There is increasing recognition that health sector performance depends critically on the quality of human resources for health (HRH). With over 60% of recurrent health expenditures worldwide devoted to HRH, a country’s ability to effectively train and deploy those resources is an important component to health systems performance. Determining the appropriate numbers and skills mix of HRH is only one part of the equation, while ensuring that capacities to train, finance and manage those resources present an entirely different set of challenges. IHSP is contributing to building the knowledge base of how health systems issues interact with HRH policy through a combination of research activities and training in human resources strategic planning. In particular, IHSP members conducted an assessment of the human resource situation and provided policy recommendations to the government of Ethiopia in collaboration with the World Health Organization.
In collaboration with the World Health Organization (WHO), IHSP developed and pilot-tested a strategic planning guide to diagnose country capacity in HRH planning and sequence recommendations for future policies. The guide is designed to identify obstacles to HRH performance commonly faced by countries (e.g., migration of health workers, poor working environment) and how three capacities of the health system — financing, education, and management — affect HRH performance through those obstacles. The guide is based on a careful review of the literature to provide evidenced-based justifications for the assessment indicators where possible. The financing module offers a framework for assessing the allocative and operational efficiency of the health workforce wage bill (i.e., recurrent expenditures on HRH). Education capacities are by analyzing six determinants of the numbers of HRH, from the initial pool of applicants to the eventual entry rate into the health workforce. The management module provides a methodology to relate factors at the macro level (e.g., decentralization policies), meso level (e.g., job classification system), and micro level (e.g., facility-level organizational culture) to HRH performance. Each module provides a menu of indicators by which the user can link each capacities in financing, education and management to the country’s obstacles to HRH performance. Based on the data collected, the tool also provides a methodology to sequence policy recommendations to improve the country’s HRH situation. This sequencing methodology includes an approach to analyzing the policy environment that is based on the IHSP’s PolicyMaker approach. see (Reich 1996).
The assessment tool is informed by a comprehensive review of literature on HRH and combines quantitative and qualitative data collection. An extensive literature review was conducted to identify the obstacles to HRH performance most commonly faced by developing countries, as well as the evidence base linking financing, education and management capacities to quality of services. Quantitative and qualitative indicators were based on the review of the evidence base, with newly developed indicators proposed when necessary. The literature review included peer-reviewed articles, “grey” literature, and previously developed assessment tools. The assessment tool was then pilot-tested in Ethiopia in collaboration with the WHO which informed subsequent revisions and refinements.
The Ethiopia field test of the strategic planning guide produced a clear current assessment according to most of the guide’s indicators, a set of recommendations for training and financing a specific cadre of health workers, processes for upgrading the management context for HRH and a sequence for investment in HRH in Ethiopia. It also reviewed the favorable political context for the recommended reforms. The report on this field test is currently under review by the government of Ethiopia and WHO.
While there has been a resurgence in interest in the role that HRH play in health systems performance, development of this HRH assessment tool indicated that much remains unknown on links between HRH and health systems performance. On the one hand, most existing tools related to assessing a country’s HRH situation and/or assisting in HRH strategic planning focus on the technical side, that is getting the numbers and skills mix right. There are many fewer instances or indicators of how HRH capacities and needs fit into the health system more generally. On the other hand, the evidence base linking system-wide capacities (i.e., capacities in financing, education and management) to obstacles to HRH performance is still lacking on many fronts. This tool is a first step towards addressing gaps in our knowledge, but much remains to be done.