Transcript Health Workforce System and Performance Metrics

Health Workforce System and
Performance Metrics
Lecture 4
Outline
1.
2.
3.
4.
5.
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
Various types of health workers
•
•
•
•
•
•
•
•
Village health worker
Trained/untrained midwife
Phlebotomist
Pharmacist
Doctor
Nurse
Drug sellers
Traditional healers
Part 1: Conceptual Framework: The Pipeline
Health System Workforce System
Migrate
Pipeline of
Professional
Health Worker
Training
Change jobs
Active Health Workers
Die
Disabled
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
What are the units and institutions?
• Units
– Schools
– Employers: Public,
Private, NGO
– Professional trade
associations
– Foreign country labor
markets (Dubai, USA)
• Institutions
–
–
–
–
Labor markets
Scholarships
Service commitments
Professional
accreditation
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
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
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?
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
Case Study: Worker Safety in Egypt
• 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
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
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?
Part 2: Syndromes in Health Workforce
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
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
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
Syndrome 2: Worker imbalance
• Definition: Worker imbalance occurs when the
cadres of workers emerging from training is illsuited 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
Diagnosing Worker Imbalance
• 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
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
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
Diagnosing Spatial Maldistribution
• Household survey data on utilization and
travel time
• Market data on prices of health services
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
Part 3:Spillovers with Other Areas
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
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
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