El proceso de la Investigación-Acción

Providing universal access requires a viable and effective health workforce. Yet, as demand has increased and as more ways of delivering effective treatment and preven- tion have become available to respond to increasing needs and demand, the size, skills and infrastructure of the workforce have not kept pace. Indeed, in many countries eco- nomic and financial crises have destabilized and undermined the workforce during the past two decades. The resulting human resources crisis affects the whole spectrum of health care activities and MNCH programmes in particular. It has long been a major concern for health workers in the field, as well as for officials in ministries of health, but the problem has proved so intractable that the international community started to recognize it explicitly only in the late 1990s.

The most visible features are the staggering shortages and imbalances in the dis- tribution of health workers. With insufficient production, downsizing and caps on

recruitment under structural adjustment and fiscal stabilization policies, and with frozen salaries and losses to the private sector, migration and HIV/AIDS, filling the supply gap will remain a major challenge for years to come (57–61). The scaling up of projected requirements for maternal, newborn and child health described in Chap- ters 5 and 6, for example, assumes the production, in the next 10 years, of at least 334 000 additional midwives (or professionals with midwifery skills), and the upgrading of 140 000 others. Some 27 000 doctors and technicians have to learn the skills to provide back-up maternal and newborn care, and the 100 000 full-time equivalent multipurpose professionals (many more under scenarios that rely less on community health workers), have to learn to follow up maternal and newborn care with integrated child care.

Along with the shortages, it appears that many countries have also witnessed a dete- rioration in the effectiveness of their workforce. The public expects skills, knowledge and competencies in maternal, newborn and child health care that health workers often lack, putting lives at risk. Upgrading can improve the effectiveness of the present workforce, but the current levels of skills are so poor and the mix so inappropriate that the potential of upgrading is limited. In-service training and supervision are generally considered key elements in improving outcomes, but there is a dire lack of evidence on cost-effec-

be maintained or reinstated. All this works better with short-term planning horizons such as the 90-day cycle used in Liberia or Darfur, Sudan, involving nongovernmental organiza- tions and humanitarian agencies, and engaging directly with peripheral service networks.

In the phase of post-crisis recovery the situation changes and a difficult transition has to be made from relief to development, in a context of competing priorities and scarce resources. Offering minimum health services in rural areas requires immediate strengthen- ing of the health care network and, crucially, of the workforce.

Mozambique’s recovery from years of war shows that support of recurrent expenditure, decentralized planning and strengthening of the information base, even at the peak of a crisis, can pay off. These measures can be the start- ing point for rationalizing aid flows, and can pave the way for integrated planning and incre- mental sector-wide approaches. Disbursement of aid for post-conflict reconstruction is often slow, and disproportionate to what the public health sector in these countries can mobilize by itself. Aid flows are particularly important for sustaining primary health care and maternal, newborn and child health care services. Inter- national actors have disproportionate power in these circumstances. But the transition from relief to development aid is particularly difficult: public administrative structures are very weak, so it takes time to re-establish the relations Building the district health systems required

for maternal, newborn and child health, let alone their equivalent in more pluralistic settings, supposes a reasonable degree of macroeconomic and political stability and a reasonable degree of budget predictability. In many of the countries where progress is stagnating, various forms of instability rule out systematic long-term approaches to rolling out health systems coverage and coordinating efforts through sector-wide approaches. Complex emergencies require the initial focus to be on repair, on getting things working, not on reform.

Even in countries in crisis, many profession- als work tirelessly at field level, often without salaries. To achieve progress, the first require- ment is for cash to get institutions working, to enable those who work in them to feed themselves and to avoid their having to resort to levying user charges or pilfering supplies. Paying decent wages to staff in place is then better than bringing in volunteers: sustainabil- ity is less an issue in these situations than pre- venting the disappearance of the basic public health system.

The first priority often is to establish institu- tional islands of dependable critical services: medical supply depots and hospitals, even if this sometimes conflicts with the urge to launch population-wide immunization programmes. Efforts should not be diluted but concentrated where the threshold for basic functioning can

that make it possible to channel funds into the health sector.

Cambodia, recovering after the decimation of its health workforce as a consequence of the actions of the Khmer Rouge, introduced accelerated training to build capacity in the early 1980s. By the time sectoral reforms were introduced, its health workforce was bloated, poorly trained and maldistributed. The upgrading of nurses to doctors eroded com- petent leadership in nursing. Donor-supported changes in the nursing curriculum resulted in the closure of one-year primary midwife train- ing, and the introduction of a postgraduate midwifery diploma that will serve to reinforce the current concentration of midwives in urban areas, where private practice provides wel- come additional income (62, 63). While aware of the critical dilemma it faces, the Cambodian Ministry of Health has been unable to mount a strategic response that will effectively redress this shortage.

The responsibility for quickly restoring acceptable standards of health services falls on under-resourced ministries of health. In such circumstances the expansion of the network to cover remote areas is far slower and more expensive than would usually be expected. If recurrent costs are underestimated when investment decisions are made, this under- mines the sector’s long-term sustainability.

Box 7.5 Rebuilding health systems in post-crisis situations

tive approaches to improving competency, particularly in conditions where pre-service training is poor and working conditions inadequate. The situation may be less critical for child care, but in many places large parts of the workforce do not reach the competency threshold required for effective and safe maternal and newborn care. Clearly, it is vital that the new professionals who will fill the numbers gap do reach that threshold.

Planning is an essential prerequisite to correct the shortages and to improve the skills mix and the working environment; so is building the institutional capacity to manage human resources for health. But to plan is not sufficient: today’s problems require solutions for today. Developing countries and countries in transition frequently have disruptive histories that have challenged cohesive workforce development. After years of neglect, the resulting problems require immediate attention, at the same time as planning and reform prepare the future (see Box 7.5). These immediate and thorny problems include working and employment conditions in the public sector, and the resulting distortions in the behaviour and productivity of the health workforce.