xxii The World Health Report 2006 and geography. Institutional weaknesses related to recruitment information and effective deployment of health workers merit serious attention, especially where there are expectations in scaling up the health workforce Workforce: enhancing performance Strategies to improve the performance of the health workforce must initially focus on existing staff because of the time lag in training new health workers. Substantial improvements in the availability, competence, responsiveness and productivity of the workforce can be rapidly achieved through an array of low-cost and practical instruments Supervision makes a big difference. Supportive yet firm-and fair-supervision is one of the most effective instruments available to improve the competence of individual health workers, especially when coupled with clear job descriptions and feedback on performance. Moreover, supervision can build a practical integration of new skills acquired through on-the-job trainir Fair and reliable compensation. Decent pay that arrives on time is crucial. The way workers are paid, for example salaried or fee-for-service, has effects on productivity and quality of care that require careful monitoring Financial and non-financial incentives such as study leave or child care are more effective when ackaged than provided on their own. Critical support systems. No matter how motivated and skilled health workers are, they cannot do their jobs properly in facilities that lack clean water, adequate lighting, heating, vehicles, drugs, working equipment and other supplies. Deci- sions to introduce new technologies- for diagnosis, treatment or communication should be informed in part by an assessment of their implications for the health workforce Lifelong learning should be inculcated in the workplace. This may include short- term training, encouraging staff to innovate, and fostering teamwork. Frequently, staff devise simple but effective solutions to improve performance and should be encouraged to share and act on their ideas. Exit: managing migration and attrition Unplanned or excessive exits may cause significant losses of workers and compro mise the systems knowledge, memory and culture. In some regions, worker illness, deaths and migration together constitute a haemorrhaging that overwhelms training capacity and threatens workforce stability. Strategies to counteract workforce attri- tion include managing migration, making health a career of choice, and stemming premature sickness and retirement. a Managing migration of health workers involves balancing the freedom of in- dividuals to pursue work where they choose with the need to stem excessive losses from both internal migration(urban concentration and rural neglect) and international movements from poorer to richer countries. Some international mi- gration is planned, for example the import of professionals into the Eastern Medi terranean Region, while other migrations are unplanned with deleterious health consequences For unplanned migration, tailoring education and recruitment to rural realities, improving working conditions more generally and facilitating the return of migrants represent important retention strategies. Richer countries receiving migrants from poorer countries should adopt responsible recruitment policies, treat migrant health workers fairly, and consider entering into bilateral agreements
xxii The World Health Report 2006 and geography. Institutional weaknesses related to recruitment information and effective deployment of health workers merit serious attention, especially where there are expectations in scaling up the health workforce. Workforce: enhancing performance Strategies to improve the performance of the health workforce must initially focus on existing staff because of the time lag in training new health workers. Substantial improvements in the availability, competence, responsiveness and productivity of the workforce can be rapidly achieved through an array of low-cost and practical instruments. Supervision makes a big difference. Supportive yet firm – and fair – supervision is one of the most effective instruments available to improve the competence of individual health workers, especially when coupled with clear job descriptions and feedback on performance. Moreover, supervision can build a practical integration of new skills acquired through on-the-job training. Fair and reliable compensation. Decent pay that arrives on time is crucial. The way workers are paid, for example salaried or fee-for-service, has effects on productivity and quality of care that require careful monitoring. Financial and non-financial incentives such as study leave or child care are more effective when packaged than provided on their own. Critical support systems. No matter how motivated and skilled health workers are, they cannot do their jobs properly in facilities that lack clean water, adequate lighting, heating, vehicles, drugs, working equipment and other supplies. Decisions to introduce new technologies – for diagnosis, treatment or communication – should be informed in part by an assessment of their implications for the health workforce. Lifelong learning should be inculcated in the workplace. This may include shortterm training, encouraging staff to innovate, and fostering teamwork. Frequently, staff devise simple but effective solutions to improve performance and should be encouraged to share and act on their ideas. Exit: managing migration and attrition Unplanned or excessive exits may cause significant losses of workers and compromise the system’s knowledge, memory and culture. In some regions, worker illness, deaths and migration together constitute a haemorrhaging that overwhelms training capacity and threatens workforce stability. Strategies to counteract workforce attrition include managing migration, making health a career of choice, and stemming premature sickness and retirement. Managing migration of health workers involves balancing the freedom of individuals to pursue work where they choose with the need to stem excessive losses from both internal migration (urban concentration and rural neglect) and international movements from poorer to richer countries. Some international migration is planned, for example the import of professionals into the Eastern Mediterranean Region, while other migrations are unplanned with deleterious health consequences. For unplanned migration, tailoring education and recruitment to rural realities, improving working conditions more generally and facilitating the return of migrants represent important retention strategies. Richer countries receiving migrants from poorer countries should adopt responsible recruitment policies, treat migrant health workers fairly, and consider entering into bilateral agreements. ■ ■ ■ ■ ■
a Keeping health work as a career of choice for women. The majority of health workers are women and "feminization" trends are well established in the male dominated field of medicine. to accommodate female health workers better more attention must be paid to their safety, including protecting them from violence. Other measures must be put in place. These include more flexible work arrange ments to accommodate family considerations, and career tracks that promote women towards senior faculty and leadership positions more effectively Ensuring safe work environments. Outflows from the workforce caused by ill ness, disability and death are unnecessarily high and demand priority attention especially in areas of high Hiv prevalence. Strategies to minimize occupational hazards include the recognition and appropriate management of physical risks and mental stress, as well as full compliance with prevention and protection guidelines. Provision of effective prevention services and access to treatment for all health workers who become Hiv-positive are the only reasonable way forward in the pursuit of universal access to HIv prevention, treatment and a Retirement planning. In an era of ageing workforces and trends towards earlier retirement, unwanted attrition can be stemmed by a range of policies. These policies can reduce incentives for early retirement, decrease the cost of employ ing older people, recruit retirees back to work and improve conditions for older workers. Succession planning is central to preserving key competencies and skills in the workforce MOVING FORWARD TOGETHER An imperative for action The unmistakable imperative is to strengthen the workforce so that health systems can tackle crippling diseases and achieve national and global health goals. A strong human infrastructure is fundamental to closing today's gap between health promise and health reality and anticipating the health challenges of the 21st century Momentum for action has grown steadily over recent years. Member States of WHO, spearheaded by health leaders from Africa, adopted two resolutions at recent World Health Assemblies calling for global action to build a workforce for national health systems, including stemming the flow of unplanned professional emigration Europe and Latin America have promoted regional observatories in human resources for health, and the South-East Asia and Eastern Mediterranean Regional Offices have launched new public health training initiatives. One hundred global health leaders n the Joint Learning Initiative recommended urgent action to overcome the crisis of human resources for health. Calls for action have come from a series of High-Level Forums for the health-related MDGs in Geneva, Abuja and Paris, and two Oslo Con- sultations have nurtured a participatory stakeholder process to chart a way forward A clear mandate has emerged for a global plan of action bringing forth national leadership backed by global solidarity National leadership Strong country strategies require both solid technical content and a credible political process. This involves embracing the breadth of issues inherent in the entry-work force-exit framework while cultivating trust and brokering agreements through ef- fective engagement of stakeholders in planning and implementation. In addition, national strategies are likely to be more successful if they adopt three priorities acting now, anticipating the future, and acquiring critical capabilities
overview xxiii Keeping health work as a career of choice for women. The majority of health workers are women and “feminization” trends are well established in the male dominated field of medicine. To accommodate female health workers better, more attention must be paid to their safety, including protecting them from violence. Other measures must be put in place. These include more flexible work arrangements to accommodate family considerations, and career tracks that promote women towards senior faculty and leadership positions more effectively. Ensuring safe work environments. Outflows from the workforce caused by illness, disability and death are unnecessarily high and demand priority attention especially in areas of high HIV prevalence. Strategies to minimize occupational hazards include the recognition and appropriate management of physical risks and mental stress, as well as full compliance with prevention and protection guidelines. Provision of effective prevention services and access to treatment for all health workers who become HIV-positive are the only reasonable way forward in the pursuit of universal access to HIV prevention, treatment and care. Retirement planning. In an era of ageing workforces and trends towards earlier retirement, unwanted attrition can be stemmed by a range of policies. These policies can reduce incentives for early retirement, decrease the cost of employing older people, recruit retirees back to work and improve conditions for older workers. Succession planning is central to preserving key competencies and skills in the workforce. Moving forward together An imperative for action The unmistakable imperative is to strengthen the workforce so that health systems can tackle crippling diseases and achieve national and global health goals. A strong human infrastructure is fundamental to closing today’s gap between health promise and health reality and anticipating the health challenges of the 21st century. Momentum for action has grown steadily over recent years. Member States of WHO, spearheaded by health leaders from Africa, adopted two resolutions at recent World Health Assemblies calling for global action to build a workforce for national health systems, including stemming the flow of unplanned professional emigration. Europe and Latin America have promoted regional observatories in human resources for health, and the South-East Asia and Eastern Mediterranean Regional Offices have launched new public health training initiatives. One hundred global health leaders in the Joint Learning Initiative recommended urgent action to overcome the crisis of human resources for health. Calls for action have come from a series of High-Level Forums for the health-related MDGs in Geneva, Abuja and Paris, and two Oslo Consultations have nurtured a participatory stakeholder process to chart a way forward. A clear mandate has emerged for a global plan of action bringing forth national leadership backed by global solidarity. National leadership Strong country strategies require both solid technical content and a credible political process. This involves embracing the breadth of issues inherent in the entry–workforce–exit framework while cultivating trust and brokering agreements through effective engagement of stakeholders in planning and implementation. In addition, national strategies are likely to be more successful if they adopt three priorities: acting now, anticipating the future, and acquiring critical capabilities. ■ ■ ■
xxiv The World Health Report 2006 a Acting now for workforce productivity by cutting waste(such as eliminating ghost workers and absenteeism) and improving performance through compen sation adjustments, work incentives, safer working conditions, and worker mo- bilization efforts. Better intelligence gathering is crucial in order to understand national situations and monitor progress or setbacks Anticipating the future by engaging stakeholders to craft national strategic plans through evidence-based information and scenarios on likely future trends. Sig nificant growth of private education and services should be anticipated, neces- stating the targeting of public funds for health equity, promotion and prevention Public action in information, regulation and delegation are key functions for mixed ublic and private systems. Acquiring critical capacities by strengthening core institutions for sound work- force development. Leadership and management development in health and other related sectors such as education and finance is essential for strategic planning and implementation of workforce policies. Standard setting, accrediting and li censing must be effectively established to improve the work of worker union educational institutions, professional associations and civil socie Global solidarity National strategies on their own, however well conceived, are insufficient to deal with the realities of health workforce challenges today and in the future. Strategies across countries are similarly constrained by patchy evidence, limited planning tools and a arcity of technical expertise. Outbreaks of disease and labour market inflections transcend national boundaries, and the depth of the workforce crisis in a significant group of countries requires international assistance. National leadership must there- fore be complemented by global solidarity on at least three fronts: knowledge and learning; cooperative agreements; and responsiveness to workforce crises a Catalysing knowledge and learning. Low-cost but significant investments in the development of better metrics for the workforce, agreement on common technical frameworks, and the identification of and support for priority research will accelerate progress in all countries. Effective pooling of the diverse technical expertise and breadth of experiences can assist countries in accessing the best talent and practices. a Striking cooperative agreements. The growing international nature of the health workforce related to the flows of migrants, relief workers and volunteers calls for cooperative agreements to protect the rights and safety of workers and to en hance the adoption of ethical recruitment practices. The current global situatie regarding avian influenza is indicative of a more fundamental need for effective international capacity to marshal the requisite human resources for acute health and humanitarian emergencies a Responding to workforce crises. The magnitude of the health workforce crisis in the world 's poorest countries cannot be overstated and requires an urgent, sustained and coordinated response from the international community. Donors must facilitate the immediate and longer-term financing of human resources as health systems investment. A 50: 50 guideline is recommended, whereby 50%of all international assistance funds are devoted to health systems, with half of this funding devoted to national health workforce strengthening strategies. Develop ment financing policies must find ways to ensure that hiring ceilings are not the primary constraint to workforce expansion. All partners should critically evaluate their modalities for supporting the workforce with a view to shedding inefficient practices and aligning more effectively with national leadership
xxiv The World Health Report 2006 Acting now for workforce productivity by cutting waste (such as eliminating ghost workers and absenteeism) and improving performance through compensation adjustments, work incentives, safer working conditions, and worker mobilization efforts. Better intelligence gathering is crucial in order to understand national situations and monitor progress or setbacks. Anticipating the future by engaging stakeholders to craft national strategic plans through evidence-based information and scenarios on likely future trends. Significant growth of private education and services should be anticipated, necessitating the targeting of public funds for health equity, promotion and prevention. Public action in information, regulation and delegation are key functions for mixed public and private systems. Acquiring critical capacities by strengthening core institutions for sound workforce development. Leadership and management development in health and other related sectors such as education and finance is essential for strategic planning and implementation of workforce policies. Standard setting, accrediting and licensing must be effectively established to improve the work of worker unions, educational institutions, professional associations and civil society. Global solidarity National strategies on their own, however well conceived, are insufficient to deal with the realities of health workforce challenges today and in the future. Strategies across countries are similarly constrained by patchy evidence, limited planning tools and a scarcity of technical expertise. Outbreaks of disease and labour market inflections transcend national boundaries, and the depth of the workforce crisis in a significant group of countries requires international assistance. National leadership must therefore be complemented by global solidarity on at least three fronts: knowledge and learning; cooperative agreements; and responsiveness to workforce crises. Catalysing knowledge and learning. Low-cost but significant investments in the development of better metrics for the workforce, agreement on common technical frameworks, and the identification of and support for priority research will accelerate progress in all countries. Effective pooling of the diverse technical expertise and breadth of experiences can assist countries in accessing the best talent and practices. Striking cooperative agreements. The growing international nature of the health workforce related to the flows of migrants, relief workers and volunteers calls for cooperative agreements to protect the rights and safety of workers and to enhance the adoption of ethical recruitment practices. The current global situation regarding avian influenza is indicative of a more fundamental need for effective international capacity to marshal the requisite human resources for acute health and humanitarian emergencies. Responding to workforce crises. The magnitude of the health workforce crisis in the world’s poorest countries cannot be overstated and requires an urgent, sustained and coordinated response from the international community. Donors must facilitate the immediate and longer-term financing of human resources as a health systems investment. A 50:50 guideline is recommended, whereby 50% of all international assistance funds are devoted to health systems, with half of this funding devoted to national health workforce strengthening strategies. Development financing policies must find ways to ensure that hiring ceilings are not the primary constraint to workforce expansion. All partners should critically evaluate their modalities for supporting the workforce with a view to shedding inefficient practices and aligning more effectively with national leadership. ■ ■ ■ ■ ■ ■
National leadership and global solidarity can result in significant structural im- provements of the workforce in all countries, especially those with the most severe crises. Such advances would be characterized by universal access to a motivated, competent and supported health workforce, greater worker, employer and public satisfaction, and more effective stewardship of the workforce by the state, civil society and professional associations. Plan of action National leadership must urgently jump-start country-based actions and sustain them for at least a decade. Table 2 summarizes targets in the plan of action over the decade 2006-2015 a Immediate actions over the next few years should consist of lead countries pio- neering national plans for scaling up effective strategies, increasing investments, utting waste, and strengthening educational institutions. Global support should accelerate progress in countries, with immediate policy attention given to intel ligence, technical cooperation, policy alignment of fiscal space and migration, and harmonization of priority initiatives and donor assistance. a At the decade' s mid-point, over half of all countries should have sound national plans with expanded execution of good policies and management practices concerned with workforce incentives, regulation and institutions. Global ad- vances will include shared norms and frameworks, strong technical support, and improved knowledge management. Responsible recruitment and alignment of priority programmes and development instruments to support the health work force should be in place. a The decade goal in all countries is to build high-performing workforces for national health systems to respond to current and emerging challenges. This means that every country should have implemented national strategic plans and should be planning for the future, drawing on robust national capacity. globally, Table 2 Ten-year plan of action 2010 2015 Country Cut waste, improve Use effective managerial Sustain high performing incentives practices workforce Education Revitalize education Strengthen accreditation Prepare workforce for the strategies and licensing Design national workforce Overcome barriers to Evaluate and redesign trategies strategies, based on robust national capacity Knowledge Develop common technical Assess performance with Share evidence-based good solidarity learning frameworks comparable metric practices Pool expertise Fund priority research Enabling policies Advocate ethical recruitment Adhere to responsible and migrant workers' rights recruitment guidelines Pursue fiscal space Expand fiscal space for health Crisis response Finance national plans for Expand financing to half of financing of national 25% of crisis countries crisis countries for all countries in Agree on best donor Adopt 50: 50 investment practices for human guideline for priority resources for health programmes
overview xxv National leadership and global solidarity can result in significant structural improvements of the workforce in all countries, especially those with the most severe crises. Such advances would be characterized by universal access to a motivated, competent and supported health workforce, greater worker, employer and public satisfaction, and more effective stewardship of the workforce by the state, civil society and professional associations. Plan of action National leadership must urgently jump-start country-based actions and sustain them for at least a decade. Table 2 summarizes targets in the plan of action over the decade 2006–2015. Immediate actions over the next few years should consist of lead countries pioneering national plans for scaling up effective strategies, increasing investments, cutting waste, and strengthening educational institutions. Global support should accelerate progress in countries, with immediate policy attention given to intelligence, technical cooperation, policy alignment of fiscal space and migration, and harmonization of priority initiatives and donor assistance. At the decade’s mid-point, over half of all countries should have sound national plans with expanded execution of good policies and management practices concerned with workforce incentives, regulation and institutions. Global advances will include shared norms and frameworks, strong technical support, and improved knowledge management. Responsible recruitment and alignment of priority programmes and development instruments to support the health workforce should be in place. The decade goal in all countries is to build high-performing workforces for national health systems to respond to current and emerging challenges. This means that every country should have implemented national strategic plans and should be planning for the future, drawing on robust national capacity. Globally, ■ ■ ■ Table 2 Ten-year plan of action 2006 2010 2015 Immediate Mid-point Decade Country leadership Management Cut waste, improve incentives Use effective managerial practices Sustain high performing workforce Education Revitalize education strategies Strengthen accreditation and licensing Prepare workforce for the future Planning Design national workforce strategies Overcome barriers to implementation Evaluate and redesign strategies, based on robust national capacity Global solidarity Knowledge and learning Develop common technical frameworks Assess performance with comparable metrics Share evidence-based good practices Pool expertise Fund priority research Enabling policies Advocate ethical recruitment and migrant workers’ rights Adhere to responsible recruitment guidelines Manage increased migratory flows for equity and fairness Pursue fiscal space exceptionality Expand fiscal space for health Support fiscal sustainability Crisis response Finance national plans for 25% of crisis countries Expand financing to half of crisis countries Sustain financing of national plans for all countries in crisis Agree on best donor practices for human resources for health Adopt 50:50 investment guideline for priority programmes
xxvi The World Health Report 2006 Figure 5 global stakeholder alliance Country leadership Support and catalysis Problem-solving Political visibility Global solidarity Knowledge and information Convenint Financial resources Alliance of stakeholders National governments Civil society/ nongovernmental organizations Financial institutions/donors nited Nations agencies Others a full range of evidence-based guidelines should inform good practice for health workers. Effective cooperative agreements will minimize adverse consequences despite increased intemational flows of workers. Sustained intemational financ ing should be in place to support recipient countries for the next 10 years as they scale up their workforce. Moving forward together Moving forward on the plan of action necessitates that stakeholders work together through inclusive alliances and networks-local, national and global-across health problems, professions, disciplines, ministries, sectors and countries. Cooperative structures can pool limited talent and fiscal resources and promote mutual learning Figure 5 proposes how a global workforce alliance can be launched to bring relevant stakeholders to accelerate core country programmes. A premier challenge is advocacy that promotes workforce issues to a high place n the political agenda and keeps them there. The moment is ripe for political support as problem awareness is expanding, effective solutions are emerging, and various countries are already pioneering interventions. Workforce development is a continu- ous process that is always open for improvement. However, immediate acceleration of performance can be attained in virtually all countries if well-documented solutions are applied. Some of the work should be implemented immediately; other aspects will take time there are no short cuts and there is no time to lose now is the time for action, to invest in the future, and to advance health -rapidly and equitably
xxvi The World Health Report 2006 a full range of evidence-based guidelines should inform good practice for health workers. Effective cooperative agreements will minimize adverse consequences despite increased international flows of workers. Sustained international financing should be in place to support recipient countries for the next 10 years as they scale up their workforce. Moving forward together Moving forward on the plan of action necessitates that stakeholders work together through inclusive alliances and networks – local, national and global – across health problems, professions, disciplines, ministries, sectors and countries. Cooperative structures can pool limited talent and fiscal resources and promote mutual learning. Figure 5 proposes how a global workforce alliance can be launched to bring relevant stakeholders to accelerate core country programmes. A premier challenge is advocacy that promotes workforce issues to a high place on the political agenda and keeps them there. The moment is ripe for political support as problem awareness is expanding, effective solutions are emerging, and various countries are already pioneering interventions. Workforce development is a continuous process that is always open for improvement. However, immediate acceleration of performance can be attained in virtually all countries if well-documented solutions are applied. Some of the work should be implemented immediately; other aspects will take time. There are no short cuts and there is no time to lose. Now is the time for action, to invest in the future, and to advance health – rapidly and equitably. Figure 5 Global stakeholder alliance Country leadership National governments Civil society/ nongovernmental organizations Financial institutions/donors Workers United Nations agencies Academia Others Alliance of stakeholders Support and catalysis Political visibility Convening Problem-solving Knowledge and information Financial resources Global solidarity