Health Workforce Development in the NIS Willy De Geyndt, Ph'D'

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Health Workforce Development in the NISWilly De
Geyndt, Ph.D.

• Presented by Kasra Navabi M.D.

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Health sector reforms

• Many countries in the world have embarked on
  health sector reforms with the intended outcomes
  of containing costs, improving quality and making
  more services more accessible to more people.

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Health sector reforms

• The words most often applied to the health sector
  include
• Rationalizing
• Reforming
• Decentralizing
• Making the sector more efficient and more
  cost-effective
• Managing
• Care/costs
• Managing
• Competition
• Achieving a perfect private/public mix of
  financing and service provision
• Separating financing health services from
  providing health services
• Redefining the respective roles of the private
  and public sectors.

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Different aspects of sector reform

• Organizational Arrangements
• Physical Infrastructure
• Financing
• Provider Payments
• Information
• WORKFORCE

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Organizational Arrangements

• New organizational arrangements have been
  developed
• Internal markets (U.K.)
• Public health companies (Colombia in 1994)
• Prepaid care and managed care (USA)
• Crown Health Authorities (New Zealand in 1993)
• National health insurance (Korea in 1989, Taiwan
  in 1995, Philippines in 1996, Russia in 1993)
• Decentralization and a higher degree of autonomy
  (corporative hospitals in Malaysia in 1996,
  restructured hospitals in Singapore in 1993).

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Physical Infrastructure

• Reconfigured by
• Reducing the number of hospital beds
• Closing and merging hospital facilities
• Relocating high technology biomedical equipment
  from the hospital to freestanding units
• Maximizing health services provision on an
  ambulatory basis

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Financing

• Sources of financing of health care have
  shifted from general tax revenues to social and
  private insurance mechanisms, and from public to
  private sources.

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Provider Payments and incentives

• Shifted from fee-for-service for each episode
  of care and from the number of days for each
  hospital stay to payments by capitation, by
  diagnosis (DRGs or Diagnosis Related Groups) or
  by case, to putting physicians on a salary and
  global hospital budgets.

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Information

• Some countries have sought solutions in improved
  information and have invested in sophisticated
  management information systems, which often have
  produced a mass of data but little information.
  Available information is often not acted upon for
  lack of management expertise.

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WORKFORCE
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WORKFORCE

• Workforce development is an integral part of
  health sector reform and of health planning and
  must be grounded in the health needs of the
  population
• Market forces will not achieve equitable
  distribution of appropriate healthcare personnel.
  Health workforce planning should be a public
  sector activity and should not be left to the
  private sector or to educational institutions
• Workforce development includes three interrelated
  actions
• Planning the workforce a quantity concern
• Training the workforce a quality concern
• Managing the workforce a performance issue
• Outcomes of health care provision are directly
  affected by how well workforce issues are handled
  and feedback on outcomes should trigger changes
  in workforce policies.

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PLANNING THE WORKFORCE

• a discrepancy between the numbers, types,
  functions, distribution and quality of health
  workers, on the one hand, and, on the other hand,
  a country's needs for their services and ability
  to employ, support and maintain them.
• In this respect it is customary to use the
  concept of workforce imbalances.

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PLANNING THE WORKFORCE

• Two types of imbalances are of concern in
  workforce planning
• Numerical Imbalances
• Current Supply
• Present and Future Requirements
• Distributional Imbalances
• Geographic
• Occupational
• Medical specialties
• Institutional
• Gender

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Numerical Imbalances

• Numerical imbalances are
• Oversupply
• Undersupply

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Distributional Imbalances

• The second imbalance is a distributional
  imbalance of which there are five types
• Geographic
• Occupational
• Medical specialties
• Institutional
• Gender

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Geographic

• Geographic imbalances
• urban/rural
• within cities
• within and among countries
• Within Turkmenistan, for example, the ratio of
  physicians per 1,000 population in 1995 ranged
  from 7.4 to 1.6 and that of nurses from 7.0 to
  5.0. The geographic imbalances are usually larger
  for physicians and dentists than for other
  members of the workforce.

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Occupational

• Occupational imbalances is health workers
  interaction and collaboration with each other and
  it is
• over-represented on the health team
• Under-represented on the health team
• The best documented imbalance is the doctor/nurse
  ratio, which in some countries can be as high as
  2-3 physicians per nurse with the resulting
  inefficiency that physicians perform a large
  number of nursing functions.

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Medical specialties

• Medical specialties imbalance refers to the
  distribution between generalists and specialists
  and the distribution among specialties.

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Medical specialties

• In 1993, Turkey had the highest percentage of all
  active physicians who were general practitioners
  (56.9) followed by Canada (46.6) the United
  States had 35 percent in 1992
• In 1993 data on some medical specialties in the
  USA (Rates per 100,000 population)
• Psychiatry 13.9
• Obstetrics/Gynecology 12.7
• General Surgery 11.0
• Anesthesiology 10.6
• Radiology 9.6
• Orthopedic Surgery 7.7
• Emergency Medicine 6.3
• Ophthalmology 6.1
• Cardiology 5.9
• Pathology 5.2
• Except for psychiatry, the medical specialties
  that attract more physicians are also the ones
  that had the highest net income

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Institutional

• Institutional imbalances occur when some health
  care facilities have too many staff and others
  are understaffed because of
• Location
• Prestige
• Working conditions
• The ability to generate additional income
• Other situation-specific factors

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Gender

• Gender imbalance refers to the number of male
  versus female physicians.
• Female Physicians as a Percent of all Active
  Physicians in OECD Countries, 1990 and 1993

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Observed Strategies to Correct Distributional
Imbalances

• Physicians cluster in the non-poor parts of
  metropolitan areas but not in poor inner-city
  neighborhoods rural areas are medically
  underserved.
• An acceptable definition of areas with a shortage
  of primary care physicians is based on an
  assumption that approximately 30 physicians are
  needed per 100,000 population or one primary care
  physician per 3,300 people.

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Strategies to achieve a better balance

• Imbalances between
• urban and rural areas
• specialists and generalist physicians
• hospitals, polyclinics and health centers
• Different strategies
• Centrally-planned economies Cuba, for example,
  requires a two-year posting in rural villages and
  the assigned doctor cannot return until the
  replacement doctor arrives. Such a strategy
  guarantees a medical presence at all times.
  Intellectuals were forcibly sent to rural areas
  during the 1966-1976 cultural revolution in
  China.
• Some Latin American countries Medical students
  in some Latin American countries fulfill a social
  service requirement before receiving their
  medical degrees.

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Strategies to achieve a better balance

• It sends out inexperienced and poorly
  motivated medical students who leave with an
  attitude of ?doing time? and, consequently, their
  performance may be unsatisfactory. Furthermore,
  due to minimal or no supervision, their learning
  experience is substandard. The net result is poor
  service to the patients and an unsatisfactory
  learning experience.

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Strategies to achieve a better balance

• money-driven strategy In the United States,
  medical students usually pay all expenses related
  to their medical education and therefore graduate
  in debt. low-income students pay for the costs of
  their medical education in exchange for an
  agreed-upon number of years of service after
  graduation in geographic areas designated by the
  government.

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Strategies to achieve a better balance

• Transferring the money for physician salaries
  from the state budget to the communities For
  example in Brazil, Villages can attract
  physicians by offering a better salary and fringe
  benefits such as housing. This motivational
  strategy has sharply reduced the number of
  villages without a doctor.

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HEALTH WORKFORCE PLANNING METHODS

• The five health workforce planning methods that
  are or have been used are
• PPR Personnel-to-Population Ratios
• Extrapolating school admissions
• Needs-based planning
• Demand-based planning
• Benchmarking

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Extrapolating school admissions

• using projected admission rates based on current
  policies of the Ministry of Health corrected for
  estimated population growth and assumed academic
  loss rate.
• It is assumed that the current skills mix among
  the categories of health professionals will
  remain unchallenged and unaffected by changes in
  the external technological, demographic and
  epidemiological environment.

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Needs-based planning

• Panels of experts estimate the per capita numbers
  of physicians needed to treat the diseases
  managed by a given specialty.
• Using this method requires the ability to
  forecast the factors that will affect the need
  for particular specialists such as the pace of
  technological change, the impact of an aging
  population and its accompanying increase in
  chronic and degenerative diseases, and the
  increasing burden of disease due to violence and
  accidents.
• Estimates are often also influenced by the number
  of available openings for advanced training or
  residencies, and specialty boards or groups may
  lobby to increase or decrease the number of
  training opportunities.

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Demand-based planning

• Current utilization is a proxy for patient demand
  and an indicator of physician requirements.
• This manpower planning method requires projecting
  current utilization into the future, taking into
  account increased utilization as a result of an
  increased supply of medical resources, and
  estimating the impact on demand and service
  delivery capability of changes in the
  epidemiology and burden of disease (HIV/AIDS,
  tuberculosis, cardiovascular diseases) and
  changes due to demographic transition (aging).

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Benchmarking

• comparing physician resources with a benchmark or
  model region or a benchmark health plan or with
  other countries or with different organizational
  arrangements.

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TRAINING THE WORKFORCE

• Education is a formal and mostly full-time
  process of learning a profession in a recognized
  institute or university.
• Training is a learning process to upgrade and
  improve the professional skills acquired during a
  prior educational experience
• In most NIS countries government control over the
  educational process is divided between the
  Ministries of Health and Education.

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TRAINING THE WORKFORCE

• The Ministry of Health (MOH) may have
  responsibility for planning the size of the
  workforce, the degree requirements, and the
  number of places in educational institutions.
• The Ministry of Education (MOE) controls the
  educational programs, their length, the level of
  instruction, faculty standards and degree
  designations.
• The balance of power between the MOH and the MOE
  is an important consideration in health workforce
  change strategies in all of the NIS countries.

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TRAINING THE WORKFORCE

• Formal education
• Universities and Institutes
• Location and Content
• Training
• On-the-Job
• Distance learning
• Continuing Medical Education (CME)
• Seminars and Workshops
• Clinical Supervision

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TRAINING THE WORKFORCE

• A major objective of training is to correct
  qualitative imbalances. Three types of
  qualitative imbalances can occur
• Overqualification or overtrained healthcare
  workers
• Underqualification or undertrained healthcare
  workers and
• Misqualification or irrelevance of training.

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Managing the Workforce

• MANAGING THE WORKFORCE
• Macro Level (Ministry of Health)
• Personnel policies
• Licensing
• Salary scales
• Information systems
• Micro Level (Points of Service)
• Incentives to perform
• Working conditions
• Income and benefits
• Quality of supervision
• Career ladders
• Team work

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Tip

• At least five methods exist to determine the
  required number and type of health workers the
  simplest method is the use of arbitrary norms to
  calculate a ratio for each type of worker related
  to the population to be served the most recent
  method uses benchmarking which calculates the
  number and type of worker needed according to a
  model region, or a benchmark, that has proven to
  have an appropriate, affordable and sustainable
  number of workers to meet the health needs of the
  population in that region