Challenges in Human Resources in Health Services

Introduction

Human resources for health refers to all people primarily engaged in actions with the primary intent of enhancing health [1]. The health workforce includes [2]:

• Those who directly deliver healthcare services
• Those who determine what should be and can be delivered given available resources, and will be delivered in reality
• Those who identify health information requirements, make and implement plans, and collect data
• Those who identify what medical products, vaccines, and technologies are purchased, stored, and distributed, and the standards applied at all stages
• Those who identify financing strategies and put them into practice at all levels
• Those who establish leadership and governance systems, lead, and govern In addition to formal care providers, informal care providers like family caregivers, patient-provider partners, volunteers and community workers are included as well.

Health workforce is crucial for a well-performing health system. Workforce availability, accessibility, acceptability and quality determine system capability to provide comprehensive health service coverage and achieve high standards of health [3]. However, all countries, regardless of socioeconomic development, are currently facing difficulties in the education, attraction, retention, distribution and performance of their workforce. This has led to global challenges observed - shortage of health workers; and poor distribution of health workforce across public and private sectors, and primary and tertiary levels of care. One possible reason could be unfavourable conditions for staff attraction and retention in less attractive areas and specialities. Other influencing factors include history and context of the country, and external factors like migration of health workers from low- or middle-income countries to high-income countries, for better pay and working conditions. As such, countries have come up with various solutions, localised to their context, as a bid to tackle these challenges. One of which, is public-private engagement through partnership between public and public sectors.

Compared to public sector, the private sector is usually more efficient, more responsive to user needs and gives better value for money. Therefore, it would be beneficial for public sector to collaborate with private sector. Some benefits of public-private partnership include better geographical coverage via service scope and scale extension; increased responsiveness to user demands by providing services where and when needed; and lowered burden on public sector by providing services for the more affluent population, saving public capacity for the less well off. Concurrently, private actors may also contribute skills and resources to enhance the public sector in management capacity, drug distribution systems, workforce training, and supply specific skill sets in shortage to public sector. In the next two sections, I will illustrate how strengthening public-private engagement through public-private partnership plays a role in addressing the human resource challenges facing the health system in Singapore. The extent which public-private engagement is able to address these challenges will also be discussed.

Singapore’s Healthcare Landscape

Similar to most developed countries, Singapore’s health system mainly consists of public and private actors. While the health system is largely under the governance of the Ministry of Health (MOH), private actors including voluntary welfare organizations (VWOs), private health insurers, non-government organizations also contribute to the health system via providing additional capacity, enhanced workforce capabilities, and healthcare financing support for the population. Due to the lack of natural resources, Singapore invests heavily in her workforce and technological advances. Currently, Singapore faces a rapidly ageing population, where the proportion of residents aged 65 years and over has increased by more than 50% from 8.5% in 2007 to 13% in 2017. In 2016, the population life expectancy at birth stood at 83 years [4]. MOH estimated that another 30,000 healthcare workers are required by year 2020 [5].

Although Singapore is equipped with advanced health system and good infrastructures - 8 public hospitals, 8 national speciality centres, 10 private hospitals and several community hospitals [6], healthcare demand continues to exceed supply, due to rising needs from the ageing population. Existing measures - allowing for influx of foreign health workers and increasing training capacity of health workforce, to mitigate the crunch in local health workforce cannot fully compensate for the shortage in health workforce. This has resulted in insufficient capacity, heavy patient loads and long waiting times for appointments at public health institutions. On top of that, traditionally Singapore’s health system has been following a hospital-centric model, with majority of the public healthcare workers employed in public hospitals. However, since onset of the silver tsunami, this model has become less relevant as it is unable to support the ageing population who have greater and longer-term healthcare needs. As such, the mal-distribution of health workforce is another major issue that needs to be addressed.

Amidst these challenges, MOH strives to ensure that Singaporeans continue to have good accessibility to all levels of healthcare services in a timely, cost-effective and seamless manner. To achieve this aim, there has been a paradigm shift in recent years, in Singapore’s approach to tackle the rising healthcare needs via the “3 Beyonds”- Beyond hospital to community; Beyond quality to value; and Beyond healthcare to health. As part of shifting care beyond hospital to community, the ministry has been pushing for initiatives to reallocate healthcare resources into the community, moving away from the hospital-centric model towards patient-centric model, where services are designed around patients’ needs.

Healthcare Public-private Partnership in Singapore

In Singapore, private practitioners- general practitioners (GP) constitute 82% of the primary health workforce, while the remaining 18% are located in government polyclinics [7]. However, government polyclinics see more than 40% of the chronic disease load, compared to private sector, who sees less than 60% of the chronic disease population. Due to the skewed distribution of primary care physicians towards private sector, MOH rolled out several public-private partnership initiatives to enable private sector to handle a greater chronic-diseased workload. In 2012, Community Health Assist Scheme (CHAS) was introduced to strengthen MOH’s partnership with GPs and private dental clinics in the provision of subsidised primary care for pioneer generation and around 50% of Singaporean households [8]. Under this scheme, means-tested patients receive subsidy for consultation and medication charges when they visit participating GPs or dental clinics. In addition, the Regional Health Systems in public sector also collaborated with GPs to set up Family Medicine Clinics (FMC), which focus on chronic disease management. To further tap on existing private community resources and facilitate greater shift of healthcare services into the community, MOH launched Primary Care Networks (PCN) in January 2018. This scheme connects GP clinics around Singapore, organising them into networks that provide holistic and team-based care [9]. Within each PCN structure, additional support services like ancillary services for chronic disease management, nurse counselling, administrative support and care coordination are available [10]. As such, chronic-diseased patients have an option to follow-up at PCN clinics instead of the overly congested polyclinics, which used to be one of the two primary care facilities, other than FMCs, providing one-stop hub services including ancillary and care coordination services.

As the burden on public sector healthcare staff is eased, more resources can be reserved for the less well-off population who may not be able to afford private healthcare services. Polyclinics also have greater bandwidth to take on more complex cases seen in hospital specialist outpatient clinics (SOC), allowing SOCs to pool resources and focus extensively on complicated cases for better patient outcomes. In intermediate residential care, public hospitals work closely with community hospitals run by VWOs. Some public-private collaborations include joint development of clinical governance standards, care pathways, workforce capacity and capability to enable seamless patient transfer across institutions. Such partnerships allow sharing and exchange of resources, skills and information, bringing about enhanced capabilities and capacities for both sectors. In long-term care sector, the ministry engages private sector to increase capacity to meet needs of Singapore’s ageing population. Portable subsidy scheme allow up to 75% subsidy in participating private nursing homes. MOH also engages private and VWO operators to manage aged care facilities like eldercare centres and nursing homes [11].

As illustrated in the examples above, strengthening engagement between public and private health providers via public-private partnership allows for existing health workforce resources skewed towards private sector to be tapped on and better utilized, thereby addressing part of the human resource challenges faced by Singapore. However, such engagements only address the challenges to a relatively small extent as they only resolve downstream situations like poor distribution of health workforce across public and private sectors, and different care settings. Upstream factors influencing workforce strength, distribution and quality cannot be fully addressed by strengthening engagements between public and private health providers. Workforce attraction, retention, and support are essential factors for developing a stable and relevant health workforce of good quality. Taking Singapore as an example, in addition to tapping on existing resources in private sector, MOH is taking a multi-prong approach in building up Singapore’s healthcare workforce. According to Healthcare Manpower Plan 2020, MOH, in partnership with healthcare providers and the Healthcare Services Employees’ Union, will develop a future-ready healthcare workforce guided by three key strategies [12]:

1. Building future skills by equipping workforce with skill required for evolving needs of the ageing population
2. Growing strong local core via investing in fresh school leavers, supporting mid-career entrants, and tapping on community support via engaging informal care providers like volunteers
3. Developing better way with technology via improving work environment and patient experiences with technology In “The Global Strategy on Human

   Resources for Health: Workforce 2030”, World Health Organization also recommended for policy and funding decisions on education and health labour market to be aligned with the evolving healthcare needs. Policies are recommended to address workforce production, inflows and outflows of health workers, mal-distribution and inefficiencies of health workforce, and regulation of private sector [13].

Furthermore, several barriers must be overcome for an effective public-private partnership. Firstly, mutual trust between public and private sector needs to be established. However, this is not an easy task as public sector’s suspicion of the private sector may exacerbated by a lack of information and communication. Secondly, different management strategies, care patterns, and information systems between public and private sectors may impede effective collaboration. Thirdly, public actors may have concerns over the opportunity cost of resources channelled through the private sector for short-term health gains, which could be applied to increase long-term sustainability of the public system. Fourth, public and private sectors need to align their vision and beliefs to move effectively in the same direction with common understanding. Finally yet importantly, users tend to move across both sectors for different care services, making the provision of integrated and continuous care is a major challenge. Adding to the complexity, the partnership and engagement levels may vary due to governance difference in different countries. Therefore, while engagements between public and private healthcare providers may address a portion of the human resources challenges faced by all health systems, this alone cannot resolve the challenges in the long-run. Upstream factors influencing workforce strength, distribution and quality must also be addressed.

Conclusion

Human resources challenges should be tackled with a multi-prong approach. Public and private engagements can be strengthened to address the short-term challenges while policies to enhance attraction, retention and support of health workforce is under the way. This would ensure the build-up of a strong, stable health workforce of good quality. A good health workforce needs to have an appropriate mix of motivated people in the right place at the right time, with the right skillset. This would in turn, facilitate the provision of an effective, efficient, high quality healthcare service, enabling the population to achieve better health. However, we should bear in mind that while human resources form an essential component of health system, other health system inputs- physical resource, intellectual resources and social resources, also need to be available and well managed for a health system to function.