facing the challenges in human resources for humanitarian

SPECIAL REPORT

Facing the Challenges in Human Resourcesfor Humanitarian HealthHani Mowafi MDMPH14 Kristin Nowak MS2 Karen Hein3

Human Resources Working Group

1 Harvard Humanitarian Initiative Harvard

University Cambridge Massachusetts

USA2 Dartmouth Medical School Lebanon

New Hampshire USA

3 Child Fund International JacksonvilleVermont USA

4 Department of Emergency MedicineBoston University Medical CenterBoston Massachusetts USA

For the Human Resources Working GroupStephen Atwood UNICEF BillBurdick

FAIMER Bill Corcoran Christian

Childrens Fund Kiera Dowries Action

Against Hunger Rigoberto Giron CARE

Christoph Gorder Americares Beth Gragg

World Education Jim James AMA

Emergency Preparedness Louise Shea IRC

AfafMeleis University of Pennsylvania

School of Nursing Masahiro Morikawa

Case Western Reserve University School of

Medicine Fitzhugh Mullan George

Washington University Sonia Khush Save

the Children Foundation Robin Nandy

UNICEF Jason Phillips IRC Adam

Richards Global Health Access Program

Beth Stanciu American Refugee Committee

CorrespondenceHani Mowafi MD MPHHarvard Humanitarian Initiative14 Story St 2nd FloorCambridge MA 02138 USAE-mail hmowafihhiharvardedu

Keywords competencies complexemergencies health human resourceshumanitarian health conference

AbbreviationsH C W = healthcare workerHRH = Human Resources for Health

IMCI=Integrated Management of ChildhoodIllness

MDG = Millennium Development GoalsNGO = non-governmental

organization

AbstractThe human resources crisis in humanitarian health care parallels that seen inthe broader area of health care This crisis is exacerbated by the lack ofresources in areas in which humanitarian action is neededmdashdifficult environ-ments that often are remote and insecuremdashand the requirement of specificskill sets is not routinely gained during traditional medical training Whilethere is ample data to suggest that health outcomes improve when workerdensity is increased this remains an area of critical under-investment inhumanitarian health care In addition to under-investment other factors limitthe availability of human resources for health (HRH) in humanitarian workincluding (1) over-reliance on degrees as surrogates for specific competen-cies (2) under-development and under-utilization of national staff and ben-eficiaries as humanitarian health workers (3) lack of standardized trainingmodules to ensure adequate preparation for work in complex emergencies (4) andthe draining of limited available HRH from countries with low prevalenceand high need to wealthier developed nations also facing HRH shortages

A working group of humanitarian health experts from implementingagencies United Nations agencies private and governmental financiers andmembers of academia gathered at Hanover New Hampshire for a conferenceto discuss elements of the HRH problem in humanitarian health care andhow to solve them Several key elements of successful solutions were high-lighted including (1) the need to develop a set of standards of what wouldconstitute adequate training for humanitarian health work (2) increasingthe utilization and professional development of national staff (3) trainingwith a purpose specific to humanitarian health work (not simply relying onprofessional degrees as surrogates) (4) and developing specific health task-based competencies thereby increasing the pool of potential workers

Such steps would accomplish several key goals such as (1) more confident-ly ensuring that individuals hired for a given post would have the capacity tofunction at a commonly understood level of training (2) greatly increasing thepotential number and types of workers available for humanitarian work (3) increas-ing the efficiency of human resources utilization in humanitarian projectsand (4) recognition that humanitarian work is a multi-disciplinary endeavorthese goals will contribute to ensuring that humanitarian health workers havea minimum training in broader humanitarian action making them moreeffective team members in the field

Efforts were made to highlight some promising pilot programs for humanresource development in humanitarian work to identify a future vision forhumanitarian health as a profession and to develop a human resources strat-egy for achieving that vision

Mowafi H Nowak K Hein K Human Resources Working Group Facingthe challenges human resources for humanitarian heath Prehospital DisastAfo200722(5)351-359

Web publication 11 October 2007

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httpwwwcambridgeorgcoreterms httpdxdoiorg101017S1049023X00005057Downloaded from httpwwwcambridgeorgcore Brown University Library on 17 Dec 2016 at 155640 subject to the Cambridge Core terms of use available at

352 Expanding Scope of Humanitarian Program Evaluation

No improvement in financing or medical products canmake a lasting difference to peoples lives until the crisisin the health workforce is solved

Anders Nordstrom Acting Director-General WorldHealth Organization

XVI International AIDS ConferenceToronto 18 August 20061

BackgroundThere is a growing human resources crisis in humanitarianhealth The critical shortage of skilled trained providersavailable to serve in humanitarian projects highlights anunder-appreciated obstacle to humanitarian health projectsIn many ways this human resources crisis parallels the gen-eral misallocation of human resources in health services inmuch of the developing world and most crucially in thosecountries facing complex emergencies24 This complicatedproblem involves a lack of (1) resources in the areas most inneed (2) recognition by funding agencies of the importanceof human resources to achieving project goals (3) investmentin human resources by governments and non-governmentalentities even when funds are available and (4) coordinationof training to meet actual needs of beneficiaries

All of this set within the context of a global crisis in humanresources for health (HRH) pulls workers away from the poor-est localities toward more affluent nations that also areattempting to fill the gaps in their own healthcare workforces

Increasing Need Increasing ScopeWhile there is a growing recognition of the crisis in HRHthe development of sustainable solutions to this challengehas been limited Humanitarian health projects face many ofthe same challenges and by their very nature occur in themost resource-poor environments In an attempt to meet thehealth needs of beneficiaries in these impoverished settingshumanitarian health agencies are forced to create parallelsystems in areas in which the health systems are broken orcreate entire health systems where there is no present func-tioning health systemmdashall with the goal of improving thecapacity of local populations to meet their healthcare needs

Over the last several decades humanitarian healthagencies have been transitioned from implementing ad hoccharitable giving to being more disciplined and sophisti-cated implementers of domestic and international healthprograms Concerns over respecting a countrys sovereign-ty maintaining neutrality between groups in a conflict andincurring the acceptance of beneficiary populationsincreasingly have made humanitarian health agencies (bothinternational and non-governmental) critical providers oflarger health programs for greater numbers of beneficiariesthan ever before Along with this transition and the accom-panying increase in the size and scope of humanitarianhealth programs comes the challenge to increase the effi-ciency and capacity for their practice

ProblemDespite being critical to meeting the MillenniumDevelopment Goals (MDG) necessitating the urgentdevelopment of workforce strategies to develop sustainablecapacity in the poorest countries HRH still are in a state of

crisis2 Increasing healthcare worker (HCW) density leadsto improved health outcomes (Figure 1) Africa which hasbeen estimated to harbor 25 of all of the worlds diseaseshas only 13 of the worlds health staff5 Six hundredthousand HCWs provide care for gt600 million people Inorder to achieve the MDGs gt1 million additional HCWswill be needed6

This shortfall is not unique to Africa There is a globalshortfall in the numbers of HCWs needed to meet theglobal demand3468 While HRH data are limited datafrom professional registries demonstrate a similar shortfallin the developed world3 A fundamental element of thisgap is the training of insufficient numbers of HCWs tomeet the global demand There is a link between the gapthat exists in HRH in developed host countries and that inunder-developed source countries In an effort to meet thegrowing demand for HRH host countries employ strate-gies to recruit HCWs from source countries that cannotafford to lose them This results in an exacerbation of theunmet need for HRH in developing countries despite evi-dence that increased HRH density leads to improved out-comes2 The downstream effect for humanitarian agenciesfrom these fatal flows is an even greater reduction of thepool of available HCWs in disaster-affected countries inwhich there is little in the way of professional support per-sonal security and financial compensation

Chen divides countries into clusters based on theirsocio-economic conditions and HCW density He describesseveral groups (Figure 2) (1) poorer worker-deficit highmortality (eg Africa) (2) richer and more worker-denselow mortality (eg Organisation for EconomicCooperation and Development (OECD) nations) (3) tran-sitional (eg Philippines Southeast Asia) and (4) othercountries (eg Middle East Latin America)2 Countries inthe first group typically have the triple threat of a largeburden of disease insufficient numbers of HCWs andinsufficient resources for training additional workers as wellas a level of poverty that results in many of the most talent-ed citizens seeking opportunities abroad resulting in furthershortages Countries in the second group have lower bur-dens of disease greater economic resources but still do nottrain to meet their demand for HRH Therefore thesenations recruit from other countries to supplement theirworkforce capacity These countries also are the largestdonors of humanitarian assistance and traditionally havebeen the headquarters of the largest international assistanceorganizations and United Nations agencies Countries inthe third group are developing rapidly and have made a sig-nificant commitment to HCW training While economicopportunities remain somewhat limited these countrieshave become net exporters of HRH while not significantlydepleting the capacity of their own workforce Countries inthe last group represent the remaining nations some haveresources and have not yet made the commitment to meet-ing their own domestic HRH needs while others lackresources but do not have significant gaps in their domesticHRH capacity Understanding the differences betweenthese groups can help to predict directions of healthcarelabor flows and identify potential sources for increasedhealthcare capacity during times of need

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Mowafi Nowak Hein et al 353

Mortality (par 1000 log)

1Dlaquoislty (worlara per 1000 log)

Prehospital and Disaster Medicine18Figure 1mdashWorker density and health outcomes

Countries also vary by the skill mix of their HCW work-force the density of HCWs and their distribution and theoverall burden of disease in their populations2 These char-acteristics also have a strong correlation For example coun-tries or regions within countries that lack adequate HCWswith sufficient training often also have a correspondinglyhigh burden of disease Unfortunately it is these areas withtheir lack of economic and human resources burdens of dis-ease and resultant social turmoil that are the most vulnera-ble to becoming full-blown humanitarian crisesmdashwhetherby the result of a disaster caused by natural hazards orthrough man-made emergencies such as armed conflict ordisplacement It is in these places that humanitarian healthagencies will continue to be faced with the challenge of howto confront such a dearth of developed capacity for healthcare while trying to accomplish their mission of alleviatingthe suffering of the affected population

Current ContextFinding a comprehensive solution to the problem of HCWemigration is beyond the scope of this paper Howeverunderstanding the context in which shortfalls of humanresources for humanitarian health exist is the key to devel-oping novel solutions to train and retain workers forhumanitarian health programs

Worldwide there is under-investment in HRHGovernment health ministries and humanitarian healthagencies operate on lean budgets and under pressure todemonstrate fiscal responsibility have tried to do morewith less This lack of investment parallels that seen indeveloping countries and much of the rest of the world Itis estimated that 60-80 of countries spend lt1 of theirGross Domestic Product (GDP) on HRH2 Budgets forHRH development in humanitarian agencies are con-strained similarly In wealthier countries a larger percent-age is spent directly on recurring human resources costs oftraining and salaries In Europe these range from 17(Czech Republic) to 71 (Cyprus)9 This often representsan expenditure on critically needed human resources thanin the poorer locations requiring humanitarian actionWhile an ideal percentage spent on human resources forhealth has yet to be established the widespread lack of cov-erage for worldwide populations continues to indicate thatcurrent expenditures may be too low

Prehospital and Disaster Medicine

Figure 2mdashCountry clusters by HCW density and mor-tality19

There also is a lack of directed training for health carein much of the world including humanitarian actionThere is heavy emphasis on professional degrees as surrogatesfor competencies or skills even when the two are not highlycorrelated Often such a dependency on limited numbersof degree holders results in an even greater deficit of HRHcapacity Few countries have national examinations to testfor competency10 The same is true for non-governmentalagencies (NGOs) and other humanitarian actors Theresult is the potential to err in both directions with a lackof available workers with professional degrees while somedegree holders cannot meet the minimum competenciesneeded for their positions Traditionally degrees and mea-sures of competency were established to ensure the safe andcompetent disbursal of services to beneficiaries Howeverby focusing on degrees and not competencies the endresult often is a lack of standardized skills in the field andan over-reliance on physicians and nurses to fill basichealthcare roles There is an urgent need for better target-ing of skills so that highly skilled providers only are utilizedin situations requiring their degree of training

Furthermore training HCWs to meet the challenges ofthe developing world especially the needs of communitiesexperiencing complex emergencies is not the same astraining for practice in the developed countries of theGlobal North3-10 Many developing nations explicitly orindirectly train HCWs to meet global standards that arenot applicable to the experience of patients in their coun-tries As such the training is geared more to passing licens-ing examinations in host countries than to addressing theproblems endemic in their home countries310 This distor-tion of training results in a mismatch between providers inthese countries and the skills needed to treat local patientsIt also leaves providers dissatisfied as they are unable topractice much of what they have learned and thus increasestheir desire to seek out professional opportunities elsewhere

The same can be said of HCWs in the humanitarian aidsetting Too often positions are advertised as requiring anMD RN MPH or other high degree designation for posi-tions that might be covered adequately by lesser-trainedindividuals Indeed Cash raises several ethical questionsregarding the use of such a high standard for training inHRH in resource-poor settings10 Is it ethical to apply sucha standard even when it limits access to care How do




Existingcivil service

Formercivil service

Trainingschools

Disapora

Private practicioners(unregulated)

Post-ConflictV Workforce

NGO trainedand employed

Cross-borderrefugee camp-trained

health workers

Rebelfactionalgroup

Informalhealth workers


Figure 3mdashPotential sources of healthcare workers in a post-conflict (NGO = non-governmental organization)Source WHO Guide to Health Workforce Development in Post-Conflict Environments 2005

Local KnowledgemdashAvailability

Humanitarian healthprofessionals

Foreign andlocal medicalprofessionals

p Trainedpara-professionals

Communityvolunteers

Pool ofpotiential HCWs

Humanitarian Health Knowledge

Figure 4mdashBalance of professional training vs local expertise3 (HCW = healthcare worker)humanitarian agencies rectify trying to deliver the best pos- Complications


sible care in a given setting when that doesnt meet thestandards they would apply elsewhere How can humani-tarian actors balance the desire for improving the lot ofbeneficiaries with a commitment to increasing the standardof care they provide to their communities10

By training other paraprofessionals who are more abun-dant in the specific skills necessary to meet health needs inthe settings of complex emergencies coverage can beexpanded to the greatest number of beneficiaries4810 TheWorld Health Organizations Guide to Workforce Developmentin Post-Conflict Environments demonstrates potential poolsof new workers for the healthcare workforce (Figures 3 and4) When drawn from the local population the training ofsuch individuals not only increases local capacity but alsoincreases the likelihood that the community will retain thathuman resource Retention remains one of the major chal-lenges of HRH for humanitarian agencies for specific indi-vidual projects and for the organization in general

The issue of brain drainwhcn the best and brightest mem-bers of developing societies emigrate to other countries insearch of improved living and working conditions greaterprofessional opportunities and higher remuneration is oneof the major human resource challenges facing the healthsector in the developing world International humanitarianhealth projects rely heavily on local professional talent asthe prime movers of programs and suffer heavily fromthese transnational flows of human capital247810

In addition to the so-called push factors of poor work-ing conditions and low pay in developing countries thedemand for trained human capital in host countries is a keydeterminant of these labor shifts It is estimated that by2020 there will be a shortfall of health professionals in theUnited States to the tune of 200000 physicians and800000 nurses6 Similar patterns of health workforceshortages can be seen in data from most OECD countriesLow birth rates in developed countries necessitate the need




for immigrants to fill the open healthcare positions in thecountries with strong economies and rapidly aging popula-tions that because of their demographic and ability to paywill continue to create an increasing demand for healthproviders in the foreseeable future Stemming the tide oftrained HCWs flowing from the poorest nations to labor-hungry wealthy nations will require addressing both pushand pull factors Furthermore since humanitarian HCWsare drawn largely from the national staff in affected coun-tries or from their regional neighbors developing andmaintaining viable HCW bases in developing nations willbe a key determinant for increasing human resource capac-ity for humanitarian health agencies as well

Ethical Implications of Human Resource RecruitmentSome analysts argue that promoting and encouraging thistransnational flow of trained labor constitutes a theft byrich countries from the developing world amounting toroughly US $500 million annually for emigration of skilledlabor from Africa alone6 Developing nations not only losea critical resource but also are denied a return on their largeinvestment in trainingmdashmost of which is funded sacrifi-cially through the public sector Potential solutions haveranged from compensating these countries directly to ini-tiating bilateral agreements that would control rates ofimmigration to establishing public campaigns to improveconditions in home countries All of these are fraught withpractical economic and ethical concerns

There is an often neglected ethical dimension to thetraining of HCWs in resource-poor settings How shouldthe need for additional human resources be balanced withthe ethical concern for ensuring technical competence ofthose taking the lives of others into their hands The allo-cation of scarce human resources also has ethical implica-tions When does the laudable goal of striving for equityresult in unacceptable inefficiency Is it ethical to sendhighly trained workers to areas where they cannot make useof their training due to a lack of support materially profes-sionally or otherwise Humanitarian assistance has anadditional complexity of operating in areas of geophysicalpolitical and military instability When should humanitar-ian health professionals not be there Are their skills toovaluable to risk in austere settings where they are likely lim-ited in their scope of practice

A further dilemma is whether health care constitutes aspecial case in the global flow of human resources8 As withworkers in other sectors physicians and nurses increasinglyare sourced globally However unlike information technol-ogy professionals with the exception of purely diagnosticradiology and a few other sub-specialties the greatest needfor healthcare providers and indeed most healthcare ser-vices are those provided in-situ Such services require thatthe professionals relocate to their places of service Thelong lead time of training a HCW from start to completionmakes them difficult to replace The loss of this criticalresource is expensive and difficult to anticipate in unstableenvironments making it almost impossible for countriesexperiencing complex emergencies to maintain a localsurge capacity to respond to sudden increases in healthcare

needs in times of crisis Filling this gap in the acute phaseand then decreasing vulnerability to such crises in the future isultimately the mission of most humanitarian health agencies

Parts of a SolutionThe Working Group for Human Resources in HumanitarianHealth included a wide range of participants including fieldworkers and managerial staff from governmental and non-governmental institutions US-based and internationalactors academics and important UN agencies with ahealthcare mandate While there were different approachesto the problem of scarcity of qualified HCWs in humani-tarian work there was broad agreement that the solutions tothis problem lie within three broad themes (1) better defi-nition of a career path for humanitarian health profession-als (2) increased recruitment training and retention ofqualified workers with emphasis on national staff and (3)greater investment in human resources for humanitarianhealth on the part of actors and financiers

Competencies for Humanitarian HealthWhile the idea of training paramedical staff to performmedical functions that do not require a nurse or physicianis not a novel approach humanitarian health projectsremain plagued by the inefficient use of their most highlytrained staff In the absence of workflow analyses and pre-cise definitions for needed skills humanitarian health pro-jects resort to the use of professional degrees as surrogatesfor specific competencies The result is a heterogeneousworkforce even within the same specialty and frequentmismatches of skill-sets with skills needed As has beendemonstrated with the Directly Observed Therapy Shortcourse for tuberculosis treatment paraprofessional staff canbe trained to perform what otherwise would be consideredhealthcare tasks using standardized diagnostic and thera-peutic protocols that provide a consistent approach andmeasurable outcomes 113 Furthermore innovative pro-grams like the Aravind Eye Institute have demonstratedthat careful workflow analysis and tasking of individualsbased purely on competencies can result in tremendoushealth outputs and measurable impacts at a low cost to thesystem and often at no cost to the beneficiary14

An over-reliance on degrees rather than competenciesalso perpetuates a lack of training in the problems of thedeveloping worldmdashas medical training focuses primarilyon maladies present in wealthy nations10 The training ofparaprofessionals from the beneficiary community to fillkey roles in healthcare delivery results in (1) more precise tar-geting of skills to face the actual needs of beneficiary popula-tions (2) greater cost-effectiveness and (3) a workforce lesslikely to emigrate and with a cultural awareness that would takeoutside practitioners months if not years to obtain (Figure 4)

Effective staff development will revolve around the issueof developing and measuring new competencies for humani-tarian health tasks and this investment must be directed atanalyzing the workflows of key humanitarian health posi-tions From that analysis competencies that reflect the actualskill set needed to fulfill the requirements of those positionsmust be developed This alone will increase the numbers ofpotential HCWs available for humanitarian projects greatly

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Human Resources Actions

-Numeric adequacy-Worker mixbull Social outreach

- Satisfactory remuneration-Work environment-Systems of support

-Appropriate skillsbullTraining and continuous learning- Leadership and entrepreneurship

Workforce Objectives

CoverageSocial andPhysical

MotivationSystem and

Support

CompetenceTraining and

Learning

Figure 5mdashHuman resources plan to health outcomes19 Source LancetPrehospital and Disaster Medicine

Hard-PayFinancial benefits-TitlePosition-Improve working conditions

Difficult-Opportunities for planned rotation between more and less

desirable posts-Self-advancement or additional experiences without

leaving an organization-Opportunities to enhance colleagueshipmdasheg professional

conferences-Provision of higher level of professionaltechnical support

Table 1mdashTypes of incentives

Trainingcan focus on yielding the necessary number ofHCWs and may allow that training to be in situ and todraw from the local beneficiary population thus increasingcultural awareness and beneficiary acceptance of servicesThis type of training with purpose can yield humanresources in increased numbers and reduce the dissatisfac-tion resulting from professional over-qualificationConcordant with having measures of minimum competen-cies is developing tools to assess those competencies on anongoing basis in the field Such measures will be critical tomaintain the quality of the care delivered and the confi-dence of the beneficiaries of that care

Increasing Recruitment of National Staff for HumanitarianHealth ProjectsRecruitment and retention of national staff for humanitarianhealth is a multi-faceted problem (Figure 5) As has beendemonstrated in studies of healdi care in the developing worlddie wage differentials between host and source countries are solarge that this problem cannot be addressed by focusing onremuneration alone15 Efforts must be made to improve work-ing conditions increase opportunities for professional advance-ment and provide a higher level of professional supportHowever it must be recognized that recruiting national staff isa process that is fraught widi potential problems

Understandably while humanitarian agencies attemptto attract the best and most qualified personnel to join theirteam they must realize the perils of doing so with excessivefinancial inducements Higher pay and improved workingconditions in these organizations can result in distortionsto the local healthcare system (Table l)This mini brain-drain from local health facilities to those run by interna-tional humanitarian agencies deplete the local facilities oftheir primary resource and breed resentment in the HCWs

Mowafi copy 2007 Prehospital and Disaster Medicine

that remain behind Without a concomitant investment inincreasing the capacity of community health resources gen-erally humanitarian health agencies run the risk of beingdiscredited in the eyes of beneficiaries the very resourcethey must rely on once the humanitarian actors have left

From Professional Development and Support to IncreasedRetention and SatisfactionHumanitarian health agencies can do much to supporttheir national and field staff and increase retention of thatstaff for future projects Some agencies like theInternational Rescue Committee the largest US NGOthat provides healthcare services during humanitariancrises have developed technical support units16 These spe-cialized units provide training and ongoing technical supportto field units in order to increase their capacity to provideservice and their capacity to collect critical data to build thecase for future additional resources Such units can reducethe stress on field staff who constantly are asked to do morewith less while assisting them to provide higher qualityservices to their beneficiaries

It has been suggested that international placements aresought by national staff and may be seen as more presti-gious posts With this in mind it is suggested that policiesfor regional promotion be established to help retain coun-try- and region-specific expertise close to where it is mosteffective Emergency response workers field epidemiolo-gists water and sanitation experts and other specialists relysignificantly on the accumulated local knowledge of whathas worked in the past Familiarity with local languagescustoms and religious traditions are invaluable resourcesthat are difficult to replace Maintaining such experts forregional deployment is a wise strategy that decreases thetime from emergency response to the effective rebuildingof health systems during times of crisis




For expatriate workers who have devoted themselves tocareers in humanitarian health there is wisdom in retain-ing country- and region-specific expertise Understandablythe most difficult posts are the ones with the highestturnover rates The austere nature of many of these settingsand their constraintsmdashsuch as unsuitability for accompa-nied families lack of communication and lack of profes-sional stimulationmdashresult in posts filled by a continuousrotation of national and expatriate staff One approach mayinvolve planned rotations where professionals in such postsare rotated in then out to a more desirable post and backin again at known intervals Thus institutional memorycan be developed and sustained at the field level andgreater efficiency can be built into the system of providingand improving health care in such settings while at thesame time maintaining HCW morale

The involvement of national staff in professional con-ferences can increase retention and skill acquisition Theisolation of difficult field placements often is cited as a fac-tor in the decision of national and expatriate health workersto leave their field posts The opportunity to share experi-ences and learn from other professionals in the field mayreduce this sense of isolation and provide for more rapiddissemination of the best practices to the field

Keys to Success

Developing new strategies for human resources develop-ment will require several key elements to success includingmentorship development of critical measures of competen-cy broader education in elements of humanitarian assis-tance and a focus on developing the capacity of beneficiarycommunities to participate in humanitarian health work

Training with PurposeAs in all professions technical expertise and professionalacumen in humanitarian health programs require mentorshipof talented junior staff in an explicit and directed fashion toyield a new crop of humanitarian leaders One innovativeprogram for humanitarian health training includes aninnovative program by the United Nations Childrens Fund(UNICEF) where promising staff are deployed as addi-tional personnel in a complex emergency along with expe-rienced field managersThis extra set of hands approach allows bullfor rapid consistent on-the-job training of emergency staff

The main argument against such an approach stemsfrom the limited resources available for trainingTraditionally it has been considered easier to recruit talent-ed professionals with relevant degrees and put them rightto work This sink or swim approach is counter-produc-tive and relies on false economies The apparent cost-sav-ings of a less robust training program quickly becomedwarfed by costly mistakes worker dissatisfaction andlower retention rates necessitating new training costs andloss of institutional memory Work conditions in humani-tarian settings are unique and require skills that not alwaysare intuitive or provided as part of routine professionalhealth training By deciding to send additional supervisedpersonnel into complex emergencies the program explicit-ly builds in professional time for junior health leaders to

learn both by doing as well as by observing more experi-enced colleagues in action without having the primaryresponsibility of decision-making The support of seniorstaff allows for the rapid transmission of information tech-niques and style in situations that are difficult to simulate

Limitations of human and financial resources result inon-the-job training of humanitarian health professionalsduring times of crisis While acquiring skills in this settingmay build character it also can result in the inappropriateallocation of already scarce resources causing costly mistakesIt is incumbent on humanitarian actors to push for new pro-grams that provide for structured mentorship and profession-al development for HHWs for it is only when such programsare given support and data are collected to demonstrate theireffectiveness will they become more widely accepted

From Competencies to CompetenceImportant advances have been established in the area ofcompetency development for healthcare in resource-poorsettings The Integrated Management of Childhood Illness(IMCI) is one example The IMCI breaks down key ele-ments of childhood health and survival into discrete tasksthat can be performed by families local practitioners andparaprofessional health staff By determining and empha-sizing key measurable tasks rather than advocatingadvanced training in pediatrics the IMCI greatly increasesthe number of potential HCWs and enhances the capacityof a community to help itself Similar measures must bedeveloped for a wider range of health problems common tohumanitarian health practice Using such guidelines canfurther define the key elements of improving and preserv-ing health in vulnerable populations This definition alsocan help determine the minimum effective level of humanresources needed to reach these desired outcomes

Using competencies as the basis for selection of HCWsrather than surrogate degrees rapidly can increase the poolof talented workers available for humanitarian health workThe development of such competencies is paramount tocreating new strategies for human resources training Suchcompetencies can be used to develop measures for moni-toring and evaluating humanitarian health programs

Efforts in this regard already have begun in the US witha focus on developing competencies for practitioners ofmedicine within the traditional healthcare systemmdashthePhysician Accountability for Physician CompetenceInitiative This project generated within the house ofmedicine has a goal of establishing a uniform system todevelop and measure competencies for physicians over thecourse of their careers This initiative is a large multi-stakeholder effort designed to incorporate all the variousaspects of a physicians practice and to envision not just thecurrent needs but also what the practice of medicine willbecome in the future as well as to develop standard train-ing and assessment strategies to meet those needs

Similarly efforts to bring together the various stake-holders of humanitarian health work should be made to setsimilar goals and standards of practice As humanitarianhealth work becomes increasingly complex and interrelat-ed commonly agreed-upon standards are needed to facili-

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Collect data toestablish keyelements of

success

DevelopmentI of professional IV organizations J

PROFESSIONALISM


Figure 6mdashAgenda items moving forward

tate the education and recruitment of competent HCWsFurthermore such an effort should be initiated and drivenby the key stakeholders in humanitarian healthmdashthe agen-cies that deliver such assistance the beneficiaries and thedonors that support their workmdashwho understand best theneeds limitations and potential scope of such work

Humanitarian-ismHumanitarian work is a multi-disciplinary endeavorIncreasingly it is recognized that humanitarian HCWsmust be grounded in the other aspects of humanitarianwork One promising direction is the partnerships of acad-emic institutions in the developed and developing world toaddress the problem of human resources in humanitarianhealth Such programs focus on the key health problemsfacing populations in complex emergencies and provide aminimum training that more broadly incorporates otherinter-related aspects of humanitarian action includingwater and sanitation shelter food and human securityhuman rights and international laws and norms Manyprograms exist to provide such training in the US andEurope including (1) the Inter-University HumanitarianStudies Initiative at Harvard Tufts and MIT (2) thecourses in refugee health taught at Johns HopkinsUniversity (3) the courses on Forced Migration andHealth at Columbia University (4) the World HealthOrganization-sponsored Health Emergencies in LargePopulations Course offered worldwide and (5) other pub-lic and private courses

Helping Communities Help ThemselvesEven with an expanded scale such programs cannot direct-ly put a dent in the vast deficit in human resources thatexists in global humanitarian health They can be mosteffective through partnerships for training in beneficiarycountries This training-the-trainers approach is the main-stay of another innovative program at the Foundation forthe Advancement of International Medical Education and


Figure 7mdashNext steps

Research Institute (FAIMER) The Foundation is a two-year fellowship program that provides training and men-torship for international health professionals with theexplicit goal of educating graduates to train future fellowsin their home countries at FAIMER Regional InstitutesCurrently there are six regional centers in South AsiaSouth America and Sub-Saharan Africa that provide acontext for training and outreach to local educational cen-ters to meet the healthcare needs of those communitiesWhile these institutes are focused on general healthcaresuch educational vehicles can be replicated for regionaltraining to meet the specific needs of humanitarian health

Ultimately programs that engage beneficiaries in thedelivery of health care to their communities hold the mostpromise for success One such model is that of theBackpack Health Worker Teams on the Thai-Burma bor-der known informally as the Backpack Medics17 Theprogram engages motivated young people from the ethnicKaren community in the refugee camps that line the bor-der between Thailand and Burma The medics receivetraining in basic healthcare diagnostic and treatment tech-

1 niques from local and expatriate health professionals Theytravel back and forth across the border to provide care andcommunity health education to gt 140000 internally dis-placed people with the goal of equipping people with theskills to manage and address their own health problemswhile working towards long-term sustainable develop-ment21 The program has increased steadily in both scaleand the extent of services provided The medics knowledgeof the local language customs and environment as well astheir investment due to their status as displaced personshave created a successful community-supported program

Humanitarian 2025Many of the elements that have been identified as componentsof success in improving human resources for humanitarianhealth can be gathered under a single headingmdashProfessionalism This idea encompasses all of the ideas of




agreed-upon standards for training minimum competen-cies for humanitarian work and more broadly minimumtraining in an agreed upon body of knowledge related towider humanitarian action

The natural progression of all new fields is toward a higherlevel of professionalism During the last 30 years new profes-sions have been on the rise Similar to wireless telecommunica-tions information technology critical care medicine andbiotechnology humanitarian work steadily has increased inscope and practice Technologies and fields of work that did notexist a few years ago have developed bodies of knowledge fieldsof practice professional associations and training programs

Humanitarian health work should and inevitably will fol-low a similar progression Humanitarian health work will bea competitive and widely recognized field associated with aknown body of knowledge clearly identifiable core compe-tencies widely accepted standards opportunities for trainingand an explicit and rewarding career path with opportunitiesfor mentorship and professional advancement (Figure 6)

Improving human resources for humanitarian healthwill require renewed vigor to advocate for funding result-ing in a need to change mindsets Too often humanresource spending is considered wasteful overhead in thethin margins of most humanitarian agency budgetsUnfortunately this funding bias also has infiltrated thesenior management of many agencies A bottom-up pushmust occur in order for support of pilot programs to iden-tify and implement best practices and to increase the yieldof human resources for humanitarian work

Part of advocating for humanitarian health HR invest-ments is advocating for developed country health HR self-sufficiency There must be a campaign to reduce the pull

forces of OECD countries by encouraging them to train asufficient number of personnel to meet their needs anddecrease the depletion of HR resources from the poorestnations Furthermore part of changing mindsets is chang-ing the actual minds present at the table Just as there is aneed to increase the participation of local staff in humani-tarian health programs there also is a need to increase therepresentation of beneficiary populations in the seniormanagement of humanitarian agencies

Globally there is a lack of adequate data on humanresources for health This knowledge deficit especially isacute in the developing world38 and almost non-existentduring humanitarian emergencies Such data will be crucialto planning and securing funding for human resourcestraining in the future Pilots to identify the key elements ofsuccess in humanitarian health training must be developedSpecifically there is a need for data on whether the currenttraining is meeting the health needs of the beneficiariesand what strategies if any have been effective in improvingthe quantity quality and retention of humanitarian healthworkers Such data can be used to develop better practices andto advocate for funding for their broad-based implementation

The Working Group felt that the next step towardachieving the vision of Humanitarian 2025 should be todevelop the core competencies that will define the body ofknowledge upon which the field will be based (Figure 7)Once such competencies have been established and widelyaccepted standardized measures of assessment can bedeveloped with a view towards ultimately creating systemsfor standardization and accreditation Such development ofcompetencies likely will serve as the basis for future confer-ences on advancing human resources for humanitarian health

References1 Nordstrom A Time to Deliver XVI International AIDS Conference Toronto

20062 Chen L Harnessing the Power of Human Resources for MDGs High level

forum on the health Millennium Development Goals Geneva 20043 Mullan F The metrics of the physician brain drain N Engl J Med

2005353(17)1810-18184 Bach S International mobility of health professionals Research Paper No

200682 Geneva United Nations University UNU-WIDER and WorldInstitute for Development Economics Research 2006

5 McCourt W Awases M Addressing the human resources crisis A case studyof the Namibian health service Hum Resour Health 20075(l)l-13

6 Chen LC Boufford Jl Fatal flowsmdashDoctors on the move N Engl J Med2005353(17)1850-1852

7 Mejia A Pizurki H Royston E Physician and Nurse Migration Analysis andPolicy Implications Geneva World Health Organization 1979

8 Stilwell B Diallo K Zurn P et al Migration of health-care workers fromdeveloping countries Strategic approaches to its management Bull WorldHealth Organ 2O0482(8)595-6O0

9 Danon-Hersch N Paccaud F Future Trends in Human Resources for HealthCare A Scenario Analysis Lausanne Switzerland University Institute ofSocial and Preventive Medicine 2005

10 Cash R Ethical issues in health workforce development Bull World HealthOrgan 200583(4)280-284

11 Blanc L Chaulet P Espinal M et al Treatment of Tuberculosis Guidelines forNational Programmes Geneva World Health Organization 2003

12 Figueroa J Bergstrom K Human Resources Development for TB ControlGeneva World Health Organization 2004

13 Luelmo F Johnson FC Shirey PW Task AnalysismdashThe Basis for Development ofTraining in Management of Tuberculosis Geneva World Health Organization20057

14 Rangan VK The Aravind Eye Institute Madurai India In Service for SightBoston Harvard Business School Publishing 1993

15 Vujicic M Zurn P Diallo K et al The role of wages in the migration ofhealth care professionals from developing countries Hum Resour Health2004(2)l-3

16 Greenough PG Nazerali R Rnk S et al Non-governmental organizationalhealth operations in humanitarian crises The case for technical supportunits Prehospital Disast Med 200722(5)369-376

17 Mowafi H Working Group 1 Human Resources for Health Hanover NHHumanitarian Health Conference 2006 personal notes

18 Anand S Barnighausen T Human resources and health outcomes Cross-country econometric study Lancet 2004364(9445)1603-1609

19 Joint Learning Initiative GEIR Human Resources for Health Overcoming theCrisis Cambridge MA Harvard University 2004

20 World Health Organization Guide to Health Workforce Development in Post-Conflict Environments Geneva World Health Organization 2006

21 httpwwwgeocitiescommaesothtmlbphwt Accessed 08 July 2007




No improvement in financing or medical products canmake a lasting difference to peoples lives until the crisisin the health workforce is solved

Anders Nordstrom Acting Director-General WorldHealth Organization

XVI International AIDS ConferenceToronto 18 August 20061

BackgroundThere is a growing human resources crisis in humanitarianhealth The critical shortage of skilled trained providersavailable to serve in humanitarian projects highlights anunder-appreciated obstacle to humanitarian health projectsIn many ways this human resources crisis parallels the gen-eral misallocation of human resources in health services inmuch of the developing world and most crucially in thosecountries facing complex emergencies24 This complicatedproblem involves a lack of (1) resources in the areas most inneed (2) recognition by funding agencies of the importanceof human resources to achieving project goals (3) investmentin human resources by governments and non-governmentalentities even when funds are available and (4) coordinationof training to meet actual needs of beneficiaries

All of this set within the context of a global crisis in humanresources for health (HRH) pulls workers away from the poor-est localities toward more affluent nations that also areattempting to fill the gaps in their own healthcare workforces

Increasing Need Increasing ScopeWhile there is a growing recognition of the crisis in HRHthe development of sustainable solutions to this challengehas been limited Humanitarian health projects face many ofthe same challenges and by their very nature occur in themost resource-poor environments In an attempt to meet thehealth needs of beneficiaries in these impoverished settingshumanitarian health agencies are forced to create parallelsystems in areas in which the health systems are broken orcreate entire health systems where there is no present func-tioning health systemmdashall with the goal of improving thecapacity of local populations to meet their healthcare needs

Over the last several decades humanitarian healthagencies have been transitioned from implementing ad hoccharitable giving to being more disciplined and sophisti-cated implementers of domestic and international healthprograms Concerns over respecting a countrys sovereign-ty maintaining neutrality between groups in a conflict andincurring the acceptance of beneficiary populationsincreasingly have made humanitarian health agencies (bothinternational and non-governmental) critical providers oflarger health programs for greater numbers of beneficiariesthan ever before Along with this transition and the accom-panying increase in the size and scope of humanitarianhealth programs comes the challenge to increase the effi-ciency and capacity for their practice

ProblemDespite being critical to meeting the MillenniumDevelopment Goals (MDG) necessitating the urgentdevelopment of workforce strategies to develop sustainablecapacity in the poorest countries HRH still are in a state of

crisis2 Increasing healthcare worker (HCW) density leadsto improved health outcomes (Figure 1) Africa which hasbeen estimated to harbor 25 of all of the worlds diseaseshas only 13 of the worlds health staff5 Six hundredthousand HCWs provide care for gt600 million people Inorder to achieve the MDGs gt1 million additional HCWswill be needed6

This shortfall is not unique to Africa There is a globalshortfall in the numbers of HCWs needed to meet theglobal demand3468 While HRH data are limited datafrom professional registries demonstrate a similar shortfallin the developed world3 A fundamental element of thisgap is the training of insufficient numbers of HCWs tomeet the global demand There is a link between the gapthat exists in HRH in developed host countries and that inunder-developed source countries In an effort to meet thegrowing demand for HRH host countries employ strate-gies to recruit HCWs from source countries that cannotafford to lose them This results in an exacerbation of theunmet need for HRH in developing countries despite evi-dence that increased HRH density leads to improved out-comes2 The downstream effect for humanitarian agenciesfrom these fatal flows is an even greater reduction of thepool of available HCWs in disaster-affected countries inwhich there is little in the way of professional support per-sonal security and financial compensation

Chen divides countries into clusters based on theirsocio-economic conditions and HCW density He describesseveral groups (Figure 2) (1) poorer worker-deficit highmortality (eg Africa) (2) richer and more worker-denselow mortality (eg Organisation for EconomicCooperation and Development (OECD) nations) (3) tran-sitional (eg Philippines Southeast Asia) and (4) othercountries (eg Middle East Latin America)2 Countries inthe first group typically have the triple threat of a largeburden of disease insufficient numbers of HCWs andinsufficient resources for training additional workers as wellas a level of poverty that results in many of the most talent-ed citizens seeking opportunities abroad resulting in furthershortages Countries in the second group have lower bur-dens of disease greater economic resources but still do nottrain to meet their demand for HRH Therefore thesenations recruit from other countries to supplement theirworkforce capacity These countries also are the largestdonors of humanitarian assistance and traditionally havebeen the headquarters of the largest international assistanceorganizations and United Nations agencies Countries inthe third group are developing rapidly and have made a sig-nificant commitment to HCW training While economicopportunities remain somewhat limited these countrieshave become net exporters of HRH while not significantlydepleting the capacity of their own workforce Countries inthe last group represent the remaining nations some haveresources and have not yet made the commitment to meet-ing their own domestic HRH needs while others lackresources but do not have significant gaps in their domesticHRH capacity Understanding the differences betweenthese groups can help to predict directions of healthcarelabor flows and identify potential sources for increasedhealthcare capacity during times of need



















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