Elsevier

The Lancet

Volume 371, Issue 9613, 23–29 February 2008, Pages 668-674
The Lancet

Articles
Effects of policy options for human resources for health: an analysis of systematic reviews

https://doi.org/10.1016/S0140-6736(08)60305-0Get rights and content

Summary

Background

Policy makers face challenges to ensure an appropriate supply and distribution of trained health workers and to manage their performance in delivery of services, especially in countries with low and middle incomes. We aimed to identify all available policy options to address human resources for health in such countries, and to assess the effectiveness of these policy options.

Methods

We searched Medline and Embase from 1979 to September, 2006, the Cochrane Library, and the Human Resources for Health Global Resource Center database. We also searched up to 10 years of archives from five relevant journals, and consulted experts. We included systematic reviews in English which assessed the effects of policy options that could affect the training, distribution, regulation, financing, management, organisation, or performance of health workers. Two reviewers independently assessed each review for eligibility and quality, and systematically extracted data about main effects. We also assessed whether the policy options were equitable in their effects; suitable for scaling up; and applicable to countries with low and middle incomes.

Findings

28 of the 759 systematic reviews of effects that we identified were eligible according to our criteria. Of these, only a few included studies from countries with low and middle incomes, and some reviews were of low quality. Most evidence focused on organisational mechanisms for human resources, such as substitution or shifting tasks between different types of health workers, or extension of their roles; performance-enhancing strategies such as quality improvement or continuing education strategies; promotion of teamwork; and changes to workflow. Of all policy options, the use of lay health workers had the greatest proportion of reviews in countries with a range of incomes, from high to low.

Interpretation

We have identified a need for more systematic reviews on the effects of policy options to improve human resources for health in countries with low and middle incomes, for assessments of any interventions that policy makers introduce to plan and manage human resources for health, and for other research to aid policy makers in these countries.

Introduction

Quality health care depends on policies to ensure that health workers who are capable of delivering such care are available in sufficient numbers.1 Challenges related to human resources for health are particularly acute in countries with low and middle incomes. These challenges include an absolute shortage of qualified staff, especially in sub-Saharan Africa; an inequitable distribution of health workers, with too few in remote rural areas; and staff absenteeism and poor motivation that are probably caused by low pay, poor supervision and support, and unsatisfactory working conditions.2 Ways to address these challenges, which have increasingly been recognised as primary barriers to scaling up the delivery of effective health services, have been outlined.1, 2, 3, 4 To make the best use of scarce resources, policy makers who are charged with the provision of effective and equitable health care need evidence that will help them to identify and select policy options.

Frameworks to conceptualise the key issues related to human resources for health have been developed,1, 2 and evidence about improving the performance of health workers has been reviewed.5 However, the full range of possible policy options has not been reviewed. Policy makers need systematic reviews to help them to identify, select, appraise, and synthesise research findings.6 Systematic reviews could increase confidence for policy makers about the probable effects of different policy options and reduce the risk of high opportunity costs associated with implementation of inappropriate policies.7 Systematic reviews can inform policy makers about how a particular policy option was implemented in other contexts, and about how they could assess it in their own context,6 but might not be applicable in countries with low and middle incomes, where human resources are problematic.8 For example, the effects of performance-based pay or contracting of private practitioners are dependent on capacity to manage such measures, which varies between health systems; some countries with low or middle incomes have very little capacity to manage such policies. However, criteria have been developed to assist policy makers to assess the applicability of research to different settings. We aimed to list all possible policy options (grouped by key objectives); to identify effects and outcomes for which evidence exists and those for which it is lacking; and to synthesise conclusions for countries with low or middle incomes.

Section snippets

Methods

We adapted, expanded, and combined several existing frameworks to generate a comprehensive list of possible policy options, grouped by key objectives and their possible effects, and by outcomes for human resources for health.1, 2 We further refined the list by soliciting input from both researchers and policy makers. We searched Medline Ovid and Embase Ovid, from 1979 to September, 2006; the Cochrane Library (which includes both the Cochrane Database of Systematic Reviews and the Database of

Results

Table 1 shows policy options grouped by key objectives in human resources for health—namely, training, regulations, financing, organisational mechanisms, and macro policies and mechanisms in other sectors. The possible effects of the policy options were grouped by key outcomes for human resources for health, as described by WHO.1

Our search yielded 759 references, of which 28 systematic reviews of effects were deemed eligible for analysis (figure). Of these 28, only a few included studies from

Discussion

Despite the widespread recognition that health workers are critical to achieving both health-related Millennium Development Goals and national health goals, and that they constitute by far the greatest expenditure in the health sector, the amount of synthesised research evidence about the effects of relevant policy options to guide policy makers in countries with low and middle incomes is inadequate. We identified a small amount of high-quality synthesised research evidence about the effects of

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