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Rev Peru Med Exp Salud Publica vol.28 n.2 Lima Jun. 2011
SYMPOSIUM: HUMAN RESOURCES FOR HEALTH
Strategies to enhance the impact of research on human resources for health on policy making
Taghreed Adam1,a,b,c , Abdul Ghaffar1,b,c
1 Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
a Scientist; b MD; c PhD
Despite global recognition of the importance of human resources for health (HRH) in achieving health system goals, very little is known about what works, for whom and under what circumstances, especially for low-income and middleincome countries. Several important events and reports have called for increased funding and capacity for HRH research in recent years and several initiatives have started as a result. Progress has been slow, however. The following strategies can be most valuable in ensuring the relevance of the generated evidence for decision making and its contribution to stronger health systems. The first is to promote national processes to set priorities for HRH research with active participation from decision makers. The second is to make conscious efforts to scale up primary research to address priority questions and to develop sustainable mechanisms to evaluate the impact of current or new HRH strategies to feed into the policy making process. The third is to invest in the development of systematic reviews to synthesize available evidence and in the adaptation of the underlying methods to make them more responsive to the type of questions and the nature of research involving HRH issues. The fourth and most important is to consistently use a systems approach in framing and addressing research questions. While a narrow approach may be more attractive and simple, health systems and the problems facing them are not. Increasing the body of evidence that takes into account the complexity of health systems, and particularly human resources for health, will advance knowledge in this area and will make big strides in the quality and usefulness of the generated evidence.
Key words: Human resources; Research; Health priorities; Systems theory (source: MeSH NLM).
There was never a stronger agreement about the critical role of human resources for health (HRH) in achieving health system goals. The 2006 World Health Report(1) and the creation of the Global Health Workforce Alliance(2), the 2008 First Global Forum on HRH in Kampala and its proceedings(3), several World Health Resolutions(4,5), and most recently, the 2011 Second Global Forum on HRH in Bangkok(6) are just a few examples of high-level meetings and reports dedicated to this very topic.
All of these influential events and reports emphasized the importance of investing in research to address the challenging questions on HRH facing low-income and middle-income countries (LMICs). Specifically, they called on global and national stakeholders to make sufficient efforts to increase the production of, capacity and funding for research on HRH issues and to improve information systems that are vital for designing and monitoring policy options(3-5).
Among the most pressing areas for research identified in these documents are research on international migration, scaling up of mid-level cadres (for example, community health workers) and interventions to attract and retain health works to address the maldistribution of human resources and inequitable access to essential health services (1,3-5).
Despite this global support and increasing momentum to place HRH high on the agenda of funders and policymakers, evidence is still limited in many areas(7,8). Like health systems, human resource issues are even more contextual and local knowledge is vital in designing appropriate strategies(9). However, several lessons can be learnt from similar contexts and rigorous research that takes into account contexts and processes is of great value to resource constraint settings, where this type of research can be prohibitively costly(10).
Given the very limited resources currently spent on health research and the competing topics of interest in different areas, priority setting for research is crucial. The Alliance for Health Policy and Systems Research (HPSR) had recently completed an exercise to set priorities on HRH research to guide future research funding at a global level(8). Through this exercise, available evidence and gaps were highlighted and priority research areas were defined and ranked using information from 24 countries in 4 regions of the world. However, global priority setting exercises are not a substitute for national efforts to set research priorities. There is nothing more empowering and promising for the future of health systems than developing a national agenda for research with the active involvement of policy makers. Not only it will promote the uptake of research, it will also ensure that the generated evidence is relevant, useful and timely.
But, more importantly, how do we address the lack of relevant primary evidence on what works in LMICs? All too often new strategies are implemented without a clear and sustainable plan for monitoring and evaluation. Several examples have shown that, unlike clinical interventions, health systems interventions do not always work the way they are expected to work, and if they do in one place they may not work in another(11,12).
The implications for primary research is to develop sustainable mechanisms to evaluate current and new strategies at country level and to ensure that contexts and processes are documented in a way that enables an understanding of what worked, how, why, for whom and under what circumstances. Failing to do so not only limits sharing of valuable lessons but may also have several important short falls in the settings in which interventions are implemented, including huge inefficiencies encumbering the already stretched health budget in LMICs(13,14).
Another important area of work is to up scale the development of systematic reviews to summarize available evidence from primary studies. Recent reviews have highlighted the very patchy and scanty evidence from systematic reviews, which when exists, it mainly is summarizing evidence from high income countries (7,8). Up scaling the development of systematic reviews will require time and resources but is an essential step for upraising available evidence, representing a global public good in the field of HRH research.
However, it has been increasingly recognized that available methodologies for systematic reviews are not always suitable for synthesizing evidence from health systems research, including HRH research. Therefore, current efforts to develop and build consensus on new, more suitable, methods will fill a void in this area(15).
Finally, given the complexity of health systems and health-system interventions, simplistic approaches to design and evaluate health system strategies are often inadequate(16). Taking into account the fundamental characteristics of complex systems will not only increase the likelihood of developing successful strategies, but will also ensure continuing success through a continuous process of monitoring and evaluation with possible modifications of the interventions as they are being implemented.
For example, experience has shown that resistance to change in policies is a very common phenomenon in complex systems, especially relevant to human resources(13). Failure to involve front-line health workers, including district managers and implementers, in the design of new strategies have been shown to lead to coping mechanisms that changes the original intervention and defies the original concepts on which it was based(14,17,18).
This is where systems thinking can be most useful in designing and evaluating new strategies to address HRH problems(10). Systems thinking helps unpacking all possible interactions between the different components of the health systems in response to the introduction of new policies. It helps understanding and anticipating both positive and, more importantly, negative or un-anticipated effects of interventions. This is crucial to the design or adaptation of polices as otherwise several well intended efforts often go in vain. Although it is a very well established concept and common practice in disciplines like engineering, economics and ecology, its use in health has not yet reached its full potential.
Building new experiences incorporating systems thinking, both in research and practice, seems to be a wise step for health system stakeholders, especially at times when big and rapid achievements are expected from already weak health systems. Translating systems thinking principles into practical experiences that are shared globally has a great potential to improve the knowledge base and policy practices and the overall aim of health systems, better health for all.
Both authors contributed to the development of this manuscript. TA drafted the manuscript.
Conflicts of Interest
No funding was received for this work
The views expressed are those of authors and not necessarily those of the organization they represent.
1. World Health Organization. The World Health Report 2006: Working together for health. Geneva: WHO; 2006. [ Links ]
3. Global Health Workforce Alliance. First global forum on human resources for health: health workers for all and all for health workers. Kampala, Uganda: WHO; 2008. [ Links ]
4. World Health Organization. World health assembly resolution (wha63.16): who: global code of practice on the international recruitment of health personnel. Geneva: WHO; 2010. [ Links ]
5. World Health Organization. World health assembly resolution (wha57.19): international migration of health personnel: a challenge for health systems in developing countries. Geneva: WHO; 2004. [ Links ]
6. Global Health Workforce Alliance. Second Global Forum on Human Resources for Health. Bangkok, Tailandia: WHO; 2011. [ Links ]
7. World Health Organization. WHO global policy recommendations: Increasing access to health workers in remote and rural areas through improved retention. Geneva: WHO; 2011. [ Links ]
8. Ranson MK, Chopra M, Atkins S, Dal Poz MR, Bennett S. Priorities for research into human resources for health in low- and middle-income countries. Bull World Health Organ. 2010;88:435-43. [ Links ]
9. Beaglehole R, Dal Poz MR. Public health workforce: challenges and policy issues. Hum Resour Health 2003;1:4. [ Links ]
10. de Savigny D, Adam T. Systems Thinking for Health Systems Strengthening. Alliance for Health Policy and Systems Research. Geneva: WHO; 2009. [ Links ]
11. Liu X, Mills A. The influence of bonus payments to doctors on hospital revenue: results of a quasi-experimental study. Appl Health Econ Health Policy. 2003;2(2):91-8. [ Links ]
12. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review--a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy. 2005;10(Suppl 1):21-34. [ Links ]
13. Kamuzora P, Gilson L. Factors influencing implementation of the Community Health Fund in Tanzania. Health Policy Plan. 2007;22:95-102. [ Links ]
14. Agyepong IA, Nagai RA. "We charge them; otherwise we cannot run the hospital" front line workers, clients and health financing policy implementation gaps in Ghana. Health Policy. 2011;99:226-33. [ Links ]
15. Alliance for Health Policy and Systems Research. Working group on health systems research synthesis. do we need an international collaboration for synthesizing healthsystem evidence? Geneva: WHO; 2010. [ Links ]
16. Shiell A, Hawe P, Gold L. Complex interventions or complex systems? Implications for health economic evaluation. BMJ. 2008;336:1281-3. [ Links ]
17. Lipsky M. Street-level Bureaucracy: Dilemmas of the Individual in Public Services. New York: Russell Sage Foundation; 1980. [ Links ]
18. Penn-Kekana L, Blaauw D, Schneider H. It makes me want to run away to Saudi Arabia': management and implementation challenges for public financing reforms from a maternity ward perspective. Health Policy Plan. 2004;19:I71-7. [ Links ]
Correspondence: Taghreed Adam,
Address: Alliance for Health Policy and Systems Research,
World Health Organization, 1211 Geneva 27, Switzerland.
Telephone: +41227913487 Fax:
Received: 06-04-11 Approved: 04-05-11
Correspondence: Taghreed Adam,
Address: Alliance for Health Policy and Systems Research, World Health Organization, 1211 Geneva 27, Switzerland.
Telephone: +41227913487 Fax: +41227914328
Email: firstname.lastname@example.org .