The ultimate goal of health workforce strategies is a delivery system that can guarantee universal access to health care and social protection to all citizens in every country. There is no global blueprint that describes how to get there--each nation must devise its own plan. Effective workforce strategies must be matched to a country's unique situation and based on a social consensus.
The workforce presents a set of interrelated problems that cannot be quickly tidied up or solved by a "magic bullet". Workforce problems are deeply embedded in changing contexts, fraught with uncertainty and exacerbated by a lack of information. Most significantly, the problems can be emotionally charged because of status issues and politically sensitive because of divergent interests. That is why workforce solutions require all stakeholders to be engaged together, both in diagnosing problems and in solving them.
The key is to mobilize political commitment to tackle workforce challenges. But this is difficult because achieving a health impact from an investment in the workforce takes time, extending well beyond election cycles. Disgruntled workers can paralyse a health system, stall health-sector reform, occasionally even bring down a government. Yet, successful strategies have been demonstrated that can energize the workforce and win public support. The political challenge is to apply known solutions, to craft new approaches, to monitor progress, and to make mid-course corrections.
Previous chapters have focused on dealing with workforce problems through the management of entry, workforce and exit. These aspects determine the performance of a health system and its ability to meet present and future challenges.
However, such problems cannot only be discussed in managerial and technical terms. The perspective of people who use the health care system must also be considered. Their expectations are not about the efficient delivery of cost-effective interventions to target populations; they are about getting help and care when faced with a health problem that they cannot cope with by themselves. In the relationship between individual health workers and individual clients, trust is of paramount importance, and it requires fair governing and effective regulations to build and sustain--which in turn involves leadership, strategic intelligence and capacity building in institutions, tools and training. These essential elements of national workforce strategies are the focus of this chapter.
BUILDING TRUST AND MANAGING EXPECTATIONS
To the general public, the term "health workers" evokes doctors and nurses. While this does not do justice to the multitude of people who make a health care system work, it does reflect the public's expectations: encounters with knowledgeable, skilled--and trustworthy--doctors and nurses who will help them to get better and who will act in their best interests.
Trust is not automatic: it has to be actively produced and negotiated. It is "slowly gained but easily lost in the face of confounded expectations" (1). In many countries the medical establishment has lost its aura of infallibility, even-handedness and dedication to the patient's interests. Fuelled by press reports of dysfunctional health care provision, public trust in health workers is eroding in the industrialized world (2) as well as in many developing countries (3-5). Poor people in particular may be sceptical or cynical when talking about their doctors, nurses or midwives: "We would rather treat ourselves than go to the hospital where an angry nurse might inject us with the wrong drug" (6). Trust is jeopardized each time patients do not get the care they need, or get care they do not need, or pay too much for the care they do receive. When patients experience violence, abuse or racketeering in health facilities their fragile trust is shattered.
The consequences of loss of trust go beyond the individual relationship between user and provider. …