PMNCH Knowledge Summary #06 Support the Workforce

Publisher: The Partnership for Maternal, Newborn and Child Health
Publication date: 2010
Language: English only

Note: Full text and all graphs, tables and references for each Knowledge Summary are available only on the PDF version.

Boosting the capacity of the health workforce is an integral part of health systems strengthening, and has to be a priority for achieving MDGs 4 and 5. A strong health workforce helps countries to uphold women's and children's rights to health and quality care. Countries and their partners have to commit to long-term support, coordinate across the public and private health sectors and forge inter-sectoral links. ln the short term, sorne countries have made significant progress through innovative approaches, such as task-shifting and incentive-based programs for the health workforce.

Midwives, nurses, doctors and frontline health workers are a crucial part of any health system, but currently, in many places, there are simply too few. A study of 198 countries found that maternal and child death rates were higher in those with fewer health workers. The Global Health Workforce Alliance asserts that: “One decade into the 21st century, the world continues to face a health workforce crisis of unprecedented proportions.”

What do we know?

The shortage of health workers worldwide is the result of multiple, complex factors, including too few people being trained in the relevant skills.There is an uneven distribution of health workers within and across countries. Highly skilled medical workers, such as obstetricians, pediatricians and other specialists, tend to be concentrated in urban areas and are more likely to seek employment in other countries, contributing to the so-called “brain drain”. Health workers face problems such as lack of opportunities for further training and career progression, low salaries5, poor work environments and unsupportive supervision/management.These factors affect workers’ motivation and performance, which adversely affect both the quality of care and health outcomes.

Recent analyses emphasize the strong link between the number of health workers, the use of health services and health outcomes in different Indian states.4,5 A 2008 study by the Public Health Foundation of India and the World Bank shows that higher worker density is associated with higher measles immunization, more attended deliveries, and lower infant mortality. However, variations in these outcomes indicate that:“there are several factors other than the workforce density which are influencing health and service utilization.This includes, among other things, the efficiency of health workers, their quality, their distribution and composition.”

What works?

Countries need to train, employ and effectively deploy adequate numbers of health workers. However, while scaling up is essential, it is not always enough. Countries also need to build the capacity of existing workers so that they perform better, and create an environment that encourages them to stay in areas where the need is greatest.This has already been shown to work in some contexts.

Improving skilled attendance through different recruitment methods

Countries need to prioritize active recruitment of more midwives and nurses. In some places (e.g. Ethiopia, Ghana and Pakistan) however, recruiting more frontline community health workers is helping to ease acute shortages in the immediate term, and is aiding deployment of workers to the areas of greatest need. The recruitment of local residents and training of married women in rural areas as nurses or midwives helps to improve retention. To meet short- term needs, task-shifting could also be a cost-effective way to train, retain and strengthen the workforce.

The private sector may be able to help countries reduce health worker shortages in some places.8 In other cases, decentralized recruitment and financing has been used, alongside special allowances and other incentives, to improve the efficiency of hiring and retaining frontline health workers on flexible short-term contracts.

However, decentralization may not be effective for recruiting higher cadre workers, or to effect an equitable distribution of workers across districts, as found in Tanzania.

Continuing education and training helps, particularly when supervision is good

Evidence shows that health workers who continue their education, training and professional development enhance not only their knowledge and skills, but also their motivation. However, this has to be accompanied by good management and continued supervision, if any short-term improvements in performance are to be maintained. For example, high workloads in India and poor management techniques in South Africa adversely affected performance, despite training.

Education and training that raises awareness of health systems issues and problems helps health workers to develop a solution-focused approach to their work, thereby improving their performance and patient relationships.

Financial incentives help when combined with non-financial incentives

Performance is improved by higher salaries or additional payments and allowances (for example, higher salaries linked to remote locations, housing benefits and school fees), because they motivate staff and increase job satisfaction. In Rwanda and Cambodia, linking financial rewards to health facility performance has helped to improve quality and uptake of care. However, to retain staff, strategies that combine financial incentives with non-financial incentives appear to work better.

Good supervision and management, and supportive colleagues, help motivation; while performance is influenced by patient satisfaction, positive feedback and collegial environments.

However, financial incentives are typically much smaller than salaries in major urban areas, in developed countries or in the private sector, so they do not affect migration patterns unless other work-related issuesexist. In Samoa, for example, doctors preferred to migrate despite being well-paid. Reasons included long working hours, high workloads and links with families who lived overseas.


Evidence shows certain strategies work, but are very context specific. A review of 55 studies on attracting and retaining staff in remote and rural areas concluded that no single solution could be applied across countries. Usually, a set of interventions is more effective than a single intervention, but this has to be determined by local needs. For example, Thailand was able to improve access to care in rural areas by recruiting local people, training them in rural areas and assigning them to places close to their home towns. In Indonesia, doctors in rural areas were paid twice as much as those in urban areas, and were also given specialist trainin

Ultimately, improvements have to occur across the health system to enable health workers to deliver effectively. Governments and international organizations have to provide the required funding, coherent health workforce plans, and policies to manage global migration as an integral part of global accountability.

Knowledge summary 6 cover

Note: Full text and all graphs, tables and references for each Knowledge Summary are available only on the PDF version.