Health Workforce System and Performance Metrics

1. Health Workforce System and Performance Metrics Lecture 4

2. Outline • Describe the units and institutions in the pipeline that produces the various types of health workers • Describe the incentives that allocate health workers to various places in the health service system • Describe institutions that mediate the choices of health workers to enter, locate, exit • Describe the chief syndromes in workforce subsystem • Describe spillover effects from health workforce system to other parts of health systems

3. Various types of health workers • Village health worker • Trained/untrained midwife • Phlebotomist • Pharmacist • Doctor • Nurse • Drug sellers • Traditional healers

4. Part 1: Conceptual Framework: The Pipeline

5. Migrate Change jobs Die Disabled Health System Workforce System Pipeline of Professional Health Worker Training Active Health Workers • Policy issues • 1) Change capacity of the pipeline: • 2)Rational distribution of workers in space • (Two mechanisms): • Command and Control • Market demands • 3) Maintain high quality performance

6. Units Schools Employers: Public, Private, NGO Professional trade associations Foreign country labor markets (Dubai, USA) Institutions Labor markets Scholarships Service commitments Professional accreditation What are the units and institutions?

7. Pipeline • Pipeline of several years; workers get distributed throughout the country at the exit of the pipeline • Professional training and ‘Non-professional’ from being on the job • How do they exit? • Migrate, change jobs, die, disabled • Policies to increase retention • Restrict migration, improve health worker safety, improve pay • Policies to change capacity of the pipeline • More trainees coming out

8. Other considerations • Besides size of pipeline 1)Rational distribution in space for reach: 2 mechanisms • Government command and control: • Market • Many end up in urban hospitals to serve urban elites 2) Maintain high quality performance • Mix of health workers • MD and MBBS physicians should be scarcest because most costly to produce • Nurses and trained ancillary workers are less costly sources of primary care

9. Politics • Physician groups universally entertain policies to impede the scope of practice of less trained health providers • Physician unions say, “Public health is endangered because less well-trained providers might miss diagnoses and fail to refer” • Others say, “Public health is endangered by shortages of service providers and over-priced physician fees.” • What do you think?

10. Retention • How do they exit? • Migrate, change jobs, die, disabled • Migration and job change • Not only because of low wages • Often migrate because of morale and a desire to practice profession better • Death and disability • Needle-stick injuries are a leading occupational risk • Hepatitis, HIV • Safety measures that are not being used • Biohazard containers, safety needles

11. Minya University Hospital has 600 beds and 1000 health workers Average health worker suffers 4 sticks per year! Hep C prevalence is 15% in Egypt Transmission 0.05% per exposure 25-30 seroconversions per year among workers (Hep C cost @ $2000-$4000 each) Injuries cost $50,000-$120,000 Needs 100,000 safety needles Safety needle costs $1.00 each Safety costs $100,000 Case Study: Worker Safety in Egypt

12. Migration • Strategies: coercive regulation; service commitments • Poaching by high-income countries to meet their own needs: how does it end? • Migrating for financial reasons: • Lack of good health insurance financing to stimulate demand and make livelihoods more secure • Tight bond between problems of manpower and financing

13. Questions for students • What does training cost? Who bears the costs? • Long- and short-term costs • Government • Opportunity cost: individuals could be working in industry but deferring gratification; return on investment • Envision what would be the ideal way: • If you were in charge, where would you put health workers? And why?

14. Part 2: Syndromes in Health Workforce

15. Syndrome 1: Worker Shortage • Definition: Worker shortage occurs when there are too few of all types of health workers relative to the population • Etiology: Pipeline too small and/or exit rates to high • Implications: • There is an imbalance between pills, procedures and time with the provider now: more pills, less time with provider • Too many unsupervised pills and procedures, • Problem in malaria (too short of a course taken, wrong drug) • TB (drug resistance later) • Medical care adapts poorly to this shortage and quality is impaired

16. Diagnosing Worker Shortage • Diagnostic question is not whether there is shortage, it is asking where the shortage is most severe. • Information Systems: • Centrally maintained staffing lists (often out of date) • Worker wage data (underutilized) • Earnings in private markets are higher in shortage areas • Household surveys can suggest utilization patterns

17. Managing Worker Shortage • Understand incentives of workers • Wages • Professional morale • Safety • International strategies • Tax poaching • Countries that poach health workers need to pay replacement costs • Offering attractions for returning health workers based on incentives

18. Syndrome 2: Worker imbalance • Definition: Worker imbalance occurs when the cadres of workers emerging from training is ill-suited to the health needs of a population • Typical imbalance is an insistence that MD or MBBS providers be the only possible source of primary care • Neglects important role of community health workers (CHW) and ru practitioner • Barefoot doctor strategy can play an important strategic role • Insisting on MDs accentuates worker shortages

19. Key role of information systems Supply shortages, surpluses Information drawn from direct inspection of last mile Qualitative evidence Need patient reports on satisfaction and aspects of care Case study: Peons (janitors) in Nepal Anthropologist finds that the peons were delivering primary care Health providers out at training or in private practice Invisible to central information system Diagnosing Worker Imbalance

20. Managing Worker Imbalance • Push and Pull Factors in the Pipeline • Push • Open more training institutions for worker types that are in scarcity • Provide scholarships tied to service commitments • Use military sector to develop professionals • Pull • Stabilize key professions like lab technicians and nurses by supporting trade associations • Make key professions more woman friendly • Offer child care packages • Retraining for housewives who have been on leave from the workforce

21. Syndrome 3: Spatial maldistribution • Definition: Spatial maldistribution occurs when health workforce is not located in accordance with disease burden • Can manifest as local area shortage OR as local area surplus of health workers • Typically a rural:urban disparity • All sorts of economic activity, health services, included are more costly to organize in rural areas

22. Diagnosing Spatial Maldistribution • Household survey data on utilization and travel time • Market data on prices of health services

23. Managing Spatial Maldistribution • Command and control • Use service commitment obligations to place health workers in shortage areas • Build facilities • Pay workers low maintenance wages and expect them to practice part time in private sector • Market solutions • Find private providers in shortage areas and work with them to improve their quality of care • Demand side financing • Vouchers plus quality certifications

24. Part 3:Spillovers with Other Areas

25. Origins of Workforce Imbalances • Households • With low levels of sophistication households have an unenlightened willingness to pay for preventive services and diagnostic tests • Too much interest in medications and injections • Fundamental effects on pull factors in the pipeline • Finance • Insurance systems exert immense pull factor on pipeline • Underdeveloped insurance in rural areas makes livelihoods unsustainable • Information systems • Essential to help managers diagnose and address problems

26. Impacts of Workforce Problems • Finance • Low actuarial and accounting workforce inhibits development of financial protection system • Health Service Delivery • Workforce shortages and imbalances play into balance between private/public also affects “reach” • Workforce alters quality of care and impact

27. Summary • Workforce is produced by a pipeline and exits from migration, job change, death and disability • Labor markets, global and local, affect workforce • Workforce syndromes include shortage, imbalance, and spatial maldistribution • Problems with workforce are linked to problems in household health demand, finance, and information systems