Having long suffered "woeful neglect," 
the study of the health workforce is enjoying increased interest in
recent years, to judge by the growing range of research being conducted
across a variety of sub-fields. This paper plumbs recent work on the
health workforce for insights into one of its important, though often
implicit, cross-cutting themes: the need for, and current weaknesses
in, the strategic management of the health workforce in
developing countries. After exploring the nature of 'strategic'
management in the health sector, I group ten lessons into four areas:
workforce structure, the 'steering' of the workforce, drivers of
behavior at the facility level and approaches to improving the
performance of human resources. The paper also sketches questions
likely to preoccupy researchers in this area in the coming years.
What is 'strategic' about the health workforce?
One conclusion of a growing number of case studies and policy analyses of the health workforce concerns the strategic nature
of health workforce issues, in several senses. The workforce, arguably
the most important input to any health system, has a strong impact on
overall health system performance [2,3].
Health sectors in developing countries have faced a wide variety of
systemic pressures in recent years. Although the specifics vary by
country setting, these have often included pressures towards
marketization of health services , civil service restructuring , decentralization [6,7]
and an overall trend towards increasing geographical and socioeconomic
disparities in many countries. The feasibility and sustainability of
reforms introduced in these systems relies heavily on the level of
'buy-in' and well-being of health sector personnel at all levels. As
West put it in her review of the National Health System in Britain:
"The quality of patient care may be related in an important way to the
quality of life experienced by staff at work" .
The health workforce is also strategic in that almost any type of desired reform outcome depends on specific changes in workforce behavior throughout
the system, and such behavior is profoundly affected by a range of
factors that are not directly under the control of central and local
authorities. Understanding and changing negative phenomena at the local
level – such as illegal user charges or drug overprescription – depends
on an understanding of the effective incentives faced by grassroots
service providers. Studying how health personnel are likely to respond
to new rules, roles, responsibilities and resources is thus essential
for gauging the feasibility of reform interventions.
'Strategic' management implies a more coordinated, systematic policy
approach to the workforce based on a clear situation analysis and
linked to at least a medium-term vision of desired outcomes for the
health sector as a whole [9,10].
Constraints on strategic management, which is both capacity- and
strategy-intensive, often stem in developing country settings from
particularly short policy horizons and weak implementation capacities [11,12].
While the literature on the health workforce is still poorly
developed in relation to other aspects of health care, a range of case
studies in recent years has yielded valuable insights regarding
patterns and challenges of strategic management in the sector. Ten
lessons stand out.
Structural aspects of the health workforce
1. Imbalances in workforce structure are both a symptom of underlying problems and a cause of poor health system performance
Several recent studies have cast new light on the 'old' problem of imbalances in the health workforce [13-16]. One contribution has been to systematic categories of imbalances, including:
• Overall supply/demand: In theory, workforce numbers
should be determined by specific objectives set by policymakers for the
health sector and by the demand for health services. In practice, a
number of factors – such as variations in the historical production of
the workforce, and the long time lag between training and deployment of
health personnel – can intervene. It is commonly thought that the
public health sectors of many countries suffer from a surplus of
workers who are not particularly productive; hence a focus in a number
of countries on downsizing the labor force.
• Profession/specialty: Imbalances in this area concern the
distribution of doctors, nurses, paraprofessionals and other health
personnel. One generalization from the public health literature is that
systems often underinvest in the production of paraprofessionals,
nurses and assistant doctors relative to the expensive education of
• Geographic: Developing countries are often said to suffer
from 'urban bias' – a situation in which the political and economic
forces of a country reinforce provision of services and investments in
urban areas, reinforcing disparities in access to health services and
in health outcomes .
This can also influence the distribution of health personnel away from
rural and remote areas that tend to be poorer. However, there may be a
tension between concentrating staff in more densely populated areas
(which may be better off) as opposed to poorer remote areas. This
reflects a broader trade-off often encountered between equity and
efficiency in health care.
• Institutional imbalances: These include the question of
how to deploy staff between curative and preventive functions of the
health sector, as well as their distribution at various tiers and
facilities of the system .
• Public/private imbalance: Most systems have some mix of
public and private personnel, and countries are arrayed somewhere along
a continuum in terms of their distribution among these poles. To imply
that there is an imbalance is to say that some important function of
the health system is being underperformed because of the distribution
of personnel along this pole. A typical example would be public health
missions that are suffering from a lack of trained personnel or
• Gender and ethnic imbalances: Since the Alma Ata summit
which gave a major boost to the concept of primary health care, a key
idea has been that the health sector should be democratic, and the
health personnel should be representative of the population. An
imbalance in this area would suggest that workforce demographics fail
to reflect important variations (in ethnicity or gender) of the client
populations, with the implication that such populations are being
The notion of "workforce imbalance" is a subjective appraisal; there
is no inherent equilibrium point for any of the variables above. That
will depend on context, objectives and values. The broader, strategic
issue concerns the means health authorities have at their disposal for
intervening in order to affect workforce imbalances. Such means are
often considerably weaker than authorities realize, not least due to an
overreliance on administrative norms and centrally dictated quotas for
workforce production and deployment, often badly out of alignment with
transitioning, decentralizing countries .
Shifting roles of the center and local governments in health workforce issues
The issue of the health workforce is complex partly because of the
great number of actors and stakeholders involved. Much of the
literature on the workforce deals with the issue of the mix of roles
and responsibilities between different levels of government, which have
been in some transition due to decentralization.
2. Capacities for strategic workforce planning in Ministries of Health are often critically weak
Information systems relating to the workforce are typically sketchy , and planning is technical rather than strategic in nature, 
for instance leaving "key questions about the distribution,
qualifications, motivation, development, and performance of staff
One consequence of this is that central-level steering of the health
workforce and the behavior of personnel at local levels is often
surprisingly weak, as noted above [5,22].
If the primary instruments employed by the central level to steer the
health system are laws, regulations and administrative norms, the
literature notes large gaps between policy and local implementation. A
study of China's health sector highlights the "difficulties involved in
efforts to influence provider behavior through a national level
legislative framework in a situation of decentralization of control
over those providers, due to extreme regional variation in economic
situations and limited resource inputs from the centre" .
Such difficulties are highlighted when, as in China, only some 30% of
health worker salaries is paid by the central government .
The balancing act Ministries of Health must walk is between being
overly prescriptive (and thus developing rules that are inappropriate
for particular local conditions) and issuing guidelines too general to
be of use. Where the policy-implementation gap is overcome, it is
usually due to the development of "specific guidelines developed by
organizations of health professionals or other advisory bodies" for the
implementation of health laws and policies "to bridge the gap between
legal theory and everyday practice" .
3. Provinces can potentially play an important role in human
resource management, but they are often constrained by overly
centralized health systems
The ability of provinces and local
governments in general to contract, hire, promote and fire human
resources is a major determinant of the flexibility of any health
system and on the viability efforts to promote improved responsiveness
(the "short route to accountability", in the World Bank's phrase ) between local service providers and the end users of services.
Yet, as suggested by Table 1,
taking several countries in East and Southeast Asia as a sample,
control over hiring and firing of workers is rather limited in a number
of countries, even those with fairly advanced stages of
decentralization (such as Indonesia and the Philippines). Some
countries in which donors play a strong role (as in Cambodia) have
introduced greater flexibility in local government contracting of
health staff, something that "provides the opportunity for signatories
to negotiate mutually agreed activities, funding and outputs for
specific health programmes" .
Yet decentralization of such powers can lead to health workforce
"fragmentation", and can pose a "threat to workers' well-being" if it
negatively affects (as in Uganda) professionalism, career mobility and
the timeliness of salary payments" .
Thus some analysts point towards a "tension between the objective of
increasing efficiency and local government autonomy, on the one hand,
and the quality and equity benefits of a uniform national service cadre
with vertical mobility, on the other" .
Table 1. Sub-national influence in human resource management in East Asia
Worker capacity, motivation, and performance
The academic literature on the workforce focuses much attention onto
the linkages between the conditions in which health personnel work and
their performance. One useful way of thinking about how to boost
workforce capacity to perform at a high level is to think of what the
workforce 'can do' (what skills and training enables people to do) and
what the workforce 'will do' (feels motivated and empowered to do).
Such an institutional analysis is essential to understanding policy
implementation gaps in the sector.
4. On the 'can do' side, workers are often unprepared to take on
their new functions in more complex systems, especially when these
systems are decentralizing
Typical training of health personnel
emphasizes factual, specialist medical knowledge. But much of what
public personnel actually must do to fulfil their functions involves
higher-order analysis, supervision and inspection, coordination across
multiple actors (including both local authorities and communities) and
a range of managerial tasks . Table 2
gives one example of tasks assigned typically to district-level health
managers. The literature notes that district managers, in particular,
feel and in reality are poorly supported in many of these functions.
District health managers are often found to be particularly weak in
systems management (community involvement and intersectoral
co-operation), monitoring activities and the systematic organization of
meetings. One study notes that district managers are "rarely involved
in the identification of priority health problems or of high-risk
groups, and fail to use health service indicators sufficiently for the
analysis of the district health system" .
Table 2. Common tasks of district-level health managers
of the complexity of the managerial environments in which health
personnel must function comes from the multiple sources of
accountability to which they are subject .
Managers and personnel at the grassroots must balance the demands of
"those responsible for specific policies, such as reproductive health
policies, and those responsible for managing the integrated delivery of
all policies, with their resultant contestations over authority and
They must also manage the increasing commercialization of services that
is an important feature of many developing country health sectors [4,30].
5. On the "will do" side of worker motivation, the literature
emphasizes the importance of considering a broad range of factors that
affect worker motivation
These can be understood in terms of
metaphorical 'daylight' and 'shadow-side' factors, distinguished by the
degree to which they are amenable to intervention by the health
authorities (and easily accessible to researchers). Both obvious
"daylight" factors such as worker terms of service and managerial
supervision can affect worker motivation and behaviour; but the hidden
or 'shadow' side of organizational life and worker motivation must also
be recognized (see figure 1).
It includes the value sets of workers (which are influenced both by
professional norms, social ideas about the professional roles workers
are playing and by the broader organizational culture of the civil
Figure 1. Factors affecting worker motivation and behavior.
shadow side also includes the availability of livelihood strategies and
alternatives. Whether health workers are 'over-' or 'under-paid,'
relative to some external standard – and debate on how to approach this
issue continues in the literature 
– is not the sole point. Rather, health workers, like all other workers
will gauge the need and possibility of earning additional income
(including any risks associated with it) when considering the effort
they put into discharging their official responsibilities. Of course,
the shadow and daylight sides are interlinked:
...confirmation and even salary are forms of recognition as well as
ways of satisfying lower order needs such as survival and security. But
environmental factors may affect which order (lower level survival
needs or higher level desire for recognition) is most prominent. The
poorer the satisfaction of basic terms of service factors, the less
likely higher order incentives are to be central .
6. On both "can" and "will do" measures, the institutional
environments in which many health workers work can be more disabling
Incentives for positive performance of the health
workforce are reported to be very weak across a range of developing
country health sectors, both from the 'daylight' and 'shadow' sides of
the health facility environment.
On the 'daylight' side, workers may feel they have little to gain
from working hard or being responsive to either their clients or
superiors. Poor career paths and promotion opportunities lead to health
workers feeling 'stuck', while official salaries often cover only part
of a worker's needs or overall income (given alternative livelihood
strategies, such as engaging in part-time private sector health
services or entirely different informal occupations) .
Also on the 'daylight' side, a range of functions related to both
performance management (by which is meant the systematic communication
of job expectations followed by regular performance reviews) and
strategic personnel planning ("the creation of new types of jobs,
re-profiling of old ones or the addition or abolishing of staff
positions in accordance with need")  – is found to be weak or typically non-existent .
The Cambodian case is typical: "sub-national units have no effective
system of performance management for individuals or work units with no
system for linking individual performance to the goals and functions of
the organization or for rewarding appropriate initiatives and behaviour".
Part of the reason performance management is rare in public services in
developing countries is that "its prerequisites (such as a living wage
for health workers, and the availability to them of drugs, equipment
and transport) are often missing" .
When the health sector is severely underresourced it is difficult to
hold people accountable for how they do their jobs. Also, workers often
feel disempowered by the narrow range of authority they are granted in
conducting their jobs and by their lack of consultation regarding major
reform efforts affecting their jobs. Even in systems undergoing
significant administrative decentralization, there is often a
disjunction between formal responsibilities and requisite resources to
meet minimum specified standards – a classic recipe for workforce
frustration and for the failure of decentralization reforms .
The 'shadow' side of organizations is also often found to undermine
morale in the health sector. The informal norms and work ethics of
frontline civil servants in more remote localities can be oriented more
towards alternative livelihood strategies and "muddling through" than
they are towards high standards of service delivery .
A sense of professionalism can be difficult to maintain especially in
remote areas, particularly where staff feel the commitment of central
and local authorities to the sector, and social expectations regarding
their performance, are weak .
7. The collective impact of weak institutional environments at the
facility level can be a strong determinant of health sector performance
note that even in well-resourced facilities, doctor training and
experience tend to be weakly correlated with the quality of care
provided, which is taken by analysts to mean,
... not that physicians are unimportant for quality but that
organisational context is far more important in setting limits (upper
and lower) for physicians than formerly recognised. Medical staff
organisation– including peer review, selection and continued review of
new staff members, and participation in policy making committees–have
also been shown to be positively related to quality of patient care .
Approaches to boosting workforce performance
8. Despite the difficulties noted above, the literature identifies
a number of characteristics of high-performing health facilities and
Such organizations share the following characteristics .
• A strong sense of mission and sense of commitment to that mission by staff.
• A relatively high level of prestige and social status accorded to those who work in the organization.
• A culture oriented towards results both individually and
organizationally. All members of the group are evaluated against
performance objectives regularly and are expected, both by managers and
by co-workers, to pull their weight; and the organization itself
constantly evaluates its performance against external objectives and
• Lines of feedback from the end users of services are open and actively used to improve service delivery.
What is striking in the literature is the notion that organizational culture can be as critical as the direct monetary incentives of the workforce .
While pay and job security are clearly important determinants of
morale, many organizations in developing countries have been able to
significantly improve performance by cultivating a participatory, open,
performance-oriented culture in which the workforce is deployed.
The literature also stresses that allowing "some autonomy in
personnel matters" is an essential facilitative condition for
developing the organizational performance culture noted above .
A review of high-performing public organizations in developing
countries found that they enjoyed autonomy to "identify positions,
advertise for candidates, establish routines for hiring people to fill
positions, promote people on the basis of organizationally defined
standards and priorities, and punish those who did not meet these
Recent trends towards the sharing of some personnel management
functions with local authorities and facility managers (as shown in
Table 1) are promising in this regard, although a number of enabling factors will be necessary to support and reorient such functions .
There is no doubt that it is possible to improve health sector
performance in developing countries using these reform approaches, as
attested by several documented case studies .
However, the health sector has some special challenges that make it
important to apply reform efforts with care, as attested in the final
two points addressing popular approaches to health sector reform.
9. Decentralization is no panacea for the health sector; it will
not strengthen accountability and performance unless factors supporting
high performance are put into place
Decentralization has been in
vogue in developing countries for over two decades, but there is no
evidence in the growing literature on health sector decentralization
that decentralization reliably increases sector performance [6,40]. A review of TB control in Nepal concludes that decentralization
...can lead to inequity, political manipulation, fragmentation,
increased bureaucratic costs and the overall weakening of the public
sector...and affects the incentives and career prospects of health
staff. This complexity raises serious questions regarding the 'why',
'what' and 'how' of decentralisation .
The important lesson in managing the process of health sector
decentralization is "to ensure that the newly empowered organization is
required to deliver clearly identifiable and measurable objectives. At
the same time the organization is given the necessary resources and
discretion over their use, to permit these objectives to be met" .
The conceptual shift that is required is to examine what approaches and
parts of decentralization work in which local contexts, and to adjust
the decentralizing reform to match this .
10. Approaches to improving performance that focus on increasing
competitive pressures on health facilities run the risk of undermining
core public health functions and values
The curative and
preventive sides of public service provision typically cannot be
delinked; the incentives of providers who often must attend to both
sets of functions are affected by increasing pressures in the area of
curative care .
It is in general hypothesized in the literature that 'what gets
measured gets done', and even more so 'what gets paid gets done'; thus,
if the material incentives shift towards curative health provision, it
is likely that managerial and staff attention will be focused there as
well. An overemphasis on revenue generation often leads to declining
access by the poor as well as overproduction of health services. This
effect may be particularly pronounced in transition settings such as
China and Vietnam [18,30,43,44];
one case study in China found that the introduction of output-related
bonuses for doctors increased "unnecessary care," drug sales and
inpatient admission rates .
Moreover, in most countries the curative and preventive sides of
health financing are linked in multiple ways. For example, in a
decentralized, commercialized health sector, implementation support for
preventive functions may be increasingly financed out of local
government budgets (which can vary dramatically) or even facility-level
revenues . This may accentuate disparities between facilities that are capable of such supplementation and those that are not.
Competitive pressures may be part of the reform mix. The move to
contract out service provision, even for preventive health functions
such as health information, to providers who are paid on the basis of
concrete outputs and outcomes is one example of a promising approach . But taken as a whole the literature can hardly be said to be optimistic.