Spotlight Interview
With Dr Gilles Dussault Conducted August 2007
Dr Gilles Dussault is Professor and Head of the Health Systems Unit at the Institute of Hygiene and Tropical Medicine, Universidade Nova de Lisboa, in Lisbon, Portugal. Prior to joining the Institute in August 2006, Dr Dussault was a Senior Health Specialist with the World Bank Institute in Washington, DC.
	ICHRN: You have worked in Anglophone, Francophone and Lusophone Africa. Are there any fundamental differences or similarities in human resources for health (HRH) issues in countries in these three language/post colonial blocs?
Dr Dussault: There are certainly great similarities in HRH issues in these countries, as the same causes produce the same effects; for instance, the lack of resources means that the production of health personnel is insufficient in some countries, and in many countries, political instability has stimulated emigration of qualified staff. In general, poor working conditions and low levels of income characterize the three groups of countries. As for differences, there is more migration from the Anglophone countries, perhaps because active recruitment is more prevalent there and because established training models from the former colonial power allows for mobility to other Commonwealth countries (from poorer to richer countries within Africa, e.g. South Africa, and from Africa to the UK). Francophone and Lusophone personnel have less opportunity to migrate for linguistic reasons. Another difference is that professional associations are stronger in Anglophone countries, where there is a stronger tradition of trade unions, medical associations and international associations. These do not often exist, or only nominally, in Francophone and Lusophone countries. A final difference relates to the impact of HIV on HRH in terms of workload and exposure to risk and the corresponding incentive to leave the sector or even the country. In Francophone countries, prevalence is generally much lower than elsewhere in the continent.
	ICHRN: Recently there has been a lot of debate about "scaling up" the workforce in Africa. What do you think will be the most effective and sustainable strategies?
Dr Dussault: Scaling up means increasing the numbers in the health workforce, but in a way that maintains quality. Scaling up strategies will vary from country to country as the needs and the capacities vary, but the main ones are likely to include: 1. Good retention mechanisms. Health workers are leaving the country as well as leaving the sector, or they retire early despite having 10-15 years of potential service remaining. Retention of the existing workforce needs to be addressed. 2. Strong investment in education. The challenge is to invest at different levels. In order to scale up the production of qualified workers, you must have candidates. Therefore, there is a need to scale up secondary education and prepare and encourage young people to enter professional schools, which implies making the health sector more attractive. Of course, investing in the training of trainers or educators is another prerequisite. 3. Upgrading health workers to a higher category, such as from enrolled nurse to registered nurse, improves the proportion of qualified workers within the workforce and the capacity to provide better services but it does not increase the stock of the workforce.
	ICHRN: There is a lot of talk about scaling up the numbers of community health workers. What are your thoughts on this?
Dr Dussault: : The scale up of numbers of community health workers (CHWs) can only be an intermediary strategy, while the increase in more qualified workers is going on. And it must be done in a well planned manner. A good example is the use of community health workers under the supervision of nurses as part of health care teams in North Eastern Brazil. The CHWs act as antennae to identify problems early and refer appropriately, to deliver bed nets, condoms etc. – tasks which can have a major impact, but do not require professional training. Before training CHWs, it is important to identify their tasks, to put in place mechanisms to ensure sustainability, and to create proper conditions of service.
	ICHRN: As someone who previously worked for the World Bank Institute, what are your views on how donors can best support improvements in HRH policy and practice?
Dr Dussault: 1. Donors need to support policy development at the country level. International organisations suffer from the same disease which they observe in countries where they work _ policies change all the time or do not even exist, personnel rotate at a high speed and continuity in support is weak. 2. Countries need to request that financial support be predictable so that they can plan interventions which require a mid and long term perspective to produce their effects. 3 Working conditions need to be improved. It is a welcomed development to see international agencies starting to supplement salaries; something they were opposed to in the past. However, this is only part of the solution as we know that financial incentives are necessary, but not sufficient, to have a stable and motivated workforce. 4. Professional associations need support. In countries, anywhere in the world, where the HRH situation is relatively good, most improvements in working conditions come not from government interventions, but from professional groups themselves. In many countries, the absence of strong professional associations makes it extremely difficult to improve the general HRH situation.
	ICHRN: What would be your advice to nursing organisations that want to increase their impact on HRH policy development at national level?
Dr Dussault: First, national nursing organisations have to exist! This is where the International Council of Nurses (ICN) has a major role to play by mobilizing other partners to help. ICN can work to ensure that such networks can function. ICN has the credibility to mobilize funds from various agencies. I have been to countries where the association is just one person with very little capacity to influence policy. Where nursing organisations do exist, ICN can help with developing and supporting leaders. Often the nursing association is not aware of its potential influence on the political process. Once they start speaking up, it is impressive how others listen. However, they do need to be well prepared. Often these professional organisations are perceived as trade unions defending individual rights. They need to be perceived as contributing to policy development or they will not be heard, they will not be listened to. Proposals should be well thought out in order to give them credibility and voice. But how can we do this when people are overloaded and cut off from the world (no access to internet)? We need to build capacity. Professional organisations need to show that what they are proposing is part of a regional movement and the result of rigorous study. Credibility is important. Nursing organisations need to work with other health professional associations. A few years back in Bangladesh, the nurses were totally separated from the medical world. The feeling was that the doctors and nurses were against each other. They were brought together in policy seminars in the mid-1990s and they soon realised that they had similar interests. One strategy may be to support the building of such alliances.
	ICHRN: Geographic maldistribution of the health workforce has been one of the issues you have focused on in your work. What do you think are the most effective policy mechanisms to improve the geographic distribution of nurses?
Dr Dussault: Again, this is a universal problem. Its impact is more important in poor countries because the needs are greater and are often left unattended, but it is a universal problem. No one has found a perfect solution. Countries need a clear plan with specific and measurable targets, based on the understanding of what makes people accept to work in poor areas or rural areas. What is the right mix of incentives? This is something each country must decide on its own because the sensitivity of the workers to incentives may vary and may change. There is a mix of professional, financial and personal incentives to choose from. For example, nurses in many countries are mostly female and they fear for their security if they go to remote regions. If they are married, they will not move because they have to think of their husband's work. So incentives for the whole family are important. A greater commitment is needed in this area. This is a difficult issue which is never resolved; the process of preventing and correcting maldistribution is a permanent one.
	ICHRN: Is there anything further you would like to communicate to our readers interested in HRH issues?
Dr Dussault: The main message is that addressing HRH is a process that needs to be conducted with a long term vision of what needs to be achieved. And we need to work in a comprehensive manner. There is no point in improving education if working conditions are not improved. There is no point in sending staff to remote regions if they are not trained or they become cut off. Also, I am not aware of any example of success which does not involve health workers themselves. Change can not be imposed from the top. It needs to involve health workers. If you have strong involvement of professional associations, a new minister or change in government will find it more difficult to discard what has been achieved and to start again in a different direction.