- Strategic management of the health workforce in developing countries: what have we learned?

Figure 2 lays out some of the central components of research concerning the strategic management of health workers in developing countries. It highlights core dimensions of workforce issues, corresponding roughly to three types of policy instruments that health policymakers have at their disposal to manage the workforce 'strategically':

Figure 2. Dimensions of health workforce research.

• Structural issues such as the recruitment and distribution of workers (policy instruments: direct investment in the production of the workforce and regulations governing their distribution);

• Management and motivation issues (policy instruments: organizational reforms, management and supervisory patterns and workforce terms of service); and

• Private sector environment (policy instruments: regulation and standard setting).

In addition to emphasizing this menu of policy choices, the framework is meant to highlight the external factors that impact on actual performance. 'External', from a health policymakers' perspective, includes both policies that originate from outside the sector – such as decentralization and public administration reform – and changing social expectations and development levels and patterns, including increased disparities throughout a country. The combined effect of these factors, including on that upon the workforce, leads to overall health sector performance, which eventually leads to particular health impacts (although these are not directly addressed here). Ideally, the system should be able to learn over time how to adjust policies and projects to achieve a more positive impact. Important questions on which some productive areas of current research on strategic workforce management are likely to continue can be situated in the figure. For example:

• What kinds of impacts are environmental and policy changes originating outside the sector having on the health workforce?

• What do these changes imply for effectiveness of different mechanisms and interventions employed by health authorities to steer and coordinate workforce issues?

• How can the health sector take advantage and avoid the risks of public sector decentralization trends? How will the roles of the central-level authorities in workforce management be changing in this process?

• How can we assess facility-level determinants of motivation and high performance, including the impact of various types of accountability mechanisms, in order to influence workforce motivation in ways that can be implemented in highly resource-constrained environments?

• What effect are private sector forces having on the set of incentives of the public health workforce? Furthermore, how can the private sector workforce itself be more effectively regulated and made to synergize to the maximum extent possible with that of the public sector?

Three additional aspects of the figure deserve mention. First, policymakers control some but not all of the levers necessary to improve health sector performance. In addition to policies, the broader institutional environment affecting local service delivery is important to consider. Second, policies can have both intended and unintended consequences on the workforce. For instance, efforts to increase competitive pressures by boosting managerial and financial autonomy of facilities can have unintended side-effects on workforce performance; these are important to analyze. Finally, the impacts of any health sector reform in large, heterogeneous countries are likely to be mixed, and a key focus of health analysts should be on the attempt to explain the resulting patterns.

Efforts to study the health workforce will likely continue to gain in prominence, and are likely to figure more prominently in the next ten years than they have in recent decades. Within the growing number of case studies and analytical reviews, the issue of what makes for effective strategic management of the health workforce deserves continued attention, particularly in developing country settings.

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