Retention strategies in Latin America: a preliminary overview. Luis Huicho Universidad Peruana Cayetano Heredia, Lima, Peru

Transcription

1 Retention strategies in Latin America: a preliminary overview Luis Huicho Universidad Peruana Cayetano Heredia, Lima, Peru

2 Context LA is one of the most inequal regions of the world Market-oriented economy reforms in 1980s and 1990s: stimulated privatization and financial investment Decentralization was additionally encouraged-which was an opportunity, but also a challenge However, real percapita growth did not happen, except in recent years

3 Context (contn d) Although the reforms resulted in economic growth, poverty has not been abated Income distribution has not improved, wealth is more concentrated now In health, this reform resulted in reduction of public sector funding, and strengthening of private sector Spent in health is only 2.9% of GDP in the region

4 Context (contn d) Health system reforms shaped health policies, including those on HRH These reforms decreased access to health services and access to HWs In LA, health inequity persists and it has even increased HRH inequitably distributed: most health workforce in urban areas This resulted in worst health indicators in poorest segments Belizan JM et al. Lancet 2007;370: )

5 Overview - Methodology Objective and scope: review and appraisal of studies aimed at describing or evaluating retention strategies of HWs in rural/remote areas in LA

6 Methodology (Cont d) Search strategy: similar to previous review (background paper for the first expert meeting) -Several databases and websites -Office visits (MoH, PAHO, NGOs): to be extended Time frame: ? to be further defined Setting: LA and The Caribbean Health cadres: doctors, nurses, midwives other cadres and CHWs as well? Managers?

7 Main findings: Summary of attraction/retention strategies in LA Primary Health Care: Cuba Clearly associated with universal access to HFs and to HWs, and with better health indicators Primary health care within a market-oriented health reform (Mexico)-Several evaluation studies on health indicators and health system (Lancet series). Presence and impact of retention strategies: pending assessment by this review Market-oriented health reform with private sector enforcement (Colombia and other countries)-associated with decreased health services coverage and utilization. Presence and impact of retention strategies: pending assessment by this review Decentralization within market economy reform: (Brazil: Southeast region, then scaled up. Also Peru, Mexico, Colombia )-Planning, budgeting and managerial problems at regional and local level. -In Brazil (family practice programmes and incentives for nurse-directed rural HWs): it was associated with decline in infant mortality and increase of immunization rates. Concern: ecological study, no control for contextual factors

8 Main findings: Summary of attraction/retention strategies in LA Community participation in administration of HFs and personnel appointment (Peru: CLAS): evidence of increased coverage of HSs, but showed poor salaries for HWs, absence of non-financial incentives, and serious managerial and corruption problems. External evaluations found it positive, but central government did not support it. Its is declining Task shifting (Brazil, Peru ): Sound evidence for advocating it. Resistance of professional associations should be appropriately faced Economic incentives (All countries): alone or as part of broader strategies. Although prevalent, no evidence of impact when isolated (most frequently). No formal evaluation studies Non-financial incentives: scarce and limited to few areas, not institutionalized at regional or national level-no evaluation studies Universal Health Insurance, and Family Doctor Programme strategy (Peru ): recently launched. An opportunity for evaluation of impact, if accompanied by a clear policy on HRH that privileges retention strategies

9 Main findings (contin d) Observatorios of HRH network (for all LA). Not a retention strategy itself, but promising as a rich source of information on several aspects of HRH, including retention strategies. No evaluation studies yet Immobility of functionaries, bonuses for seniority (Bolivia)-No evaluation studies Mobility within the career ladder (Chile)-No evaluation studies Dual Practice (Peru, Chile...): unofficially promoted, widely prevalent-no evaluation studies Compulsory service (Peru, Ecuador ): if isolated, unlike to have impact-in Ecuador claimed to have increased willingness to stay-unsubstantiated

10 Discussion: Context Public funding for social programmes has recently increased But it is not enough. Funding is focused on social security and social welfare programmes, excluding those without employment Renewed emphasis in Primary Health Care is encouraging, and retention strategies should be considered within this broader perspective

11 Discussion: Retention strategies Several bundled and single strategies implemented or to be implemented in the region However, scarcity of studies with clear description of implementation characteristics, And scarcity of formal evaluation studies or with a clear evaluation component

12 Main conclusions Economic inequalities need to be tackled in the long term in LA if inequitable HWs distribution is to be solved National and regional governments need to develop comprehensive policies for HRH that include carefully planned attraction/retention strategies Implementation of strategies should be adequate-definition of adequacy needed (this meeting task?) Studies on incentives urgenty needed at country level Evaluation of impact of the different strategies must accompany implementation efforts at country level

13 Main conclusions (contin d) Implementation and evaluation studies badly needed Need of developing indicators for adequacy of implementation and for impact of different strategies Reviews of evidence should be extended to several health interventions, looking for retention strategies included within them Focus on doctors and nurses should be extended to other cadres and to community health workers-there is enough evidence supporting task shifting