Coherence between health policy and human resource strategy: implications for China’s health system reform

This blog post was originally published in International Health Policies

By Xiaoyun Liu

The lack of coherence between health policies and human resource (HR) strategy is one of the major causes for the failure to meet health goals, such as the MDGs. A recently published article in Health Policy and Planning, co-authored by myself, explores the relationship and the degree of coherence between health policy — in this case maternal health policy — processes and HR strategy in Vietnam, China and India. In this commentary, I will focus on China.

The study identified mixed levels of coherence between the development of maternal health policy and HR strategies. In the study, we distinguished three models. A ‘Separation’ model means there is no relationship at all between the health policy and HR strategy. In a ‘Fit’ model, HR strategies are developed or adjusted to respond to the requirements of a health policy. Finally, a ‘Dialogue’ model takes this relationship one step further. It recognizes the need for two-way communication and some debate. Alternative policy options may be considered when the HR capacity does not meet the requirements of a certain health policy.

An example of ‘separation’ was found in China’s policy regarding domestic violence against women. In spite of a legal instrument laying out the policy, there was hardly any planning of HR resources for implementation.

In another policy on skilled birth attendance in China, in order for traditional birth attendants (TBA) to cease delivering babies and encourage pregnant women to have institutionally based birth deliveries, this policy introduced both rewards and sanctions to deter TBAs from continuing to do the deliveries themselves, which shows a ‘fit’ model.

Examples of ‘Dialogue ’ were not found in China, but ‘ethnic midwives’ in Vietnam and Female Health Workers (FHW) in India were trained and employed to provide birth delivery service in the remote regions of the two countries. Neither of these are considered skilled birth attendants (SBA) due to basic and limited training on midwifery skills.

The ‘Fit’ model was also found in the policy implementation stage in China. When access to health facilities was found to be a major constraint for pregnant women living in remote areas in China, a stretcher service was introduced for institutional delivery. Volunteers from the remote communities were mobilized as stretcher bearers when needed, which proved to be a successful innovation for supporting the institutional delivery policy. In the adolescent reproductive health policy, the evaluations of each programme produced wide-ranging recommendations including those related to HR for the next programme.

These findings have significant implications for China’s ongoing health system reform, which started in 2009.

First, appropriate actors such as the HR departments and/or ‘HR champions’ who are supportive of the policy should be involved to ensure that HR strategy is considered. In the overall design of the health system reform, HR were not among the components of the (five pillar) reform. Lack of HR expertise involvement in the policy process may have contributed to this lack of ‘Fit’ and ‘Dialogue’.

Second, HR strategy should be considered at the policy development stage or even before, at the agenda-setting stage. If one takes the essential public health service package as an example, to implement such an ambitious health service package, serious consideration should be paid to the numbers, capacities, and incentives of public health workers at grassroots level primary health care (PHC) facilities. More meaningful ‘Dialogues’ should be conducted between the health policy and HR strategies.

Third, HR strategies should be monitored (including checking coherence with the health policy) at the implementation stage and adjustments made where necessary, especially as HR requirements for successful implementation of the policy may change over time. Public hospital reforms in China result in considerable expansion of secondary and tertiary public hospitals. This will inevitably draw health professionals from lower level health facilities, especially PHC facilities, to those larger hospitals. Without keeping a close eye on the health labor market dynamics and monitoring the distribution and flow of health professionals between PHC and hospitals, the considerable efforts to strengthen PHC in the reform may be in vain due to the potential loss of health professionals.

Xiaoyun Liu is Associate Professor in Health Systems Research at the China Center for Health Development Studies, Peking University