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Decision-makingTowards evidence-informedpolicy-making in human resourcesfor health: the state of researchArticle by Manuel M Dayrit (pictured), Mario Roberto Dal Poz,Hugo Mercer and Carmen DoleaHealth systems in many countries are failing to respondto the health needs of their population. Part of thereason for this is the current crisis in the healthworkforce, which is expressed in severe shortages,imbalances and a poor knowledge base on effectiveness ofinterventions. In order to make health systems moreresponsive to current and emerging health needs, countriesmust strengthen their health workforce. Research can helppolicy-makers pose and find answers to the critical questionsregarding the status of their workforce, its level ofperformance and the problems health workers face.Need for more evaluation studies to knowwhat works and what does notResearch is required – not only to give policy-makers a betterunderstanding of the present situation of their country’shealth workforce, but also to discover which policyinterventions work or do not work. What can we say aboutthe status of research in human resources for health?First, the knowledge base in human resources for healthdevelopment is weak and uneven overall, compared to otherdomains of health systems research, such as health financingor health sector reform, even though efforts to identifypriorities in the health workforce research agenda havealready started 1,3 . Given that close to half of healthexpenditure is spent on the health workforce, it seemsincredible that there is so little research investment or solidevidence in this area. Moreover, the existing knowledge baseis largely skewed towards high-income countries, medicaldoctors and descriptive reports, as opposed to interventionstudies or best practice assessments 1,2 .An examination of the Cochrane Collaboration systematicreviews identified only 12 reviews on topics related to humanresources for health, most of them in the domain of healthworkforce management 4 . A more detailed analysis points outthat not only is there a very limited number of systematicTitle of Cochranesystematic reviewResearch questionNumber of studies(initial/final)Total numberof subjectsResultsSubstitution of doctorsby nurses in primary careTo investigate the impact ofnurses working assubstitutes for primary caredoctors on:✜ health outcomes✜ process of care✜ resource use✜ costs4253 articles initially25 articles, relating to 16studies, met inclusioncriterian/a✜ No difference in quality of care and health outcomesbetween appropriately trained nurses and doctors.✜ Nurses tend to provide more health advice and achievehigher levels of patient satisfaction, compared withdoctors.✜ Even though using nurses may save salary costs, nursesmay order more tests and use other services, which maydecrease the cost savings of using nurses instead ofdoctors.Lay health workers (LHW)in primary andcommunity health careTo assess the effects ofLHW interventions inprimary and communityhealth care on health carebehaviours, patients’health and well-being, andpatients’ satisfaction withcare8637 abstracts initially400 potentially eligible43 eventually included210 110consumers✜ LHWs show promising benefits in promotingimmunization uptake and improving outcomes for acuterespiratory infections and malaria, when compared tousual care.✜ For other health issues, evidence is insufficient to justifyrecommendations for policy and practice.✜ There is also insufficient evidence to assess which LHWtraining or intervention strategies are likely to be mosteffective.Audit and feedback:effects on professionalpractice and health careoutcomesAre audit and feedbackeffective in improvingprofessional practice andhealth care outcomes?85 RCTsOnly 10 of the 85 includedstudies to be of highmethodological quality>3500 healthprofessionals✜ Audit and feedback can improve professional practice,but the effects are variable.✜ When it is effective, the effects are generally small tomoderate.✜ The results of this review do not provide support formandatory or unevaluated use of audit and feedback.Table 1: Short description of results of three Cochrane systematic reviews on human resources for health160 ✜ Global Forum Update on Research for Health Volume 4
Decision-makingreviews in this field, but the final number of studies that metthe selection criteria is very limited, too, compared to theinitial pool of abstracts. This may mean that either theselection criteria for systematic reviews were too rigid, or theactual number of good quality evaluative studies in the fieldof human resources for health has been limited (see Table 1for a detailed analysis of three of the systematic reviews).Also, most of the studies come from developed countries.Second, much of the research is descriptive. For example,available studies have pointed to global shortages, regionalimbalances and increasing migration of health workers, aswell as dissatisfaction of health workers with their workingconditions 5-9 . On the other hand, many country-basedsituation analyses have pointed towards geographicalimbalances and significant understaffing in rural areas. Thereare paradoxical in-country shortages of nurses even wheremany nurses remain unemployed. And there are situationswhere doctors engage in dual employment 10, 11 .Third, the knowledge about effective solutions to addresschallenges described is far less developed 5, 12, 13 . And hereinlies a major gap. From a country perspective, policy-makersneed to know what solutions are available to them. Theywould also like to know how much an intervention will cost,how difficult it is to implement and its likely impact in theshort run. Knowing what sort of interventions have worked inother settings would give them an idea of what they can tryin their own context.Currently, there are very few evaluation studies of effectiveinterventions or impact assessment studies on humanresources for health. Also, there are very few sources of bestpractice collections in health workforce development. Effortshave started to systematize the knowledge about effectiveinterventions, but only a very small number of promisingpolicy levers were identified through an extensive search ofrecent systematic reviews 14 .Need for more operations and contextspecificresearchWhat is really needed is more operational research andcontext-specific research. Policy-makers in countries may nothave the means to support sophisticated research such assystematic reviews, but they should certainly have thecapacity to use it. Hence there is a need to develop the criticalmass of researchers in countries, with the appropriate skills todo research, use it and make its relevance evident to policymakers.Also, country-based studies should be encouraged bypolicy-makers, within the umbrella of a national strategy ofhealth research that should accommodate the priorities ofHuman Resources for Health (HRH) research within thepriorities of overall health system research.In general, preference should be given to research that:✜ develops and evolves from purely descriptive studies toconceptual research, policy analysis and operationsresearch;✜ promotes international and comparative research byconsidering multi-site, multi-level and multi-countryresearch projects to improve comparability andtransferability of findings, such as the African migrationstudy or the European nursing exit study;✜ integrates research into ongoing or planned interventionsand processes such as health sector reforms so thatlessons can be drawn, compared and shared from theexperiences of different countries 1 .Bringing the answers into the policy-makingprocessOnce research has provided us with the answers we need, weshould move to the next stage: using that knowledge.In the field of human resources for health, effective actionmust cut across many sectors. These include, among others:health, education, labour, civil service, the private sector –which operates many educational institutions – and theregulatory system. Gathering all the various actors,researchers and policy-makers from the different sectorsaround the same table will take some doing. A recentexample from Canada may provide inspiration for similarprocesses to be developed in other settings.In the year 2000, the Canadian government established anew national programme of Research Chairs to attract andretain some of the best researchers. One of the specific aimsof the Chairs is to promote the best possible use of researchresources through strategic institutional planning and throughcollaboration among institutions and between sectors. Forexample, in the domain of health workforce research at theUniversity of Toronto, research topics are both agreed uponand discussed with local and national policy-makers. Theprocess of engaging policy-makers in the development ofresearch topics, keeping them informed of the results ofresearch and cultivating champions among policy-makershas helped to address some crucial policy issues in nursingworkforce development in Canada (L O’Brien-Pallas, oralpresentation at World Health Organization (WHO), Geneva,January 2006).Regional and national observatories are other potentialmechanisms for harvesting and disseminating newknowledge, provided they effectively engage the full range ofstakeholders and their institutions. The experience of theObservatory on Human Resources for Health in the region ofthe Americas demonstrates that the observatory can be aneffective mechanism to improve information and evidenceand to advance the advocacy for human resources issues.The recently launched Africa HRH Observatory is hopedto provide a new impetus for research and evidence forthat region 15 .The way forward: encourage local productionand reach out to external researchIn conclusion, without good research to answer the policyquestions in health workforce development, we will failto find innovative solutions to long-festering problems. Policymakersmust reach out to researchers in their own countriesand facilitate the development of national research withinthe framework of a national strategy of health systemsresearch.Therefore, this policy brief recommends that both policymakersand researchers at country level:Global Forum Update on Research for Health Volume 4 ✜ 161
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Editorial Advisory Board:Luis Gabri
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Contents096 Child immunization: acc
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IntroductionResearch contributions
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IntroductionType IType IIType IIIPr
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Introductionmaking), takes account
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Access to healthStrengthening healt
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Access to healthTraining more healt
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Access to healthimperative for acti
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Access to healthReferences1.Further
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Access to healthDeterminantsAvailab
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Access to healthThe authors are inv
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Access to healthCombining health an
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Access to health100%Availability of
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Access to healthMandatory clinical
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Access to healthWhile there are som
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Access to healthReferences continue
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Access to healthintegrating individ
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Access to healthA social determinan
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Access to healthemployment conditio
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Access to healthMaking human rights
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Access to healthResources outsideth
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Access to healthReferences1.McCoy D
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Access to healthand financial burde
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Access to healthDiscrimination as a
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Access to health“Two months ago I
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Access to healthsocio-cultural and
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Access to healthand conference stat
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InnovationTowards the development o
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InnovationMajor classificationMajor
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Innovation60% of enterprises5040302
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InnovationUsing the power ofintelle
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Innovationbe adapted - and harnesse
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InnovationFinancing of vaccine R&D-
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InnovationFinancing Ultimate Interm
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Innovationsome of this risk might b
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InnovationChild immunization:accele
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Innovationare revealing previously
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InnovationDeveloping countries % De
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Innovationcapacities. It is indeed
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