What is the most important role of nurses in managing health information systems in public health?

The Canadian health care system is publicly funded and consists of five general groups: the provincial and territorial governments, the federal government, physicians, nurses and allied health care professionals. The roles of these groups differ in numerous aspects. See Figure 2 for an overview of the major stakeholders in the Canadian health care system.

Overview of the major stakeholders in the Canadian health care system. Figure 2 depicts the major stakeholders in the Canadian health care system and how they relate.

Provincial and territorial governments are responsible for managing and delivering health services, including some aspects of prescription care, as well as planning, financing, and evaluating hospital care provision and health care services [5]. For example, British Columbia has shown its commitment to its health care program by implementing an increase in funding of CAD 6.7 million in September 2003, in order to strengthen recruitment, retention and education of nurses province-wide [6]. In May 2003, it was also announced that 30 new seats would be funded to prepared nurse practitioners at the University of British Columbia and at the University of Victoria [6]. Recently the Ontario Ministry of Health and Long Term Care announced funding for additional nurse practitioner positions within communities. Furthermore, most provinces and territories in Canada have moved the academic entry requirement for registered nurses to the baccalaureate level, while increasing the length of programmes for Licensed Practice Nurses to meet the increasing complexity of patient-care needs. Several provinces and territories have also increased seats in medical schools aimed towards those students wishing to become family physicians [7].

The federal government has other responsibilities, including setting national health care standards and ensuring that standards are enforced by legislative acts such as the Canada Health Act (CHA) [5]. Constitutionally the provinces are responsible for the delivery of health care under the British North America (BNA) Act; the provinces and territories must abide by these standards if they wish to receive federal funding for their health care programs [8]. The federal government also provides direct care to certain groups, including veterans and First Nation's peoples, through the First Nationals and Inuit Health Branch (FNIHB). Another role of the federal government is to ensure disease protection and to promote health issues [5].

The federal government demonstrates its financial commitment to Canada's human resources in health care by pledging transfer funds to the provinces and direct funding for various areas. For example, in the 2003 Health Care Renewal Accord, the federal government provided provinces and territories with a three-year CAD 1.5 billion Diagnostic/Medical Equipment Fund. This was used to support specialized staff training and equipment that improved access to publicly funded services [6].

The third group – private physicians – is generally not employed by the government, but rather is self-employed and works in a private practice. They deliver publicly-funded care to Canadian citizens. Physicians will negotiate fee schedules for their services with their provincial governments and then submit their claims to the provincial health insurance plan in order to receive their reimbursement [5].

The roles of nurses consist of providing care to individuals, groups, families, communities and populations in a variety of settings. Their roles require strong, consistent and knowledgeable leaders, who inspire others and support professional nursing practice. Leadership is an essential element for high-quality professional practice environments in which nurses can provide high-quality nursing care [9].

In most Canadian health care organizations, nurses manage both patient care and patient care units within the organization. Nurses have long been recognized as the mediators between the patient and the health care organization [10]. In care situations, they generally perform a coordinating role for all services needed by patients. They must be able to manage and process nursing data, information and knowledge to support patient care delivery in diverse care-delivery settings [10]. Workplace factors most valued by nurses include autonomy and control over the work environment, ability to initiate and sustain a therapeutic relationship with patients and a collaborative relationship with physicians at the unit level [11].

In addition to doctors and nurses, there are many more professionals involved in the health care process. Allied health care professionals can consist of pharmacists, dietitians, social workers and case managers, just to name a few. While much of the focus is on doctors and nurses, there are numerous issues that affect other health care providers as well, including workplace issues, scopes of practice and the impact of changing ways of delivering services [12]. Furthermore, with health care becoming so technologically advanced, the health care system needs an increasing supply of highly specialized and skilled technicians [12]. Thus we can see the various roles played by these five groups and how they work together to form the Canadian health care system.

Canada differs from other nations such as the United States of America for numerous reasons, one of the most important being the CHA. As previously mentioned, the CHA sets national standards for health care in Canada. The CHA ensures that all Canadian citizens, regardless of their ability to pay, will have access to health care services in Canada. "The aim of the CHA is to ensure that all eligible residents of Canada have reasonable access to insured health services on a prepaid basis, without direct charges at the point of service" [6].

Two of the most significant stipulations of the CHA read: "reasonable access to medically necessary hospital and physician services by insured persons must be unimpeded by financial or other barriers" and "health services may not be withheld on the basis of income, age, health status, or gender" [5]. These two statements identify the notable differences between the Canadian and American health care systems. That is, coverage for the Canadian population is much more extensive.

Furthermore in Canada, there has been a push towards a more collaborative, interdisciplinary team approach to delivering health care; this raises many new issues, one of which will involve successful knowledge transfer within these teams [13]. Effective knowledge management, which includes knowledge transfer, is increasingly being recognized as a crucial aspect of an organization's basis for long-term, sustainable, competitive advantage [34]. Even though health care in Canada is largely not for profit, there will still be the need for effective knowledge management practices to be developed and instituted. The introduction of interdisciplinary health teams in Canadian hospitals is a relatively new phenomenon and their connection to the knowledge management policies and agendas of governments and hospital administrations raises important questions about how such teams will work and to what extent they can succeed in dealing with the more difficult aspects of knowledge management, such as the transfer of tacit knowledge.

The multidisciplinary approach tends to be focused around specific professional disciplines, with health care planning being mainly top-down and dominated by medical professionals. Typically there is a lead professional (usually a physician) who determines the care and, if necessary, directs the patient to other health care specialists and allied professionals (aides, support workers). There is generally little involvement by the patient in the direction and nature of the care. Interdisciplinary health care is a patient-centred approach in which all those involved, including the patient, have input into the decisions being made.

The literature on teamwork and research on the practices in hospitals relating to multidisciplinary teams suggests that interdisciplinary teams face enormous challenges [13], therefore multidisciplinary teamwork will continue to be a vital part of the health care system. However, the goal of this teamwork should not be to displace one health care provider with another, but rather to look at the unique skills each one brings to the team and to coordinate the deployment of these skills. Clients need to see the health worker most appropriate to deal with their problem [14].

Some of the issues regarding the Canadian public system of health have been identified in the Mazankowski Report, which was initiated by Alberta's Premier Ralph Klein in 2000. Many issues have arisen since this time and have been debated among Canadians. One of the most contentious, for example, is the possibility of introducing a two-tier medical system. One tier of the proposed new system would be entirely government-funded through tax dollars and would serve the same purpose as the current publicly-funded system. The second tier would be a private system and funded by consumers [5].

However, the CHA and the Canadian Nurses Association (CNA) are critical of any reforms that pose a threat to the public health care system. It should be noted that although Canada purports to have a one-tier system, the close proximity of private, fee-for-service health care in the United States really creates a pay-as-you-go second tier for wealthy Canadians. In addition, many health care services such as most prescriptions and dental work are largely funded by individuals and/or private or employer paid insurance plans.

It is important to realize the differences between the proposed two-tier system and the current health care system. Presently, the public health care system covers all medically necessary procedures and the private sector provides 30% for areas such as dental care. With the new system, both public and private care would offer all services and Canadians would have the option of choosing between the two.

The proposal of the two-tier system is important because it highlights several important issues that concern many Canadians, mainly access to the system and cost reduction. Many Canadians believe the current public system is not sustainable and that a two-tiered system would force the public system to become more efficient and effective, given the competition of the private sector. However, the two-tiered system is not within the realm of consideration, since the majority of Canadians are opposed to the idea of a privatized system [5]. No proposals have come forward that show how a privately funded system would provide an equal quality of services for the same cost as the current publicly funded system.

United States of America

The health care system in the United States is currently plagued by three major challenges. These include: rapidly escalating health care costs, a large and growing number of Americans without health coverage and an epidemic of substandard care [15].

Health insurance premiums in the United States have been rising at accelerating rates. The premiums themselves, as well as the rate of increase in premiums, have increased every year since 1998; independent studies and surveys indicate that this trend is likely to continue over the next several years [15]. As a result of these increases, it is more difficult for businesses to provide health coverage to employees, with individuals and families finding it more difficult to pay their share of the cost of employer-sponsored coverage [15]. The rising trend in the cost of employer-sponsored family health coverage is illustrated in Figure 3.

The trend of the cost of employer-sponsored family health care coverage in the United States. Source: National Coalition on Health Care 2004 pg.9. //www.nchc.org/materials/studies/reform.pdf. Figure 3 illustrates the increase in health insurance premiums since 2001. These increases are making it more difficult for businesses to continue to provide health coverage for their employees and retirees [15].

To help resolve this problem, health maintenance organizations (HMO) have been introduced, with the goal of focusing on keeping people well and out of hospitals in the hope of decreasing employer costs. HMOs are popular alternatives to traditional health care plans offered by insurance companies because they can cover a wide variety of services, usually at a significantly lower cost [16]. HMOs use "networks" of selected doctors, hospitals, clinics and other health care providers that together provide comprehensive health services to the HMOs members [16]. The overall trade-off with an HMO is reduced choice in exchange for increased affordability.

Another problem to address regarding the American health care system is the considerable and increasing number of Americans without health coverage. Health care coverage programs such as Medicare offer a fee-for-service plan that covers many health care services and certain drugs. It also provides access to any doctor or hospital that accepts Medicare [17]. Patients with limited income and resources may qualify for Medicaid, which provide extra help paying for prescription drug costs [17]. However, according to figures from the United States Census Bureau, the number of Americans without health coverage grew to 43.6 million in 2002; it is predicted that the number of uninsured Americans will increase to between 51.2 and 53.7 million in 2006 [15].

Those Americans without health care insurance receive less care, receive care later and are, on average, less healthy and less able to function in their daily lives than those who have health care insurance. Additionally, the risk of mortality is 25% higher for the uninsured than for the insured [15].

Despite excellent care in some areas, the American health care system is experiencing an epidemic of substandard care; the system is not consistently providing high-quality care to its patients [15]. There appears to be a large discrepancy between the care patients should be receiving and the care they are actually getting. The Institute of Medicine has estimated that between 44 000 and 98 000 Americans die each year from preventable medical errors in hospitals [15].

It is also useful to examine the demographic characteristics of those Americans more likely to receive substandard care. Research shows that those Americans with little education and low income receive a lower standard of care [18]. This finding may be explained by the fact that patients who have lower education levels tend to have more difficulty explaining their concerns to physicians, as well as eliciting a response for those concerns because health professionals often do not value their opinions [18].

Case studies

As shown by the extensive literature, statistics and public opinion, there is a growing need for health care reform in the United States of America. There is a duty and responsibility of human resources professionals to attempt to elicit change and implement policies that will improve the health care system.

Case 1

It is informative to examine case studies in which human resources professionals have enacted positive change in a health care setting. One such case from 1995 is that of a mid-sized, private hospital in the New York metropolitan area. This case presents a model of how human resources can be an agent for change and can partner with management to build an adaptive culture to maintain strong organizational growth [19].

One of the initiatives made by human resources professionals in an attempt to improve the overall standard of care in the hospital was to examine and shape the organization's corporate culture. Steps were taken to define the values, behaviors and competences that characterized the current culture, and analyze these against the desired culture [19]. A climate survey was conducted in the organization; it became the goal of the human resources professionals to empower employees to be more creative and innovative [19]. To achieve this, a new model of care was designed that emphasized a decentralized nursing staff and a team-based approach to patient care. Nursing stations were redesigned to make them more accessible and approachable [19].

Human resources management also played an important role in investing in employee development. This was achieved by assisting employees to prepare and market themselves for internal positions and if desired, helping them pursue employment opportunities outside the organization [19]. This case makes obvious the important roles that human resources management can play in orchestrating organizational change.

Case 2

Another case study that illustrates the importance of human resources management to the health care system is that of The University of Nebraska Medical Center in 1995. During this period, the hospital administrative staff recognized a variety of new challenges that were necessitating organizational change. Some of these challenges included intense price competition and payment reform in health care, reduced state and federal funding for education and research, and changing workforce and population demographics [20]. The organizational administrators recognized that a cultural reformation was needed to meet these new challenges. A repositioning process was enacted, resulting in a human resources strategy that supported the organization's continued success [20]. This strategy consisted of five major objectives, each with a vision statement and series of action steps.

• Staffing: Here, the vision was to integrate a series of organization-wide staffing strategies that would anticipate and meet changing workforce requirements pertaining to staff, faculty and students. To achieve this vision, corporate profiles were developed for each position to articulate the core competences and skills required [20].

• Performance management: The vision was to hold all faculty and staff accountable and to reward individual and team performance. With this strategy, managers would be able to provide feedback and coaching to employees in a more effective and timely manner [20].

• Development and learning: The vision was to have all individuals actively engaged in the learning process and responsible for their own development. Various unit-based training functions were merged into a single unit, which defined critical technical and behavioral competencies [20].

• Valuing people: The vision was to have the hospital considered as a favored employer and to be able to attract and retain the best talent. To facilitate this vision, employee services such as child care and wellness were expanded [20].

• Organizational effectiveness. The vision was to create an organization that is flexible, innovative and responsive [20]. The developments of these human resources strategies were essential to the effectiveness of the organization and to demonstrate the importance of human resources in the health care industry.

Both these case studies illustrate that effective human resources management is crucial to health care in a practical setting and that additional human resources initiatives are required if solutions are to be found for the major problems in the United States health care system.

Germany

Approximately 92% of Germany's population receives health care through the country's statutory health care insurance program, Gesetzliche Krankenversicherung (GKV). GKV designed an organizational framework for health care in Germany and has identified and constructed the roles of payers, providers and hospitals. Private, for-profit companies cover slightly less than 8% of the population. This group would include, for example, civil servants and the self-employed. It is estimated that approximately 0.2% of the population does not have health care insurance [21]. This small fragment may be divided into two categories: either the very rich, who do not require it, or the very poor, who obtain their coverage through social insurance. All Germans, regardless of their coverage, use the same health care facilities. With these policies nearly all citizens are guaranteed access to high-quality medical care [22].

While the federal government plays a major part in setting the standards for national health care policies, the system is actually run by national and regional autonomous organizations. Rather than being financed solely through taxes, the system is covered mostly by health care premiums [22]. In 2003, about 11.1% of Germany's gross domestic product (GDP) went into the health care system [23] versus the United States, with 15% [24] and Canada at 9.9% [25]. However, Germany still put about one third of its social budget towards health care [22].

The supply of physicians in Germany is high, especially compared to the United States, and this is attributed largely to the education system. If one meets the academic requirements in Germany, the possibility to study medicine is legally guaranteed [26]. This has led to a surplus of physicians and unemployment for physicians has become a serious problem. In 2001, the unemployment rate for German physicians of 2.1% led many German doctors to leave for countries such as Norway, Sweden and the United Kingdom, all of which actively recruit from Germany [27].

Germany's strong and inexpensive academic system has led the country to educate far more physicians than the United States and Canada. In 2003, Germany had 3.4 practicing physicians per 1000 inhabitants [23], versus the United States, which had 2.3 practicing physicians per 1000 inhabitants in 2002 [24] and Canada, which had 2.1 practicing physicians per 1000 inhabitants in 2003 [25]. It is also remarkable that health spending per capita in Germany (USD 2996) [23] amounted to about half of health spending per capita in the United States (USD 5635) [24], and slightly less than Canada's health spending (USD 3003) [25]. This clearly demonstrates the Germans' strength regarding cost containment.

There are several issues that physicians face in the German health care system. In a 1999 poll, 49.9% of respondents said they were very or fairly satisfied with their health care system, while 47.7% replied they were very or fairly dissatisfied with it [28]. Furthermore, the degree of competition between physicians is very high in Germany and this could lead to a reduction in physician earnings. Due to this competition, many younger physicians currently face unemployment. The German law also limits the number of specialists in certain geographical areas where there are issues of overrepresentation [22]. Thus, the oversupply of physicians in Germany leads to many challenges, including human resources management in the health care system.

In Germany a distinction is made between office-based physicians and hospital-based physicians. The income of office-based physicians is based on the number and types of services they provide, while hospital-based physicians are compensated on a salary basis. This division has created a separated workforce that German legislation is now working to eliminate by encouraging the two parties to work together, with the aim of reducing overall medical costs [22].

Developing countries

Accessing good-quality health care services can be incredibly arduous for those living in developing countries, and more specifically, for those residing in rural areas. For many reasons, medical personnel and resources may not be available or accessible for such residents. As well, the issue of migrant health care workers is critical. Migrant health workers can be defined as professionals who have a desire and the ability to leave the country in which they were educated and migrate to another country. The workers are generally enticed to leave their birth country by generous incentive offers from the recruiting countries [29].

Developing countries struggle to find means to improve living conditions for their residents; countries such as Ghana, Kenya, South Africa and Zimbabwe are seeking human resources solutions to address their lack of medically trained professionals. Shortages in these countries are prevalent due to the migration of their highly educated and medically trained personnel.

Professionals tend to migrate to areas where they believe their work will be more thoroughly rewarded. The International Journal for Equity in Health (2003) suggested that those who work in the health care profession tend to migrate to areas that are more densely populated and where their services may be better compensated. Health care professionals look to areas that will provide their families with an abundance of amenities, including schools for their children, safe neighborhoods and relatives in close proximity. For medical professionals, the appeal of promotions also serves as an incentive for educating oneself further [30]. As one becomes more educated, the ability and opportunity to migrate increases and this can lead to a further exodus of needed health care professionals.

These compelling reasons tend to cause medical professionals to leave their less-affluent and less-developed areas and migrate to areas that can provide them with better opportunities. This has caused a surplus in some areas and a huge deficit in others. This epidemic can be seen in nations such as Nicaragua. Its capital city, Managua, holds only one fifth of the country's population, yet it employs almost 50% of the medically trained health care workers. The same situation can be found in other countries, such as Bangladesh, where almost one third of the available health personnel are employed "in four metropolitan districts where less than 15% of the population lives" [30]. Clearly this presents a problem for those living outside these metropolitan districts.

Other possible explanations put forth by Dussault and Franceschini, both of the Human Development Division of the World Bank Institute, include "management style, incentive and career structures, salary scales, recruitment, posting and retention practices" [31]. Salary scales can differ quite drastically between originating and destination countries, which are shown in Figures 4 and 5. They also state that in developing countries the earning potential one would see in more affluent or populated urban areas is much higher than one would expect to earn in rural areas.

Ratio of nurse wages (PPP USD), destination country to source country. Source: Vujicic M, Zurn P, Diallo K, Orvill A, Dal Poz MR 2004. //www.human-resources-health.com/content/2/1/3. Figure 4 shows the difference between the wage in the source country and destination country for nurses. This difference is also known as the "wage premium" [29].

Ratio of physician wages (PPP USD), destination country to source country. Source: Vujicic M, Zurn P, Diallo K, Orvill A, Dal Poz MR 2004. //www.human-resources-health.com/content/2/1/3. Figure 5 shows the difference between the wage in the source country and destination country for physicians [29].

As more health professionals emigrate to urban areas, the workloads for those in the rural areas greatly increase. This leads to a domino effect, in that those in such dire situations look for areas where they may be able to find more satisfactory and less demanding working conditions [31]. Vujicic et al. (2004) summarizes numerous variables that influence the migration pattern and has created a formula to express their impact. It is possible to quantify the factors, and human resources professionals need to look at the costs and benefits of altering the factors so that the migration pattern is more favorable. This formula is expressed as the results shown in Table 1, which shows the different reasons for one to migrate in terms of the popularity of a given reason.

There is a tendency for developed countries faced with decreasing numbers of nationally trained medical personnel to recruit already-trained individuals from other nations by enticing them with incentives. Zimbabwe has been particularly affected by this problem. In 2001, out of approximately 730 nursing graduates, more than one third (237) of them relocated to the United Kingdom [29]. This was a dramatic increase from 1997, when only 26 (approximately 6.2%) of the 422 nursing program graduates migrated to the United Kingdom [29]. This leads to the loss of skilled workers in developing countries and can be very damaging, since the education systems in developing countries are training individuals for occupations in the medical profession, yet are not able to retain them [29].

Countries that have the capacity to educate more people than necessary in order to meet their domestic demand have tried to counterbalance this problem by increasing their training quota. Vujicic et al. (2004) identify that "the Philippines has for many years trained more nurses than are required to replenish the domestic stock, in an effort to encourage migration and increase the level of remittance flowing back into the country" [29].

Developed countries attract internationally trained medical professionals for many reasons. To begin with, "political factors, concerns for security, domestic birth rates, the state of the economy and war (both at home and abroad)" [26] influence the number of people that will be allowed or recruited into a country. Also, due to the conditions of the labor market compared to the demand in developed countries, governments may make allowances to their strict policies regarding the type of and number of professionals they will allow into their country [29]. This can be seen in a Canadian example:

Canada maintains] a list of occupations within which employment vacancies [are] evident. Potential immigrants working in one of these [listed] occupations would have a much higher chance of being granted entry than if they worked in a non-listed occupation [29].

Though Canada attracts internationally trained medical professionals, those employment vacancies may not always be open. Although there may be up to 10 000 international medical graduates (IMG) in Canada, many are not legally allowed to practice. Many immigrants cannot afford the costs of retraining and may be forced to find a new job in a completely unrelated field, leaving their skills to go to waste [32]. In 2004, Ontario had between 2000 and 4000 IMGs looking for work in medical fields related to their training and background [33]. That year, IMG Ontario accepted 165 IMGs into assessment and training positions, which was a 50% increase over the last year, and a 600% increase from the 24 positions in 1999 [33].

Another appeal for developed countries with regard to foreign trained health care professionals is that they may be less of a financial burden to the host country than those trained domestically. This is because educational costs and the resources necessary for training are already taken care of by the international medical schools and governments [29]. Though these reasons may make recruiting foreign medical professionals seem appealing, there are still ongoing debates as to whether those trained outside the host country are equally qualified and culturally sensitive to the country to which they migrate. Developing countries are addressing these concerns by establishing health professional training programs similar to those in developed countries [29]. These practices can be seen in, "the majority of nursing programs in Bangladesh, the Philippines and South Africa [which] are based on curricula from United Kingdom or USA nursing schools" [29]. Because of these actions, those who are trained may be more likely to leave and use their skills where they will be recognized and more highly rewarded.

There are also ethical considerations when examining the practice of recruiting health care professionals, particularly if they are recruited from regions or countries where health care shortages already exist. The rights of individuals to move as they see fit may need to be balanced against the idea of the greater good of those left behind.

Due to the shortages, it has been found the level of health service in rural or poor areas has decreased, leading to lower quality and productivity of health services, closure of hospital wards, increased waiting times, reduced numbers of available beds for inpatients, diversion of emergency department patients and underuse of remaining personnel or substitution with persons lacking the required skills for performing critical interventions [30].

The article "Not enough here, too many there: understanding geographical imbalances in the distribution of the health workforce" (2003), states that a reduced number of health care workers in a given area has a direct effect on the life expectancy of its residents. For example, in the rural areas of Mexico, life expectancy is 55 years, compared to 71 years in the urban areas. Additionally, in "the wealthier, northern part of the country, infant mortality is 20/1000 as compared to more than 50/1000 in the poorer southern states" [31].

Globalization – a common thread

While the issues raised in this article are common to many countries, the approaches taken to address them may not be the same in each country. Factors affecting the approaches that can be taken, some of which have been raised, include demographics, resources and philosophical and political perspectives. However, an overarching issue that affects not only health care but many other areas is that of globalization itself.

Different countries have traditionally had different perspectives on health care that have influenced their approaches to health care delivery. In Canada for example, health care is considered a right; its delivery is defined by the five main principles of the Canada Health Act, which officially precludes a significant role for private delivery of essential services. In the United States, health care is treated more as another service that, while it should be accessible, is not considered a right. Therefore there is a much larger private presence in health care delivery the United States than there is in Canada. In other parts of the world, the approach to health care falls between these perspectives.

As the move towards globalization for many goods and services increases, countries will have to consider how this will affect their approaches to health care delivery. As mentioned earlier, there is already a degree of labor mobility within a country that affects the quality and availability of health care services. There is also already a degree of international mobility of health care workers, as shown by the number of workers recruited developed countries.

While the international mobility of labor is generally not as unencumbered as that for goods and capital, that may be changing as more and more regional free trade agreements are considered. Canada, the United States and Mexico have NAFTA (North American Free Trade Agreement), Europe has the EU (European Union) and talks are under way to consider expanding the NAFTA agreement to include Central and South America, to expand EU membership and to consider an Asian trading bloc including China and India.

If health care becomes a part of these new trade agreements, countries will be obliged to treat health care delivery according to the rules of the agreement. Using the NAFTA as an example, if health care is included, governments could not treat domestic providers more favorably than foreign firms wanting to deliver services. In Canada the concern is that it would mean the end of the Canada Health Act, since NAFTA would allow private, for-profit American or Mexican firms to open.

All five issues raised in this research would be affected by the increase in international trade agreements that included health care. Therefore, governments, health care providers and human resources professionals cannot ignore this important consideration and trend when examining solutions to the issues. Depending upon their relative negotiation strengths and positions, some countries may not benefit as much as others with these agreements.

For example, it is more likely that countries with well-developed private, for-profit, health care expertise, such as the United States, would expand into developing countries rather than the other way around. If there is an increased ability for labor mobility, then it is likely that health care professionals in the poorer, developing countries would move to where the opportunities are better. We already see this internally in the move from rural to urban centers; this would likely continue if the health care professionals had the opportunity to move out of country to where they could have greater financial rewards for their expertise.

When considering the countries examined in this paper, it is likely that Canada and the United States would initially be the two most likely to move towards a more integrated approach to health care delivery. There is already a trade agreement in place, many of the factors influencing health care are similar (demographics, training, level of economic development, geography, cultural factors) and they are currently each other's largest trading partners. While the current agreement, which includes Mexico, does not cover health care, there is pressure to broaden the agreement to include areas not currently covered. If this happens, human resources professionals will have to increase their understanding of what the new health care delivery realities could be. For example, if the move is more towards the Canadian example of a largely not-for-profit, mainly publicly-funded health care delivery system, then it will be more of an adjustment for the American professionals.

However, the likelihood of the Canadian approach to health care's being adopted in the United States is very slim. During the presidency of Bill Clinton, the government attempted to introduce a more universal health care delivery system, which failed completely. Even though there are over 40 million Americans with no health care coverage, the idea of a universal, publicly-funded system went nowhere. Also, within Canada there is increasing pressure to consider a more active role for private health care delivery. Therefore, it is more likely that Canadian health care and human resource professionals will have to adapt to a style more like the American, privately delivered, for-profit approach.

If this is the direction of change, human resources professionals in Canada will need to adjust how they approach the challenges and new realities. For instance, there would likely be an increased role for insurance companies and health maintenance organizations (HMO) as they move towards the managed care model of the United States. With an HMO approach, financial as well as health needs of the patients are considered when making medical decisions. An insured patient would select from the range of services and providers that his/her policy covers and approves. Human resources professionals would need to work with a new level of administration, the HMO, which currently does not exist to any significant degree in Canada.

As mentioned earlier, it is likely that developing countries would be receiving health care models and approaches from developed countries rather than the other way around. In particular, a country such as the United States that has a strong, private, for-profit approach already in place would likely be the source from which the health care models would be drawn. Therefore, health care, as well as human resources professionals in those countries, would also need to adapt to these new realities.

In Germany, where there is currently an oversupply of physicians, a move towards a more global approach to health care delivery, through increased trade agreements, could result in even more German health care professionals' leaving the country. The challenge to be addressed by human resource professionals within the German health care system in this situation would be to prevent, or slow, the loss of the best professionals to other countries. Spending public resources in educating professionals only to have significant numbers of them leave the country is not a financially desirable or sustainable situation for a country.

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From: The importance of human resources management in health care: a global context