Strategies: working lifespan of entry–workforce–exit
In tackling these world health problems, the workforce goal is simple – to get the right workers with the right skills in the right place doing the right things! – and in so doing, to retain the agility to respond to crises, to meet current gaps, and to anticipate the future.
A blueprint approach will not work, as effective workforce strategies must be matched to a country’s unique history and situation. Most workforce problems are deeply embedded in changing contexts, and they cannot be easily resolved. These problems can be emotionally charged because of status issues and politically loaded because of divergent interests. That is why workforce solutions require stakeholders to be engaged in both problem diagnosis and problem solving.
This report lays out a “working lifespan” approach to the dynamics of the workforce. It does so by focusing on strategies related to the stage when people enter the workforce, the period of their lives when they are part of the workforce, and the point at which they make their exit from it. The road map (see Figure 4) of training, sustaining and retaining the workforce offers a worker perspective as well as a systems approach to strategy. Workers are typically concerned about such questions as: How do I get a job? What kind of education do I need? How am I treated and how well am I paid? What are my prospects for promotion or my options for leaving? From policy and management perspectives, the framework focuses on modulating the roles of both labour markets and state action at key decision-making junctures:
- Entry: preparing the workforce through strategic investments in education and effective and ethical recruitment practices.
- Workforce: enhancing worker performance through better management of workers in both the public and private sectors.
- Exit: managing migration and attrition to reduce wasteful loss of human resources.
Entry: preparing the workforce
A central objective of workforce development is to produce sufficient numbers of skilled workers with technical competencies whose background, language and social attributes make them accessible and able to reach diverse clients and populations. To do so requires active planning and management of the health workforce production pipeline with a focus on building strong training institutions, strengthening professional regulation and revitalizing recruitment capabilities.
- Building strong institutions for education is essential to secure the numbers and qualities of health workers required by the health system. Although the variations are enormous among countries, the world’s 1600 medical schools, 6000 nursing schools and 375 schools of public health in aggregate are not producing sufficient numbers of graduates. Addressing shortfalls will require building new institutions and ensuring a more appropriate mix of training opportunities – for example, more schools of public health are needed. Commensurate with the shift in expectations of graduates from “know-all” to “know-how”, improving education calls for attention to both curricular content and pedagogical learning methods. Teaching staff, too, require training as well as more credible support and career incentives so that a better balance with the competing demands of research and service can be achieved. Greater access to education at lower cost can be achieved by regional pooling of resources and expanding the use of information technologies such as telemedicine and distance education.
- Assuring educational quality involves institutional accreditation and professional regulation (licensing, certification or registration). Rapid growth of the private sector in education calls for innovative stewardship to maximize the benefits of private investments while strengthening the state’s role in regulating the quality of education. Too often lacking or ineffective in low income countries, structures for regulation are rarely developed sufficiently to ensure quality, responsiveness and ethical practice. State intervention is necessary in order to set standards, protect patient safety, and ensure quality through provision of information, financial incentives and regulatory enforcement.
- Revitalizing recruitment capabilities is necessary in order to broker more effectively demands from the labour market that often overlook public health needs. Recruitment and placement services should aim not only to get workers with the right skills to the right place at the right time but also to achieve better social compatibility between workers and clients in terms of gender, language, ethnicity 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.
- 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.