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Human Resources for Health (HRH)

A major barrier to access to health care is the shortage of competent and motivated staff in health services.

Human resources are the core of health care delivery systems and the main determinant of quality. It has been recognised widely that human resources problems are a major obstacle in the realisation of health outcomes.

Van Dormael M (2006). Le systéme de soins et les soins de santé primaries au Mali. Keynote speech to a seminar on “Quality of Health Systems” organised by the Direction Nationale de la Santé, RIAC Mali and WHO, Bamako.

Van Dormael M, Kegels G & Marchal B (2005) Human Resources for Health: Confronting complexity and diversity. Background issues to the HRH seminar. Be-Cause Health Seminar on Human Resources for Health in Developing Countries, Brussels, November 10th 2005.

HRH problems have three interlinked aspects: availability (2a), competence (2b) and management at operational level (2c).

2a. Availability of HRH

This includes the absolute numbers of health workers, their distribution and their skill-mix. Availability is influenced by policy, planning and organisation, by training, by attraction and absorption capacity of health services, by attrition and brain drain and by changes in epidemiology and medical technology.

Marchal B, Kegels G (2003). Health workforce imbalances in times of globalization: brain drain or professional mobility? Int J Health Plann Mgmt 18: S89-S101.

In many low income countries, especially in sub-Saharan Africa, HRH problems are chronic and have to do with all above factors. In some countries, problems are worsening, with increasing imbalances in all dimensions and inadequate regulation of training facilities leading to problems in quality. In several countries with a high HIV/AIDS burden, increasing demand for care and attrition leads to an acute crisis situation.

Marchal B, De Brouwere V, Kegels G (2005). HIV/AIDS and the health workforce crisis: What are the next steps? Tropical Medicine and International Health (2005) Vol 10 No.4: 300-304.

Kober K, Van Damme W (2004). Scaling up access to antiretroviral treatment in southern Africa: who will do the job? The Lancet 364:103-107.

Kegels G and Marchal B (2006) AIDS and the Health Workforce in Africa. Making Sense. Medicus Mundi International; 63 pp.

Strategies to tackle HRH problems need to be comprehensive and address all levels. National and international human resource policies should be developed and adjusted. The organisation of HRH and models of health delivery should be assessed. Important elements to consider are the concentration and integration of disease control into general health services and task-shifting. Strategies improving competence (see 2b) and motivation (see 2c) also improve attraction and retention. So did material and moral support mechanisms in Mali help to attract young doctors to settle and remain in first line facilities in rural areas.

Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha M, Anwar I, Achadi E, Adjei S, Padmanabhan P, Marchal B, De Brouwere V, van Lerberghe W (2006). Going to scale with professional skilled care. The Lancet, 368, 1377-1386.

Unger JP, De Paepe P, Ghilbert P, Soors W, Green A (2006). Integrated care: a fresh perspective for international health policies. International Journal of Integrated Care 6(15):10.

Marchal B, De Brouwere V, Kegels G (2005). HIV/AIDS and the health workforce crisis: What are the next steps? Tropical Medicine and International Health (2005) Vol 10 No.4: 300-304.

Marchal B, De Brouwere V. (2004). Global human resources crisis. [Letter] The Lancet 363. 2191-92.

Marchal B, Kegels G, De Brouwere V (2004). Human resources in scaling up HIV/AIDS programmes: just a killer assumption or in need of new paradigms? AIDS, 18(15):2103-2105.

Buttiëns H, Marchal B, De Brouwere V (2004). Skilled attendance: let us go beyond the rhetoric. Tropical Medicine & International Health, 9, 6, 653-4.

Van Dormael M, Dugas S, Kone Y, Coulibaly S, Sy M, Desplats D. (2008) Appropriate training and retention of community doctors in rural areas: a case study from Mali. Human Resources For Health 6:25.

2b. Competence of HRH

This includes technical skills, interpersonal skills, patient-centred attitude and professionalism. To develop these skills and characteristics, education and socialisation are essential. The quality of medical education in many low income countries is suffering and continued professional development and in-service training are still underdeveloped.

In Mali, professional training for community doctors was developed to improve their capacities to integrate clinical and public health responsibilities and to manage their health centres. Trainees were very satisfied, especially about the attention for professionalism and the exchange with other professional experts, resulting in professional socialisation. The training led to increased confidence and self-esteem. Other aspects of competence were developed to a certain extent. Conditions which contributed to the success were: professional experts combined with thematic experts, exposure to a practical module and the linkage with an active professional association.

Van Dormael M, Dugas S, Kone Y, Coulibaly S, Sy M, Desplats D. (2008) Appropriate training and retention of community doctors in rural areas: a case study from Mali. Human Resources For Health 6:25.

Coulibaly S, Desplat D, Kone Y, Nimaga K, Dugas S, Farnarier G, Sy M, Balique H, Doumbo OK, Van Dormael M. Une médecine rurale de proximité: l'expérience des médecins de campagne au Mali. Education for Health 2007; 20(2):1-9.

Van Dormael M. L’introduction des sciences sociales dans une expérience de formation continue des médecins de campagne au Mali [Abstract]. Colloque International AMADES : Anthropologie et Médecine : confluences et confrontations dans les domaines de la formation, des soins et de la prévention, Marseille, 25-27/10/2007.

Dugas S, Van Dormael M (2006). Formation préalable à l’installation des médecins de campagne au Mali: Présentation et bilan de trois années d’expérience. Synthèse de l’atelier-bilan réunissant l’association des médecins de campagne (AMC), Santé-Sud Mali, l’IMT d’Anvers à Bamako les 27 & 28 Avril 2006.

Another intervention was the organisation of exchange visits between Malian community doctors and family doctors in France. This triggered reflectivity, stimulated inspiration and brought acquaintance with new skills and methods. It contributed to improved individual competences, professional awareness and a stronger professional association.

Van Dormael M, Dugas S, Diarra S (2007) North-South exchange and professional development: experience from Mali and France Family Practice 2007 24: 102-107.

Other methods to improve competence are: continuous medical education (seminars, supervision by experienced peer professionals, audits, intervision, based on long-term relationships, trust and support), the development of a professional association (allowing sharing of experience, socialisation, coaching and self-regulation) and action research (stimulating reflectivity and drive for improvement).

Unger, J. P., Ghilbert, P., and De Paepe, P. (2004) Continuous medical education with(out) coaching? e-Letter. BMJ , 4 May 2004.

Unger JP, Ghilbert P, Fisher JP. Doctor-patient communication in developing countries [Letter]. British Medical Journal 2003; 327(7412): 450.

Van Dormael M, Dugas S, Kone Y, Coulibaly S, Sy M, Desplats D. (2008) Appropriate training and retention of community doctors in rural areas: a case study from Mali. Human Resources For Health 6:25.

2c. Management of HRH at operational level

If competent HRH are available in health services, then their motivation and behaviour is still dependant on working conditions, the organisational context and management.

Demotivation among HRH is a widespread phenomenon, although the perception of management and public can be different from that of the staff themselves. Influencing factors are: poor working conditions, skill imbalances, different lines of authority without clear task-definitions leading to tensions and team dysfunctioning, the incapacity of the management to distinguish and differentiate between good performance and wrong behaviour of staff, leading to perceptions of impunity, inequity and powerlessness.

Gruénais ME, Rachih N, Bousbaa A, Houssam Touria, Khalil J, De Brouwere V. Une approche qualitative de la question de la ‘démotivation’ des personnels de santé. Le point de vue des acteurs de la région sanitaire du Grand Casablanca. Février 2008.

The management of HRH deals with administrative tasks and with human relations. It aims to optimize the staff’s contribution to organisational performance by motivation, commitment and staff development. High commitment management is a combination of specific complementary HRM practices (e.g. open access to information and communication in all directions and at all levels, reduction of status differences, comprehensive staff-motivation). A study in a well-performing hospital in Ghana showed that these approaches promoted a culture of excellence, based on a shared vision, and perpetuated through team work, peer pressure, meetings and supervision. Open access to managers and grass root involvement of managers at operational level contributed to the maintenance of a motivating environment. In an organisation which disposes of a minimum of resources, and with capable leadership, these interventions can contribute to higher commitment of staff by increased perception of organisational support and the creation of a culture of trust.

Marchal B., Kegels G. (2007). Focusing on the software of managing health workers: what can we learn from high commitment management practices? Int J Health Plann Mgmt 2007 Jun 5.

Marchal B, Denerville E, Dedzo McD, De Brouwere V, Kegels G. Decentralisation, decision spaces and human resource management at hospital level. High commitment human resource management approaches used by the management team of Ghana’s Cape Coast Central Regional Hospital. Research report, October 2005.

We also studied mechanisms likely to increase staff commitment to quality of care. Quality of medical care is a balance between standardisation of medical interventions and creativity of the health professional to react to individual patients. Quality management aims to improve quality of specific interventions, but also aims at a more durable and generalised effect, by having the approach itself accepted by the whole organisation.

Most African health systems have characteristics of a Weberian (machine) bureaucracy, in which hierarchical structure is very important and health professionals work according to standardised procedures with little ability to respond to individual patient demands. In those contexts, quality management interventions should strive for more patient focus, more responsiveness and more professionalism. An intervention in Morocco with clinical audits aimed to trigger self-regulation and improvement. We found that the current conditions, especially the characteristics of a machine bureaucracy (limited accountability to patients, little willingness to be reflective or to change) may not be favourable to reach the intended outcome. The confrontation with new mechanisms, opposed to the one prevailing in the organisational culture, can lead to tension among the staff and the organisation exposed, leading to different reactions and coping mechanisms. External support is important to reconcile those tensions. In general, staff accepts interventions inside the project context, but is hesitant to adopt the mechanisms elsewhere in the organisation. The effects of quality management interventions are then not generalised and durable.

Blaise P. Kegels G. Innovating for quality in bureaucratic organizations: the challenge of change in public health systems. A realistic evaluation of quality projects in Africa. In: ‘Innovating for quality’', 22nd International Conference of the International Society for Quality in Health Care (ISQua). Vancouver, 25-28 October 2005. Book of Abstracts, p 23-24 [abstract].

Blaise P, Ten years of quality projects and their effect on the organisational culture of the Moroccan health care system. In Blaise P, Culture qualité et organisation bureaucratique, le défi du changement dans les systèmes publics de santé. Une évaluation réaliste de projets qualité en Afrique [PhD dissertation] Université Libre de Bruxelles. Bruxelles, Janvier 2005.(ref 2.23)

Blaise P, Sahel A, Gruénais ME, De Brouwere V. Introducing routine clinical audit in public hospitals to improve quality of care: potential and pitfalls. The case of Casablanca public health hospitals in Morocco. In: Improving health care. The challenge of continuous change', 23rd International Conference of the International Society for Quality in Health Care (ISQua). London, 22-25 October 2006. [abstract & poster]

Blaise P, Gruénais ME, Nani S, Sahel A, De Brouwere V. Does clinical audit promote professional reflexivity? The experience of Casablanca public hospitals in Morocco with quality of care improvement. In: Proceedings of the 9th Toulon-Verona Conference Quality in Services Paisley, Scotland, 7-8 September 2006.

Blaise P & Kegels G. (2004) A realistic approach to the evaluation of the quality management movement in health care systems: a comparison between European and African contexts based on Mintzberg's organizational models. International Journal of Health Planning and Management 19: 337-364.

Unger JP, Marchal B, Dugas S, Wuidar MJ, Burdet D, Leemans P et al. Interface flow process audit: using the patient's career as a tracer of quality of care and of system organisation [E-letter]. International Journal of Integrated Care 4. 2004.

Filippi V, Brugha R, Browne E, Gohou V, Bacci A, De Brouwere V, Sahel S, Goufodji S, Alihonou E, Ronsmans C. 2004. How to do (or not to do) . . . Obstetric audit in resource poor settings: lessons from a multi-country project auditing ‘near miss’ obstetrical emergencies. Health Policy and Planning, 19(1), 57-66.

Blaise P. Kegels G. Quality Management in health care systems in Africa: one concept, many faces, contrasted results. An analysis of 3 case studies from Africa, Quality in higher education, health care and local government. 5th Toulon Verona Conference ISEG, 19-20 Sept 2002.

Blaise P (2004) Managing change in bureaucratic health care organisations; a case study of a quality improvement project in Zimbabwe. Quality in Higher Education, Health Care, Local Government. 6th Toulon-Verona conference. 11-12 September 2003, Oviedo.

Other interventions to improve the responsiveness of care to patients and the quality of care, which are studied by ITM, are the formation of a partnership between population and health care providers by community health insurance and the change of orientation of health facilities. The challenge is to develop regulation systems in health systems which find the optimal balance between a reliance on market incentives, bureaucratic mechanisms (rules and procedures) and professionalism (the internalisation of common values).

Criel B, Alpha Ahmadou Diallo, Van der Vennet J, Waelkens M-P & Wiegandt A (2005). La difficulté du partenariat entre professionnels de santé et mutualistes: le cas de la mutuelle de santé Maliando en Guinée-Conakry. Tropical Medicine & International Health, Vol 10, N°5, pp 450-463.

Unger JP, Marchal B & Green A. (2003). Quality standards for health care delivery and management in publicly-oriented health services. Int J Health Planning and Management 2003; 18: S79-S88.

Blaise P. Kegels G. Innovating for quality in bureaucratic organization: the challenge of change in public health systems. A realistic evaluation of quality projects in Africa. In: ‘Innovating for quality’', 22nd International Conference of the International Society for Quality in Health Care (ISQua). Vancouver, 25-28 October 2005. Book of Abstracts, p 23-24 [abstract].

Guindo G, Dubourg D, Marchal B, Blaise P, De Brouwere V. 2004. Measuring unmet obstetric need at district level: how an epidemiological tool can affect health service organization and delivery. Health Policy and Planning, 19 (Suppl. 1), 87-95.