Primary health care should be delivered through skilled and motivated human resources for health (HRH) in achieving the goals of universal health care, said Dr. Fely Marilyn Lorenzo of the College of Public Health, University of the Philippines-Manila. The rationale for human resource development should have “the right number of people, in the right place, at the right time, with the right skills, with the right motivation and attitudes, at the right cost, doing the right work and under the right work conditions,” added Lorenzo.
The global picture
Critical shortage of health workers, defined relative to the needs of a country, are observed in 57 countries, which makes up 30 percent of 193 WHO member states. In some countries, there is overproduction combined with maldistribution of professionals. One example is the Philippines which produces nurses that are maldistributed, with areas or pockets of shortages even in the face of overproduction. There are some countries like Norway and France, where there is underproduction without shortage. The Philippines has a combined problem of overproduction, maldistribution, high out-migration, minimal to non-existent in-migration and low return migration.
Lorenzo explained the importance of strong health workforce in achieving the United Nations’ millennium development goals (MDGs). She noted that the density of health workers is directly proportional to the probability of survival in vulnerable groups such as infants, children and pregnant patients. For example, WHO statistics from the last decade showed countries with fewer health workers have more cases of maternal mortality.
It is important to look at the problem globally and to address shortages of health workers worldwide. Lorenzo said that migration trend in one country has the propensity to affect another state. An example would be a developed country like the US or New Zealand opening recruitments for health workers, which then encourages migration of Filipino health care professionals who do not have better option in the Philippines.
The local situation
Lorenzo clarified that the critical ratio for adequate care worldwide is considered at 23 doctors, nurses and midwives per 100,000 population, with the mix of expertise depending on the need.
“Fortunately we’re one of the few developing countries that are endowed with a lot of human resources. We are above this critical level. We are somewhere around 30,” said Lorenzo. However, our neighbors Vietnam, Cambodia and Laos are below the critical level.
The Philippines would usually produce 45,000 to 100,000 nurses per year from 335 nursing colleges, 2,000 doctors per year from 30 medical colleges, 1,5000 midwives from 129 schools, and 2,000 dentists per year from 31 dental schools. However, the problem lies not with the number but with the distribution of health care professionals in the Philippines. Doctors in the Philippines, for example, are concentrated in the National Capital Region, with the least number in southern part of the Philippines.
According to the Implementing Rules and Regulation of Magna Carta for Public Health Workers, there should be at least one rural health physician and one nurse for every 20,000 residents, while there is more need for midwives that should be one for every 5,000 residents. In addition, there should be one rural health inspector for every 20,000 residents and one rural health dentist for every 50,000 residents. Lorenzo explained that the number required is not being followed despite the population growth in each municipality.
“When we deplore our [municipal] and city health officers for not taking care of the population, it is because they are already doing too much,” said Lorenzo.
For professionals such as physical therapists, medical technologists, pharmacist and other allied medical professionals, there are no standard ratio of manpower to population. Positions are usually limited to the institutional level such as hospitals, and are typically done on a contractual or job order basis. It has become worse in the past few years that even doctors are also hired on a contractual basis, said Lorenzo. In fact, when asked why nurses and doctors leave their posts, they usually say that they have no real jobs.
Importance of retention strategies
Lorenzo explained important reasons why we should retain health workers. Firstly, we need to recoup skill development investment by retaining health workers. High turnover of professionals would mean losing what has been invested on both their education and skills training. Apart from skills development investment, other reasons include institutional memory sustainability, loyalty and motivation. When properly motivated, long-standing health workers ensure high quality and continuity of care.
Lorenzo stated that transformative education is one of the strategies to retain health care practitioners in the community. It ensures relevance, as well as high quality service and appropriate skill mix. Recently, the global trend has been to improve education by training health workers based on the needs of the community. Lorenzo cited the School of Health Sciences in Tacloban under the University of the Philippines as an example customized education where students are trained to spot schistomiasis, among other things, as it is one of the most common diseases in the area.
Apart from education, practice is another area to improve retention. It helps improve working conditions as applied in working relationships, facilities and general working environment. It is important to recognize that young people have different demands and needs, said Lorenzo. Based on migration surveys, one of the reasons for leaving cited is that workers are not happy because they are not treated right. Professionals feel that people abroad are encouraged to have independent thinking or collaborative relationships, which are not common views in the Philippines. Relationships between doctors and nurses and technologists are also common areas of dissatisfaction. Thus, Lorenzo emphasized the need to facilitate work-life balance. Young people have been noted to choose a particular career because they see the possibility of having a social life, which is difficult for a lot of the health professionals.
Career progression is another way to encourage retention. In the Philippines, there are very few institutions that implement life-long learning. The health care industry should follow examples of other scientific disciplines where workers are given opportunities to improve their knowledge, which in the long run could help improve careers and opportunities.
Based on projections of human resources for various health disciplines from 2005 to 2030, Lorenzo stated that we are not meeting the ideal numbers. Although we have been improving facilities and infrastructures, it will not make any difference if we don’t have human resources for health.
It is also important to look at Asian relational frameworks that might affect medical practice locally. An example would be the ASEAN Mutual Recognition Agreements, which would allow South East Asian health professionals to practice from one country to another without requiring to take the licensure exam in the receiving country. This might encourage more migration out of the Philippines, which highlights the importance of retention strategies.
Lorenzo also mentioned the importance of maintaining competitive edge in the academe. She stated that based on the assessment of university standards compared to other Asian universities, many of the graduate programs in state universities would fail the evaluation. The quality of education should continuously improve, especially with recent efforts to align the Philippine Qualification Framework with Asian Qualification Framework. This is expected to result in common educational standards with neighboring countries, allowing for common assessment of skills such as independent and critical thinking, among others.
To conclude, Lorenzo quoted the World Health Report 2006 on Working Together for Health, which states that health workers save lives and are in need of support and education. Otherwise, they will leave.
“That is not a threat. That is not a promise. It’s already a fact of life,” said Lorenzo.