By international standards, health workers in Ethiopia are in short supply. In addition, those who do enter the health fields and remain in the country disproportionately live and work in the capital, Addis Ababa. This paper uses detailed data gathered from nearly 1,000 health workers to examine the incentives and constraints that health workers face when choosing where to work, the likely responses of workers to alternative incentive packages, and the longer term performance of the health worker labour market. This working paper was produced as part of the World Bank's Africa Region Health Systems for Outcomes (HSO) Program. The Programme funded by the World Bank, the Government of Norway, the Government of the United Kingdom and the Global Alliance for Vaccines and Immunization (GAVI), focuses on strengthening health systems in Africa to reach the poor and achieve tangible results related to Health, Nutrition and Population. The main pillars and focus of the program center on knowledge and capacity building related to Human Resources for Health, Health Financing, Pharmaceuticals, Governance and Service Delivery, and Infrastructure and ICT.

The human resources crisis in the health sector has been gathering attention on the global stage. To date, however, most of this attention has focused on shortages of health human resources (HRH) at the national level. At least as important are problems at the sub-national level. Massive geographic and skill mix imbalances are reflected in the perilous undersupply of HRH in most rural areas. Virtually all Sub-Saharan African countries suffer from significant geographic imbalances. Very little substantive information or documentation exists on the problem. Even less is known about the lessons from policies aimed at addressing urban-rural human resource imbalances, let alone experiences of Sub-Saharan Africa countries, with such policies. There also appears to be a disconnect between the objectives and efforts of policymakers on the one hand and the functioning of national health labor markets and labor market behavior on the other hand. This disconnect hinders policy effectiveness and the efficient utilization of resources intended to narrow urban-rural inequities.In Sub-Saharan Africa government policies, often limited to the management of public sector vacancies, appear to be elaborated, prescribed, and implemented independently of labor market considerations. Partly as a result, they are unable to effectively address urban-rural imbalances, which are an outcome of labor market dynamics. This report discusses and analyzes labor market dynamics and outcomes (including unemployment, worker shortages, and urban-rural imbalances of categories of health workers) from a labor economics perspective. It then use insights from this perspective as a basis for elaborating policy options that incorporate the underlying labor market forces. The goal of the study is to address undesirable outcomes (including urban-rural HRH imbalances) more effectively. The book is thus suitable for researchers, policy analysts and policy makers with an interest in understanding and improving the allocation of human resources for health in the developing world.

Although the quest for growth remains as elusive as it was more than a decade ago, there is now much greater consensus on the policies and institutional changes that are needed to foster growth and economic development. But debate continues on the timing, sequencing, and local adaptation of these reforms. Furthermore, although the benefits of reform are well documented--the reasons as to why and when reforms occur still remain somewhat unclear. Many countries go through long periods of stagnation or even decline, without being able to create an environment for change, while others seem able to break the hold of vested interests and start following paths of reform. In October 2004, the Operations Evaluation Department (OED) of the World Bank held a conference on the Effectiveness of Policies and Reform. This event provided a forum at which participants--over 500 government officials, civil society representatives, and World Bank staff--could discuss how to improve the effectiveness of World Bank support for development policies and reform programs. Included in this volume are the contributions of distinguished development practitioners on issues such as: the links between good performance and policy change; how windows of opportunity can best be used to promote reform; how ownership of policies and reform programs can be encouraged; and how developed country policies can be improved to create a better global environment for development. Ajay Chhibber is director of the Operations Evaluation Department of the World Bank and was World Bank country director for Turkey from 1997 to 2003. R. Kyle Peters is senior manager, Country Evaluation and Regional Relations, in the Operations Evaluation Department of the World Bank. Barbara J. Yale is a consultant with the Operations Evaluation Department of the World Bank.

This book was produced to support the policy dialogue on Human Resources for Health (HRH) in Ghana. Despite some recent successes, further improvements in health outcomes are in part hampered by the lack of skilled service providers, or human resources for health (HRH), particularly in rural areas, that prevent critical health services from being accessed and adequately delivered to those that need them most. To address the lack of information to guide the development of policies and programs on HRH, the book aims to paint a comprehensive picture on HRH, consolidating new and existing evidence on stock, distribution and performance of health workers to focus on the “what”, as in “What is the situation on HRH?” and the “how”, as in “How is this situation explained?” . The book highlights in particular new evidence on some of the underlying determinants impacting stock, distribution and performance of health workers in Ghana, including health worker production and attrition, management and accountability structures, the capacity of health training institutions, and health worker compensation. As is made clear, any potential policies to improve the situation on HRH need to be well targeted, and take into account some of the fiscal and political challenges that are specific to the health labor market in Ghana. The data and findings presented in this book are the result of extended and close collaboration between the Ghana Ministry of Health, and the World Bank’s Africa Region Technical Team on HRH and will provide a better basis for Ghanaian decision makers and external partners to dialogue on HRH and related policies, resulting in concrete HRH actions. More broadly, it will be of interest to all those working to improve Human Resources for Health in Africa and beyond.

By international standards, health workers in Ethiopia are in short supply. In addition, those who do enter the health fields and remain in the country disproportionately live and work in the capital, Addis Ababa. This paper uses detailed data gathered from nearly 1,000 health workers to examine the incentives and constraints that health workers face when choosing where to work, the likely responses of workers to alternative incentive packages, and the longer term performance of the health worker labour market. This working paper was produced as part of the World Bank's Africa Region Health Systems for Outcomes (HSO) Program. The Programme funded by the World Bank, the Government of Norway, the Government of the United Kingdom and the Global Alliance for Vaccines and Immunization (GAVI), focuses on strengthening health systems in Africa to reach the poor and achieve tangible results related to Health, Nutrition and Population. The main pillars and focus of the program center on knowledge and capacity building related to Human Resources for Health, Health Financing, Pharmaceuticals, Governance and Service Delivery, and Infrastructure and ICT.

The human resources crisis in the health sector has been gathering attention on the global stage. To date, however, most of this attention has focused on shortages of health human resources (HRH) at the national level. At least as important are problems at the sub-national level. Massive geographic and skill mix imbalances are reflected in the perilous undersupply of HRH in most rural areas. Virtually all Sub-Saharan African countries suffer from significant geographic imbalances. Very little substantive information or documentation exists on the problem. Even less is known about the lessons from policies aimed at addressing urban-rural human resource imbalances, let alone experiences of Sub-Saharan Africa countries, with such policies. There also appears to be a disconnect between the objectives and efforts of policymakers on the one hand and the functioning of national health labor markets and labor market behavior on the other hand. This disconnect hinders policy effectiveness and the efficient utilization of resources intended to narrow urban-rural inequities.In Sub-Saharan Africa government policies, often limited to the management of public sector vacancies, appear to be elaborated, prescribed, and implemented independently of labor market considerations. Partly as a result, they are unable to effectively address urban-rural imbalances, which are an outcome of labor market dynamics. This report discusses and analyzes labor market dynamics and outcomes (including unemployment, worker shortages, and urban-rural imbalances of categories of health workers) from a labor economics perspective. It then use insights from this perspective as a basis for elaborating policy options that incorporate the underlying labor market forces. The goal of the study is to address undesirable outcomes (including urban-rural HRH imbalances) more effectively. The book is thus suitable for researchers, policy analysts and policy makers with an interest in understanding and improving the allocation of human resources for health in the developing world.

Although the quest for growth remains as elusive as it was more than a decade ago, there is now much greater consensus on the policies and institutional changes that are needed to foster growth and economic development. But debate continues on the timing, sequencing, and local adaptation of these reforms. Furthermore, although the benefits of reform are well documented--the reasons as to why and when reforms occur still remain somewhat unclear. Many countries go through long periods of stagnation or even decline, without being able to create an environment for change, while others seem able to break the hold of vested interests and start following paths of reform. In October 2004, the Operations Evaluation Department (OED) of the World Bank held a conference on the Effectiveness of Policies and Reform. This event provided a forum at which participants--over 500 government officials, civil society representatives, and World Bank staff--could discuss how to improve the effectiveness of World Bank support for development policies and reform programs. Included in this volume are the contributions of distinguished development practitioners on issues such as: the links between good performance and policy change; how windows of opportunity can best be used to promote reform; how ownership of policies and reform programs can be encouraged; and how developed country policies can be improved to create a better global environment for development. Ajay Chhibber is director of the Operations Evaluation Department of the World Bank and was World Bank country director for Turkey from 1997 to 2003. R. Kyle Peters is senior manager, Country Evaluation and Regional Relations, in the Operations Evaluation Department of the World Bank. Barbara J. Yale is a consultant with the Operations Evaluation Department of the World Bank.

This book was produced to support the policy dialogue on Human Resources for Health (HRH) in Ghana. Despite some recent successes, further improvements in health outcomes are in part hampered by the lack of skilled service providers, or human resources for health (HRH), particularly in rural areas, that prevent critical health services from being accessed and adequately delivered to those that need them most. To address the lack of information to guide the development of policies and programs on HRH, the book aims to paint a comprehensive picture on HRH, consolidating new and existing evidence on stock, distribution and performance of health workers to focus on the “what”, as in “What is the situation on HRH?” and the “how”, as in “How is this situation explained?” . The book highlights in particular new evidence on some of the underlying determinants impacting stock, distribution and performance of health workers in Ghana, including health worker production and attrition, management and accountability structures, the capacity of health training institutions, and health worker compensation. As is made clear, any potential policies to improve the situation on HRH need to be well targeted, and take into account some of the fiscal and political challenges that are specific to the health labor market in Ghana. The data and findings presented in this book are the result of extended and close collaboration between the Ghana Ministry of Health, and the World Bank’s Africa Region Technical Team on HRH and will provide a better basis for Ghanaian decision makers and external partners to dialogue on HRH and related policies, resulting in concrete HRH actions. More broadly, it will be of interest to all those working to improve Human Resources for Health in Africa and beyond.