ArticlesEffects of policy options for human resources for health: an analysis of systematic reviews
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.
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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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