Articles
Effects of policy options for human resources for health:
an analysis of systematic reviews
Mickey Chopra, Salla Munro, John N Lavis, Gunn Vist, Sara Bennett
Summary
Lancet 2008; 371: 668–74
See Editorial page 623
See Comment page 629
Health Systems Research Unit,
Medical Research Council of
South Africa, Cape Town, South
Africa (M Chopra MSc,
S Munro MA); Norwegian
Knowledge Centre for the
Health Services, Oslo, Norway
(G Vist PhD); Department of
Clinical Epidemiology and
Biostatistics, McMaster
University, Ontario, Canada
(J N Lavis MD); and Alliance for
Health Policy and Systems
Research, World Health
Organization, Geneva,
Switzerland (S Bennett PhD)
Correspondence to:
M Chopra, Health Systems
Research Unit, MRC, Van Zyl
Drive, Parow, Western Cape
7535, South Africa
mickey.chopra@mrc.ac.za
Background Policy makers face challenges to ensure an appropriate supply and distribution of trained health workers
and to manage their performance in delivery of services, especially in countries with low and middle incomes. We
aimed to identify all available policy options to address human resources for health in such countries, and to assess
the effectiveness of these policy options.
Methods We searched Medline and Embase from 1979 to September, 2006, the Cochrane Library, and the Human
Resources for Health Global Resource Center database. We also searched up to 10 years of archives from five relevant
journals, and consulted experts. We included systematic reviews in English which assessed the effects of policy
options that could affect the training, distribution, regulation, financing, management, organisation, or performance
of health workers. Two reviewers independently assessed each review for eligibility and quality, and systematically
extracted data about main effects. We also assessed whether the policy options were equitable in their effects; suitable
for scaling up; and applicable to countries with low and middle incomes.
Findings 28 of the 759 systematic reviews of effects that we identified were eligible according to our criteria. Of these,
only a few included studies from countries with low and middle incomes, and some reviews were of low quality. Most
evidence focused on organisational mechanisms for human resources, such as substitution or shifting tasks between
different types of health workers, or extension of their roles; performance-enhancing strategies such as quality
improvement or continuing education strategies; promotion of teamwork; and changes to workflow. Of all policy
options, the use of lay health workers had the greatest proportion of reviews in countries with a range of incomes,
from high to low.
Interpretation We have identified a need for more systematic reviews on the effects of policy options to improve
human resources for health in countries with low and middle incomes, for assessments of any interventions that
policy makers introduce to plan and manage human resources for health, and for other research to aid policy makers
in these countries.
Introduction
Quality health care depends on policies to ensure that
health workers who are capable of delivering such care
are available in sufficient numbers.1 Challenges related
to human resources for health are particularly acute in
countries with low and middle incomes. These challenges
include an absolute shortage of qualified staff, especially
in sub-Saharan Africa; an inequitable distribution of
health workers, with too few in remote rural areas; and
staff absenteeism and poor motivation that are probably
caused by low pay, poor supervision and support, and
unsatisfactory working conditions.2 Ways to address
these challenges, which have increasingly been
recognised as primary barriers to scaling up the delivery
of effective health services, have been outlined.1–4 To make
the best use of scarce resources, policy makers who are
charged with the provision of effective and equitable
health care need evidence that will help them to identify
and select policy options.
Frameworks to conceptualise the key issues related
to human resources for health have been developed,1,2
and evidence about improving the performance of
health workers has been reviewed.5 However, the full
range of possible policy options has not been reviewed.
668
Policy makers need systematic reviews to help them to
identify, select, appraise, and synthesise research
findings.6 Systematic reviews could increase confidence
for policy makers about the probable effects of different
policy options and reduce the risk of high opportunity
costs associated with implementation of inappropriate
policies.7 Systematic reviews can inform policy makers
about how a particular policy option was implemented
in other contexts, and about how they could assess it in
their own context,6 but might not be applicable in
countries with low and middle incomes, where human
resources are problematic.8 For example, the effects of
performance-based pay or contracting of private
practitioners are dependent on capacity to manage such
measures, which varies between health systems; some
countries with low or middle incomes have very little
capacity to manage such policies. However, criteria
have been developed to assist policy makers to assess
the applicability of research to different settings. We
aimed to list all possible policy options (grouped by key
objectives); to identify effects and outcomes for which
evidence exists and those for which it is lacking; and to
synthesise conclusions for countries with low or middle
incomes.
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Articles
Methods
We adapted, expanded, and combined several existing
frameworks to generate a comprehensive list of possible
policy options, grouped by key objectives and their
possible effects, and by outcomes for human resources
for health.1,2 We further refined the list by soliciting
input from both researchers and policy makers. We
searched Medline Ovid and Embase Ovid, from 1979 to
September, 2006; the Cochrane Library (which includes
both the Cochrane Database of Systematic Reviews and
the Database of Reviews of Effectiveness); and the
Human Resources for Health Global Resource Center
database. We searched for systematic reviews and metaanalyses of manpower and personnel in developing
countries. We used the following subject headings and
text words: “health manpower”, “foreign professional
personnel”, “foreign medical graduates”, “emigration”,
“immigration”, “migration”, “human resources”,
“health manpower”, “foreign personnel”, “foreign
graduate”, “brain drain”, “border crossing”, “health
personnel”, “personnel management”, “health services
needs and demand”, “resource allocation”, “health care
rationing”, and “international educational exchange”.
We searched back issues of Bulletin of the World Health
Organization, Health Policy and Planning, Human
Resources for Health, Human Resources for Health
Development, and Implementation Science for ten years,
or since the earliest publication if this was more recent.
We searched the reference lists of the reviews that we
identified. We also asked experts about existing reviews
and those that were underway or being updated. Two
researchers independently assessed the titles and
abstracts that were identified by the searches. Studies
that did not meet one or more of our inclusion criteria
were excluded at this stage. The remaining articles were
retrieved and assessed in full text.
We included systematic reviews if they were published
in English; if they examined the effects of policy options
that could affect the supply, distribution, efficiency, and
performance of health workers; and if their methods
sections contained explicit selection criteria. If a
systematic review had been updated we only included
the most recent version. We gave financial assistance to
two review teams (the systematic review about
underserved areas9 and the systematic review about use
of lay health workers10) to complete their work in time
to be included.
Two researchers independently determined eligibility,
extracted data, and assessed quality for each review. We
extracted information on the background and origin
(setting and country) and characteristics of each of the
studies that were included in the systematic reviews. We
collected information about the quality of analysis and the
main results of the systematic reviews. We also assessed
whether the policy options reviewed in the studies were
equitable, suitable for scaling up, and applicable to
countries with low and middle incomes. Disagreements
www.thelancet.com Vol 371 February 23, 2008
between researchers were resolved by discussion. We
developed forms to use for standardised data extraction,
and used a checklist for quality assessment of the
systematic reviews. We evaluated whether the quality of
the evidence for each important outcome was either high,
moderate, low, or very low according to four main criteria:
study design, study limitations, consistency, and
directness.11,12 We used a so-called GRADE evidence profile
to summarise these results for each of the critical
outcomes in the comparison and the average profile for
the systematic reviews were assessed.11,12
Supply
(quantity) of
health workers
Distribution
of health
workers
Efficient use Performance
of health
of health
workers
workers
Training interventions
Increase numbers of new students
Yes
Recruit foreign graduates
Yes
Recognise previous learning
Yes
Improve curriculum content
Yes
Yes
Yes9
Adjust relative numbers of specialist,
generalist, and midlevel training
positions
Yes
Refine admission criteria
Yes9
Yes
Use reserved entry or quotas for specific
groups
Yes
Yes
Introduce conditional scholarships
Yes
Yes
Diversify location of training sites
Yes9
Yes
Involve communities (eg, in selection
of trainees)
Yes
Yes
Recruit and train faculty
Yes
Introduce training approaches (eg,
problem-based learning)
Yes
Regulatory mechanisms
Recognise overseas qualifications
Yes
Introduce temporary employment
regulations
Yes
Yes9
Yes
Yes
Expand roles of midlevel workers
Yes
Require service in underserved regions
Yes9
Restrict migration of workers
Yes
Ensure competence
Yes
Introduce malpractice regulations
Yes
Financial mechanisms
Increase trainee salaries
Yes
Yes
Raise wages
Yes
Yes
Provide non-wage benefits
Yes
Yes
Introduce incentives for return of
skilled migrants
Yes
Establish retirement policies
Yes
Align pay with performance
Yes
Yes
Yes13
Alter remuneration methods (eg, fee
for service, list, or salary)
Yes
Yes
Yes13,14
Provide technology and supplies
Yes
Yes
Yes
Adjust relative remuneration
Provide incentives for workers in
underserved regions
Yes9,15
(Continues on next page)
669
Articles
Supply
(quantity) of
health workers
Distribution
of health
workers
Efficient use Performance
of health
of health
workers
workers
(Continued from previous page)
Organisational mechanisms
Change recruitment policies
Introduce performance management
systems
Yes
Change workflow or workload
Yes16–18
Yes
Increase numbers of nurses
Yes
Yes19–21
Improve information flow or use
electronic health records
Yes22
Yes
Allow medical care for staff (eg, HIV/
AIDS treatment)
Yes
Yes
Employ lay health workers
Yes10
Yes10
Yes10
Use private-sector workers
Yes
Integrate health-care services
Yes23
Decentralise health care
Yes
Yes
Promote team work
Yes22,24
Use community health planning
Yes24,25
Yes
Substitute or extend roles of health
workers
Yes10,26–32
Involve the community
Adopt quality improvement and
continuous education strategies
Yes25,33–38
Macro policies and mechanisms in other sectors
Estimate human resource needs and
plan for supply
Yes
Yes
Yes
Regulate the civil service
Yes
Yes
Yes
Table 1: Policy options that could affect outcomes for human resources in health
759 potentially relevant articles
identified and screened
725 articles excluded
716 not relevant
9 not systematic
reviews
34 articles retrieved for more
detailed evaluation
6 articles excluded
5 not relevant
1 near-duplicate
28 systematic reviews of effects
analysed
Figure: Study profile
Role of the funding source
The sponsor of the study had no role in study design,
data collection, data analysis, data interpretation, or
writing of the report. The corresponding author had
full access to all the data in the study and had final
responsibility for the decision to submit for publication.
670
Results
Table 1 shows policy options grouped by key objectives
in human resources for health—namely, training,
regulations, financing, organisational mechanisms,
and macro policies and mechanisms in other sectors.
The possible effects of the policy options were grouped
by key outcomes for human resources for health, as
described by WHO.1
Our search yielded 759 references, of which
28 systematic reviews of effects were deemed eligible
for analysis (figure). Of these 28, only a few included
studies from countries with low and middle incomes,
and some reviews were of low quality (table 2). Most of
these systematic reviews focused on policy options to
alter the organisation of human resources; only a few
investigated training interventions, financial mechanisms, or regulations.
We identified no reviews about wider country-level
policies or policies in other sectors that might affect
human resources for health care. The main
organisational mechanisms investigated in these trials
were substitution or extension of the roles of health
workers, and strategies to improve quality of health care
and implement continuous education.
Only one review addressed the effects of training and
regulatory mechanisms on improving the distribution
of health workers to underserved regions (table 2).9 The
review reported that no studies of effects met their
eligibility criteria, and none of the studies were from
countries with low and middle incomes. However, the
investigators did note that changes in the admission
policies of medical schools (eg, bias towards male
applicants or those with an interest in general practice
or with a service orientation) and the establishment of
medical schools in rural areas were associated with an
increased proportion of graduates working in rural
settings and underserved areas.9
In terms of financial policies, one systematic review
examined the effects of performance-based incentives,11
and two the effects of remuneration methods on the
performance of health workers.13,14 We identified reviews
that compared renumeration methods such as fundholding, in which providers are paid for each patient
registered, and capitation, in which providers are paid
according to the population size covered. Compared
with capitation, implementation of a fee-for-service
method was associated with more primary-care visits,
more visits to specialists, more diagnostic and curative
services, and higher compliance with the recommended
number of visits, together with fewer hospital referrals
and fewer repeat prescriptions.14 Our search identified
some low-quality evidence that suggested attempts to
control costs through freezing the fee-per-service were
countered by increased numbers of patients seen, and
low-quality evidence that managed-care interventions
did reduce costs.13 Compared with salaried remuneration,
introduction of a fee-for-service method resulted in
www.thelancet.com Vol 371 February 23, 2008
Articles
Quality
Studies
reviewed
Studies in countries
with low and
middle incomes
Training interventions and regulatory mechanisms
No reliable evidence to support policies that have been introduced to address the urban–rural gap.9 Little research on the short-term or
long-term effect of measures to require service in underserved areas, or of incentives such as scholarships or bursaries with commitments for
return of service.9
Average
32
0
Average
89
Not reported
4
Not available
Low
10
Not reported
Outreach visits with education for health-care professionals were effective, as were education and reminders.16 Assistance from nurse
facilitators to design and implement office routines to increase uptake of screening programmes were effective.16 Reminder interventions were
effective for physicians.16
Average
65
Not reported
Organisational change (such as use of separate clinics devoted to prevention, use of planned-care visit for prevention, or specific prevention
activities by non-physician staff) was more effective than financial incentives and reminders for patients.17 Patient education and feedback were
least effective.17
High
108
Not reported
Staffing with higher registered nurses reduced hospital-related mortality, failures to rescue, cardiac arrest, hospital-acquired pneumonia, and other
adverse events.19
Low
94
0
Lower patient-to-nurse ratios and richer mixes of skills reduced inpatient mortality.20
Low
43
0
Nurse staffing was associated with patient safety; nurse characteristics and organisational factors were moderating factors.21
Low
73
Mixed results for electronic patient records for nurses and doctors.22 Data entry into a centralised computer increased physician time used for
records.22
Low
23
Not reported
Lay health workers can improve uptake of immunisation in children and reduce child morbidity and mortality, compared with usual care.10 Lay High
health workers can also effectively promote exclusive breastfeeding up to 6 months of age, but are less effective in high-income countries than
others.10 Lay health workers can improve treatment of tuberculosis compared with institution-based directly observed therapy.10 No clear
evidence for other uses of lay health workers.10
48
17 (35%)
Financial mechanisms
Fund-holding interventions negatively affected the workloads of general practitioners.13 The effects of freezes on fee-for-service tariff were
countered by increased workload.13 Managed care reduced costs of admission by 20%.13
High
Compared with capitation, fee-for-service remuneration caused a greater reduction in hospital referrals and repeat prescriptions; achieved higher
compliance with a recommended number of visits; and resulted in more patient visits and greater continuity of care.14 However, patient satisfaction
with access to physicians was lower with fee-for-service remuneration than with salaried payment.14
Financial incentives for rural service were effective in attracting practitioners to serve in rural areas.15 Of those offered financial incentives
to stay in rural practice, 29% of physicians remained in practice after 8 years, and 80% of physicians who left an index practice left rural
practice.15
Organisational mechanisms
Integrated primary health care services had mixed effects, but had apparent cost savings.23
Average
Joint decisions by medical teams reduced average length of hospital stay for patients, but with no difference in mortality rates, or the type of care to High
which patients were released.22 Staff in intervention wards were more satisfied than others, had stronger perceptions of teamwork, and better
understanding of patient care.22
4
4 (100%)
2
1 (50%)
Patients kept more appointments because of pharmacist services, but with little or no reduction in use of health services, and mixed effects on
prescription of inappropriate drugs by pharmacists.26
Average
25
0
Some evidence that replacement model (where a primary care provider refers patients to a mental health worker) reduced psychotropic
prescribing and mental-health referral in the short term, and inconsistent evidence that it reduced consultation rates.27 Some evidence that
the consultant-liaison model for mental health services had a direct effect on prescribing when part of complex, multifaceted
interventions.27
High
38
0
Substitution of midwives or general practitioners for obstetricians did not increase the risk of anaemia, urinary tract infection, caesarean
section, malpresentation, or perinatal mortality.18 Substitution reduced of pregnancy-induced hypertension and pre-eclampsia.18 Less frequent
antenatal visits did not affect preterm delivery, low birthweight, size for gestational age, pre-eclampsia, induction of labour, caesarean section,
antenatal haemorrhage, admission to neonatal intensive care unit, perinatal mortality, or maternal mortality. Reduced visits cost per
pregnancy were beneficial to both service and patient.18
Average
10
3 (30%)
Use of care assistants led to greater organisational effectiveness.28 Some evidence that substitution of nurses for doctors could be effective.28 Low
Little evidence about the effects of different skill mixes across other groups of health workers and professions, or development of new
roles.28
Combinations of reminders and patient-directed interventions had moderate effects.34 Educational materials, educational meetings, and audit
and feedback in combination might have, at best, a small effect on implementation of guidelines.34 Audit and feedback alone had modest
effects on guideline implementation.34 Patient-mediated interventions could improve performance.34 Reminders have a moderate effect on
implementation of guidelines.34 Educational materials and educational outreach were relatively ineffective.34
High
Patient satisfaction was higher in patients cared for by nurses than by doctors.29 Nurses had much longer consultations and undertook more
investigations.29 Nurse practitioners were as accurate as doctors in interpreting radiographs.29
37
Not reported
235
5 (2%)
Average
34
1 (3%)
Substitution of nurses for doctors at first contact and ongoing care made no difference to patient outcomes.30 Patient compliance, rates of
consultation or direct costs did not differ.30 Tests and investigations for patients who needed urgent attention were the same or better, as was the
process of care outcomes.30 Nurse-led care produced higher patient satisfaction and knowledge.30
Average
16
Not reported
Insufficient evidence on the financial and opportunity costs of extended roles for health professionals.31 Evidence of effect of extended roles is
limited.31 Extended scope of practice interventions can improve ease and speed of access to specialist services.31
Low
21
Not reported
(Continues on next page)
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Quality
Studies
reviewed
Studies in countries
with low and
middle incomes
(Continued from previous page)
Substitution of more highly trained professionals by general practitioners in accident and emergency rooms reduced use of such facilities.32
General practitioners made less use of diagnostic investigations and made fewer referrals to secondary services.
High
33
0
Education in evidence-based medicine had some positive effect on improved knowledge and attitudes, but little change in behaviour.33
Low
17
Not reported
Increased ratio of primary health-care physicians to doctors39 was associated with lower mortality, neonatal death and rate of low birthweight
babies.39 Gatekeeper system resulted in lower health-care costs and lower rate of increase in outpatient costs.39 Gatekeeper groups had lower rates
of service utilisation.39
Low
47
Not reported
Audit and feedback had small to moderate effects.35 Audit and feedback were less effective than reminders and opinion leaders, but more effective High
than incentives.35 The contribution of audit and feedback in multifaceted interventions was small.35
118
4 (3%)
Guidelines used by professionals allied to medicine did not differ from standard physician care.37 Guidelines and dissemination and/or
implementation strategy vs. no guidelines effective or partially effective.37 No difference between guidelines plus dissemination and/or
an intervention with opinion leaders and lectures vs. guidelines pus dissemination and/or implementation strategy with opinion
leaders.37
Average
18
0
Planned educational activities had small to moderate effects on practice with interactive workshops alone or combined with didactic sessions.36
Use of didactic sessions did not show effects in practice.36
Average
32
4 (1%)
Some evidence that professional performance was improved by revision of professional roles and computer systems for knowledge
management.38 Some evidence that patient outcomes were improved by multidisciplinary teams, integrated care services, and computer
systems.38 Cost savings were reported from integrated care services.38
Low
36
Not reported
High=high quality, well designed study. Average=average quality study, with only minor limitations. Low=low quality study, with major limitations.
Table 2: Main findings of systematic reviews of effects of policy options on human resource outcomes
more patient visits, greater continuity of care, and
higher compliance with the recommended number of
visits; however, patients were less satisfied with access
to their physician.14 One review reported that
immunisation coverage increased in response to a
performance-based incentive for doctors.11
One of the two systematic reviews that examined the
effects of financial incentives for work in underserved
regions was of poor quality,15 and the other identified no
studies that met its inclusion criteria.9 Despite its
limitations, the first review showed that students in a
high-income country who were given funding on the
condition that they did rural service were more likely to
practise in rural regions at the end of their training
than others.15
Two high-quality systematic reviews16,17 showed that
organisational interventions that change workflow or
workload can increase efficiency in high-income country
settings. One review showed that use of nurse facilitators
to design and implement office routines helped to
improve uptake of preventive-screening procedures,
whereas
physician
education
and
combined
interventions were ineffective.16 The other review also
showed that organisational changes, such as the
establishment of a separate clinic devoted to prevention
and screening activities, the use of a planned-care visit
for prevention, or the designation of specific prevention
responsibilities to non-physician staff, were much more
effective than were educational approaches.
Three systematic reviews, that surveyed observational
studies from high-income countries, consistently
showed that increased numbers of nursing staff were
associated with improved inpatient outcomes.19–21 Use
672
of electronic health records was shown to have variable
effects on efficiency in high-income country settings,
where such interventions tend to be easier to implement
than in countries with low and middle incomes.22
One systematic review10 of 48 randomised controlled
trials, of which three were from South America, six
from Africa, and seven from Asia, examined the use of
lay health workers (also called community health
workers). 39 trials examined policies that used lay
health workers to increase numbers of health workers
and extend services (ie, to do activities not usually
provided by health professionals).10 Only four trials
examined whether lay health workers could be used to
broaden the distribution of services (eg, to serve remote
or disadvantaged populations) or to increase efficiency
(eg, to substitute for care provided by health
professionals).10
The review found high quality evidence that
supervision of directly observed therapy for tuberculosis
patients by lay health workers produced better
completion rates than supervision by institution-based
therapy by nurses (p=0.05).10 We identified moderatequality evidence that an intervention with lay health
workers reduced child mortality and morbidity,10 and
good-quality evidence that use of lay health workers also
resulted in greater uptake of immunisation in children,
and promoted exclusive breastfeeding (but not the
initiation of breastfeeding or any breastfeeding up to 6
months of age).10
One systematic review23 did not find any consistent
benefit of integration of services in countries with low
and middle incomes. Teamwork, defined as interventions
to improve collaboration between doctors and nurses,
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was shown to be a promising intervention, with the
potential to reduce costs and have a positive effect on
practitioners and patients.24 However, this review was
based on two studies, only one of which was in a country
with a low or middle income (Thailand).
Eight systematic reviews10,26–32 examined the effects of
substitution, extension of roles, or task shifting, and
concluded that substituting nurses for physicians can
result in comparable or better patient outcomes and
satisfaction. However, these results might not be
applicable to countries with low and middle incomes.30
Cost reductions could be offset by greater numbers of
tests and admissions, but this would depend on the pay
differentials between doctors and nurses in different
settings.28 Extension of the role of general practitioners
into emergency care settings reduced not only the use
of such facilities, but also use of diagnostic investigations and referrals to secondary services.29 Substitution
of cheaper care assistants for nurses can have mixed
effects in high-income country settings but these effects
have typically been shown in low-quality studies.28
Extension of the role of pharmacists in high-income
country settings did not change the outcomes from
those of services delivered by other health professionals.23
Substitution of lay health workers for health
professionals could have mixed effects in countries with
low and middle incomes.10
Six systematic reviews5,33–38 from high-income
countries addressed quality improvement and
continuous education strategies that aim to improve
the knowledge, attitudes, and behaviours of health
workers (such as audit with feedback). These can
achieve, on average, a 10% improvement in performance.
However, the effects for any single strategy can vary and
few studies have been done in countries with low and
middle incomes. Quality improvement and continuous
education strategies that focus on organisational
strategies (such as multidisciplinary teams for patient
care and integrated care services) can improve patient
outcomes in high-income country settings.
Discussion
Despite the widespread recognition that health workers
are critical to achieving both health-related Millennium
Development Goals and national health goals, and that
they constitute by far the greatest expenditure in the
health sector, the amount of synthesised research
evidence about the effects of relevant policy options to
guide policy makers in countries with low and middle
incomes is inadequate. We identified a small amount of
high-quality synthesised research evidence about the
effects of a few policy options for improvement of
human resources for health. These include organisational mechanisms that could increase efficiency
(such as substitution or shifting tasks between different
types of health workers, or extension of their role);
organisational mechanisms that could enhance the
www.thelancet.com Vol 371 February 23, 2008
performance of health workers (such as quality
improvement or continuing education strategies); and
organisational mechanism that could both increase
efficiency and enhance performance (such as promotion
of teamwork and changes to workflow).
Some policy options (such as the use of lay health
workers) were investigated in countries with a range of
incomes, from high to low. However, since most
research was done only or mainly in high-income
countries, it might have little applicability to countries
with low and middle incomes. This might be especially
true for policy options that depend on strong
organisational and management systems (eg, payment
for performance or changes in workflow), or on
particular price or wage differentials (eg, substitution of
lower cadres of workers for nurses, or nurses for
doctors). Moreover, in many domains, high-quality
evidence about effects was lacking, either because
studies had not been systematically reviewed (or
reviewed to a high quality); because a systematic review
identified no studies that met their inclusion criteria
(eg, for studies of financial mechanisms); or both
(eg, for policy options that address the supply and
distribution of health workers).
The main limitations of our study were that our search
might have missed potentially eligible systematic reviews
since a wide range of terminology is used to describe
policy options for human resources for health;
publications on this topic are poorly indexed; and we
used 1979 as the base year for our search. We also
excluded systematic reviews that were published in
languages other than English. The systematic reviews
that we identified had their own limitations, including
the potential for publication bias against negative
findings, their occasionally poor quality, and their limited
applicability to countries with low and middle incomes.
Other types of systematic reviews and other
considerations will also aid policy-making processes.
Policy makers need information about cost-effectiveness,
relationships, mechanisms, and meanings. For
example, is delivery of a programme by nurse
practitioners more cost-effective than delivery by
physicians? Are medical students from regions with
few human resources more likely than other students
to return to practise in these regions? Why would a
scheme for remuneration of health workers lead to
unexpected outcomes? How have training programmes
been viewed and experienced by health workers?
Moreover, policy makers must also contend with values
and beliefs; stakeholder power; institutional constraints;
flows of donor funding; and other types of information
such as local assessments of need, costs, and the
availability of resources.
Contributors
MC, SM, JL, and SB conceived of and designed the study. MC, SM,
and GV analysed systematic reviews. MC, SM, SB, and JL drafted the
manuscript. All authors have seen and approved the final version.
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Articles
Conflict of interest statement
We declare that we have no conflict of interest.
Acknowledgments
We thank Uta Lehmann, David Sanders, and Jimmy Volmink for their
assistance with development of the conceptual framework.
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