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Background: Regulation is a critical function in the governance of health workforces. In many countries, regulatory councils for health professionals guide the development and implementation of health workforce policy, but struggle to perform their responsibilities, particularly in low- and middle-income countries (LMICs). Few studies have analyzed the influence of colonialism on modern-day regulatory policy for health workforces in LMICs. Drawing on the example of regulatory policy from India, the goals of this paper is to uncover and highlight the colonial legacies of persistent challenges in medical education and practice within the country, and provide lessons for regulatory policy in India and other LMICs.Main Body: Drawing on peer-reviewed and gray literature, this paper explores the colonial origins of the regulation of medical education and practice in India. We describe three major aspects: (1) Evolution of the structure of the apex regulatory council for doctors-the Medical Council of India (MCI); (2) Reciprocity of medical qualifications between the MCI and the General Medical Council (GMC) in the UK following independence from Britain; (3) Regulatory imbalances between doctors and other cadres, and between biomedicine and Indian systems of medicine.Conclusions: Challenges in medical education and professional regulation remain a major obstacle to improve the availability, retention and quality of health workers in India and many other LMICs. We conclude that the colonial origins of regulatory policy in India provide critical insight into contemporary debates regarding reform. From a policy perspective, we need to carefully interrogate why our existing policies are framed in particular ways, and consider whether that framing continues to suit our needs in the twenty-first century. [ABSTRACT FROM AUTHOR]

Background: A strong health workforce is a key building block of a well-functioning health system. To achieve health systems goals, policymakers need information on what works to improve and sustain health workforce performance. Most frameworks on health workforce planning and policymaking are high-level and conceptual, and do not provide a structure for synthesizing the growing body of empirical literature on the effectiveness of strategies to strengthen human resources for health (HRH). Our aim is to create a detailed, interactive logic model to map HRH evidence and inform policy development and decision-making.Methods: We reviewed existing conceptual frameworks and models on health workforce planning and policymaking. We included frameworks that were: (1) visual, (2) comprehensive (not concentrated on specific outcomes or strategies), and (3) designed to support decision-making. We compared and synthesized the frameworks to develop a detailed logic model and interactive evidence visualization tool.Results: Ten frameworks met our inclusion criteria. The resulting logic model, available at hrhvisualizer.org , allows for visualization of high-level linkages as well as a detailed understanding of the factors that affect health workforce outcomes. HRH data and governance systems interact with the context to affect how human resource policies are formulated and implemented. These policies affect HRH processes and strategies that influence health workforce outcomes and contribute to the overarching health systems goals of clinical quality, responsiveness, efficiency, and coverage. Unlike existing conceptual frameworks, this logic model has been operationalized in a highly visual, interactive platform that can be used to map the research informing policies and illuminating their underlying mechanisms.Conclusions: The interactive logic model presented in this paper will allow for comprehensive mapping of literature around effective strategies to strengthen HRH. It can aid researchers in communicating with policymakers about the evidence behind policy questions, thus supporting the translation of evidence to policy. [ABSTRACT FROM AUTHOR]

Background: Increasing feminization of medical professions is well-acknowledged. However, this does not always equate to equitable representation of women within medicine, regarding their socio-demographic indicators, regions, sectors and fields of practice. Thus, this paper quantifies the gap in supply of female medical doctors in relation to demand, towards reaching different gender equity scenarios.Methods: A retrospective review of the Health Professions Council of South Africa's (HPCSA) database on registered medical doctors (medical practitioners and medical specialists) from 2002 until 2019 was utilized as an indicator of supply. Descriptive statistics were used to summarize data, and inferential statistics (considering a significance level of 0.05) were utilized to determine the association between the number of male and female doctors, disaggregated by demographic variables. We forecasted future gaps of South African male and female doctors up to 2030, based on maintaining the current male-to-female ratio and attaining an equitable ratio of 1:1.Results: While the ratio of female doctors per 10 000 population has increased between 2000 and 2019, from 1.2 to 3.2, it remains substantially lower than the comparative rate for male doctors per 10 000 population which increased from 3.5 in 2000 to 4.7 in 2019. Men continue to dominate the medical profession in 2019, representing 59.4% (27,579) of medical doctors registered with the HPCSA with females representing 40.6% (18,841), resulting in a male-to-female ratio of 1:0.7. Female doctors from the Black population group have constantly grown in the medical workforce from 4.4% (2000), to 12.5% (2019). There would be a deficit of 2242 female doctors by 2030 to achieve a 1:1 ratio between male and female medical doctors. An independent-samples t-test revealed that there was a significant difference in the number of male and female doctors. The Kruskal-Wallis test indicated that there was a sustained significant difference in terms of the number of male and female doctors by population groups and geographical distribution.Conclusions: Based on the investigation, we propose that HRH planning incorporate forecasting methodologies towards reaching gender equity targets to inform planning for production of healthcare workers. [ABSTRACT FROM AUTHOR]

Background: Shortages of physicians in remote, rural and other underserved areas and lack of general practitioners limit access to health services. The aims of this article are to identify the challenges faced by policy and decision-makers in Portugal to guarantee the availability and geographic accessibility to physicians in the National Health Service and to describe and analyse their causes, the strategies to tackle them and their results. We also raise the issue of whether research evidence was used or not in the process of policy development.Methods: We analysed policy and technical documents, peer-reviewed papers and newspaper articles from 1995 to 2015 through a structured search of government websites, Portuguese online newspapers and PubMed and Virtual Health Library (Biblioteca Virtual em Saúde (BVS)) databases; key informants were consulted to validate and complement the documentary search.Results: The challenges faced by decision-makers to ensure access to physicians were identified as a forecasted shortage of physicians, geographical imbalances and maldistribution of physicians by level of care. To date, no human resources for health policy has been formulated, in spite of most documents reviewed stating that it is needed. On the other hand, various isolated and ad hoc strategies have been adopted, such as incentives to choose family health as a specialty or to work in an underserved region and recruitment of foreign physicians through bilateral agreements.Conclusions: Health workforce research in Portugal is scarce, and therefore, policy decisions regarding the availability and accessibility of physicians are not based on evidence. The policy interventions described in this paper should be evaluated, which would be a good starting point to inform health workforce policy development. [ABSTRACT FROM AUTHOR]

Background: Human resources for health represent an essential component of health systems and play a key role to accelerate progress towards universal health coverage. Many countries in sub-Saharan Africa face challenges regarding the availability, distribution and performance of health workers, which could be in part addressed by providing effective financial incentives. Methods: Based on an overview of the existing literature, the paper highlights the gaps in the existing research in low-income countries exploring the different components of health workers' incomes. It then proposes a novel approach to the analysis of financial incentives and delineates a research agenda, which could contribute to shed light on this topic. Findings: The article finds that, while there is ample research that investigates separately each of the incomes health workers may earn (for example, salary, fee-for-service payments, informal incomes, "top-ups" and per diems, dual practice and non-health activities), there is a dearth of studies which look at the health workers' "complex remuneration", that is, the whole of the financial incentives available. Little research exists which analyses simultaneously all revenues of health workers, quantifies the overall remuneration and explores its complexity, its multiple components and their features, as well as the possible interaction between income components. However, such a comprehensive approach is essential to fully comprehend health workers' incentives, by investigating the causes (at individual and system level) of the fragmentation in the income structure and the variability in income levels, as well as the consequences of the "complex remuneration" on motivation and performance. This proposition has important policy implications in terms of devising effective incentive packages as it calls for an active consideration of the role that "complex remuneration" plays in determining recruitment, retention and motivation patterns, as well as, more broadly, the performance of health systems. Conclusions: This paper argues that research focusing on the health workers' "complex remuneration" is critical to address some of the most challenging issues affecting human resources for health. An empirical research agenda is proposed to fill the gap in our understanding. [ABSTRACT FROM AUTHOR]

Background: Health workforce planning is based on estimates of future needs for and supply of health care services. Given the pipeline time lag for the training of health professionals, inappropriate workforce planning or policies can lead to extended periods of over- or under-supply of health care providers. Often these policy interventions focus on one determinant of supply and do not incorporate other determinants such as changes in population health which impact the need for services. The aim of this study is to examine the effect of the implementation of various workforce policies on the estimated future requirements of the GP workforce, using South Australia as a case study. This is examined in terms of the impact on the workforce gap (excess or shortage), the cost of these workforce policies, and their role in addressing potential non-policy-related future scenarios.Methods: An integrated simulation model for the general practice workforce in South Australia was developed, which determines the supply and level of services required based on the health of the population over a projection period 2013-2033. The published model is used to assess the effects of various policy and workforce scenarios. For each policy scenario, associated costs were estimated and compared to baseline costs with a 5% discount rate applied.Results: The baseline scenario estimated an excess supply of GPs of 236 full-time equivalent (FTE) in 2013 but this surplus decreased to 28 FTE by 2033. The estimates based on single policy scenarios of role substitution and increased training positions continue the surplus, while a scenario that reduces the number of international medical graduates (IMGs) recruited estimated a move from surplus to shortage by 2033. The best-case outcome where the workforce achieves balance by 2023 and remains balanced to 2033, arose when GP participation rates (a non-policy scenario) were combined with the policy levers of increased GP training positions and reduced IMG recruitment. The cost of each policy varied, with increased role substitution and reduced IMG recruitment resulting in savings (AUD$752,946,586 and AUD$3,783,291 respectively) when compared to baseline costs. Increasing GP training costs over the projection period would cost the government an additional AUD$12,719,798.Conclusions: Over the next 20 years, South Australia's GP workforce is predicted to remain fairly balanced. However, exogenous changes, such as increased demand for GP services may require policy intervention to address associated workforce shortfalls. The workforce model presented in this paper should be updated at regular intervals to inform the need for policy intervention. [ABSTRACT FROM AUTHOR]

Background: In Nigeria, several challenges have been reported within the health sector, especially in training, funding, employment, and deployment of the health workforce. We aimed to review recent health workforce crises in the Nigerian health sector to identify key underlying causes and provide recommendations toward preventing and/or managing potential future crises in Nigeria.Methods: We conducted a scoping literature search of PubMed to identify studies on health workforce and health governance in Nigeria. A critical analysis, with extended commentary, on recent health workforce crises (2010-2016) and the health system in Nigeria was conducted.Results: The Nigerian health system is relatively weak, and there is yet a coordinated response across the country. A number of health workforce crises have been reported in recent times due to several months' salaries owed, poor welfare, lack of appropriate health facilities and emerging factions among health workers. Poor administration and response across different levels of government have played contributory roles to further internal crises among health workers, with different factions engaged in protracted supremacy challenge. These crises have consequently prevented optimal healthcare delivery to the Nigerian population.Conclusions: An encompassing stakeholders' forum in the Nigerian health sector remain essential. The national health system needs a solid administrative policy foundation that allows coordination of priorities and partnerships in the health workforce and among various stakeholders. It is hoped that this paper may prompt relevant reforms in health workforce and governance in Nigeria toward better health service delivery in the country. [ABSTRACT FROM AUTHOR]

Background: This study sought to better understand the drivers of skilled health professional migration, its consequences, and the various strategies countries have employed to mitigate its negative impacts. The study was conducted in four countries-Jamaica, India, the Philippines, and South Africa-that have historically been "sources" of health workers migrating to other countries. The aim of this paper is to present the findings from the Indian portion of the study.Methods: Data were collected using surveys of Indian generalist and specialist physicians, nurses, midwives, dentists, pharmacists, dieticians, and other allied health therapists. We also conducted structured interviews with key stakeholders representing government ministries, professional associations, regional health authorities, health care facilities, and educational institutions. Quantitative data were analyzed using descriptive statistics and regression models. Qualitative data were analyzed thematically.Results: Shortages of health workers are evident in certain parts of India and in certain specialty areas, but the degree and nature of such shortages are difficult to determine due to the lack of evidence and health information. The relationship of such shortages to international migration is not clear. Policy responses to health worker migration are also similarly embedded in wider processes aimed at health workforce management, but overall, there is no clear policy agenda to manage health worker migration. Decision-makers in India present conflicting options about the need or desirability of curtailing migration.Conclusions: Consequences of health work migration on the Indian health care system are not easily discernable from other compounding factors. Research suggests that shortages of skilled health workers in India must be examined in relation to domestic policies on training, recruitment, and retention rather than viewed as a direct consequence of the international migration of health workers. [ABSTRACT FROM AUTHOR]

Background: Dramatic increases in the migration of human resources for health (HRH) from developing countries like the Philippines can have consequences on the sustainability of health systems. In this paper, we trace the outflows of HRH from the Philippines, map out its key causes and consequences, and identify relevant policy responses.Methods: This mixed method study employed a decentered, comparative approach that involved three phases: (a) a scoping review on health workers' migration of relevant policy documents and academic literature on health workers' migration from the Philippines; and primary data collection with (b) 37 key stakeholders and (c) household surveys with seven doctors, 329 nurses, 66 midwives, and 18 physical therapists.Results: Filipino health worker migration is best understood within the context of macro-, meso-, and micro-level factors that are situated within the political, economic, and historical/colonial legacy of the country. Underfunding of the health system and un- or underemployment were push factors for migration, as were concerns for security in the Philippines, the ability to practice to full scope or to have opportunities for career advancement. The migration of health workers has both negative and positive consequences for the Philippine health system and its health workers. Stakeholders focused on issues such as on brain drain, gain, and circulation, and on opportunities for knowledge and technology transfer. Concomitantly, migration has resulted in the loss of investment in human capital. The gap in the supply of health workers has affected the quality of care delivered, especially in rural areas. The opening of overseas opportunities has commercialized health education, compromised its quality, and stripped the country of skilled learning facilitators. The social cost of migration has affected émigrés and their families. At the household level, migration has engendered increased consumerism and materialism and fostered dependency on overseas remittances. Addressing these gaps requires time and resources. At the same time, migration is, however, seen by some as an opportunity for professional growth and enhancement, and as a window for drafting more effective national and inter-country policy responses to HRH mobility.Conclusions: Unless socioeconomic conditions are improved and health professionals are provided with better incentives, staying in the Philippines will not be a viable option. The massive expansion in education and training designed specifically for outmigration creates a domestic supply of health workers who cannot be absorbed by a system that is underfunded. This results in a paradox of underservice, especially in rural and remote areas, at the same time as underemployment and outmigration. Policy responses to this paradox have not yet been appropriately aligned to capture the multilayered and complex nature of these intersecting phenomena. [ABSTRACT FROM AUTHOR]

Background: Well-trained, well-distributed and productive health workers are crucial for access to high-quality, cost-effective healthcare. Because neither a shortage nor a surplus of health workers is wanted, policymakers use workforce planning models to get information on future labour markets and adjust policies accordingly. A neglected topic of workforce planning models is productivity growth, which has an effect on future demand for labour. However, calculating productivity growth for specific types of input is not as straightforward as it seems. This study shows how to calculate factor technical change (FTC) for specific types of input.Methods: The paper first theoretically derives FTCs from technical change in a consistent manner. FTC differs from a ratio of output and input, in that it deals with the multi-input, multi-output character of the production process in the health sector. Furthermore, it takes into account substitution effects between different inputs. An application of the calculation of FTCs is given for the Dutch hospital industry for the period 2003-2011. A translog cost function is estimated and used to calculate technical change and FTC for individual inputs, especially specific labour inputs.Results: The results show that technical change increased by 2.8% per year in Dutch hospitals during 2003-2011. FTC differs amongst the various inputs. The FTC of nursing personnel increased by 3.2% per year, implying that fewer nurses were needed to let demand meet supply on the labour market. Sensitivity analyses show consistent results for the FTC of nurses.Conclusions: Productivity growth, especially of individual outputs, is a neglected topic in workforce planning models. FTC is a productivity measure that is consistent with technical change and accounts for substitution effects. An application to the Dutch hospital industry shows that the FTC of nursing personnel outpaced technical change during 2003-2011. The optimal input mix changed, resulting in fewer nurses being needed to let demand meet supply on the labour market. Policymakers should consider using more detailed and specific data on the nature of technical change when forecasting the future demand for health workers. [ABSTRACT FROM AUTHOR]

Background: Evidence-based health workforce policies are essential to ensure the provision of high-quality health services and to support the attainment of universal health coverage (UHC). This paper describes the main characteristics of available health workforce data for 74 of the 75 countries identified under the 'Countdown to 2015' initiative as accounting for more than 95% of the world's maternal, newborn and child deaths. It also discusses best practices in the development of health workforce metrics post-2015.Methods: Using available health workforce data from the Global Health Workforce Statistics database from the Global Health Observatory, we generated descriptive statistics to explore the current status, recent trends in the number of skilled health professionals (SHPs: physicians, nurses, midwives) per 10 000 population, and future requirements to achieve adequate levels of health care in the 74 countries. A rapid literature review was conducted to obtain an overview of the types of methods and the types of data sources used in human resources for health (HRH) studies.Results: There are large intercountry and interregional differences in the density of SHPs to progress towards UHC in Countdown countries: a median of 10.2 per 10 000 population with range 1.6 to 142 per 10 000. Substantial efforts have been made in some countries to increase the availability of SHPs as shown by a positive average exponential growth rate (AEGR) in SHPs in 51% of Countdown countries for which there are data. Many of these countries will require large investments to achieve levels of workforce availability commensurate with UHC and the health-related sustainable development goals (SDGs). The availability, quality and comparability of global health workforce metrics remain limited. Most published workforce studies are descriptive, but more sophisticated needs-based workforce planning methods are being developed.Conclusions: There is a need for high-quality, comprehensive, interoperable sources of HRH data to support all policies towards UHC and the health-related SDGs. The recent WHO-led initiative of supporting countries in the development of National Health Workforce Accounts is a very promising move towards purposive health workforce metrics post-2015. Such data will allow more countries to apply the latest methods for health workforce planning. [ABSTRACT FROM AUTHOR]

Background: People with disabilities face challenges accessing basic rehabilitation health care. In 2006, the United Nations Convention on the Rights of Persons with Disabilities (CRPD) outlined the global necessity to meet the rehabilitation needs of people with disabilities, but this goal is often challenged by the undersupply and inequitable distribution of rehabilitation workers. While the aggregate study and monitoring of the physical rehabilitation workforce has been mostly ignored by researchers or policy-makers, this paper aims to present the 'challenges and opportunities' for guiding further long-term research and policies on developing the relatively neglected, highly heterogeneous physical rehabilitation workforce.Methods: The challenges were identified through a two-phased investigation. Phase 1: critical review of the rehabilitation workforce literature, organized by the availability, accessibility, acceptability and quality (AAAQ) framework. Phase 2: integrate reviewed data into a SWOT framework to identify the strengths and opportunities to be maximized and the weaknesses and threats to be overcome.Results: The critical review and SWOT analysis have identified the following global situation: (i) needs-based shortages and lack of access to rehabilitation workers, particularly in lower income countries and in rural/remote areas; (ii) deficiencies in the data sources and monitoring structures; and (iii) few exemplary innovations, of both national and international scope, that may help reduce supply-side shortages in underserved areas.Discussion: Based on the results, we have prioritized the following 'Six Rehab-Workforce Challenges': (1) monitoring supply requirements: accounting for rehabilitation needs and demand; (2) supply data sources: the need for structural improvements; (3) ensuring the study of a whole rehabilitation workforce (i.e. not focused on single professions), including across service levels; (4) staffing underserved locations: the rising of education, attractiveness and tele-service; (5) adapt policy options to different contexts (e.g. rural vs urban), even within a country; and (6) develop international solutions, within an interdependent world.Conclusions: Concrete examples of feasible local, global and research action toward meeting the Six Rehab-Workforce Challenges are provided. Altogether, these may help advance a policy and research agenda for ensuring that an adequate rehabilitation workforce can meet the current and future rehabilitation health needs. [ABSTRACT FROM AUTHOR]

Background: Increasing the availability of health workers in remote and rural areas through improved health workforce recruitment and retention is crucial to population health. However, information about the costs of such policy interventions often appears incomplete, fragmented or missing, despite its importance for the sound selection, planning, implementation and evaluation of these policies. This lack of a systematic approach to costing poses a serious challenge for strong health policy decisions.Methods: This paper proposes a framework for carrying out a costing analysis of interventions to increase the availability of health workers in rural and remote areas with the aim to help policy decision makers. It also underlines the importance of identifying key sources of financing and of assessing financial sustainability.The paper reviews the evidence on costing interventions to improve health workforce recruitment and retention in remote and rural areas, provides guidance to undertake a costing evaluation of such interventions and investigates the role and importance of costing to inform the broader assessment of how to improve health workforce planning and management.Results: We show that while the debate on the effectiveness of policies and strategies to improve health workforce retention is gaining impetus and attention, there is still a significant lack of knowledge and evidence about the associated costs. To address the concerns stemming from this situation, key elements of a framework to undertake a cost analysis are proposed and discussed.Conclusions: These key elements should help policy makers gain insight into the costs of policy interventions, to clearly identify and understand their financing sources and mechanisms, and to ensure their sustainability. [ABSTRACT FROM AUTHOR]

Background: The purpose of this paper is to present a complex yet transparent, computable model to simulate the regulation of the flow of personnel through a previously described multipleentry, multiple-exit eye care training scheme linked to the health workforce. This methodology should be a useful tool for the planner; it can address changes and feedbacks over time and be sensitive to any unexpected consequences of the interactions. The same model template can be applied to calculate the finances associated with the personnel flow. Presentation of the hypothesis: The worth of any model or set of concepts of human resources for health is considerably enhanced by actual field application. However, implementation involves the selection of one set of parameters and a large, long-term commitment of resources. A far less expensive and time-consuming, yet still effective, method of testing assumptions and ideas would be to simulate their application using a variety of possible inputs, structural configurations and/or desired outcomes. To that end, this paper presents a computable, dynamic model of personnel flows within a health system. Testing the hypothesis: Some testing of the model has been demonstrated in a previous paper. However, the value of the model is that all stakeholders can enter their own data and parameter assumptions and readily review the outcomes. Implications of the hypothesis: The complex yet easy-to-use model presented in this paper opens the debate on current and future policy to any stakeholder. A very wide range of scenarios can be considered and a selected option can be monitored and changed dynamically over time. [ABSTRACT FROM AUTHOR]

The study of the health workforce has gained in prominence in recent years, as the dynamic interconnections between human resource issues and health system effectiveness have come into sharper focus. This paper reviews lessons relating to strategic management challenges emerging from the growing literature in this area. Workforce issues are strategic: they affect overall system performance as well as the feasibility and sustainability of health reforms. Viewing workforce issues strategically forces health authorities to confront the yawning gaps between policy and implementation in many developing countries. Lessons emerge in four areas. One concerns imbalances in workforce structure, whether from a functional specialization, geographical or facility lens. These imbalances pose a strategic challenge in that authorities must attempt to steer workforce distribution over time using a limited range of policy tools. A second group of lessons concerns the difficulties of central-level steering of the health workforce, often critically weak due to the lack of proper information systems and the complexities of public sector decentralization and service commercialization trends affecting the grassroots. A third cluster examines worker capacity and motivation, often shaped in developing countries as much by the informal norms and incentives as by formal attempts to support workers or to hold them accountable. Finally, a range of reforms centering on service contracting and improvements to human resource management are emerging. Since these have as a necessary (but not sufficient) condition some flexibility in personnel practices, recent trends towards the sharing of such functions with local authorities are promising. The paper identifies a number of current lines of productive research, focusing on the relationship between health policy reforms and the local institutional environments in which the workforce, both public and private, is deployed. [ABSTRACT FROM AUTHOR]

Background: Despite a global recognition from all stakeholders of the gravity and urgency of health worker shortage in Africa, little progress has been achieved to improve health worker coverage in many of the African human resources for health (HRH) crisis countries. The problem consists in how policy is made, how leaders are accountable, how the World Health Organization (WHO) and foreign donors encourage (or distort) health policy, and how development objectives are prioritized in these countries.Methods: This paper uses political economy analysis, which stems from a recognition that the solution to the shortage of health workers across Africa involves more than a technical response. A number of institutional arrangements dampen investments in HRH, including a mismatch between officials' tenure in office and program results, the vertical nature of health programming, the modalities of Overseas Development Assistance (ODA) in health, the structures of the global health community, and the weak capacity in HRH units within Ministries of Health. A major change in policymaking would only occur with a disruption to the political or institutional order.Results/conclusions: The case study of Ethiopia, who has increased its health workforce dramatically over the last 20 years, disrupted previous institutional arrangements through the power of ideas-HRH as a key intermediate development objective. The framing of HRH created the rationale for the political commitment to HRH investment. Ethiopia demonstrates that political will coupled with strong state capacity and adequate resource mobilization can overcome the institutional hurdles above. Donors will follow the lead of a country with long-term political commitment to HRH, as they did in Ethiopia. [ABSTRACT FROM AUTHOR]

Background: This paper describes a rapid assessment of Cambodia's current system for regulating its health professions. The assessment forms part of a co-design process to set strategic priorities for strengthening health profession regulation to improve the quality and safety of health services. A health system approach for strengthening health professions' regulation is underway and aims to support the Government of Cambodia's plans for scaling up its health workforce, improving health services' safety and quality, and meeting its Association of South East Asian Nations (ASEAN) obligations to facilitate trade in health care services.Methods: The assessment used a mixed methods approach including: A desktop review of key laws, plans, reports and other documents relating to the regulation of the health professions in Cambodia (medicine, dentistry, midwifery, nursing and pharmacy); Key informant interviews with stakeholders in Cambodia (The term "stakeholders" refers to government officials, people working on health professional regulation, people working for the various health worker training institutions and health workers at the national and provincial level); Surveys and questionnaires to assess Cambodian stakeholder knowledge of regulation; Self-assessments by members of the five Cambodian regulatory councils regarding key capacities and activities of high-performing regulatory bodies; and A rapid literature review to identify: The key functions of health professional regulation; The key issues affecting the Cambodian health sector (including relevant developments in the wider ASEAN region); and "Smart" health profession regulation practices of possible relevance to Cambodia.Results: We found that the current regulatory system only partially meets Cambodia's needs. A number of key regulatory functions are being performed, but overall, the current system was not designed with Cambodia's specific needs in mind. The existing system is also overly complex, with considerable duplication and overlap between governance and regulatory arrangements for the five regulated professions.Conclusions: There is considerable scope for reform to the current regulatory system to better align the system to Cambodia's: Current needs and circumstances; Health system strategic priorities; and International obligations. Cambodia is also well placed to base its reformed regulatory system on recent developments of "smart regulatory practices" for health professionals. [ABSTRACT FROM AUTHOR]

In this paper, we analyse the medical specialty training system in Spain (the so-called "residency system"). In order to do so, we a) summarize its historical evolution; b) describe the five major architectural pillars on which the system is currently based; c) analyse the special contract of the specialist-in-training; d) discuss the three major challenges for the medical specialist training future: the evolution and expansion of the residency system to other health professions, the issue of grouping specialties with a common core trunk and the continuity of the learning process; and e) draw four conclusions that may be relevant for those who are in the process of developing or revising their own medical specialization systems. [ABSTRACT FROM AUTHOR]

Background: The health systems in the Americas region are characterized by fragmentation and segmentation, which constitute an important barrier to expanding coverage, achieving integrated primary health care, and reducing inefficiency and discontinuity of care. An assessment of the human resources for health (HRH) programmes that have been implemented at the country level was developed as part of the measurement of the 20 HRH regional goals for 2007-2015, adopted in 2007 by the Pan American Sanitary Conference (CSPA). Methods: The exercise was a combination of academic research and the development/application of an advocacy tool involving policy makers and stakeholders to influence the decision-making in the development, implementation, or change of HRH programmes while building evidence through a structured approach based on qualitative and quantitative information and the exchange and dissemination of best practices. Results: This paper covers the methodological challenges, as well as a summary of the main findings of the study, which included 15 countries: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama in the Central America, Dominican Republic in the Caribbean, Chile, Colombia, Ecuador and Peru in the Andean sub region, and Argentina, Paraguay, and Uruguay in the South Cone. Despite the different contexts, the results showed that the programmes evaluated faced common challenges, such as lack of political support and financial unsustainability. Conclusions: The evaluation process allowed the exchange and dissemination of practices, interventions, and programmes currently running in the region. A shared lesson was the importance of careful planning of the implementation of programmes and interventions. The similarities in the problems and challenges of HRH among the participating countries highlighted the need for a cooperation programme on the evaluation and assessment of implementation strategies in the Americas region. [ABSTRACT FROM AUTHOR]

Background: Most African countries are facing a human resources for health (HRH) crisis, lacking the required workforce to deliver basic health care, including care for mothers and children. This is especially acute in rural areas and has limited countries' abilities to meet maternal, newborn, and child health (MNCH) targets outlined by Millennium Development Goals 4 and 5. To address the HRH challenges, evidence-based deployment and training policies are required. However, the resources available to country-level policy makers to create such policies are limited. To inform future HRH planning, a scoping review was conducted to identify the type, extent, and quality of evidence that exists on HRH policies for rural MNCH in Africa. Methods: Fourteen electronic health and health education databases were searched for peer-reviewed papers specific to training and deployment policies for doctors, nurses, and midwives for rural MNCH in African countries with English, Portuguese, or French as official languages. Non-peer reviewed literature and policy documents were also identified through systematic searches of selected international organizations and government websites. Documents were included based on pre-determined criteria. Results: There was an overall paucity of information on training and deployment policies for HRH for MNCH in rural Africa; 37 articles met the inclusion criteria. Of these, the majority of primary research studies employed a variety of qualitative and quantitative methods. Doctors, nurses, and midwives were equally represented in the selected policy literature. Policies focusing exclusively on training or deployment were limited; most documents focused on both training and deployment or were broader with embedded implications for the management of HRH or MNCH. Relevant government websites varied in functionality and in the availability of policy documents. Conclusions: The lack of available documentation and an apparent bias towards HRH research in developed areas suggest a need for strengthened capacity for HRH policy research in Africa. This will result in enhanced potential for evidence uptake into policy. Enhanced alignment between policy-makers' information needs and the independent research agenda could further assist knowledge development and uptake. The results of this scoping review informed an indepth analysis of relevant policies in a sub-set of African countries. [ABSTRACT FROM AUTHOR]

Background: Ghana is one of the sub-Saharan African countries making significant progress towards universal access to quality healthcare. However, it remains a challenge to attain the 2015 targets for the health related Millennium Development Goals (MDGs) partly due to health sector human resource challenges including low staff motivation. Purpose: This paper addresses indicators of health worker motivation and assesses associations with quality care and patient safety in Ghana. The aim is to identify interventions at the health worker level that contribute to quality improvement in healthcare facilities. Methods: The study is a baseline survey of health workers (n = 324) in 64 primary healthcare facilities in two regions in Ghana. Data collection involved quality care assessment using the SafeCare Essentials tool, the National Health Insurance Authority (NHIA) accreditation data and structured staff interviews on workplace motivating factors. The Spearman correlation test was conducted to test the hypothesis that the level of health worker motivation is associated with level of effort by primary healthcare facilities to improve quality care and patient safety. Results: The quality care situation in health facilities was generally low, as determined by the SafeCare Essentials tool and NHIA data. The majority of facilities assessed did not have documented evidence of processes for continuous quality improvement and patient safety. Overall, staff motivation appeared low although workers in private facilities perceived better working conditions than workers in public facilities (P <0.05). Significant positive associations were found between staff satisfaction levels with working conditions and the clinic's effort towards quality improvement and patient safety (P <0.05). Conclusion: As part of efforts towards attainment of the health related MDGs in Ghana, more comprehensive staff motivation interventions should be integrated into quality improvement strategies especially in government-owned healthcare facilities where working conditions are perceived to be the worst. [ABSTRACT FROM AUTHOR]

Background Globally, abundant opportunities exist for policymakers to improve the accessibility of rural and remote populations to primary health care through improving workforce retention. This paper aims to identify and quantify the most important factors associated with rural and remote Australian family physician turnover, and to demonstrate how evidence generated by survival analysis of health workforce data can inform rural workforce policy making. Methods A secondary analysis of longitudinal data collected by the New South Wales (NSW) Rural Doctors Network for all family physicians working in rural or remote NSW between January 1st 2003 and December 31st 2012 was performed. The Prentice, Williams and Peterson statistical model for survival analysis was used to identify and quantify risk factors for rural NSW family physician turnover. Results Multivariate modelling revealed a higher (2.65-fold) risk of family physician turnover in small, remote locations compared to that in small closely settled locations. Family physicians who graduated from countries other than Australia, United Kingdom, United States of America, New Zealand, Ireland, and Canada also had a higher (1.45-fold) risk of turnover compared to Australian trained family physicians. This was after adjusting for the effects of conditional registration. Procedural skills and public hospital admitting rights were associated with a lower risk of turnover. These risks translate to a predicted median survival of 11 years for Australian-trained family physician non-proceduralists with hospital admitting rights working in small coastal closely settled locations compared to 3 years for family physicians in remote locations. Conclusions This study provides rigorous empirical evidence of the strong association between population size and geographical location and the retention of family physicians in rural and remote NSW. This has important policy ramifications since retention grants for rural and remote family physicians in Australia are currently based on a geographical 'remoteness' classification rather than population size. In addition, this study demonstrates how survival analysis assists health workforce planning, such as through generating evidence to assist in benchmarking 'reasonable' lengths of practice in different geographic settings that might guide service obligation requirements. [ABSTRACT FROM AUTHOR]

Background: This paper reports on progress in implementing human resources for health (HRH) policies in Brazil, in the context of the implementation and expansion of the Unified Health System (Sistema Unico de Saúde - SUS).The three main objectives were: i) to reconstruct the chronology of long term HRH change in Brazil, and to identify and discuss the precursors, drivers, and enablers for these changes over a long time period; (ii) to examine how change was achieved by describing facilitators and constraints, and how policies were adapted to deal with the latter; and (iii) to report on the current situation and draw policy implications.Methods: A mixed methods approach was used. A literature review was conducted using pre-defined keywords; and stakeholders were contacted and asked to provide relevant information, data and policy reports.Results: There are two key features of HRH change which are related to the implementation of SUS which merit attention: the achievement of staffing growth, and the improvement in HRH policy making and management. Staff growth rates across the period have been high enough to exceed population growth rates. As a consequence, the ratio of staff to population has improved. In 1990 the physician ratio per 1000 inhabitants was 1.12. In 2007, it was 1.74. Another critical factor in achieving staffing growth has been HRH policy making capacity and influence within the political establishment.Conclusions: Policies have had to adapt to changing circumstances, whilst focusing on sequential improvements aimed at achieving long term goals. The end objectives, of improving care and access to care, have been kept in view. No one Ministry could secure all the resources and impetus for change that has been required, hence the need for inter-ministry, inter-governmental and inter-agency collaboration, and the development of alliances of shared interest. Across the period of thirty years or more, not all initiatives have been equally successful, but a momentum has been maintained. There was no single long term plan or strategy, but in Brazil this has enabled the progress to be adapted and re-oriented as the broader context changed over the years. [ABSTRACT FROM AUTHOR]

Background: There is a lack of evidence to inform policy development on the reasons why health professionals migrate. Few studies have sought to empirically determine factors influencing the intention to migrate and none have explored the relationship between factors. This paper reports on the first international attempt to investigate the migration intentions of pharmacy students and identify migration factors and their relationships. Methods: Responses were gathered from 791 final-year pharmacy students from nine countries: Australia, Bangladesh, Croatia, Egypt, Portugal, Nepal, Singapore, Slovenia and Zimbabwe. Data were analysed by means of Principal Components Analysis (PCA) and two-step cluster analysis to determine the relationships between factors influencing migration and the characteristics of subpopulations most likely and least likely to migrate. Results: Results showed a significant difference in attitudes towards the professional and sociopolitical environment of the home country and perceptions of opportunities abroad between those who have no intention of migrating and those who intend to migrate on a long-term basis. Attitudes of students planning short-term migration were not significantly different from those of students who did not intend to migrate. These attitudes, together with gender, knowledge of other migrant pharmacists and past experiences abroad, are associated with an increased propensity for migration. Conclusion: Given the influence of the country context and environment on migration intentions, research and policy should frame the issue of migration in the context of the wider human resource agenda, thus viewing migration as one form of attrition and a symptom of other root causes. Remuneration is not an independent stand-alone factor influencing migration intentions and cannot be decoupled from professional development factors. Comprehensive human resource policy development that takes into account the issues of both remuneration and professional development are necessary to encourage retention. [ABSTRACT FROM AUTHOR]

Background: Anticipating physician supply to tackle future health challenges is a crucial but complex task for policy planners. A number of forecasting tools are available, but the methods, advantages and shortcomings of such tools are not straightforward and not always well appraised. Therefore this paper had two objectives: to present a typology of existing forecasting approaches and to analyse the methodology-related issues. Methods: A literature review was carried out in electronic databases Medline-Ovid, Embase and ERIC. Concrete examples of planning experiences in various countries were analysed. Results: Four main forecasting approaches were identified. The supply projection approach defines the necessary inflow to maintain or to reach in the future an arbitrary predefined level of service offer. The demand-based approach estimates the quantity of health care services used by the population in the future to project physician requirements. The needs-based approach involves defining and predicting health care deficits so that they can be addressed by an adequate workforce. Benchmarking health systems with similar populations and health profiles is the last approach. These different methods can be combined to perform a gap analysis. The methodological challenges of such projections are numerous: most often static models are used and their uncertainty is not assessed; valid and comprehensive data to feed into the models are often lacking; and a rapidly evolving environment affects the likelihood of projection scenarios. As a result, the internal and external validity of the projections included in our review appeared limited. Conclusion: There is no single accepted approach to forecasting physician requirements. The value of projections lies in their utility in identifying the current and emerging trends to which policy-makers need to respond. A genuine gap analysis, an effective monitoring of key parameters and comprehensive workforce planning are key elements to improving the usefulness of physician supply projections. [ABSTRACT FROM AUTHOR]

Imbalance in the health workforce is a major concern in both developed and developing countries. It is a complex issue that encompasses a wide range of possible situations. This paper aims to contribute not only to a better understanding of the issues related to imbalance through a critical review of its definition and nature, but also to the development of an analytical framework. The framework emphasizes the number and types of factors affecting health workforce imbalances, and facilitates the development of policy tools and their assessment. Moreover, to facilitate comparisons between health workforce imbalances, a typology of imbalances is proposed that differentiates between profession/specialty imbalances, geographical imbalances, institutional and services imbalances and gender imbalances. [ABSTRACT FROM AUTHOR]

Background: In the face of rising demand for medical services due to ageing populations, physician migration flows are increasingly affecting the supply of physicians in Organisation for Economic Cooperation and development (OECD) countries. This paper offers an integrated perspective on the impact of physician migration on home and host countries and discusses international regulation and policy approaches governing physician migration. Methods: Information about migration flows, international regulation and policies governing physician migration were derived from two questionnaires sent to OECD countries, a secondary analysis of EUROSTAT Labour Force Surveys, a literature review and official policy documents of OECD countries. Results: OECD countries increasingly perceive immigration of foreign physicians as a way of sustaining their physician workforce. As a result, countries have entered into international agreements regulating physician migration, although their success has been limited due to the imposition of licensing requirements and the protection of vested interests by domestic physicians. OECD countries have therefore adopted specific policies designed to stimulate the immigration of foreign physicians, whilst minimising its negative impact on the home country. Measures promoting immigration have included international recruitment campaigns, less strict immigration requirements and arrangements that foster shared learning between health care systems. Policies restricting the societal costs of physician emigration from developing countries such as good practice guidelines and taxes on host countries have not yet produced their expected effect or in some cases have not been established at all. Conclusions: Although OECD countries generally favour long-term policies of national selfsufficiency to sustain their physician workforce, such policies usually co-exist with short-term or medium-term policies to attract foreign physicians. As this is likely to continue, there is a need to create a global framework that enforces physician migration policies that confer benefits on home and host countries. In the long term, OECD countries need to put in place appropriate education and training policies rather than rely on physician migration to address their future needs. [ABSTRACT FROM AUTHOR]

Background: For any wide-ranging effort to scale up health-related priority interventions, human resources for health (HRH) are likely to be a key to success. This study explores constraints related to human resources in the health sector for achieving the Millennium Development Goals (MDGs) in low-income countries. Methods and framework: The analysis drew on information from a variety of publicly-available sources and principally on data presented in published papers in peer-reviewed journals. For classifying HRH constraints an analytical framework was used that considers constraints at five levels: individual characteristics, the health service delivery level, the health sector level, training capacities and the sociopolitical and economic context of a country. Results and discussion: At individual level, the decision to enter, remain and serve in the health sector workforce is influenced by a series of social, economic, cultural and gender-related determinants. For example, to cover the health needs of the poorest it is necessary to employ personnel with specific social, ethnic and cultural characteristics. At health-service level, the commitment of health staff is determined by a number of organizational and management factors. The workplace environment has a great impact not only on health worker performance, but also on the comprehensiveness and efficiency of health service delivery. At health-sector level, the use of monetary and nonmonetary incentives is of crucial importance for having the accurate skill mix at the appropriate place. Scaling up of priority interventions is likely to require significant investments in initial and continuous training. Given the lead time required to produce new health workers, such investments must occur in the early phases of scaling up. At the same time coherent national HRH policies are required for giving direction on HRH development and linking HRH into health-sector reform issues, the scaling-up of priority interventions, poverty reduction strategies, and training approaches. Multisectoral collaboration and the sociopolitical and economic context of a country determine health sector workforce development and potential emigration. Conclusions: Key determinants of success for achieving international development goals are closely related to human-resource development. [ABSTRACT FROM AUTHOR]

This paper reviews the challenges facing the public health workforce in developing countries and the main policy issues that must be addressed in order to strengthen the public health workforce. The public health workforce is diverse and includes all those whose prime responsibility is the provision of core public health activities, irrespective of their organizational base. Although the public health workforce is central to the performance of health systems, very little is known about its composition, training or performance. The key policy question is: Should governments invest more in building and supporting the public health workforce and infrastructure to ensure the more effective functioning of health systems? Other questions concern: the nature of the public health workforce, including its size, composition, skills, training needs, current functions and performance; the appropriate roles of the workforce; and how the workforce can be strengthened to support new approaches to priority health problems. The available evidence to shed light on these policy issues is limited. The World Health Organization is supporting the development of evidence to inform discussion on the best approaches to strengthening public health capacity in developing countries. WHO's priorities are to build an evidence base on the size and structure of the public health workforce, beginning with ongoing data collection activities, and to map the current public health training programmes in developing countries and in Central and Eastern Europe. Other steps will include developing a consensus on the desired functions and activities of the public health workforce and developing a framework and methods for assisting countries to assess and enhance the performance of public health training institutions and of the public health workforce. [ABSTRACT FROM AUTHOR]

Inequitable distribution of doctors with high concentration in urban cities negatively affects the public health objective of Health for All. Thus it is one of the main concerns for most health policy makers, particularly in developing countries. This paper aims to summarize strategies to solve inequitable distribution of human resources for health (HRH) between urban and rural areas, by using four decades of experience in Thailand as a case study for analysis. [ABSTRACT FROM AUTHOR]

Background: Pre-eclampsia is one of the leading causes of maternal death in Mozambique. Limited access to health care facilities and a lack of skilled health professionals contribute to the high maternal morbidity and mortality rates in Mozambique and indicate a need for community-level interventions. The aim of this review was to identify and characterise health policies related to the role of CHWs in the management of pre-eclampsia and eclampsia in Mozambique.Methods: The policy review was based on three methods: a desk review of relevant documents from the Mozambique Ministry of Health (n = 7), contact with 28 key informants in the field of health policy in Mozambique (n = 5) and literature review (n = 699). Policy documents obtained included peer-reviewed articles, government and institutional policies, reports and action plans. Seven hundred and eleven full-text documents were assessed for eligibility and included based on pre-defined criteria. Qualitative analysis was done to identify main themes using content analysis.Results: A total of 56 papers informed the timeline of key events. Three main themes were identified from the qualitative review: establishment of the community health worker programme and early challenges, revitalization of the CHW programme and the integration of maternal health in the community health tasks. In 1978, following the Alma Alta Declaration, the Mozambique government brought in legislation establishing primary health care and the CHW programme. Between the late 1980s and early 1990s, this programme was scaled down due to several factors including a prolonged civil war; however, the decision to revitalise the programme was made in 1995. In 2010, a revitalised programme was re-launched and expanded to include the management of common childhood illnesses, detection of warning signs of pregnancy complications, referrals for maternal health and basic health promotion. To date, their role has not included management of emergency conditions of pregnancy including pre-eclampsia and eclampsia.Conclusion: The role of CHWs has evolved over the last 40 years to include care of childhood diseases and basic maternal health counselling. Studies to assess the impact of CHWs in providing services to reduce maternal morbidity and mortality are recommended. [ABSTRACT FROM AUTHOR]

Background: From 2006, the Association of South East Asian Nations (ASEAN) has been developing Mutual Recognition Arrangements (MRAs) across key professions, including medicine, dentistry and nursing, that would facilitate the development of an ASEAN Economic Community, with shared regional standards and easier mobility of the workforce. This paper examines the interface between those agreements and the registration, professional education and mobility of health personnel in Cambodia.Methods: This qualitative health policy analysis combined documentary and policy review with key informant interviews with 16 representatives of agencies relevant to the development and implementation of the MRAs in health. Thematic analysis identified three themes: registration, education and mobility.Results: Cambodia is an active participant in the ASEAN MRA processes for doctors, dentists and nurses reporting progress annually. Education of health professionals has been increasingly formalised in the past 25 years, with nursing moving towards a 4-year bachelor degree. The private university sector has substantially increased, with English increasingly used as a language of instruction. Recent legislation provides for enforcement through fines and/or imprisonment to ensure all practising health professionals hold initial registration as a health professional and a renewable licence to practise as a health practitioner. Continuing Professional Development is a mandatory requirement for licence renewal. This is consistent with the MRA guidelines, though the capacity for enforcement appears limited. The Medical Council of Cambodia (MCC), and more recently, the Dental and Nursing Councils, have introduced continuing professional development initiatives, using them strategically as a positive reinforcer of registration. Midwifery education and registration in Cambodia does not conform with ASEAN guidelines. In education, course durations in medicine and dentistry are longer than regional counterparts, though anxiety around maintaining clinical standards has resulted in the introduction of a National Exit Examination and reluctance to abbreviate courses. The introduction of reforms appears to reference regional standards, though parity is still some way off. Mobility at present is infrequent and more likely to result from informal mechanisms than through the MRA mechanisms.Conclusion: The Royal Government of Cambodia is committed to the ASEAN MRA process. Developments in registration appear to use regional standards as benchmarks, as do reforms in the education of health professionals, though domestic factors appear to more directly impact on developments. Informal mechanisms facilitate the limited mobility currently occurring, with little formal application of the MRA provisions evident at this point. [ABSTRACT FROM AUTHOR]

Background: This paper arises from a four-country study that sought to better understand the drivers of skilled health worker migration, its consequences, and the strategies countries have employed to mitigate negative impacts. The four countries-Jamaica, India, the Philippines, and South Africa-have historically been "sources" of skilled health workers (SHWs) migrating to other countries. This paper presents the findings from South Africa.Methods: The study began with a scoping review of the literature on health worker migration from South Africa, followed by empirical data collected from skilled health workers and stakeholders. Surveys were conducted with physicians, nurses, pharmacists, and dentists. Interviews were conducted with key informants representing educators, regulators, national and local governments, private and public sector health facilities, recruitment agencies, and professional associations and councils. Survey data were analyzed using descriptive statistics and regression models. Interview data were analyzed thematically.Results: There has been an overall decrease in out-migration of skilled health workers from South Africa since the early 2000s largely attributed to a reduced need for foreign-trained skilled health workers in destination countries, limitations on recruitment, and tighter migration rules. Low levels of worker satisfaction persist, although the Occupation Specific Dispensation (OSD) policy (2007), which increased wages for health workers, has been described as critical in retaining South African nurses. Return migration was reportedly a common occurrence. The consequences attributed to SHW migration are mixed, but shortages appear to have declined. Most promising initiatives are those designed to reinforce the South African health system and undertaken within South Africa itself.Conclusions: In the near past, South Africa's health worker shortages as a result of emigration were viewed as significant and harmful. Currently, domestic policies to improve health care and the health workforce including innovations such as new skilled health worker cadres and OSD policies appear to have served to decrease SHW shortages to some extent. Decreased global demand for health workers and indications that South African SHWs primarily use migratory routes for professional development suggest that health worker shortages as a result of permanent migration no longer pertains to South Africa. [ABSTRACT FROM AUTHOR]