Human Resources For Health
Human Resources For Health
Human Resources For Health
Abstract
Designers and implementers of decentralization and other reform measures have focused much
attention on financial and structural reform measures, but ignored their human resource
implications. Concern is mounting about the impact that the reallocation of roles and
responsibilities has had on the health workforce and its management, but the experiences and
lessons of different countries have not been widely shared. This paper examines evidence from
published literature on decentralization's impact on the demand side of the human resource
equation, as well as the factors that have contributed to the impact. The elements that make such
an impact analysis exceptionally complex are identified. They include the mode of decentralization
that a country is implementing, the level of responsibility for the salary budget and pay
determination, and the civil service status of transferred health workers.
The main body of the paper is devoted to examining decentralization's impact on human resource
issues from three different perspectives: that of local health managers, health workers themselves,
and national health leaders. These three groups have different concerns in the human resource
realm, and consequently, have been differently affected by decentralization processes. The paper
concludes with recommendations regarding three key concerns that national authorities and
international agencies should give prompt attention to. They are (1) defining the essential human
resource policy, planning and management skills for national human resource managers who work
in decentralized countries, and developing training programs to equip them with such skills; (2)
supporting research that focuses on improving the knowledge base of how different modes of
decentralization impact on staffing equity; and (3) identifying factors that most critically influence
health worker motivation and performance under decentralization, and documenting the most
cost-effective best practices to improve them. Notable experiences from South Africa, Ghana,
Indonesia and Mexico are shared in an annex.
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reforms. This is particularly true of the many countries works leading to different degrees of autonomy of HRM
where the impetus to transfer power away from the center [human resource management]"[2]. Second, the location
stems from political, as opposed to health sector, con- of responsibility over the salary budget of health workers
cerns. has a large bearing on the way decentralization impacts
on them. A third set of factors consists of the way that
Reallocation of roles and responsibilities always affects reforms deal with the civil service system and health work-
the health workforce and the way it is managed. This is ers' participation in it. Other important factors include:
true irrespective of the extent to which health leaders are
allowed to shape the decentralized structures and man- • size of the country
agement systems. Concern has been mounting among
health managers and workers about the impact that • socioeconomic status of the country
decentralization has had on human resources for health
(HRH) and the way they are managed. Attention to this • legal and regulatory rigidity of the civil service system
issue has, however, been lacking outside the health sector
itself. Dussault and Dubois echo the concerns of many • significance of the public sector as an employer in the
observers, when they comment, "In many reforms, there health sector
is discordance between the elevated attention given to
issues of financing and structural transformation and the • power of labor unions
low attention given to HRH issues..."[1]. One conse-
quence of this lack of attention is that experiences and les- • influence of professional associations
sons of different countries have not been widely shared.
• historical patterns in the way health services are organ-
This paper aims to examine evidence from published lit- ized and managed.
erature on decentralization's impact on the demand side
of the human resource equation, and the factors that have Modes of decentralization
contributed to this impact. The main focus is on the expe- Decentralization options adopted by countries include:
rience of developing countries, but evidence from other
countries is also considered, as appropriate. The paper • deconcentration to lower levels within a national minis-
starts by cataloging the various elements that make an try structure
impact analysis of this type exceptionally complex. The
main body of the paper is devoted to examining decen- • delegation to semi-autonomous bodies, such as hospital
tralization's impact from three perspectives: that of local or local health boards
health managers, health workers themselves, and national
health leaders. This analysis aims to focus on the big pic- • devolution to separate local governments
ture view, highlighting the most important areas. While
the emphasis is on the demand side, the analysis does not • privatization to NGOs and for-profit organizations.
totally ignore supply side issues, acknowledging that
demand and supply are intricately interlinked. The paper Multiple modes of decentralization are generally found in
concludes with recommendations regarding three key the same country, and implemented at the same time.
concerns that require prompt attention and collaboration Decentralization may cover all or only some of the health
between national authorities and international agencies. programs and services that the public sector provides. For
Notable experiences from South Africa, Ghana, Indonesia example, communicable disease control programs may
and Mexico are described in an annex, as these countries continue to be run vertically from the center, while other
grapple with human resource implications of decentrali- primary care programs are decentralized. Donor-funded
zation. programs are also likely to remain under central control.
Furthermore, the allocation of new roles and responsibil-
Analytic complexity ities is commonly expressed in quite general terms. This
A full analysis of decentralization's impact on human lack of detail and clarity allows for multiple and varying
resource management in the health sector would require interpretations by managers at different levels of the
a multidimensional Rubik's cube. A multitude of factors health system.
influence both decentralization's impact and the health
sector's response. First and most obvious of these is the Responsibility over the salary budget and pay
mode of decentralization that a country is implementing. determination
As Wang et al. point out, "...the different organizational Salary budget may be:
forms of decentralization will provide structural frame-
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• determined at the central level for all staff and trans- • Remove health workers from the national civil service: All
ferred to decentralized units as a separate salary budget public sector health workers become employees of a
"national health service" with its own terms and condi-
• incorporated in a grant from the national government to tions of service (e.g. Ghana), or transferred staff are "de-
the decentralized units linked" from it with local terms and conditions of work
(e.g. Zambia).
• determined centrally and transferred to decentralized
units as a salary budget for seconded civil servants, and Perspective of local health managers
determined and funded by decentralized units for local Local health managers have a range of new responsibili-
hires. ties, depending on the powers that have been decentral-
ized to them. Under devolution, they are accountable to
Systems of pay determination are traditionally highly cen- the local political head, such as a municipal mayor or a
tralized in most countries. As Bach points out, "For gov- provincial governor. Under delegation, the local health
ernments there is an understandable reluctance to manager may be accountable to a district health board or
delegate significant autonomy for pay determination to a hospital board. The national-level health authority,
lower organizational levels because of the desire to main- however, often continues to issue directives to local health
tain tight control of the public sector pay bill"[3]. Appro- managers, particularly in the early days of decentraliza-
priate roles of central and local levels in determining staff tion. This can make it very difficult for local managers to
pay remain controversial. As Wang et al. point out, know who they should actually respond to!
"...complete autonomy of local determination [of staff
pay/salaries] is rare and staff pay is often a combination of Local health managers have three main concerns in
both local and central influence"[2]. human resource management, regardless of their span of
responsibility. They want to staff their facilities or services
Civil service options at decentralization appropriately. They want their employees to perform well
The rigidity of a centrally managed civil service, including and be productive at work. They want well-functioning
the inflexibility in pay structures, is a concern the world routine personnel administration systems in order to
over. The nature and extent of a country's reform process improve efficiency and minimize labor conflicts.
dictates, however, whether decentralization is accompa-
nied by any attempt to change health workers' incorpora- Staffing services
tion in the civil service. Decentralization of powers over Decentralization makes local health managers responsi-
the health system thus may or may not be accompanied ble for improving the way health services are targeted to
by a corresponding decentralization of human resource meet priority health needs, organized, and managed
management responsibilities. within the available budget. To do this, they need a work-
force whose staff numbers and mix are as appropriate as
Countries have defined the civil service status of trans- possible to these needs, and whose cost is affordable. To
ferred staff in the public sector health workforce in four foster the development of such a workforce, the manager
main ways: needs to: (a) revise, as necessary, the existing personnel
structure, (b) staff the structure with the most appropriate
• Retain a uniform national civil service: Health workers are health workers, and (c) keep payroll costs under control.
seconded or transferred to decentralized units (e.g. dis-
tricts) under centrally defined civil service terms (e.g. Analyzing the current staffing situation and planning its
Papua New Guinea and the Philippines) improvement are essential steps in revising the personnel
structure. With new responsibilities having been trans-
• Decentralize the national civil service: Health workers are ferred to the decentralized level, a more appropriate per-
transferred to decentralized units, with civil service proc- sonnel structure might require the creation of new types of
esses also decentralized to newly created local-level public jobs, re-profiling of old ones or the addition or abolishing
service commissions (e.g. Uganda) of staff positions in accordance with need. What proof do
we have that this is taking place in decentralized coun-
• Mixed model: Old employees are seconded to decentral- tries?
ized units under the national civil service with centrally
defined terms. New hires are employed directly by the Literature on low- and middle-income countries provides
decentralized units under locally defined terms (e.g. little evidence that decentralization has resulted in crea-
Jamaica) tion of new posts, job re-profiling, or an improved staff
mix [2]. A tightly centrally-controlled civil service may not
allow local managers to create new posts, or their budget
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may be insufficient to increase staffing levels, even if they Employees' performance and productivity
have this power. Planning skills, particularly human To improve the performance and productivity of health
resource skills, are generally weak at the peripheral level in workers, local health managers need to assess staff per-
most developing countries. Human resource planning formance, supervise employees, and respond appropri-
responsibilities are often transferred to local managers ately to identified performance gaps. Local managers are
without providing them with adequate skills for these also responsible for ensuring that employees have the nec-
roles. Human resource databases frequently deteriorate as essary resources and tools to do their job. Performance
a result of decentralization, further hindering local and and productivity are influenced by staff motivation,
national planning [4,5]. In the United Kingdom, a review another concern of the manager. Attending to all these
of historical staffing patterns did take place after decen- issues appropriately is a considerable challenge in
tralization to the NHS trusts, but as Buchan reports, this resource poor settings, where decentralization has thrust
created a tension between local health managers con- management responsibilities to managers who are inex-
cerned about costs, and health professionals whose main perienced in human resource management.
interest was patient care [5].
Martinez and Martineau point out that effective perform-
Local health managers want staff to be recruited and ance management is rare in public services in developing
appointed without undue delay, and only the best-quali- countries, because its prerequisites (such as a living wage
fied candidates to be selected. The ability to transfer staff for health workers, and the availability to them of drugs,
between geographic areas and health facilities, as needs equipment and transport) are often missing [14]. The sys-
change, is also important. The extent to which local health tems used to appraise staff performance are frequently
managers can influence the recruitment and appointment outdated or poorly understood by local staff [15,16]. In
of qualified candidates depends on the type of decentrali- many developing countries, decentralization has con-
zation, the nature of the country's public service system, fused supervision responsibility, diminished technical
and the degree of financial autonomy that the local level supervision capacity, and reduced the number of supervi-
has for paying staff. Wang et al. point out that deconcen- sion visits [17,18]. Part of this confusion is the result of
tration is unlikely to transfer recruitment and hiring to the some health programs being decentralized, while others
local level, while delegation and devolution are most remain central responsibilities. Even when all programs
likely to involve a more extensive transfer of these respon- are decentralized, old program allegiances of staff create
sibilities [2]. Restrictions to timely recruitment and hiring tension and potential conflict between the supervisees
from centrally set human resource budget ceilings and leg- and the new local health manager.
islative controls are common concerns of local health
managers. They also complain about political interference Decentralization brings considerable new skill needs, par-
and nepotism in hiring decisions [6-10]. ticularly in management competencies. Local managers'
capacity to respond to these and other performance gaps
By increasing local authority and introducing flexibility in through training is, however, restricted. They lack funds to
hiring practices, decentralization can change the nature of pay for such training, and often have little or no capacity
the labor market. The result is rising competition for staff to plan and implement in-service training programs at the
between decentralized units. A serious concern for manag- local level [19].
ers in poorer areas of many countries is the lack of effec-
tive mechanisms at their disposal for attracting and There is evidence that in a number of countries, decentral-
retaining staff [11]. ization has compromised the ready availability of drugs,
supplies and transport that are essential for good staff per-
Local managers, concerned about their budget, are inter- formance and productivity [20,21]. This has been the
ested in finding ways to curtail labor costs by controlling result of more complex procurement systems and funding
salary levels. Their autonomy to do so is, however, cuts to local health budgets.
restricted by centrally determined pay limits, nationally
unified salary scales and packages, and overall budget ceil- Staff motivation has been affected through rapid change,
ings. Because of these constraints, local managers are keen and the perception of health workers that their compensa-
to find ways to convert fixed salary costs to variable costs tion levels and working conditions have been negatively
through flexible employment arrangements, such as time- affected by decentralization. Bach emphasizes that man-
bound contracts. New payment mechanisms, such as agers have paid insufficient attention to addressing such
merit- and market related pay and special bonuses are issues as working hours, working conditions and career
emerging in Western and Eastern Europe and also in Latin structures that can have an significant long-term effect on
America [12,13]. They remain controversial, and there is staff performance and morale [22].
little information on their short and long-term impact.
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[27]. Considerable differences in salary levels and other one to cover for the health worker who does go away for
terms of employment have also emerged in South Africa, training.
where salary levels are determined locally. [Personal com-
munication with Dr. Jon Rohde.] Published literature includes few examples of improved
professional development opportunities as a result of
Pensions have arisen as an important issue for health decentralization. In many resource poor countries, decen-
workers in countries such as Zambia, which have tried to tralization has instead reduced the prospects for develop-
break the rigidity of the civil service system by making ing and maintaining skills. Reduced training budgets,
health workers local employees. Public sector employees isolation from national training opportunities and weak
are usually included in a large national pension scheme, local training capacity are all to blame for the lack of
covering all civil servants. The contributions are paid by appropriate capacity building opportunities.
the national government, and are part of benefit packages
that have been negotiated with labor unions. Under dev- Career mobility has become more restricted, particularly
olution, local authorities may be reluctant or out-right in devolved settings. The traditional career path from pri-
refuse to accept the financial burden of paying for the pen- mary to higher levels of care and from lower to higher lev-
sions of prior civil servants. Thus, a new pension fund to els of administration is no longer as feasible as before.
cover local employees may be needed. In Jamaica, for Many factors are at play: complexities of transferring
example, regionally hired health workers now belong to a between decentralized units, or from the decentralized to
private pension fund. Contributions to it come both from the national level, fractured or non-existent information
the regional health authority and the individual channels about job opportunities, skill levels that are get-
employee. Previously, the government paid the total con- ting outdated because of the scarcity of training opportu-
tribution. nities, etc.
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above-mentioned four roles or developed the requisite tant in countries that have experienced a rapid growth of
human resource capacity to assume them effectively. private institutions of higher education. Many of these
institutions have been established with profit motives,
Strategic human resource planning and resource and the training facilities and curricula may not conform
management to national standards [31].
National government leaders have the responsibility to
take a strategic, long-term view about the preparation of Those establishing regulatory systems and implementing
human resources to meet the emerging needs and oppor- the regulatory practices must adopt a long-term view of
tunities. Health needs are not static. Epidemiological and human resource development. Strategic national human
technological transitions, new and emergent diseases, the resource planning considerations must inform the devel-
growth of private practice, and changing patient expecta- opment of regulations. The regulatory role of the national
tions all alter the demands placed on the health sector. As government must be exercised in close collaboration with
Biscoe underscores, "HR strategies should be initiated at professional associations. In seeking to effect change
the national level where it is in the national interest to do through regulatory practices, the national government
so"[29]. needs to take account of the conservative nature of the
professions, and anticipate a slower pace of change.
Strategic human resource planning at the national level
includes monitoring external and internal threats to the Vigilance for equity in staffing
country's ability to maintain a stable and competent The more that decentralization hands real power to local
health workforce, well aligned with national health prior- levels, the more equity will suffer, unless appropriate
ities [30]. Such threats come from many sources, e.g. equalization mechanisms have been established. Manage-
increased out-migration of highly trained staff, reduced or rial capacity and resource bases vary widely between
inappropriate training outputs from private universities decentralized units. Well-managed and well-resourced
that are replacing publicly funded higher education insti- decentralized units will rapidly pull ahead of others. They
tutions, loss of staff through HIV/AIDS, etc. Appropriate will have higher staffing levels; offer better salaries, bene-
responses to such threats need to be devised and imple- fits, and career development opportunities; and provide
mented in collaboration with national and local stake- more appealing working conditions than their resource-
holders. poor or badly managed counterparts. The employees they
attract will be more experienced and better qualified, and
With very few exceptions, "a generally very patchy picture remain in service longer, further increasing the inequity of
of HR planning" emerges in the literature [22]. Human staffing.
resource planning capacity, even at the national level, is
weak, particularly so in developing countries. Data bases National health leaders must vigilantly monitor emerging
on staff numbers and skills were already inadequate in inequities in the quality and quantity of staffing between
many countries prior to decentralization, but suffered fur- decentralized units. They must devise appropriate mecha-
ther deterioration from it. Where planning has taken nisms to respond to such inequities. Finally, they need to
place, it has often been narrowly focused on certain occu- develop these mechanisms in full consultation with local
pations only. It has generally been oriented toward look- health managers and other stakeholders.
ing only at numbers, leaving "key questions about the
distribution, qualifications, motivation, development, Legal protection of staff
and performance of staff unexplored"[22]. Decentralization has generated a number of legal con-
cerns for health workers. As local employees, what protec-
The management of government and donor resources for tion do they have against unfair hiring practices or unjust
in-service and specialty training is another important dismissal? What legal resources do they have, if they are
national government responsibility. This includes the sued for malpractice? Does the national malpractice insur-
identification and management of resources to meet the ance that covered them as national civil servants still
vast management training needs that decentralization car- apply when they are seconded or transferred to the
ries with it. employ of local governments? Addressing such important
legal concerns is an important central government respon-
Regulating professional training and practice sibility that requires the establishment or maintenance of
The national government is responsible for establishing appropriate mechanisms for legal protection of all staff on
good systems for accrediting training programs and for the public payroll.
certifying graduates as having obtained either a basic or a
specialty qualification. This regulatory and normative role
of a national government in training is especially impor-
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Decentralization's purported negative impact on staffing • Lack of accurate and timely human resource informa-
equity is the second issue. The emerging evidence about tion and functioning HR management systems at district
increasing staffing inequity is of great concern. Hard data and provincial levels (e.g. job descriptions, performance
to back up these concerns have, however, been difficult to evaluation systems, etc.)
gather because of problems with deteriorating data bases
and the lack of appropriate research. The definition and • Lack of authority of local managers to reallocate staff,
implementation of evidence-based strategies to address create new posts or change the existing ones
equity concerns requires improving the knowledge base
about the impact of different modes of decentralization • Mismatch between HR standards, set at the national or
on staffing equity, and the variables that are particularly provincial levels, and the ability of disadvantaged districts
beneficial or damaging in this regard. Critical research to attract and retain staff to meet such standards
questions must be defined, appropriate research funded
and implemented, and the results widely communicated. • Inequities in salary levels, terms of employment and
continuing education opportunities, rising disparities in
Health worker motivation and performance is the third financial capacity and local budget allocations
issue requiring urgent action. Anecdotal evidence from a
large number of decentralized countries shows that the • Pressure on local governments to award salary levels that
rapid changes and uncertainties associated with decentral- they cannot afford, as a result of local labor negotiations
ization have had a disastrous impact on staff morale. in which unions compare salary awards of different local
Those factors that under decentralization most critically governments
impact health worker motivation and performance must
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• Poor morale and lowered performance due to staff con- it eventually became the basis for national policy. The
cerns about the security of their employment and limita- methodology that emerged, Community Health Planning
tions to their career development and Services (CHPS), now aims to increase access to
health care in the whole country.
Positive experiences include some managers' creative use
of their decentralized powers, such as the decision to (Based on personal communication with Dr. Delanyo
freeze salaries of health workers who took an extended, Dovlo, previously Director of Human Resources Develop-
unauthorized absence, which achieved a dramatic ment in the Ministry of Health, Ghana.)
improvement in staff discipline. Other encouraging exam-
ples include the improvement of skill levels through an Indonesia
innovative two-year District Management and Leadership Law 22/1999 on regional governments in Indonesia initi-
Course in Eastern Cape Province. The course is organized ated a radical decentralization of powers over a large
through in-service, but awards the graduates an academic number of government functions. Central government
qualification. In the same province, supervision improved civil servants who worked in a region were now brought
through the development and application of a supervisory together with local government personnel in a regional
manual that establishes the expected standards of work. government structure. In the health sector, over a quarter
The use of the manual assures an objective supervision of a million health personnel were transferred to regional
based on positive reinforcement, and ensures that the governments. They included medical officers who had for
obligations of the supervisee and the supervisor are docu- many years been seconded to regional health offices, as
mented in writing. well as hospital staff who were only now being trans-
ferred.
[Based on personal communication with Ms. Nomath-
emba Mazaleni and Dr. Jon Rohde, Equity project, Eastern Almost 2.4 million civil servants in total were reassigned
Cape province, South Africa, and information in Mar- from the central to local governments. No other decentral-
tineau et al. 2003 [See [32]].] izing country has undertaken such a massive transfer of
staff. Its successful completion was one of the greatest
Ghana achievements of Indonesia's transition to regional auton-
The Ghana Strengthening District Health Systems Initia- omy. The transfer did not involve a physical relocation for
tive (SDHS) aimed to improve management at the decen- most staff, but was mainly a bureaucratic process. In fact,
tralized levels. It prepared the ground for a successful and observers have commented that the fact that staff transfers
stable health sector reform process in Ghana. The were a routine task of the Civil Service Board was one of
approaches used, i.e. problem analysis and solving, team the main reasons for the success. While the scale of the
based training focusing on self-identified needs, and reg- transfers was enormous, the work required was not new,
ular facilitated progress reviews and feedback, were critical and the Civil Service Board was appropriately structured
for making districts better planners and advocates for their to undertake it.
specific needs. As district capacity increased, regional and
national supervisory levels began to demand more train- The transition was not without huge challenges. Develop-
ing for themselves in order to be better equipped to sup- ing a staff list for each regional office took much longer
port the newly identified district needs. than expected. Substantial differences initially existed
between the lists of the central government and those in
An encouraging example of how innovative local deci- the local offices. Each staff member required a decree
sion-making can have a national impact comes from the ordering his or her transfer. Each region, in turn, needed
Nkwanta District in the remote Northern Volta Region. records of individual entitlements, such as leave and fam-
The Nkwanta District team attended district health sys- ily allowances. The capacity of some regional offices of the
tems training at the Navrongo Health Research Center, Civil Service Board was grossly inadequate for a task of
exposing them to methods of research that had achieved this magnitude. They had to await additional funding and
health gains. Navrongo had had good results from using the purchase of needed computer equipment.
community health nurses, who lived within the commu-
nities they served, to deliver primary health care and fam- Matters were complicated further in May 2000, when the
ily planning services. The Nkwanta District Director and central government approved a program to rationalize the
his team decided to implement a similar scheme in their pay of civil servants. This included a pay rise which the
district, and the high level of decentralized decision mak- regions had not budgeted for, since they were unaware
ing in Ghana allowed the Director to place community that it was coming. Late payment of the increases created
health nurses in particularly deprived sections of the labor disturbances that exposed flaws in the prepared staff
Nkwanta district. This decision had such good results that lists. In a number of regencies, hundreds of health work-
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ers, for example, were found to be still on the provincial ers because of constraints in training capacity and compe-
payroll. tition for posts in the preferred urban locations. While 90
% of transferred physicians do meet the requirements for
Regions now have the power to hire, appoint, transfer and the posts they hold, 16%-31% of all medical, paramedical
fire personnel. It is alleged that they tend to favor staff and administrative staff have not yet completed their
who originate from the same region. While no systematic studies to gain an appropriate qualification. Without such
research exists on the distribution of civil servants, availa- a qualification, they cannot be confirmed in their posi-
ble data from the Civil Service Board reveals a highly une- tions. It is the fully qualified health personnel, who obtain
qual distribution of health staff. Authority for training is the positions in the major urban centers [34]. In response
also now with the regions. It is not clear what training to the increased need for public health managers at state
regions are planning or undertaking, nor whether suffi- and municipal levels, state governments have attempted,
cient funds have been allocated for such training. What but failed to persuade local universities and health insti-
role the central government will play in human resource tutes to provide post-graduate training and continuing
development is also yet to be determined. In the mean- education for these key personnel. Public health and man-
time, decentralized staff remain concerned about their agement training remain centralized in the principal aca-
removal from the career paths and opportunities that their demic centers, located in the center of the country.
prior employment status with the national government
made possible. One of the most damaging results of decentralization is
the fragmentation in labor policy. Most states hire person-
[Based on Turner and Podger [33].] nel through (at least) two different mechanisms, i.e. 'fed-
eral' and 'state' contracts. These contracts result in quite
Mexico different labor benefits and working conditions for per-
Mexico decentralized considerable powers over the health sonnel, with the consequence that two health workers
sector from the federal to the state governments. The aim who hold the same type of post and perform similar tasks
was to increase health care accessibility and coverage, and may have very different earnings. The fragmented labor
some 116,000 health workers were transferred from fed- policy is a very divisive factor for labor relations at both
eral to state employment. Three main strategies have been the federal and state levels. Finding a solution remains
used to strengthen human resources, and develop the staff one of Mexico's most important human resource chal-
required to implement decentralized service delivery. lenges [35,36].
First, federal initiatives, aimed at increasing service
demand, are linked with considerations about the availa- [Based on information provided by Dr. Armando Arre-
bility of appropriate staff at the state level. Second, staff dondo and Mr. Emanuel Orozco, Health Systems
qualifications are improved through training. Third, Research Center, National Institute of Public Health,
adjustments are sought in the legal framework governing Cuernavaca, Mexico, including the referenced documents
labor matters. they cite.]
Most health workers are reluctant to accept rural postings Competing interests
because the working conditions and quality of life com- None declared.
pare unfavorably with what they are accustomed to in the
urban areas. In order to meet the needs of underserved Acknowledgements
rural areas, the Ministry of Health provides scholarships Preparation of this paper was made possible with support from the Rock-
to recent graduates in nursing, medicine and social work efeller Foundation. It was originally written for the Joint Learning Initiative
who agree to do their Social Service time in such areas. (JLI) on Human Resources for Health and Development, presented in the
JLI Working Group 3 meeting in May 2003 in Veyrier, France, and revised
These efforts have, however, failed because of the shortage
for publication.
of both federal and state staff positions and funding. State
governments have chosen to concentrate the available References
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