Achieving change

A review of the literature shows a surprisingly common view about how human resources for health might be better addressed. Two key themes – the need for a systemic approach and the need to involve stakeholders – are summarised here. 

Taking a systemic approach to human resources problems

In the section the systemic aspects of human resource management are explored. The following three references give some suggestions about how this aspect of human resources can be addressed.

In response to an identification of weaknesses in human resources in the health sector, a paper Human resources for health policies: a critical component in health policies presents proposals on how the policy process is conducted in the development of HRH. The development of the health workforce is concluded to be a crucial part of the health policy development process. To achieve success, further input is required in order to attain the provision of effective, efficient, accessible, viable and high-quality services by personnel. These services should be present in sufficient numbers and appropriately allocated across different occupations and geographical regions. The proposals to achieve the changes required include:

• to move beyond the traditional approach of personnel administration to a more global concept of human resources management (HRM)
• to give more weight to the integrated, interdependent and systemic nature of the different components of HRM when preparing and implementing policy
• to foster a more proactive attitude among human resources (HR) policy-makers and managers
• to promote the full commitment of all professionals and sectors in all phases of the process.

The paper highlights four crucial conditions that will be required to assist in successful implementation of the proposals: institutional/technical capacities, political feasibility, social acceptability and affordability. 
 

Involving stakeholders in addressing human resources issues

The ideal process for addressing human resources can best be summarised by considering the attached diagram. [box 1]

Key stakeholders get together – the stakeholders will depend on local circumstances but might include, the Ministry of Health, the Ministry of Finance, the Ministry of Education, the Civil Service Commission, representatives of professionals and other staff, and academic institutions.

Analyse the situation – understanding the situation in the context of the system is important and helps determine what needs to be done

Agreeing priority issues – there will often be too many issues to address all at once and it will be important therefore to address those considered to be most important

Identify local solutions – this is where experience from elsewhere might help Government decide what approaches might be adopted.

Agree interventions – the solutions have to locally determined and designed

Implement interventions – a plan for implementation will help

Feedback to analyse the problems - this feedback is crucial for two reasons: the system is complex and unexpected results may arise, and secondly because of this it is important to build capacity in the problem solving process itself

The blue boxes in the diagram ("analysing the situation" and "technical assistance") are the activities where the development partners for Government have tended to provide support. It perhaps would be more effective for development partners to support the process itself. The Pan American Health Organization has done just that in its Human Resource Observatories initiative in the Americas, as described in Development and strengthening of human resources management in the health services. The initiative now covers 20 countries.

In the WHO discussion paper Achieving the right balance: the role of policy-making processes in managing human resources for health problems, the authors propose an explanation for the gap between policy formulation and implementation in human resource for health and uses a WHO framework for correcting what is proposed to be an imbalance between the many complex components and dynamics that form human resources for health policies (HRH). The paper is built upon a hypothesis that countries that successfully implement HRH policies and as a result ameliorate HRH problems are those that:

• adjust the specific HRH strategies to meet the demands of their country's health sector reforms, the political/macroeconomic context, and government administrative policies
• use policy-making processes that are consultative, "owned by the country", based on sound data, and supported by adequate human and financial resources. In other words, to achieve the right balance (number, type, distribution) in a country's health workforce may also require striking the right balance between context-appropriate strategies (content) and organizational change mechanisms (process).

In HR and new approaches to public sector management: improving HRM capacity, Stephen Bach reviews HR issues in health sector reform, and explores how new approaches to HR management in health provision can enable reform. The evidence on the impact of HR capacity on health sector effectiveness indicates that:

• HR issues should be treated as central to the reform process, and be taken into account from the outset.
• Attention needs to be paid to the process of reforms as well as to their content; the timing of planned change and the involvement of different stakeholders can be crucial to successful implementation.
• How human resources have been managed in the past, and the institutions and incentives that have developed from these systems, will impact on the success of reform.
• More effective HR management involves going beyond narrow issues of pay and training to considering the broader incentives and systems for encouraging and managing good performance.

Arriving at clear, universal principles to guide HR management in all health sectors can be difficult: health systems vary widely, and models of HR practice tend to focus on individual firms rather than complex national systems like health provision. However, three general principles can be arrived at to guide the development of effective HR strategy:

• Ownership: an effective HR strategy must be owned by key stakeholders, including ministry officials, trade unions and staff. The use of widely-agreed mission statements and corporate values, and clear messages about the goals of HR strategy can help foster ownership.
• External fit: HR strategy should be in line with the external health policy environment if it is to be effective. Crucially, HR strategy should be developed as part of the organisation’s overall policies and agendas, rather than as a separate means of quantifying the numbers of staff needed at different levels.
• Internal fit: personnel policies need to be internally consistent if they are to be effective. Competency frameworks can help ensure ‘internal fit‘, by linking HR needs to the attitudes and behaviour of staff.