Foggy Lens?: An Economist

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Foggy Lens? An Economists Take on The Global
Health Workforce Crisis

• Leonard Davis Institute, January 19 2007
• Marko Vujicic
• Human Development Network
• The World Bank

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Outline

• An overview of global health workforce issues
• Why a labor economics approach?
• Illustrations from developing countries

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Overview

• 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

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Overview

• 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

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Overview
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Overview
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Overview

• Health care is a labor intensive field

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Overview
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Overview
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Overview

• Positive relationship between health workforce
  availability and MDG-related health outcomes

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Overview
Source JLI, 2004
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Overview
Tanzania workforce availability versus
requirements for MDG-related services
Source Kurowski et al , 2003
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Overview

• WHO estimates global shortage of 2.4 million
  skilled health workers based on population ratio

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Overview

• 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!!!

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A 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

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A Labor Market Approach
Education And Training Programs
Health Care Facilities
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A 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

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Supply 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

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Demand 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!!

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A Labor Market Approach
Education And Training Programs
Health Care Facilities
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Policies 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
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Policies 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
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Policies to address inflows and outflows
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Policies to address inflows and outflows
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Policies to draw health workers back into the
health care sector
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Many 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
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Productivity 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

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Productivity 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

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Productivity Analysis in Ghana
Total Wage Bill/1,000,000
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Productivity Analysis in Ghana
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Productivity 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.

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Productivity 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.

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Productivity 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)

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Productivity Analysis in Ghana

• Results independent of different weighting
  schemes
• Decrease in productivity over time but suggests
  data quality issues

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Productivity Analysis in Ghana