Pan American Health Organization HUMAN RESOURCES: A CRITICAL FACTOR IN HEALTH SECTOR REFORM. Regional Meeting - San Jose, Costa Rica 3 - 5 December de 1997 SERIES HUMAN RESOURCES DEVELOPMENT 8 Washington D,.C. May 1998 HUMAN RESOURCES DEVELOPMENT PROGRAM (HSR) HEALTH SYSTEMS AND SERVICES DEVELOPMENT DIVISION (HSP) PAN AMERICAN HEALTH ORGANIZATION WORLD HEALTH ORGANIZATION TABLE OF CONTENTS Page REPORT 4 1. HUMAN RESOURCES: A CRITICAL FACTOR IN HEALTH SECTOR REFORM 1 2. THE HEALTH SECTOR REFORM PROCESSES AND THE DEVELOPMENT AND MANAGEMENT OF HUMAN RESOURCES IN THE REGION 4 3. THE CONTEXT: STATE REFORMS AND THE DEVELOPMENT OF HUMAN RESOURCES 6 3.1 State Reform and Human Resources 6 3.2 Educational Reforms 7 3.3 Labor Change Trends in Health Services 8 3.4 Human Resources for Public Health and the Teams Question 9 3.5 State Reforms, Decentralization and Public Policy 11 4. SECTORAL REFORM, FLEXIBILITY, AND HUMAN RESOURCE REGULATION 13 5. DECENTRALIZATION AND HUMAN RESOURCES MANAGEMENT 18 6. HUMAN RESOURCES AND CHANGES IN HEALTH CARE MODELS 22 7. THE FUTURE OF PUBLIC HEALTH 26 8. EDUCATION AND PROFESSIONAL PRACTICE IN SECTORAL REFORM 28 9. HUMAN RESOURCES AND TECHNICAL COOPERATION 34 Pan American Health Organization 10. EPILOGUE 38 ANNEX 1: List of Participants 40 ANNEX 2: REGIONAL MEETING: HUMAN RESOURCES: A KEY FACTOR IN HEALTH SECTOR REFORM 52 REPORT The Regional Meeting "Human Resources: a Critical Factor in Health Sector Reform," was held in the city of San José, Costa Rica, from 3 to 5 December 1997, under the aegis of the Government of Costa Rica and the Pan American Health Organization (PAHO/WHO). Of special relevance at this meeting, attended by 120 participants, was the presence of ministers, vice ministers, and high-ranking officials in the health sector; national and international university authorities; international experts; health and education officials from Costa Rica; and consultants from the different international cooperation agencies committed to the sectoral reform processes (Appendix 1). The purpose of the meeting was to make health sector officials of the Region aware of the strategic importance of human resources for the progress and achievement of the objectives of sectoral reform processes. It aimed to analyze the problems of the countries' human resources in the context of the reforms and to encourage political commitment, and an opinion and action stream favorable to the changes required for the development of health human resources. The initial objectives appear in Appendix 2. This meeting helped clarify the reforms' determining factors and constituted a step forward in the reforms' progress. It is important to point out that it generated a number of orienting criteria for the countries and for PAHO/WHO to reformulate their personnel development action. This report contains a synthesis of the most important individual and collective contributions resulting from both plenary sessions and working groups, as well as the main conclusions and recommendations. The meeting was called to order with an invitation to initiate a broad dialogue and exchange of ideas; to study existing problems; perform critical analysis; and question focuses and methods of approaching the subject of human resources in the health field. These are believed to be the best ways to establish a basis for agreement to reassess the role of personnel in health care and sectoral transformation. The task of reassessing human resources in health, is part of the global end-of-the-century trend towards recognizing the centrality of institutional subjects in the augment of social capital of the countries of the Americas. However, such reassessment is based on the recognition that the task of changing the working conditions and education of health sector personnel is still pending in many countries involved in sectoral change processes. Within the human resources field, reform processes have displaced the problematic axis by making labor matters more visible and redefining the guiding criteria for personnel education, taking into consideration decentralization and changes in financing, organization, management, and health care models. The inaugural message was clear--debate broadly on the conceptual and axiological principle that human resources constitute a basic element of sectoral reform. At present, health-sector reform in the countries of the Americas constitutes one of the most important processes in the realm of social policy, given the Region's economic, state, and social transformations. The meeting became a most appropriate opportunity to analyze the reforms and Pan American Health Organization their implications for health personnel at a very special time in history. On one hand we are about to witness the end of a century, with the premonitory messages and inevitable balances it entails; on the other hand, new paradigmatic changes are occurring in the understanding of development, the role of the State, and the participation of both subjects and collective actors in social life. In observance of the mandates of its governing bodies and in response to its Strategic and Program Guidelines, PAHO/WHO has established technical cooperation in the field of national sectoral reform processes as an essential axis for its action. Consequently, within the framework of the Systems and Services Development Division planning of activities oriented towards sectoral reforms, the Human Resources Development Program organized this meeting, heeding the call of several countries and representative regional organizations involved in training health personnel. This event was held in coordination with the national sectoral departments responsible for human resources and those responsible for the reforms. 1. HUMAN RESOURCES: A CRITICAL FACTOR IN HEALTH SECTOR REFORM(1) The analysis and balance of almost five years of reform experience at the Costa Rican Social Security Administration illustrate in exemplary fashion the strategic role that human resources play in every change process in the health sector. An added value of this case as an example lies in the fact that the essential role of human resources was not taken into account when the reform was designed. The two years it took to design the change strategy allowed for the establishment of essential criteria, such as the determination of geographical areas, population coverages, and the redefinition of health care teams, with the intention to confront what had been defined as the reform's central problem: the lack of equitable and universal access to services. The basic health care package, the openness of the different programs, and criteria and monitoring levels for health and teamwork were also decided upon at that time. Upon completion of the design, and while facing political viability for the change, it became evident that something important was missing: human resources. Who would implement the designed proposal? What kind of training and information did they have concerning the proposal (given the confusion and fears that were aroused among the collective actors)? What motivation could they have to undertake a profound and structured reform? It was at this time that the human resources dimension appeared as the center of and the driving force for change. To continue ignoring this would have been an invitation to failure and would have created enemies of the change process. The great lesson learned is that the change in the health scene shall be accomplished with the people already there, with the existing staff. This human resource is the great capital required for change. The question was how to generate favorable and stable conditions--encompassing all possibilities, such as subsidies, recognition, incentive systems, improved working conditions, but, above all, staff education--to ensure staff participation in such change? This lesson demonstrates the need to build up a great educational capacity, make training an instrument for change, and make the induction to work a mandatory requirement. Thanks to this experience, the CCSS now provides for the broad and extensive training of all staff, the promotion of its own cadres, greater possibilities for emerging cadres, the opening of opportunities for discussion Pan American Health Organization and analysis, and the strengthening and creation of alliances. In the case of the CCSS, the signing of an agreement with the University of Costa Rica, which will assume health care responsibilities for a large sector of San José, is significant. The message is very clear: the change in sectoral reform processes begins when the human resources undertake it as their own change. 2. THE HEALTH SECTOR REFORM PROCESSES AND THE DEVELOPMENT AND MANAGEMENT OF HUMAN RESOURCES IN THE REGION(2) Health sector reform processes are aimed at introducing substantive changes at different levels of the sector, as well as in its relations and functions, with the purpose of increasing benefit equity, efficiency in its administration, and effectiveness in its services, to satisfy the population's health needs. The final objective is to help improve the population's living conditions and health, through the reduction of inequality and the improvement of health care. Thus, there are efforts to modernize public institutions, search for new relationships between actors, and seek a new balance among the public domain, the private domain, and the necessary financial sustainability. Justification for the reforms lies as much in the need to confront the health situation as to improve