Spotlight Interview
With Joy Phumaphi Conducted July 2008
Joy Phumaphi is Vice President of the Human Development Network at the World Bank. Prior to joining the World Bank in 2007, Ms. Phumaphi was Assistant Director General for Family and Community Health at the World Health Organization. Previously she served as the Minister of Health of Botswana.
	ICHRN: Can you briefly describe for our readers what the World Bank's current policies and activities are in the area of nursing/health human resources?
Joy Phumaphi: Human resources for health are one of the most important components of health systems, and are crucial to improving health service delivery. The Bank's support to our client countries in this area includes funding in service training of health workers, analytic work to improve the information base for human resources for health policy, civil service reforms that address the entire civil service, and working with Ministries of Health to cost out human resources for health strategies.
	ICHRN: What is the World Bank doing to strengthen personnel management in the health sector?
Joy Phumaphi: We are supporting analytic work in several countries in Africa and East Asia. This work focuses on better understanding the labour market for nurses and other health workers, and the type of incentives that are needed in order to improve retention, motivation and performance. This work is supported by the governments of Norway and the Netherlands as well as the Gates Foundation. The evidence base for human resources for health policy is quite weak overall and it is important to work on this so that policy makers can make better informed decisions. For example, contingent valuation studies for health workers in Ethiopia provided the government with information on what level of pay increase and other incentives are needed in order to attract health workers to rural areas. In addition, several of our projects have specific components that focus on human resources for health. For example, a new lending operation in the northern mountainous provinces of Vietnam has a fairly extensive human resources for health component that includes an innovative scheme for improving retention.
	ICHRN: What do you consider the priority challenges in the area of health workforce planning and development? How is the Bank meeting these challenges?
Joy Phumaphi: As mentioned, the first is the lack of evidence for policy decisions. This area is so important yet the information base for decision making is so weak. It is important to work with countries to strengthen the monitoring capacity of information systems. We are doing this through several streams of analytic work. Second, in this area of health systems strengthening there needs to be a better link between the health, education and finance sectors. Training capacity for doctors is often controlled by the ministry of education; the wage bill for health workers by the ministry of finance. Coordination is often a major challenge. Scaling up the health workforce or changing the pay method for health workers has implications for the ministry of education and the civil service. Third, coordinating donor support in this area is a challenge. There is emerging evidence that the many donor initiatives, while bringing much needed resources, often bring unintended consequences to the labour market for health workers. It is important that donors adhere to the Paris Declaration of aid harmonisation to minimize things like wage distortions. The International Health Partnership [see www.who.int/healthsystems/ihp/en/] country compacts provide a promising way forward for coordinated donor support for health system strengthening.
	ICHRN: What is the World Bank's perspective on health worker migration? Is it regarded as an issue that requires policy intervention? If, so what types of intervention?
Joy Phumaphi: We know that migration has historically had an important impact on development and that it has costs and benefits both within the health sector and beyond. It is clear that given the projected increases in shortages of health care workers – especially nurses – in OECD countries over the next 15-20 years the demand for foreign trained professionals will increase significantly. The question that policy makers and all sides of the debate need to ask then is, “What policy options do we have to help scale up training of health workers in developing countries and improve retention?” The World Health Organization is working on developing an international code of practice for the recruitment of health workers to better manage migration. This is one avenue to explore as bilateral agreements will not be enough. Working with countries to expand training capacity is another option. Some recent work by the World Bank in the English-speaking Caribbean has shown lack of tutors, instructors and supervisors to be the main constraint to increasing training capacity for nurses in this Region where migration – not just health workers but general migration – is so prevalent. Given the key role that migration policies in OECD countries play in determining migration flows it is also important that the Bank and other global agencies such as WHO and the Global Health Workforce Alliance engage destination countries as well. We also need to have much better information on why people migrate as migration tends to be a symptom of a bigger problem and not the root cause of health worker shortages.
	ICHRN: A number of donors, such as development agencies, are investing resources to improve pay and conditions for nurses and other health staff in developing countries as a means to improve retention. What is the World Bank's view on this practice?
Joy Phumaphi: This needs to be looked at on a country by country basis and there are no general solutions or policies. Every labour market situation is different for different cadres and requires tailored interventions. What is needed at the country level is a much better understanding of why health workers are dissatisfied, what makes them leave the sector or the country and what policy options are most likely to have the biggest impact. We have been working with countries to develop tools that can be applied to get at some of these solutions. The first policy response proposed is often to increase wages. But there are non-wage incentives that have been shown to have just as big an impact on retention. Moreover, the sustainability of wage and other financial incentive increases are also key issues to consider as well as the spillover effects into other sectors – when health workers are part of the civil service. Rwanda is an interesting recent example where the government changed the method of paying health workers, instituting a performance based allowance scheme that did not inflate the overall civil service wage bill.
	ICHRN: What is the World Bank's view on scaling up of the health workforce in Africa? Where do you think the priority efforts should be placed?
Joy Phumaphi: Again, priorities need to be looked at country by country. There is no one size fits all solution. Certainly Region wise, there are the lowest levels of staffing globally. However, when you look at how much variation there is in service delivery outcomes across countries and the number and type of health workers it clearly shows us that we need to look beyond numbers. We also need to think outside our current models on training. Ethiopia has done a remarkable job with their health extension worker programme. When I see some of the data on absenteeism and productivity that is coming out of some of the work the Bank is supporting in countries in Africa it clearly points to the need for better use of the currently trained workforce. A forthcoming study the Bank carried out also found significant inefficiencies in the recruitment, deployment and other human resource management functions within the health sector in several countries. What is important is to identify the specific health workforce issues in each country and to design well tailored policy responses. The Bank is working with several countries to do this.