As I sit at home under lockdown due to the current pandemic, whilst watching the events unfold through 24 hr news, it is evident that the neglect by governments of Human Resources for Health is now being revealed. The situation with insufficient numbers of staff, insufficiently equipped and trained is clear.
It is equally clear that the results of years of lack of attention and lip service to Public Health services including staffing is now being revealed as a major problem.
The issue of the increased number of outbreaks of zoonotic diseases and the potential for a pandemic have been forecasted. Perhaps the currently most circulated and prophetic forecast is that of Bill Gates in 2015 in a Ted Talks presentation “The Next Outbreak? We’re not ready.” It is evident that lessons from other major epidemics such as SARS, Ebola etc, were ignored or were not taken seriously.
The front line in this pandemic are the first responders such as the health worker, who are inadequately protected due to the lack of safety equipment even masks and gloves. The mortality rate amongst health workers is high. Governments are recalling retired health professionals who most probably have not had the training to deal with situations such as this, or, who’s knowledge is out of date.
For the first time developed countries are facing the problems that continually afflict less developed countries, such as lack of, or maldistribution of staff, inability or inequality in provision of the most basic requirements to do the job safely. In the meantime, politicians continue to spout meaningless numbers whilst the complete inadequacy of ability to provide equitable distribution of Personal Protective Equipment (PPE) and testing equipment is hourly being revealed by 24-hour news.
Whilst focus has been on government hospitals, the dire situation of COVID-19 related deaths in retirement homes is now being revealed. We are being informed of positive cases being returned to their residential homes where staff do not have the PPE to deal with positive cases putting both staff and other residents at risk.
There is immense global appreciation and admiration being demonstrated by the general public in most countries for the frontline workers of all health services. This is demonstrated in each country weekly and is covered widely by the media.
One such example is in the UK where a 99 year-old World War 2 Veteran survived the virus and, on discharge from hospital, wished to show his appreciation of the health workers. Encouraged by his family, using a walking frame, he aimed to raise GBP1000 by walking 1000 laps of his garden. This effort, with the help of the media, went viral and he raised a staggering 29 million pounds for the National Health Service.
This outpouring of support from the general public of their wish to express their gratitude and support the frontline health workers who are putting their lives on the line must be harnessed. It must be used to put pressure on politicians to realistically and practically improve the approach to Human Resources for Health. It is essential to prevent governments from slipping back to “more of the same” flawed systems and letting things lurch on until the next pandemic, repeating all the same mistakes. There will be a short window period to do this before the general public forget and politicians conveniently forget and just concentrate on the next election.
Once this pandemic is over, the entire health systems must be reviewed and there are many HR issues that must be addressed the most important of which are:
- Review and revision of training
- Adequate, appropriately distributed staff that is appropriately equipped for the job they must do.
- Adequate funding.
1. Review and revision of training.
In many countries there is a lack of, or very weak, linkages between Ministries of Health and Education. Training institutions frequently train health professionals based on international model curricula and not what is required for the job they must do within their own country context. They are trained in correct clinical procedures but not taught to adapt the procedures safely in the common situation of lack of supplies and equipment in the health facilities where they are posted. Feedback from decentralised level in many countries informs that new graduates require more than the normal supervision and mentoring requiring intensive in-service training to be given almost immediately.
The Ministry of Health (MOH) as the consumer of the product must define the product they require from pre-service training. The Ministry of Education (MOE) as the producer of the product must follow the specifications of the MOH and produce the defined product of training.
The move towards Degree Nursing has become increasingly academic to the detriment of teaching Clinical Skills. In many countries it is difficult to get experienced clinicians to teach in institutions resulting in the top graduates who have weak clinical skills being sent to train as teachers. This then results in those “taught by the book, then teaching by the book”. In some regions of the world graduates from Degree Nursing programmes claim to be managers and are not prepared to put their hands on a patient. Degree Programmes have also been replacing more clinically practical diploma level programmes which are being phased out.
Following the Pandemic there must be a very thorough review of the curricula to identify:
- Does health professional and allied training meet the actual needs of the health service in these evolving health scenarios?
- Have we got the correct cadres with the appropriate clinical skills?
- What are the essential skills required?
- What are the skills that require to be strengthened?
- What are non-essential skills?
- How effectively is nosocomial infection taught?
- How is Public Health taught?
This analysis equally applies to other frontline health workers? Medical supplies staff, cleaners, drivers, volunteers (general and health) as these workers frequently work with the most vulnerable groups such as the elderly. Lack of orientation to these volunteers and carers and lack of PPE can put them and the people they assist in danger.
2. Workforce Planning and Distribution.
Workforce planning has traditionally been based on facility- based planning and ratios, which plans on equal numbers of staff of each cadre for each type of facility. However, this has not taken onto account the demographic, environmental and geographical factors which affect the workload of individual facilities. This approach, combined with weak HR management and supervision, has continued to perpetuate maldistribution and low motivation of health personnel.
The use of workload analysis methodology resulted in development of the WHO Workload Indicators of Staffing Needs (WISN). It is in essence a time and motion study. However instead of the industrial use of the methodology, whereby supervisors with stopwatches in factories timed repetitive actions on a conveyor belt. Efforts to apply this to health care provision in the 1970s was strongly resisted by health professionals. This was because the time given to each case they dealt with did not fit with the “conveyor belt” concept as each patient was different.
This WISN methodology, developed by Peter Shipp in 1998, taking the time and motion study method but involving the staff who are actually doing the work to assess the time it takes for their activities, relate it to their workload using annual health statistics and calculate their staffing needs. It was introduced to countries with minimal success as it was applied form “top down”. It was found that the language was complex, and its lack of “user-friendliness” resulted in difficulties in translation and consequent misinterpretation. Based on experiences in several countries, the WISN methodology was revised to a more user-friendly format including an added WISN software and country examples.
Experience in Indonesia of using WISN from “bottom up” proved immensely powerful. When health workers at the front line of health services, namely health centre level, were trained in WISN there were many unexpected outcomes. Analysis of the results and discussion with managers, who accepted and acted on these results greatly raised motivation whereby staff in isolated health centres reviewed and revised their working practice and developed their own goals and targets for health service delivery.
Support of use of this methodology in the post- COVID-19 period through involving the front line staff to provide input to calculate their staffing needs in individual facilities would not only be a motivational but also an acknowledgement that they as qualified and experienced practitioners can provide evidence of their staffing needs to avoid replicating the previous methods leading to maldistribution.
Along with this the input of the staff themselves regarding future provision of supplies and equipment for their facilities and service units can be beneficial to ensure they can work safely and effectively.
The feeding of this evidence from bottom up to the top will ensure regional and national planning is more appropriate than the blanket approaches of top down planning.
3. Adequate funding for HR System.
Human Resources are the most expensive resource of any health service and has been given the least attention. I personally liken HRD to a “Cinderella service”. Expensive training is frequently unlinked to the actual health service delivery required in a country due to the gap between Education and Health Ministries. Lack of planning of training of the different cadres is unlinked to the needs of the health service, resulting in expending scarce funding costly on in-service training to fill the gap between their training and what they need to do the job.
Over production of some cadres and underproduction of others, results in maldistribution and default task shifting.
All these approaches result in poor utilization of scarce financial resources due to flawed planning and management.
Health worker salaries are overall extremely low in comparison to the level of responsibility they carry, and in the case of the pandemic, the high risks.
The Challenge
The underfunding of overall funding for health systems, particularly Public Health services and Human Resources, must be taken seriously since the implications of its neglect for the global economy is immense.
- How can the public appreciation, support and concern for the health and frontline workers be harnessed to ensure, post pandemic, that politicians do not replicate flawed approaches?
- How can we ensure that they act on the lessons learned and not just pay lip service to them?
- The most effective way to influence politicians is through the ballot box, and this is where harnessing the appreciation of the general public is important. How can this be achieved during the short window period post pandemic?
Who can take a lead in this?
