Can we halt health workforce deterioration in failed states? Insights from Guinea-Bissau on the nature, persistence and evolution of its HRH crisis
Can we halt health workforce deterioration in failed states? Insights from Guinea-Bissau on the nature, persistence and evolution of its HRH crisis
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我们能否阻止失败国家卫生人力的恶化？
作者：
G. Russo;E. Pavignani;C. Guerreiro;C. Neves
背景几内亚比绍是世界上最贫穷和最不发达国家之一。在贫困、政治动荡和国家撤军的背景下，过去四十年来，其卫生人力 (HW) 陷入资源不足、绩效不佳和自由放任等日益严重的危机之中。 方法本研究旨在根据最近关于陷入困境的卫生系统的文献，分析几内亚比绍卫生人力资源 (HRH) 的状况，目的是帮助了解卫生工作者的工作方式 对旷日持久的动乱、由此产生的扭曲以及可能考虑的对策作出反应。通过文件分析、焦点小组讨论、14 次半结构化访谈和 5 次深度访谈，我们探索了实地可见的模式。 结果自独立以来，几内亚比绍经历了政治事件，这些事件反映了医疗保健领域及其卫生人力的演变，例如不同的政变企图、侨民浪潮和不断变化的外部援助。长期资金短缺和“稳定的政治不稳定”导致公共卫生服务商业化，并导致培训和部署卫生人员的机制存在缺陷。在缺乏任何形式的治理的情况下，卫生工作者开始拥有并运营卫生系统。我们表明，只有通过观察其历史演变和更广泛的社会经济背景才能理解几内亚比绍的人权危机。对于受统治国家的人权状况恶化，没有快速的解决办法。然而，认识到根深蒂固的扭曲和理解决定关键行为者行为的力量是确定解决方案的重要前提。结论几内亚比绍的案例研究表明，任何不考虑卫生当局对有效私有化医疗领域的有限影响力的政策从一开始就注定要失败。改善卫生系统治理和培训质量应优先于扩大人力资源卫生。必须通过激励措施而不是行政命令来管理臃肿且低效的劳动力队伍，以便在更高的薪酬和更好的工作条件下提高技能和生产力。通过现实和持续的投资，捐助者的支持对于引发积极的变化可能至关重要。
BackgroundGuinea-Bissau is one of the world’s poorest and least developed countries. Amid poverty, political turmoil and state withdrawal, its health workforce (HW) has been swamped for the last four decades in a deepening crisis of under-resourcing, poor performance and laissez-faire.MethodsThe present study aimed at analysing the human resources for health (HRH) situation in Guinea-Bissau in light of the recent literature on distressed health systems, with the objective of contributing to understanding the ways health workers react to protracted turmoil, the resulting distortions and the counter-measures that might be considered. Through document analysis, focus group discussions, 14 semi-structured and 5 in-depth interviews, we explored patterns as they became visible on the ground.ResultsSince independence, Guinea-Bissau experienced political events that have reflected on the healthcare arena and on the evolution of its health workforce, such as different coup attempts, waves of diaspora and shifting external assistance. The chronic scarcity of funds and a ‘stable political instability’ have lead to the commercialisation of public health services and to flawed mechanisms for training and deploying health personnel. In absence of any form of governance, health workers have come to own and run the health system. We show that the HRH crisis in Guinea-Bissau can only be understood by looking at its historical evolution and at the wider socio-economic context. There are no quick fixes for the deterioration of HRH in undergoverned states; however, the recognition of the ingrained distortions and an understanding of the forces determining the behaviour of key actors are essential premises for the identification of solutions.ConclusionsGuinea-Bissau’s case study suggests that any policy that does not factor in the limited clout of health authorities over a effectively privatised healthcare arena is doomed from the start. Improving health system governance and quality of training should take precedence over expanding HRH. A bloated and ineffective workforce must be managed through incentives rather than administrative orders, in order to improve skills and productivity against higher remuneration and better working conditions. Donor support might be crucial to trigger positive changes, through realistic and sustained investments.