Why we need multi-level health workforce governance: Case studies from nursing and medicine in Germany

How can intersectoral collaboration and action help improve the education, recruitment, and retention of the health and care workforce? A scoping review

Inadequate numbers, maldistribution, attrition, and inadequate skill-mix are widespread health and care workforce (HCWF) challenges. Intersectoral-inclusive of different government sectors, non-state actors, and the private sector-collaboration and action are foundational to the development of a responsive and sustainable HCWF. This review presents evidence on how to work across sectors to educate, recruit, and retain a sustainable HCWF, highlighting examples of the benefits and challenges of intersectoral collaboration. We carried out a scoping review of scientific and grey literature with inclusion criteria around intersectoral governance and mechanisms for the HCWF. A framework analysis to identify and collate factors linked to the education, recruitment, and retention of the HCWF was carried out. Fifty-six documents were included. We identified a wide array of recommendations for intersectoral activity to support the education, recruitment, and retention of the HCWF. For HCWF education: formalise intersectoral decision-making bodies; align HCWF education with population health needs; expand training capacity; engage and regulate private sector training; seek international training opportunities and support; and innovate in training by leveraging digital technologies. For HCWF recruitment: ensure there is intersectoral clarity and cooperation; ensure bilateral agreements are ethical; carry out data-informed recruitment; and learn from COVID-19 about mobilising the domestic workforce. For HCWF retention: innovate around available staff, especially where staff are scarce; improve working and employment conditions; and engage the private sector. Political will and commensurate investment must underscore any intersectoral collaboration for the HCWF.

Identifying strategic human resource management ability in the clinical departments of public hospitals in China: a modified Delphi study

OBJECTIVES

Chinese public hospitals are managed like a bureaucracy, which is divided into two levels of hospital and departmental management. Improving strategic human resource management ability (SHRMA) within clinical departments can improve department performance and service quality, which is an important way for public hospitals to obtain an advantage in a diversified competitive medical market. However, there is a lack of specialised evaluation tools for SHRMA in clinical departments to support this effort. Therefore, this study aims to develop an index for evaluating the SHRMA of clinical departments in public hospitals.

STUDY DESIGN AND SETTING

The Delphi technique was carried out with 22 experts, and an evaluation index of the SHRMA in the clinical departments of public hospitals was constructed. The weight of each indicator was calculated by the intuitive fuzzy analytic hierarchy process.

RESULTS

The SHRMA index constructed in this study for the clinical departments in public hospitals includes 5 first-level indicators, 13 second-level indicators and 36 third-level indicators. The first-level indicators are distributed in weight among human resource maintenance (0.204), human resource planning (0.201), human resource development (0.200), human resource stimulation (0.198) and human resource absorption (0.198). The top three weighted indicators on the second level are job analysis and position evaluation (0.105), career management (0.103) and salary incentivisation (0.100).

CONCLUSIONS

The index constructed in this study is scientific and feasible and is expected to provide an effective tool for the quantitative evaluation of SHRMA in the clinical departments of public hospitals in China.

Health workforce response to Covid-19: What pandemic preparedness planning and action at the federal and state levels in Germany?: Germany's health workforce responses to Covid-19

Introduction

The Covid‐19 pandemic has required countries to prepare their health workforce for a rapid increase of patients. This research aims to analyse the planning and health workforce policies in Germany, a country with a largely decentralised workforce governance mechanism.

Methods

Systematic search between 18 and 31 May 2020 at federal and 16 states on health workforce action and planning (websites of ministries of health, public health authorities), including pandemic preparedness plans and policies. The search followed World Health Organisation (WHO) Europe's health workforce guidance on Covid‐19. Content analysis was performed, informed by the themes of WHO.

Results

The pandemic preparedness plans consisted of no or limited information on how to expand and prepare the health workforce during pandemics. The 16 states varied considerably regarding implementing strategies to expand health workforce capacities. Only one state adopted a policy on task‐shifting despite a federal law on task‐shifting during pandemics.

Conclusions

Planning on the health workforce, its capacity and skill‐mix during pandemics was limited in the pandemic response plans. Actions during the peak of the pandemic varied considerably across states, were implemented ad hoc and with limited planning. Future action should focus on integrated planning and evaluation of workforce policies.

The vulnerabilities of the Brazilian health workforce during health emergencies: Analysing personal feelings, access to resources and work dynamics during the COVID-19 pandemic

Public health emergencies are a test of resilience for health systems, which depend on health workforces that are well managed and cared for. The COVID‐19 pandemic exposed the weakness of many health systems in preparing their health workforces. The crisis also exacerbated the unequal conditions between different professions, an issue that is still understudied in the workforce literature. This paper analyzes the consequences of the COVID‐19 pandemic for different health professionals, considering the ways in which Brazil's the health system does or does not protect them. We also analyse the role of pre‐existing inequalities between different professions and social groups within the workforce in shaping their different experiences of the pandemic. We present data comparing the perceptions of different health professionals facing the pandemic in Brazil: physicians, nurses, and community health workers. Data were collected in an online survey in Brazil with 1630 health care workers between June 15th and July 1st. Findings suggest that none of the professions felt well prepared to work under emergencies. However, differences relating to professional background were exacerbated during the pandemic, creating unequal conditions for different health workers. These inequalities may pose new challenges for the post‐pandemic scenario.

Governance in health workforce: how do we improve on the concept? A network-based, stakeholder-driven approach

BACKGROUND

Health workforce governance has been proposed as key to improving health services delivery, yet few studies have examined the conceptualisation of health workforce governance in detail and exploration in literature remains limited.

METHODS

A literature review using PubMed, Google Scholar and grey literature search was conducted to map out the current conceptualisation of health workforce governance. We identified all published literature relating to governance in health workforce since 2000 and analysed them on two fronts: the broad definition of governance, and the operationalisation of broad definition into key dimensions of governance.

RESULTS

Existing literature adopts governance concepts established in health literature and does not adapt understanding to the health workforce context. Definitions are largely quoted from health literature whilst dimensions are focused around the sub-functions of governance which emphasise operationalising governance practices over further conceptualisation. Two sub-functions are identified as essential to the governance process: stakeholder participation and strategic direction.

CONCLUSIONS

Although governance in health systems has gained increasing attention, governance in health workforce remains poorly conceptualised in literature. We propose an improved conceptualisation in the form of a stakeholder-driven network governance model with the national government as a strong steward against vested stakeholder interests. Further research is needed to explore and develop on the conceptual thinking behind health workforce governance.

Human resources for health interventions in high- and middle-income countries: findings of an evidence review

Many high- and middle-income countries face challenges in developing and maintaining a health workforce which can address changing population health needs. They have experimented with interventions which overlap with but have differences to those documented in low- and middle-income countries, where many of the recent literature reviews were undertaken. The aim of this paper is to fill that gap. It examines published and grey evidence on interventions to train, recruit, retain, distribute, and manage an effective health workforce, focusing on physicians, nurses, and allied health professionals in high- and middle-income countries. A search of databases, websites, and relevant references was carried out in March 2019. One hundred thirty-one reports or papers were selected for extraction, using a template which followed a health labor market structure. Many studies were cross-cutting; however, the largest number of country studies was focused on Canada, Australia, and the United States of America. The studies were relatively balanced across occupational groups. The largest number focused on availability, followed by performance and then distribution. Study numbers peaked in 2013-2016. A range of study types was included, with a high number of descriptive studies. Some topics were more deeply documented than others-there is, for example, a large number of studies on human resources for health (HRH) planning, educational interventions, and policies to reduce in-migration, but much less on topics such as HRH financing and task shifting. It is also evident that some policy actions may address more than one area of challenge, but equally that some policy actions may have conflicting results for different challenges. Although some of the interventions have been more used and documented in relation to specific cadres, many of the lessons appear to apply across them, with tailoring required to reflect individuals' characteristics, such as age, location, and preferences. Useful lessons can be learned from these higher-income settings for low- and middle-income settings. Much of the literature is descriptive, rather than evaluative, reflecting the organic way in which many HRH reforms are introduced. A more rigorous approach to testing HRH interventions is recommended to improve the evidence in this area of health systems strengthening.

Hospital Volunteering Experiences Suggest that New Policies are Needed to Promote their Integration in Daily Care: Findings from a Qualitative Study

OBJECTIVE

To explore Hospital Volunteers' (HVs) motivations and experiences, as well as the strategies they adopt to overcome challenging situations during volunteering and the needs they perceive.

METHODS

Eleven Italian HVs were purposively approached between January and July 2016, using face-to-face semi-structured interviews. The interviews were audio-recorded, transcribed verbatim and analysed using the descriptive phenomenological approach.

RESULTS

Hospital volunteering emerged as a complex experience characterised by five themes: (a) becoming a volunteer; (b) developing skills; (c) experiencing conflicting emotions; (d) overcoming role difficulties by enacting different resources and strategies; and (e) addressing emerging needs.

CONCLUSIONS

According to the findings, hospital policies aimed at promoting volunteer integration in daily care are needed and should be based on (a) a shared vision between the hospital and the volunteer associations regarding the HVs' role and skills; (b) the development of integrated models of care combining different workforces (i.e. professionals and volunteer staff); (c) appropriate training of HVs at baseline; (d) individualised continuous education pathways aimed at supporting HVs both emotionally and in the development of the required skills; and (e) tailored education that is directed to health-care staff aimed at helping them to value the service provided by HVs.

A strife of interests: A qualitative study on the challenges facing oral health workforce policy and planning

Oral health workforce policy has often lacked systematic connections with broader health policy, and system-based reforms that would enable more effective responses to future needs of the population. The aim of the study was to better understand challenges facing oral health workforce policy and planning and identify potential solutions. In-depth interviews of 23 senior oral health leaders and/or health policy experts from 15 countries were conducted in 2016-17. Grounded theory principles using the Straussian school of thought guided the qualitative analysis. The findings identified: (i) narrow approach towards dental education, (ii) imbalances in skills, jobs and competencies, and (iii) geographic maldistribution as major challenges. An overarching theme -"strife of interests" - shed light on the tension between the profession's interest, and the needs of the population. A key aspect was the clash for power, dominance and authority within the oral health workforce and across health professions. This study argues that appreciating the history of health professions and recognising the centrality of the strife of interests is necessary in developing policies that both address professional sensitivities and are in line with the needs of the population. Integration and closer collaboration of oral health professionals with the mainstream medical and health professions has emerged as the key issue, but the solutions will be diverse and dependent on country- or context-specific scenarios.

Reports of rationing from the neglected realm of capital investment: Responses to resource constraint in the English National Health Service

Health systems around the world face financial pressures that can affect sustainability and patient outcomes, and there is a vast literature devoted to the allocation of scarce health care resources. Capital spending - for example on estates, equipment and information technology - is an important but often neglected area of this literature. This study explores the constraints on the allocation of capital budgets in health care, before addressing the question: what is the role of priority setting and rationing in responses to these constraints? The paper presents findings from interviews conducted with senior finance professionals in 30 National Health Service local provider organisations across England. Findings suggest a pervasive sense of impending crisis, with capital restrictions limiting investment in buildings, infrastructure and equipment. The paper applies a conceptual classification scheme from the classic rationing literature (the forms of rationing framework) and identifies widespread practices of 'selection', 'dilution' and 'delay', with 'denial' and 'termination' comparatively rare. Practices of 'deflection' and 'deterrence' are ascribed to national actors as a means of restricting the flow of capital resources to the system. The study suggests that there is little by way of tailored support for priority setting in capital spending, and a perception that decisions are often reactive and short term. It also suggests that wider system features and dynamics can preclude or constrain priority setting at the organisational level. The authors use these findings to suggest future conceptual development of the forms of rationing framework and make recommendations for research and practice in this area.

A Heuristic Governance Framework for the Implementation of Child Primary Health Care Interventions in Different Contexts in the European Union

To adopt and implement innovative good practices across the European Union requires developing policies for different political and constitutional contexts. Health policies are mostly decided by national political processes at different levels. To attain effective advice for policy making and good practice exchange, one has to take different models of governance for health into account. We aimed to explore which concepts of governance research are relevant for implementing child health policies in a European Union context. We argue that taking into account the insights of good intersectoral and multilevel governance in research and practice is essential and promising for future analyses. These governance concepts help to understand what actors and institutions are potentially of relevance for developing and implementing child-centric health care approaches not only within health care but also outside health care. The framework we developed has the potential to advise on and thus support effectively the spreading and implementation of good practices of child-centric health policy approaches across the European Union. With this heuristic framework, the variety of relevant stakeholders and institutions can better be mapped and taken into account in implementation processes. Also, the normative side-particularly stressing values that make governance "good governance"-is to be taken into account.

Standardization of medical service indicators: A useful technique for hospital administration

Background

Many comparability problems appear in the process of the performance assessment of medical service. When comparing medical evaluation indicators across hospitals, or even within the same hospital, over time, the differences in the population composition such as types of diseases, comorbidities, demographic characteristics should be taken into account. This study aims to introduce a standardization technique for medical service indicators and provide a new insight on the comparability of medical data.

Methods

The medical records of 142592 inpatient from three hospitals in 2017 were included in this study. Chi-square and Kruskal-Wallis tests were used to explore the compositions of confounding factors among populations. The procedure of stratified standardization technique was applied to compare the differences of the average length of stay and the average hospitalization expense among three hospitals.

Results

Age, gender, comorbidity, and principal diagnoses category were considered as confounding factors. After correcting all factors, the average length of stay of hospital A and C were increased by 0.21 and 1.20 days, respectively, while that of hospital B was reduced by 1.54 days. The average hospitalization expenses of hospital A and C were increased by 1494 and 660 Yuan, whilst that of hospital B was decreased by 810 Yuan.

Conclusions

Standardization method will be helpful to improve the comparability of medical service indicators in hospital administration. It could be a practical technique and worthy of promotion.

Primary care workforce development in Europe: An overview of health system responses and stakeholder views

Better primary care has become a key strategy for reforming health systems to respond effectively to increases in non-communicable diseases and changing population needs, yet the primary care workforce has received very little attention. This article aligns primary care policy and workforce development in European countries. The aim is to provide a comparative overview of the governance of workforce innovation and the views of the main stakeholders. Cross-country comparisons and an explorative case study design are applied. We combine material from different European projects to analyse health system responses to changing primary care workforce needs, transformations in the general practitioner workforce and patient views on workforce changes. The results reveal a lack of alignment between primary care reform policies and workforce policies and high variation in the governance of primary care workforce innovation. Transformations in the general practitioner workforce only partly follow changing population needs; countries vary considerably in supporting and achieving the goals of integration and community orientation. Yet patients who have experienced task shifting in their care express overall positive views on new models. In conclusion, synthesising available evidence from different projects contributes new knowledge on policy levers and reveals an urgent need for health system leadership in developing an integrated people-centred primary care workforce.

The Life Story Experience of "Migrant Dentists" in Australia: Potential Implications for Health Workforce Governance and International Cooperation

BACKGROUND

The migration of dentists is a major policy challenge facing both developing and developed countries. Dentists from over 120 countries migrate to Australia, and a large proportion are from developing countries. The aim of the study was to assess the life story experience (LSE) of migrant dentists in Australia, in order to address key policy challenges facing dentist migration.

METHODS

A national survey of all migrant dentists resident in Australia was conducted in 2013. Migrant experiences were assessed through a suite of LSE scales, developed through a qualitative-quantitative study. Respondents rated experiences using a five-point Likert scale.

RESULTS

A total of 1022 migrant dentists responded to the survey (response rate = 54.5%). LSE1 (health system and general lifestyle concerns in home country), LSE2 (appreciation towards Australian way of life) and LSE3 (settlement concerns in Australia) scales varied by migrant dentist groups, sex, and years since arrival to Australia (chi-square, P < .05). In a logistic regression model, migrants mainly from developing countries (ie, the examination pathway group) faced greater health system and general lifestyle concerns in their home countries (9.32; 3.51-24.72) and greater settlement challenges in Australia (5.39; 3.51-8.28), compared to migrants from well-developed countries, who obtained direct recognition of qualifications. Migrants also are more appreciative towards the Australian way of life if they had lived at least ten years in Australia (1.97; 1.27-3.05), compared to migrants who have lived for less than ten years.

CONCLUSION

Migrant dentists, mainly from developing countries, face challenges both in their home countries and in Australia. Our study offers evidence for multi-level health workforce governance and calls for greater consensus towards an international agenda to address dentist migration. Better integration of dentist migration with the mainstream health workforce governance is a viable and opportunistic way forward.

Regional health workforce monitoring as governance innovation: a German model to coordinate sectoral demand, skill mix and mobility

BACKGROUND

As health workforce policy is gaining momentum, data sources and monitoring systems have significantly improved in the European Union and internationally. Yet data remain poorly connected to policy-making and implementation and often do not adequately support integrated approaches. This brings the importance of governance and the need for innovation into play.

CASE

The present case study introduces a regional health workforce monitor in the German Federal State of Rhineland-Palatinate and seeks to explore the capacity of monitoring to innovate health workforce governance. The monitor applies an approach from the European Network on Regional Labour Market Monitoring to the health workforce. The novel aspect of this model is an integrated, procedural approach that promotes a 'learning system' of governance based on three interconnected pillars: mixed methods and bottom-up data collection, strong stakeholder involvement with complex communication tools and shared decision- and policy-making. Selected empirical examples illustrate the approach and the tools focusing on two aspects: the connection between sectoral, occupational and mobility data to analyse skill/qualification mixes and the supply-demand matches and the connection between monitoring and stakeholder-driven policy.

CONCLUSION

Regional health workforce monitoring can promote effective governance in high-income countries like Germany with overall high density of health workers but maldistribution of staff and skills. The regional stakeholder networks are cost-effective and easily accessible and might therefore be appealing also to low- and middle-income countries.

Migration of Spanish nurses 2009-2014. Underemployment and surplus production of Spanish nurses and mobility among Spanish registered nurses: A case study

BACKGROUND

After the financial crisis of 2008, increasing numbers of nurses from Spain are going abroad to work.

OBJECTIVES

To examine the health and workforce policy trends in Spain between 2009 and 2014 and to analyze their correlation with the migration of nurses.

DESIGN

Single embedded case study.

DATA SOURCES

We examined data published by: Health Statistics, Organization for Economic Cooperation and Development (1996 to 2013); Ministry of Education, Culture and Sports (2006 to 2013); Ministry of Employment and Social Security (2009 to 2014); Ministry of Health, Social Services and Equality (1997 to 2014); and National Institute of Statistics (1976 to 2014). In addition to reviewing the scholarly literature on the topic in Spanish and English, we also examined Spanish mobility laws and European directives.

POPULATION

We used the Organization for Economic Cooperation and Development definition of "professionally active nurses" which defines practising nurses and other nurses as those for whom their education is a prerequisite for employment as a nurse. Moreover, we used the term "nursing graduate" as defined by Spanish Ministry of Education to describe those who have obtained a recognized qualification in nursing in a given year, the term "registered nurses" is defined by Spanish law as nurses registered in the Nurses Associations and "unemployed nurses" are those without work and registered as seeking employment.

RESULTS

A transformation of the Spanish health system has reduced the number of employed nurses per capita since 2010. Moreover, reductions in public spending, labour market reforms and widespread unemployment have affected nurses in two ways: first by increasing the number of applicants per vacancy between 2009 and 2013, and second, by an increase in casual positions. However, despite the poor job market and decreasing job security, the number of registered nurses and nursing graduates in Spain per year has continued to grow, increasing the pressure on the labour market.

CONCLUSIONS

Spain is transforming from a stable nursing labour market, to one that is increasingly producing nurses for foreign markets, principally in Europe. With its low birth rate, increased life expectancy and increasing rates of chronic disease, it is critical for Spain to have sufficient nurses now and into the future. It is important that there be continued study of this phenomenon by Spanish policy makers, health service providers and educators in order for Spain to develop health human resources policies that address the health care needs of the Spanish population.

Where health workforce governance research meets health services management

A deficit of one million healthcare workers forecasted in the European Union by 2020 turns the ‘universal truth’ that there is ‘no health without a workforce’ into the perhaps biggest challenge for future healthcare systems and services management. We argue that effective healthcare management needs systematic connections with health workforce macro- and meso-levels of governance. We seek to explore the overlaps and the benefits of closer connections using health workforce planning, recruitment and retention and the changes in the skills mix and competencies of the health workforce as three illustrative examples. Two major areas of management intervention are emerging: (1) changes in the composition of the skills and competencies in the health workforce guided by a needs-based services management approach rather than by professional interests and (2) changes in the management of workplace and career conditions. Furthermore, an integrated governance approach is needed that connects innovations at the organizational level of services management with health workforce policy and systems-based governance interventions.

Health workforce development in the European Union: A matrix for comparing trajectories of change in the professions

This article assesses professional development trajectories in top-, middle- and basic-level health workforce groups (doctors, nurses, care assistants) in different European Union countries using available international databases. Three theoretical strands (labour market, welfare state, and professions studies) were connected to explore ideal types and to develop a matrix for comparison. With a focus on larger EU-15 countries and four different types of healthcare systems, Germany, Italy, Sweden and the United Kingdom serve as empirical test cases. The analysis draws on selected indicators from public statistics/OECD data and micro-data from the EU Labour Force Survey. Five ideal typical trajectories of professional development were identified from the literature, which served as a matrix to compare developments in the three health workforce groups. The results reveal country-specific trajectories with uneven professional development and bring opportunities for policy interventions into view. First, there is a need for integrated health labour market monitoring systems to improve data on the skills mix of the health workforce. Second, a relevant number of health workers with fixed contracts and involuntary part-time reveals an important source for better recruitment and retention strategies. Third, a general trend towards increasing numbers while worsening working conditions was identified across our country cases. This trend hits care assistants, partly also nurses, the most. The research illustrates how public data sources may serve to create new knowledge and promote more sustainable health workforce policy.

Medical workforce education and training: A failed decentralisation attempt to reform organisation, financing, and planning in England

The 2010-2015 Conservative and Liberal Democrat coalition government proposed introducing a radical decentralisation reform of the organisation, financing, and planning of medical workforce education and training in England. However, following public deliberation and parliamentary scrutiny of the government's proposals, it had to abandon and alter its original proposals to the extent that they failed to achieve their original decentralisation objectives. This failed decentralisation attempt provides important lessons about the policy process and content of both workforce governance and health system reforms in Europe and beyond. The organisation, financing, and planning of medical workforce education is as an issue of national importance and should remain in the stewardship of the national government. Future reform efforts seeking to enhance the skills of the workforce needed to deliver high-quality care for patients in the 21st century will have a greater chance of succeeding if they are clearly articulated through engagement with stakeholders, and focus on the delivery of undergraduate and postgraduate multi-professional education and training in universities and teaching hospitals.