Transforming health: empowering human resources in primary health care

By: Daniel Andrés Sierra García

IFMSA Guatemala

Universidad de San Carlos de Guatemala

More than any other organization, health organizations are highly dependent on their workforce; therefore, the ability of each country to reach its health goals depends mainly on the knowledge, skills, motivation and deployment of the people responsible for delivering and organizing health services. The global crisis of health workforce is well known, even more in developing countries like most of the Latin American countries. This crisis is characterized by the deficit and unequal distribution of health workers setting the major obstacle for fulfilling the Universal Health Coverage.

We understand the health workforce as all the people engaged in actions whose primary intent is to enhance health. These human resources include not only health service providers such as doctors and nurses, but also the health management and support workers that are critical to a well-functioning health system. In order to achieve Universal Health Coverage, four critical dimensions are needed to be accomplished by the health workforce: availability, accessibility, acceptability and quality. 

Human Resources for Health: the current situation in Guatemala

About 17 million people live in Guatemala. More than 50% of the population live in rural areas and approximately 40% are indigenous people. According to the United Nations, the main problem in Guatemala is the inequality. The Gini index, a coefficient that measures the wealth distribution in a country’s population, for Guatemala rises to 0.63, one of the highest in the world. This means Guatemala is one of the most unequal countries, conditioning the population to the lack of opportunities for development and human rights exercise. 

In terms of human resources, Guatemala has an availability of 12.5 health workers per 10,000 population, the lowest health worker density in Central America; way below the WHO-recommended bare minimum for a functioning health system. There is a density of 25.7 health workers per 10,000 population in urban areas, compared to only 3.0 in rural areas.

Healthcare accessibility is compromised because of inequitable geographical distribution of health workers, where at least three million Guatemalans live further than five kilometers from a health facility. This situation affects the families who live in mountainous regions with difficult terrain and without access to motor vehicles. 

People acceptability is also a highly relevant topic in a country as diverse as Guatemala, where 40% of the population self-identify as indigenous and have their own culture and language. This sets a barrier for physicians to practice medicine with the rural population because of the popular misconceptions as regards health and disease. Physicians must be able to address this different understanding of health in order to meet the health needs of people and give the best attention possible.

Transforming healthcare: from curative to preventive medicine

In comparison with other health systems, Guatemalan health network is distributed only in three levels of care. Primary care level has focused its attention on healing actions, when its main activity should be the promotion of health and prevention of diseases. The resources, including human resources, are concentrated in the tertiary hospital network, meaning that primary care is lagging, leaving prevention and promotion far behind. It is also a fact that in rural areas, there is huge population dispersion; therefore, it’s extremely difficult for the conventional health delivery system to respond to the demand to achieve the social goal of health for all. 

A triad has been proposed to understand what is needed to fulfill health coverage. The triad is represented by the doctor, the diagnostic and therapeutic technology, and the treatment. Considering this proposal, if one of the parts is missing, there’s no chance to reach Universal Health Coverage; therefore, there has to be enough resources of each component in order to deliver quality healthcare in each level. 

So, it’s logical to move the workforce to where healthcare is needed, right? Even when it sounds easy, it is not. Many factors influence the physicians’ decision of where to work. The personal background, family conditions, the financial aspects, the working and living conditions, the working opportunities and the people’s acceptance are some of these factors. For a doctor in a rural area, practicing medicine represents a complex challenge to address, and it’s not an easy decision to make.

While there’s still a disproportionate market of opportunities full of inequalities for healthcare delivery and unfair pay for workers, health needs and the burden of diseases won’t be able to be addressed in an effective way. National, regional and global policies are needed to encourage physicians to relocate to rural areas and deliver preventive health in a local scope. There’s enough evidence that shows that health prevention and promotion is the best investment a health system can make, but human resources capable of giving acceptable healthcare are needed for this intervention to be effective. 

The challenge: changing the mindset

It’s kind of crazy to believe that in a few years, we are going to join the health workforce. Are we going to let things stay the same? As said before, health delivery highly depends on the workforce. Guatemala, Latin America and the rest of the world need physicians with a totally new mindset to change how health is delivered. If we continue on the same road where we are right now, in the near future the healthcare won’t be able to answer to the needs of the population. Globalization, people aging, non-communicable diseases, climate change and new technologies are challenges that we will face and we as members of the health workforce have to be prepared to address. 

Changing the way of delivering health, from curative to preventive, is the key to improve our capacity as a health workforce. I’m sure that as in Guatemala, many other countries face the same problems. So that is our challenge: creating a new paradigm of empowering people to be actors in their own health, so they are able to improve their community’s well being and contribute to fulfill personal and common development. To the extent that we empower people, this will increase the number of people who are part of the human resources working towards improving health. And this doesn’t mean you need to move to a remote rural area, but to deliver your services in your very own community focused on building capacity that enables people to take the best decisions for their well-being. 

References: 

Avila C, Bright R, Gutierrez JC, Hoadley K, et al. Guatemala health system assessment 2015. USAID. 2015. 

Zoio G, Cavada A, Sarmento R, Dal Poz M. Recursos humanos para la salud: crisis global y cooperación internacional. Ciência & Saúde Coletiva. 2017; 2(7): 2237-2246. 

The World Health Organization. Human resources for health. Toolkit for monitoring health systems strengthening. 2009.

The World Health Organization. Increasing access to health workers in remote and rural areas through improved retention. 2010.

United Nations. Guatemala: common country assessment. 2014.

Organización Panamericana de la Salud. Desigualdades en salud en Guatemala. 2015.