Shortage of health workforce? What is the solution? Globalization helps?

Who are the HUMAN RESOURCES in a hospital?

Shortage of health workforce? hmmm....i can't imagine. Can you give me a clear picture?

This is Bappenas study in 2005 conducted in 32 districts.  What can you see from the table? do u get the picture? okay let's see the figure below....

There are currently 57 countries with critical shortages equivalent to a global deficit of 2.4 million doctiors, nurses and midwives. The proportional shortfalls are greatest in sub-Saharan Africa.

Still remember the 1st tutorial scenario is about?

The shortage of medical doctors happens especially in remote areas and other unattractive areas, where community’s health status is also lower than those in non-remote areas.  Quality of service suffers because of this shortage. In regions without medical specialist, a general practicioner can be forced to do specialists’ tasks. This situation may violate Medical Practice Laws and needs specific additional clinical training for the general practicioner. It needs a careful preparation for taskshifting.

This scenario happens in all the countries, I bet. It is not limited in Indonesia, but also Malaysia. It reminded me of the district hospital, Batu Gajah Hospital, where i did my clinical attachment in M'sia during July holidays. In that hospital, there are no specialist, but medical officers only. The medical officers are very busy, and they have lots of workloads 24/7. When I was working in the general ward, the doctor in the emergency department was sick. So, the doctor who was in charge of the general ward, had to go to emergency department to cover for the ER doctor, so she did not visit her ward in that morning, not until she settled the problem in ER. Normally, she finished checking every patient in her ward by 12pm, but on that day, she finished by 2pm....there was another case. The medical officers refer a lot of patients to the provincial hospital, Hospital Ipoh, whenever they can't manage the case. For instance, when the medical officer in the labour ward could not detect the placenta of the pregnant woman by using USG, she referred the patient to hospital ipoh. Another example, a pregnant woman had entered stage 2, but having difficulty in delivering the baby. I could see the head of the baby when the nurse was trying to assist in the delivery. Along that period, there were only nurses. They called the sister, the head of the nurse, in the labour ward. She then discovered the patient having fever and the amniotic fluid are stained with meconium. Then they called the medical officer to come. But after 20min, the M.O. did not reach there yet. After the doctor reached there, she decided to send the patient to hospital Ipoh. Note, journey from Batu Gajah Hospital to Hospital Ipoh took 30 mins. In the journey of sending the patient to the destination, what would happen? Would the baby and the mother affected? If there is prolonged stage 2, it may cause baby's condition unstable..just like what we had learnt in the skill lab "neonatal resuscitation" in Block 4.1.  These are the problems encountered in the hospitals where there is shortage of physicians.

Another scenario in Puskesmas that i had did my attachment in year 3. There was lack of physicians in the puskesmas when the two doctors had left the puskesmas after they finish their magang. So on the day when the two doctors had left the puskesmas, there were no doctors because coincidentally, another doctor went to other place to attend a talk. So, when we practised, we made diagnosis and prescribed the medicine without the guidance of a doctor. phewwww~~~@.@ hmm..reading until here, what is your comment? unethical to the patient? yes, it was unethical. =(

What threatens the health system, affecting the way the health workers respond?

Demographic and epidemiological transition drive changes in population-based health threats to which the workforce must respond. Financing policies, technological advances and consumer expectations can dramatically shift demands on the workforce in health systems. Workers seek opportunities and job security in dynamic health labour markets that are part of the global political economy. In many countries, health sector reform under structural adjustment capped public sector employment and limited investment in health worker education, thus drying up the supply of young graduates. Expanding labour markets intensified professional concentration in urban areas and accelerated international migration from the poorest to the wealthiest countries. Countries with critical shortage of workforce is characterized by severe shortages, inappropriate skill mixes, and gaps in service coverage.

Table: Passing rates of Indonesian nurses

Insufficiency of health workers often coexist in a country with large numbers of unemployed health professionals? You may ask: why would this happen paradoxically?  this could be due to poverty, imperfect private labour markets, lack of public funds, bureaucratic red tape and political interference.

In Indonesia, decentralization had exerted negative impacts on human resource. Few agenda, thus, are raised and wished to be settled:

a) communication with the central government, on the issue of preparing, supplying, educating and training the specialists, technicians, etc for those districts having difficulty of getting health workforces.

b) inter-district communication on how to administer regional health system, with direct implication of human resource management.

c) currently, not all the districts have the capability in managing human resources. They still need the assistance from the central government and the networking between districts in order to fulfil their demand for the health workforces.

So, what are the solutions?

Focus on 3 junctures:

a) Entry: preparing the workforce through strategic investments in education and effective and ethical recruitment practices.This can be done by building strong instituitions for education and at the same time, assure the educational quality through instituitional accreditation and professional regulation (licensing, certification or registration).

b) Workforce: enhancing worker performance through better management of workers in both the public and private sectors

c) Exit: managing migration and attrition to reduce wasteful loss of human resources. In poor countries and rural areas, international (from poor to rich country) and internal (rural to urban area) migration are the factors contributing to the shortage of workforce. Therefore, retention strategies should be made! This can done by tailoring education and recruitment to rural realities, improving working conditions more generally and facilitating the return of migrants, reduce occupational hazards, provision of effective prevention services,etc.

How about globalization? Does it help?

There are four ways: 

a) Cross-border trade (eg. get the service by telecommunicating)

b) Consumption abroad (patients travel to the other country to get health service)

c) Commercial presence (an international hospital owned by foreigners)

d) Natural presence (foreigners work in the local)

Each method has its pros n cons. To reduce the cons, policy should be made. for example, for consumption abroad, the foreign patients generate more revenues for providers. BUT, who gets the benefit? The public sector or the private? The truth is...the economic gains accrue to private investors. Hence, policy should be made, such as tax on medical tourist revenues.

In tutorial scenario 1:

some foreign countries offer medical doctors to work in remote areas in Indonesia. However, is it proper to allow foreign doctors to work in those difficult areas?   

In my opinion, importing foreign doctors may help, but short term only. When importing the health workers from other countries, assessment should be made; whether they are competent? are they willing to work in a rural area where the working environment is not too ideal? Do they have language barrier and how are they going to solve it? Bilateral agreements and contracts should be made. In long run, the best way to solve the problem of the shortage is producing more competent local medical practitioners through education and training. Besides that, the strategy of how to distribute the workforce within the country. I think contract should be made between the government and the health workers (fresh graduates), such as they have to serve the public sector for at least 3 years. That would be the mandatory service, but not up to the individual.

Reference:

1. The WHO Report 2006: Working together for health

2. Dr. Yodi Mahendradhata; Lecture: Globalization of trade in health services and workforce

3. Prof. Dr. Laksono: Lecture: Introduction of Block 4.2 and Health Systems and Its Outcome

4. Laksono Trisnantoro. Desentralisasi Kesehatan Di Indonesia Dan Perubahan Fungsi Pemerintah: 2001-2003. UGM Press. Juni 2005.

5. Dr. Andreasta Meliala; Lecture: Human Resource Management in Health Care Setting.