Title: Foggy Lens?: An Economist
1Foggy Lens? An Economists Take on The Global
Health Workforce Crisis
- Leonard Davis Institute, January 19 2007
- Marko Vujicic
- Human Development Network
- The World Bank
2Outline
- An overview of global health workforce issues
- Why a labor economics approach?
- Illustrations from developing countries
3Overview
- Goal 1 Eradicate extreme poverty and hunger
- Goal 2 Achieve universal primary education
- Goal 3 Promote gender equality and empower women
- Goal 4 Reduce child mortality
- Goal 5 Improve maternal health
- Goal 6 Combat HIV/AIDS, malaria and other
diseases - Goal 7 Ensure environmental sustainability
- Goal 8 Develop a Global Partnership for
Development
4Overview
- Global commitment to reduce poverty MDGs
- Health Related MDGs
- Goal 4 Child Mortality
- Reduce by two thirds, between 1990 and 2015, the
under-five mortality rate. - Goal 5 Maternal Mortality
- Reduce by three quarters, between 1990 and 2015,
the maternal mortality ratio. - Goal 6 HIV AIDS and Infectious Disease
- Have halted by 2015 and begun to reverse the
spread of HIV/AIDS. - Have halted by 2015 and begun to reverse the
incidence of malaria and other major diseases
5Overview
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8Overview
9Overview
- Health care is a labor intensive field
10Overview
11Overview
12Overview
- Positive relationship between health workforce
availability and MDG-related health outcomes
13Overview
Source JLI, 2004
14Overview
Tanzania workforce availability versus
requirements for MDG-related services
Source Kurowski et al , 2003
15Overview
- WHO estimates global shortage of 2.4 million
skilled health workers based on population ratio
16Overview
- In many developing countries particularly SSA -
there are fewer health workers than required for
delivering key services - In addition to shortages other key health
workforce issues are - Distribution
- Geographic
- Skill mix
- Age
- Performance
- Productivity
- Quality
- But workforce is not the only issue in improving
health systems!!!
17A Labor Market Approach
- Traditional health workforce policy tended to
focus on determining the health workforce level,
distribution and skill mix that is required to
meet the needs of the population. - Staffing norms for facilities
- Per capita staffing level targets
- Analysis of staffing requirements for MDG related
interventions - Once this level was determined, training capacity
was adjusted, posts assigned, with minimal regard
for labor market dynamics
18A Labor Market Approach
Education And Training Programs
Health Care Facilities
19A Labor Market Approach
- However, this approach ignores important
behavioural characteristics of - health workers (supply side)
- employers (demand side)
- Health workers respond to economic, political
incentives unrelated to population needs - Employers respond to economic, political
incentives unrelated to population needs
20Supply of health workers
- Health workers respond to incentives
- Financial
- Salaries
- Bonuses/allowances
- Car/housing loans
- Non-financial
- Working conditions (HIV risk, hours)
- Satisfaction, being respected
- Promotion criteria
- Continuing education
21Demand for health workers
- Need to distinguish between
- Needs-based employment level
- the number, skill mix, distribution of health
workers required to meet the health needs of the
population - Demand for health workers
- the number, skill mix, distribution of health
workers employers are willing to hire funded
positions - The demand for health workers depends on
- government and household budget levels
- wages in the health sector
- donor aid
- the political environment
- all of which are independent of population need!!
22A Labor Market Approach
Education And Training Programs
Health Care Facilities
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24Policies on enrolment Policies on selecting
students
Policies to draw health workers back into the
health care sector
Policies to retain health workers in remote
areas Policies to govern dual practice Policies
to improve productivity, quality of care Policies
on skill mix
Policies to mobilize unemployed health workers
25Policies on enrolment Policies on selecting
students
Policies to draw health workers back into the
health care sector
Policies to retain health workers in remote
areas Policies to govern dual practice Policies
to improve productivity, quality of care Policies
on skill mix
Policies to mobilize unemployed health workers
26Policies to address inflows and outflows
27Policies to address inflows and outflows
28Policies to draw health workers back into the
health care sector
29Many doctors know what to do but simply dont do
it, responding to their direct incentives public
doctors are on salary and have very little
incentive to provide service and private doctors
want repeat business. Would be a good start to
consider incentives for public doctors to perform
at higher levels (perhaps through bonus schemes
or empowering local authorities to hire and fire).
Policies to retain health workers in remote
areas Policies to govern dual practice Policies
to improve productivity, quality of care Policies
on skill mix
30Productivity Analysis in Ghana
- To develop an aggregate measure of workforce
productivity - to monitored performance regularly at the
sub-national level in Ghana - To be used as a basis for resource allocation
- To identify factors that are correlated with
workforce productivity - To build on previous analysis by
- Testing the validity of different measures of
workforce productivity - Examining trends in workforce productivity over
time - To provide recommendations on further analytic
work including improvements in data collection
31Productivity Analysis in Ghana
- CSI measure of health care services provided
to the population - CHRH measure of the quantity of human
resources for health -
- Define the Service Unit
- Define the Categories of Health Services to
Include as Outputs in the Numerator - Determine a Method of Aggregating Different
Categories of Health Services into a Composite
Service Indicator - Define the Categories of Human Resources to
Include as Inputs in the Denominator - Determine a Method of Aggregating Different
Categories of Human Resources for Health into a
Composite Staffing Indicator
32Productivity Analysis in Ghana
Total Wage Bill/1,000,000
33Productivity Analysis in Ghana
34Productivity Analysis in Ghana
- Health Status People may simply not need health
care services because they enjoy relatively high
health status. - Population Density There may be relatively few
people living in the service unit catchement area
(i.e. population density may be low). - Effective Demand People may need health care
services but they simply do not use them, either
because they prefer traditional medicine or home
care or because they can not afford the services.
35Productivity Analysis in Ghana
- The Availability of Other Inputs Health workers
need other inputs such as pharmaceuticals, beds
and diagnostic equipment in order to produce
health care services. Workforce productivity may
be low because there are inadequate supplies of
complementary inputs. - Quality of Care Inpatients days and outpatient
visits are not homogenous. In service units
providing higher quality of care, workforce
productivity may be low if high quality care
requires more human resources for health inputs. - Skill Mix The particular mix of personnel used
in service units will have an impact on health
care services produced as well as the human
resources for health inputs. - Absenteeism If absenteeism varies across service
units, it will lead to variations in workforce
productivity. Absenteeism can be controlled for
by adjusting the relevant measure of human
resources for health inputs is for total hours
worked or total hours spent providing clinical
care.
36Productivity Analysis in Ghana
- Results
- No systematic predictors of workforce
productivity for what we could measure - Availability of other inputs
- Skill mix
- Case complexity beyond our weighting scheme
- Suggests a degree of
- Randomness believable!
- Omitted variables
- Demand (population density)
37Productivity Analysis in Ghana
- Results independent of different weighting
schemes - Decrease in productivity over time but suggests
data quality issues
38Productivity Analysis in Ghana