1. Review of human resources for health (HRH) related activities in the Bank’s portfolio of Latin America and the Caribbean Christoph Kurowski Brinnon Garrett The LAC HNP Team PAHO

2. LAC health workers on strike

3. Overview 1. Shortcomings in health workforce performance – common themes 2. The root of performance shortcomings 3. HRH in the LAC portfolio 4. Reflections from Task Team Leaders 5. Summary and conclusions

4. What’s wrong with the health labor force in LAC? Health system performance Health workforce performance Health workforce performance levers (macro and micro) Imbalances Low productivity Skill mix

5. Region Nurse per physician ratio Africa 5.5 East Asia and Pacific 4.5 Europe and Central Asia 2.4 South Asia 2.3 Latin America & Caribbean 1.9 Latin America 0.4

6. At the root of shortcomings – Health system characteristics Health system performance Health workforce performance

7. At the root of shortcomings – Health system characteristics contd. Health system characteristics  Vertically segmented  Segments fragmented (e.g. decentralization)  Within segments varying contract systems Workforce implications  Highly segmented labor market  Regulation and management challenges  Multi-employment  Varying incentive environments Performance implications  Availability and quality imbalances between and within segments  Tensions between and within segments

8. At the root of shortcomings – the political economy Health workforce performance Health workforce performance levers (macro and micro) Quick transition in administrations and health authorities Labor unions

9. HRH in the LAC portfolio Project includes component to leverage health workforce performance 247 HRH or workforce issues explicitly recognized947 Project supports research to understand HRH and workforce issues 347 Project addresses in one or another way HRH issues47 Project includes subcomponent to leverage health workforce performance 747

10. What activities do Bank projects support? Strategic workforce management  Planning (11)  Legislation (5)  Medical education (4) Training (47) Physical work environment (38) HRH performance management  Remuneration (9)  Non-monetary incentives (6)  Job descriptions (6)  Career development (5)  Performance benchmarking (4)  Licensing (2)  HR MIS (2)

11. HRH in the LAC lending portfolio TrainingSpecific interventionsOthers 410 (7.7%)250 (4.7%)4,680 (87.6%) Million US$

12. Reflections from task team leaders  All Task Team Leaders are aware of HRH issues  The majority considers workforce performance a serious constraint to health system performance  HRH issues are always part of the dialogue with clients  Commonly, the Bank and stakeholders other than governments bring up HRH issues

13. Reflections from task team leaders – contd.  HRH issues are less frequently addressed in projects than they are part of the policy dialogue  TTL’s engage primarily with MoH’s that do have limited leverage over health labor issues  Governments are reluctant to address issues and political feasibility is the major concern (e.g. labor unions)  Some TTL’s believe their technical expertise is insufficient to pursue an effective dialogue  HRH activities in projects are limited to training that “promises political visibility without rocking the boat”

14. Summary  Significant health workforce performance shortcomings are a major limitation to health system performance  Certain health system characteristics typical for the region are not conducive for optimal workforce performance  Health workforce performance limitations are a major concern of stakeholders, however are rarely addressed in reform efforts and projects  Policies and other mechanisms to improve workforce performance are often considered not politically feasible  Among performance levers, the Bank supports primarily short-term training of health workers  Within Bank projects, there is a trend towards more comprehensive approaches

15. Conclusions 1.Reform projects need to acknowledge the importance of HRH  Consider reform implications on workforce performance  Address workforce performance shortcomings 2. The Bank needs to engage more broadly with relevant national stakeholders, probably most effectively, in a multi-sector approach 3. The Bank, in collaboration with regional and global partners, needs to strengthen its technical expertise in order to engage more effectively in policy dialogues with clients