https://www.who.int/surgery/global_volume_surgery.pdf

An estimation of the global volume of surgery: a modelling strategy based on available data

An estimation of the global volume of surgery : a modelling strategy based on available data. Commentary

There is a crisis in human resources for health care, with a chronic and global shortage of well-trained health workers, most acutely felt in those countries where they are most needed, says Dr Lee Jong-Wook, the World Health Organization (WHO) Secretary General, in his foreword to the 2006 World Health Report (WHO, 2006). People, he says, are the vital ingredient in strengthening health care systems, but the solution is not straightforward; nor is there a consensus about how to proceed. Health care workers around the world, says the report, are experiencing increasing stress and insecurity, exacerbated by concentrations of population in urban areas and migration from the poorest to the richest countries, compounded where the skills of limited yet expensive professionals are ill-matched to the profile of local health care needs. That crisis has the potential to deepen in coming years as demand for services escalates in countries facing lower fertility and ageing populations. It has been recognized for some time that the shift from acute tertiary hospital care to patient-centred, home-based and team-driven care will require new skills and collaboration between workers and with patients. In particular a team approach is required to respond to the needs of individuals with chronic conditions and to address challenges in public health. Therefore health care employers and managers need to pay attention to building teams if they are to meet the challenges and targets of the future. Care for patients with chronic conditions must be organized and coordinated over time among providers and across settings, sharing power with patients and working with community groups. Outcomes will then improve, asserts the WHO in a related report (WHO, 2005). It argues that health care providers must work interdependently, demonstrating mutual respect, trust, support and appreciation of each discipline’s unique contribution. They must reconcile abstract notions of ‘‘public health’’ while responding to patients’ pressing needs and concerns. The report enunciates core competencies required for working with patients with chronic conditions: patient-centred care; partnering; quality improvement; information and communication technology; and a public health perspective. To dismiss these reports as merely re-treading familiar ground would be to miss their point. The force of their argument lies in the broad consensus of informed opinion that they represent, endorsed by the evidence that they muster. The case for concerted action is compelling and the challenge for readers of this Journal plain: to demonstrate how interprofessional education and practice development can and does help to deliver the required outcomes, as another WHO report argued so persuasively almost 20 years ago (WHO, 1988). We have learned much during the intervening years about means to ends in interprofessional education, which may well help to realize the WHO goals. But our credibility, and our capacity to respond to the needs where they are greatest, depends crucially upon our readiness, coming as we do overwhelmingly from developed countries, Journal of Interprofessional Care, January 2007; 21(1): 1 – 2

Working together for health.

Health workforce needs-based shortages and skill mix imbalances are significant health workforce challenges. Task shifting, defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training, is a potential strategy to address these challenges. This study uses an economics perspective to review the skill mix literature to determine its strength of the evidence, identify gaps in the evidence, and to propose a research agenda. Studies primarily from low-income countries published between 2006 and September 2010 were found using Google Scholar and PubMed. Keywords included terms such as skill mix, task shifting, assistant medical officer, assistant clinical officer, assistant nurse, assistant pharmacist, and community health worker. Thirty-one studies were selected to analyze, based on the strength of evidence. First, the studies provide substantial evidence that task shifting is an important policy option to help alleviate workforce shortages and skill mix imbalances. For example, in Mozambique, surgically trained assistant medical officers, who were the key providers in district hospitals, produced similar patient outcomes at a significantly lower cost as compared to physician obstetricians and gynaecologists. Second, although task shifting is promising, it can present its own challenges. For example, a study analyzing task shifting in HIV/AIDS in sub-Saharan Africa noted quality and safety concerns, professional and institutional resistance, and the need to sustain motivation and performance. Third, most task shifting studies compare the results of the new cadre with the traditional cadre. Studies also need to compare the new cadre's results to the results from the care that would have been provided--if any care at all--had task shifting not occurred. Task shifting is a promising policy option to increase the productive efficiency of the delivery of health care services, increasing the number of services provided at a given quality and cost. Future studies should examine the development of new professional cadres that evolve with technology and country-specific labour markets. To strengthen the evidence, skill mix changes need to be evaluated with a rigorous research design to estimate the effect on patient health outcomes, quality of care, and costs.

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Health workforce skill mix and task shifting in low income countries: a review of recent evidence

Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review.

A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance.

When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.

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Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review

The World Health Report 2006 - Working together for health contains an expert assessment of the current crisis in the global health workforce and ambitious proposals to tackle it over the next ten years starting immediately The report reveals an estimated shortage of almost 43 million doctors midwives nurses and support workers worldwide The shortage is most severe in the poorest countries especially in sub-Saharan Africa where health workers are most needed Focusing on all stages of the health workers career lifespan from entry to health training to job recruitment through to retirement the report lays out a ten-year action plan in which countries can build their health workforces with the support of global partners

Van Lerberghe W

Papers

Working together for health. The World Health Report 2006.