Investing in human resources for health: the need for a paradigm shift

Development partner strategies and support in the area of human resources for health (HRH) have been shaped by key reports and events over the past decade. Since 2004, when The Lancet published the Joint Learning Initiative’s call to overcome the HRH crisis,¹ the global health community has been trying to address the critical issues surrounding HRH. The 10-year action plan on HRH proposed in The world health report 2006² and the establishment in the same year of the Global Health Workforce Alliance have drawn unprecedented attention to HRH. Thanks to a growing body of evidence,² HRH issues have gradually made their way into the global health arena. Consensus has emerged on the “power of health workers”¹ and their critical importance to health system strengthening and disease control programmes.²

Increased international resources have flowed towards HRH over the past decade, either directly through targeted HRH funds or indirectly through programmes for disease control or health system strengthening. In some countries, development partners have contributed to the achievement of tangible results. Rwanda’s performance-based payment to health workers and Ethiopia’s health extension programme have both been heralded as successes.³ In spite of these efforts, however, global investment in HRH has suffered setbacks that have undermined its effectiveness and impact. Such investment remains uncoordinated and fragmented. International programmes sometimes compete for the few existing HRH, which exacerbates the HRH crisis. Furthermore, investment in HRH has been largely focused on short-term solutions to the crisis rather than on building sustainable HRH systems. The global health community needs to think strategically about how to make investments in HRH more efficient, effective and relevant to country needs. The following paradigm shifts will be critical to future international investment in HRH:

1. From a global to a country-specific approach. HRH issues are not only multifaceted, but also specific to each country. Although this is not a new idea, it has yet to be fully translated into investment practice. International efforts first need to focus on helping countries to develop an HRH strategy reflective of specific domestic contexts and international best practices. Development partners then need to jointly align their resources with the country strategies while building on the experience of the International Health Partnership.

2. From short-term solutions to long-term system-building. Although health workforce remuneration and in-service training – the forms of support most commonly offered by development partners⁴ – are important, they maintain the workforce but do not truly strengthen the system. They may help redress acute shortages but cannot solve the system’s deeper deficiencies. Development partners need to invest in building sustainable HRH systems through measures such as pre-service training.

3. From a public-sector-centric to a comprehensive labour market approach. Investment in HRH has traditionally been biased towards public-sector and supply-side solutions. With half of the health expenditures in Africa coming from private sources and the number of private medical and nursing schools rising in developing countries, this approach is outdated. The recent labour market analysis³ lends support to a comprehensive approach to integrating supply and demand, the public and private sectors, and health and other critically important sectors. Unless the investment aligns with this integrated approach, it will only partially address the overall problem.

4. From the traditional health education model to a modernized production system. The field of health has evolved rapidly in recent decades, yet health workforce training curricula have barely changed. A shifting disease burden and strides in information and communication technologies make reforms in health education mandatory. Task delegation, the redistribution of responsibilities and patient empowerment are changing the workforce landscape in high- and low-income countries. Future investment, both international and domestic, will need to finance a modernized system for the production of a diversified workforce.

5. Towards greater investment in building knowledge and in a comprehensive data system. A knowledge base to inform HRH policies and strategies must be created. We can only demonstrate results if countries put comprehensive information systems in place, but they often lack the resources to do so.

The global health community must embrace these paradigm shifts if it is to deal effectively with the critical issues surrounding HRH.