Human Resources for Health: an introduction and overview

Barbara McPake,Institute for International Health and

Development,Queen Margaret University, Edinburgh

Structure of session

• Numbers of workers in the health sector• Distribution of workers in the health sector• Performance and incentives

Numbers

Source: Global Health Observatory http://apps.who.int/ghodata/, accessed 14th July 2011.

Doctors per 10,000

population

Nurses and midwives per

10,000 population Total Year

Ghana 0.85 10.46 11.31 2009Kenya 1.4 12 13.4 2002Malawi 0.19 2.83 3.02 2008Tanzania 0.08 2.42 2.5 2006China 14.15 13.77 27.92 2009Bangladesh 2.95 2.72 5.67 2007India 5.99 12.97 18.96 2005Cambodia 2.27 7.86 10.13 2008Netherlands 39.21 148 187.21 2007/8UK 27.39 103.02 130.41 2009USA 26.72 98.15 124.87 2004/5

What is the difference between a doctor and a nurse?

• Can define in terms of training• Can define in terms of skills• Can define in terms of activities

Nurse practitioners in the US“A nurse practitioner is a health care provider that can diagnose, treat, and monitor various disease processes. In some states, they can prescribe narcotics as well. So far, there are only four states that still won't allow this component of practice. In some states, a NP must have a collaborative agreement with a MD, some may require direct supervision. Some NPs may have their own private practices without physician oversight at all. NPs can obtain privileges at hospitals so that they can round. Some states allow NPs to admit their own patients to hospitals.”

http://arnp.blogspot.com/2007/07/what-does-nurse-practitioner-do.html

Source: Global Health Observatory http://apps.who.int/ghodata/, accessed 14th July 2011.

Doctors per 10,000 population

Nurses and midwives per 10,000 population

Ratio Nurses and midwives: Doctors

Ghana 0.85 10.46 12.30Kenya 1.4 12 8.57Malawi 0.19 2.83 14.89Tanzania 0.08 2.42 30.25China 14.15 13.77 0.97Bangladesh 2.95 2.72 0.92India 5.99 12.97 2.16Cambodia 2.27 7.86 3.46Netherlands 39.21 148 3.77UK 27.39 103.02 3.76USA 26.72 98.15 3.67

Maternal Mortality Ratio (2008)

Skill

ed b

irth

atten

danc

e (m

ost r

ecen

t yea

r ava

ilabl

e) Maternal mortality ratio and skilled birth attendance: African countries

South Africa

NamibiaGabon

Chad

SomaliaGuinea Bissau

Tanzania

Niger

KenyaUganda

Malawi

Source: Global Health Observatory http://apps.who.int/ghodata/, accessed 14th July 2011.

Mowafi et al. Prehospital and Disaster Medicine, 2007 based on analysis of Anand and Barnighausen

Worker density and health outcomes

How many health workers do we need?

• The answer is 2.28/1,000 population! (22.8/10,000 population)

• How has that been worked out?

Source: WHR 2006

Source: The World Health Report (2006) Working Together for Health, WHO, Geneva, 2006

• What are the factors that are resulting in such critical shortages of HRH in Africa?

• What can be done about it?

Total number of nurses verified to apply for foreign registration from January 1993 to December 2006, Kenya

Source: Nursing Council of Kenya, 2007

Malawi Emergency Human Resources Programme

• 5 year investment of US$95.6m from international partners

• 36% of budget for 52% salary top-up for 11 cadres of professional health workers

• Expanded training capacity• Used international volunteer

doctors, especially for training• Doctor numbers increased

460% from 43 to 241• Nurse numbers increased 36%

Distribution

Country Measure of imbalanceNicaragua Mexico Indonesia Bangladesh Brazil Ghana

50% of health personnel in where 20% or population lives.15% of doctors unemployed, underemployed or inactive, but rural posts remain unfilledHealth staff reluctant to locate in remote islands and forest locations35% of doctors; 30% of nurses live in metropolitan areas where 15% of population livePhysicians per 1000 population by region varies from 0.52 to 2.0587% of general physicians worked in urban regions, while 66% of population lives in rural areas

Estimates of geographical workforce imbalance from a range of settings

Dussault, G. and Franceschini, M.C. (2006) Human Resources for Health, 4

Health service provider densities in Zambia

Source: WHR 2006

Distribution of health workers by district in Tanzania

Source: Munga and Maested, Human Resources for Health, 2009, 7: 4

Source: Munga and Maested, Human Resources for Health, 2009, 7: 4

Distribution of health workers by district and cadre, Tanzania

Source: Munga and Maested, Human Resources for Health, 2009, 7: 4

The Kenyan Emergency Hire Programme

• Many unemployed health workers in Kenya• Severe maldistribution – health workers posted to

rural and underserved areas tend to succeed in relocating their posts to urban centres

• Emergency hire programme offered post specific contracts using extra civil-service recruitment process

• 830 health workers recruited and posted • Kenyan government aims to integrate these

workers to the civil service

Distribution of emergency hires in the Kenya emergency hire programme

Source: Capacity Project, 2009

Performance and incentives

‘That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrowing toe-nail receives a few shillings: he who cuts your inside out receives hundreds of guineas, except when he does it to a poor person for practice.’

George Bernard Shaw, 1909

www.qmu.ac.uk/iihd

• “The problem with salary is the lack of economic incentives to provide care efficiently. A physician who is lazy may provide little care, and one that is not dedicated may provide poor care”

• Andrew Jones The Elgar Companion to Health Economics

What is an incentive?

• Economic incentives are defined as allowing ‘individuals to behave in accordance with expected material rewards or favours that can be traded for such rewards, including leisure’

• Social norms: people behave in accordance with social rewards such as approval of disapproval of others

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Institutional structures and incentives

• Simple framework: incentives for efficiency strengthen as institutions more private and subject to market forces

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‘High powered incentives’More money for specific units of activity

‘Low powered incentives’Satisfaction in a job well donePrestigeVague relationship to specific types of output

PUBLIC SECTOR? PRIVATE SECTOR?

EffortLess effort?

Over-simplification

• Suggests all non-financial incentives are ‘low-powered’

• Few cases correspond to the extremes; real incentive regime requires analysis everywhere– Even small businesses taxed/sometimes

subsidised – investments and rewards shared– Well tuned to performance promotion systems

with steep pay structures arise in public sector

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Incentives can be ‘perverse’ as well as induce effort

• ‘Opportunism’ (self-interest seeking with guile) also responds to financial incentives

• A scheme in India pays public midwives a bonus if they deliver at night. The number of night deliveries increased more than expected.

• Hospital league tables in the UK ‘named and shamed’ hospitals with low bed occupancy. Bed occupancy increased but discharges did not.

• Scope for opportunism increases with problems of measurement

• Lots of measurement problems in the health sector

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Think about a work situation you experienced

• Was it in a public or private institution?• What motivated you to work hard (think about

financial and non financial incentives)?• What made you feel like your efforts would be

wasted?• Did you encounter incentives to do things you knew

were pointless or even harmful?• Think of one measure that would have improved the

incentive environment

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Comparative Analysis of Financial Incentive Strategies to Motivate and

Retain Health Workers in South Africa, Tanzania and Malawi

Steve Thomas1, Charles Normand1, Prudence Ditlopo2, Maureen Chirwa3, Aziza Mwisongo4, Duane Blaauw2, Cameron Bowie3,

Fresier Maseko3 and Posy Bidwell1

1. Trinity College Dublin, 2.University of the Witwatersrand, 3. University of Malawi, 4. National Institute for Medical Research, Tanzania

Year Financial2004

2004

2007

1. Rural allowance: increase in salary to attract doctors & professional nurses in rural areas (8% -22% depending on health worker category)

2. Scarce skills allowance: increase in salary to attract doctors & nurses with certain skills (10% - 15%)

3. Occupational Specific Dispensation: general salary increase for nurses (20% - 80%)

Case study 1: South Africa

Have the incentives worked?(South Africa)Case Study Positive Negative

Rural Allowances 49% satisfied who receive it29% motivated to do a better job“…it motivates them to stay”

Divisive. Not based on remoteness. Too low.“once you readjust it’s not enough”

Scarce Skills 38% satisfied who receive it38% motivated to do a better job

Divisive between doctors and nurses

Occupational Specific Dispensation

50% agree that OSD motivates them to do the job better

Huge disappointments. Division between different cadres of staff. Unequal treatment across provinces.

Case study 2: TanzaniaYear Financial2006

2006

1. Accelerated salary package: increase in salary for medical personnel by an average of 36% (from 31% for pharmacists to 45% for medical assistants).

2. Mkapa Fellowship Programme: a team of three fellows were placed in hard to reach areas to strengthen HIV related activities. Their incentive package included various financial, material and non-financial incentives

Have the incentives worked?(Tanzania)Case Study Positive Negative

Special Accelerated Salary package

Salaries less important in affecting performance than equipment, training and social factors of placement

91% said dissatisfied with remuneration levelsStill key obstacle facing providers

Fellowships Change agents – helped motivation and cover, increased patient throughput

Effectiveness limited by other constraints (equipment, transport, staff numbers, lack of supervision)Divisive –other cadres

Year FinancialMalawi

2005

2005

2006

1. Salary top-up: a 52% increase for 11 cadres of health workers (part of Emergency Human Resources Programme)

2. “Locum” scheme: staff worked extra time for extra pay to fill gaps caused by staff shortages.

3. Relief scheme: health workers who are off duty were paid to ‘relieve’ or cover duties of those off sick or on leave in rural clinics and health centres (HIV focus)

Case study 3: Malawi

Have the incentives worked? (Malawi)Case Study

Positive Negative

Salary Increase

Salaries keeping pace with cost of living and top-up key to new recruitmentNurses quite well paid c.f. other countries

Basic salary still insufficient – need to increase by further 54% to stop moonlighting

Locum Has ensured continuous cover and helped fill gaps.76% say it is an incentive

81% or providers are not happy with the incentive62% of managers unhappy with the current design

Relief 72% of health workers said it is an incentive50% of respondents unlikely to leave post

Only 30% said it had improved retentionCompromises quality40-47% experiencing burnout

Lessons from across the case studies

• Financial incentives produce losers as well as winners• Boost to morale and motivation may be short lived if

there isn’t a long term plan (but greivances endure!)• Once you start paying for something, it’s difficult to

stop• In incentivising something (like quantity of service),

do you disincentives something else (like quality of service?)

• Discretion and decentralisation allow for flexibility but create disparities

Summary

• Huge shortages of health workers in Africa• Problems of maldistribution within countries

are as important as they are globally• There are examples of successful

internationally supported programmes to improve both of these

• Incentive management is complex – it’s not always best to strengthen incentives