consequences to identify the distribution of
costs and benefits from current trends.
Available literature signals but does not adequately elaborate the role of institutional and
governance factors in policy development on human resource issues, but provides
sufficient evidence that it is an area where stakeholder perceptions and interests cannot be
ignored. Whatever process is used to generate and analyse evidence needs to be
accompanied by opportunities for reflection and input from key stakeholders, from
national to international level.
|
Related documents
