Academic journal article Bulletin of the World Health Organization

How Much Is Not Enough? Human Resources Requirements for Primary Health Care: A Case Study from South Africa/Combien En Manque-T-Il ? Besoins En Ressources Humaines Pour Les Soins De Sante Primaire : Etude De Cas Menee En Afrique Du Sud/Cuantificar la Escasez. Necesidades De Recursos Humanos En la Atencion Primaria De Salud: Estudio De Casos En Sudafrica

Academic journal article Bulletin of the World Health Organization

How Much Is Not Enough? Human Resources Requirements for Primary Health Care: A Case Study from South Africa/Combien En Manque-T-Il ? Besoins En Ressources Humaines Pour Les Soins De Sante Primaire : Etude De Cas Menee En Afrique Du Sud/Cuantificar la Escasez. Necesidades De Recursos Humanos En la Atencion Primaria De Salud: Estudio De Casos En Sudafrica

Article excerpt

Introduction

The central role of human resources in the improvement of the health sector is increasingly recognized with a particular focus on planning, training, staff retention, scopes of practice of the staff and human resources management. (1,2) Staff costs typically represent around 70% of district health expenditure (3) and managers are under pressure to ensure optimum allocation of the right quantity of the right categories of staff to achieve maximum quality, efficiency and equity. Given changing patterns of population, burden of diseases, scope of practice and clinical practices this allocation needs to be reviewed at regular intervals. There are several approaches that could be used to assess appropriate allocation of staff.

The needs-based approach assesses the amount and scope of services to be delivered at each type of facility through a normative approach informed by experts' opinion. While very informative, this approach, when used alone, has several limitations. First, it equates needs with demand. There is much published work on the impact of infrastructure, education, economic status, customs and beliefs on patterns of help seeking. (4,5) Needs are not always translated into demand for health services, and the needs-based approach may overestimate the level of health services to be delivered. Second, the needs-based approach is dependent on the package of services offered, and does not easily reflect changes in services offered. Third, there is an underlying assumption that health care resources will be deployed in accordance with relative levels of need. Human resources are often used to meet demands that do not coincide with needs, while the needs of many vulnerable and marginalised populations remain unmet. Finally, the needs-based approach does not adapt easily to changes in pattern of diseases or prevalence. (6)

The population-based approach defines ratios of health workers to population. These ratios are calculated from the target use rates built from the needs-based approach. The population-based approach thus shares the same limitations as the needs-based approach. In addition, the population-based approach does not reflect rapid changes in population size well, nor does it reflect the impact of infrastructure or geographical access on use of health services.

A utilization-based approach takes the actual level of use over a year (i.e. the expressed demand) as the basis for calculation of staff requirements. However, this approach has often been used in a narrow fashion, and does not take into account variations in use of substitute health workers or the possibility of changing levels of productivity. (7)

In this paper we describe the adaptation of WHO's workload indicator of staff needs (WISN) (8) to reflect challenges and policy options in rural areas of South Africa.

Methods

Inadequate numbers and poor distribution of health workers have been identified as crucial challenges for the South African health system, in particular in rural areas. The Primary Health Care Core Package for South Africa (9) defines clinics, satellites and mobile dinics as being nurse-based, with occasional sessions by doctors, and community health centres as being referral centres, requiring doctors on site. Nurses fall into three categories: professional nurses who have four years of training, enrolled nurses who have two years and enrolled nurse assistants who have one year.

The following assumptions and inputs were formulated after initial desk work to identify previous studies, followed by consultation with the National Department of Health, districts and facilities:

* Allocation of types of consultation to categories of health workers was done in collaboration with the South African Nursing Council, to ensure that existing scopes of practice were respected.

* Community health centres were allocated a resident doctor in line with policy, while clinics have visiting doctors whose target frequency of visit was defined by the district. …

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