Chapter Four: Making the Most of Existing Health Workers

Article excerpt

A country's health workforce is made up of health workers who are at many different stages of their working lives; they work in many different organizations and under changing conditions and pressures. Whatever the circumstances, an effective workforce strategy has to focus on three core challenges: improving recruitment, helping the existing workforce to perform better, and slowing the rate at which workers leave the health workforce. This chapter explores the second of these challenges: optimizing the performance of current workers.

Strategies to boost worker performance are critical for four reasons:

* They will be likely to show results sooner than strategies to increase numbers.

* The possibilities of increasing the supply of health workers will always be limited.

* A motivated and productive workforce will encourage recruitment and retention.

* Governments have an obligation to society to ensure that limited human and financial resources are used as fairly and as efficiently as possible.

This chapter outlines four dimensions of workforce performance: availability, competence, responsiveness and productivity, and reviews the levers available to improve these different dimensions. Many ways of improving performance exist, some aimed at individual health workers and some directed at the organizations in which they work.


Health workforce performance is critical because it has an immediate impact on health service delivery and ultimately on population health. A well-performing workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances.

Evaluations of health workforce performance by the extent to which it contributes to the desired improvement in population health leave no doubt that performance can vary widely. Box 4.1 provides one illustration of how health workers use available financial resources to very different effect on infant mortality, even after controlling for education and poverty in the population. Examining performance this way reveals areas where a workforce is performing well and areas where improvements should be possible, but this method does not explain why performance varies or what can be done about it.

Box 4.1 Infant mortality and health worker density, Viet Nam

Infant mortality rates were examined in relation to the density
of health service providers in 1999. Average results
across the provinces are represented by the black points in
the figure below. Many provinces, denoted by the red points,
do better than expected for their health worker densities
--they lie below the black line--while others do less well.
More detailed analysis reveals that this is explained, in part,
by differences in financial resource availability, measured
in terms of health expenditure per capita. An indicator
was derived of the efficiency with which health workers
in each province use the available financial resources to
reduce mortality, controlling for education and poverty.
Efficiency ranges from 40% to 99%, raising the question
of why health workers in some provinces seem to perform
better than in others (1, 2).


Another approach is to look at four dimensions of workforce performance that are believed to contribute to the achievement of better service delivery and health (see Table 4.1). Looking at the problem this way can help in selecting areas for action.

This simple outline sets the scope for any health workforce strategy and provides a framework for assessing whether or not it is having its desired effects. This framework moves beyond the traditional focus on inputs (having the right number of staff, in the right place, at the right time, with the right skills, and the right support to work (3)) to consider workforce outputs and outcomes. …