WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA
ORGANlSATIONMONDIAl.EDE LA SANIE BUREAU REGIONAL DE L'AFRIQUE
ORGANIZAÇAo MUNDIAL DE SAÛDE SEDE REGIONAL EM AFRICA
REGIONAL COMMITTEE FOR AFRICA Forty-ejghth session Harare ZiInbabwe. 31 Au~st - 4 September 1998 Proyjsjonal allenda item 8.4
AFR/RC48110
11 May 1998 ORIGINAL: FRENCH
REGIONAL STRATEGY FOR THE DEVELOPMENT OF HUMAN RESOURCES FOR HEAL TH Report of the Regional Director
EXECUTIVE SUMMARY 1. Health for ail, through primary health care, proclaimed twenty yeaTS ago at the Alma-Ata Conference, will remain a major objective for the years and century to corne. 2. Arnong the many resources to be mobilized to this end, human resources constitute the most precious. Unfortunately, they bave not always received the attention they deserve, hence the persisting significant gaps between ongoiog reforms io the health sectar and the management ofhuman resources for health. Il is therefore crucial !hat the changes taking place in the organization, functioning and financing ofhealth care systems be accompanied by appropriate measures for developing both human resources for health and supporting institutions. 3. The strategy proposed io this document aims to strengthen the capacity of Member States to optimize the utilization of their human resources for health with a view ta achieving the health objectives of the Region. 4. 1bis strategy is essentially grounded on the following: barmonization of global and national health policies with the development of human resources for health, iocluding io the private sector; strengthening of iostitutional capacity; reorientation of medical training and practice; coverage of the whole country by competent and motivated health teams; research on the development of human resources for health; and regulation of professional practice. 5. The Regional Committee is iovited to examine the proposed strategy and to make suggestions for developing human resources for health and accelerating the iInplementation of the new health for ail policy in the African Region.
CONTENT Page
IN1RODUCTION .. . .. .. . . . ................. . .... . . .... ......... .. ... ... . . .. ... . .! mSTIFICATION.. ...... ......... .. .... ... ..... .. . .. .. ..... ...... ........... . . .. . 1 Situation analysis ................................ .. ...... ,.. .. . .... . .... . .. .. .1 F dctors related to the overal/ national situation. .... .... ....... .. . . ..... . . .... ... 1 Factors related to the health sector . . .. ... .. ; ...• . ...................... .. .... 2
Guiding principles. . ... . .....•......•.... ... ...... • ... ....... .. .. .. .. ...... .... 3 Poliey basis .. .. ..... ...... ... .......... ....•. .... ....... .. .•. .. ........ . . 3 Social justification. ... ..... . . .. ........ ... .... . ..... .......... . . .. ...... .. .3 Programmatic justification .......... .......... .. .... . . . ...... ... .... • .. ..... 3
REGIONAL STRATEGY FOR 11IE DEVELOPMENT OF HUMAN RESOURCES FOR HEAL111 . . . . .. . . .. . .. . .. .. .. .. . .. .. . .. .. . .. .. .. . .. . .. .. . .. .. .. .3 Aims and objectives ..... ..... ... . ... ....... ..... .. ... .... .. ...... ... ...... ... .3 Strategie objectives . . .. . ... ...... ....... ............... ........... ......... 4 Targets ..... , .................. . ........... . .. .. . .. . ..... . .• . . ..... .. . ... 4
Principal thrusts ..... .. . . ........................................ . .... . ........ 4 Priorily interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . • . . .. .4 Planning the development of human resources for health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Education or training and skills development .......... ..... .. . . .... ... .... ......... 6 Administration and management ...... ....... ... ... ........ . .... ..... . .. .. .. . .. .. 6 Research ... . .... .. . . .... ... . ... ....... . .. . •. .... .. ..... . ...... .............. 7 Regulation of health professions .. ....... .. ... • . . ... .•. ......•. ...... • ..... .. 8
Mobilization of resources ..... . . . ... ... .... ... . . .. . ... . .......... . .. . .. ..... ... . 8 Managerial framework ... ...... . ..... .. .. . . .................... .. ........... . . 9 Monitoring of implementation .. ....... . ... ........ .... . . ......... ....... ....... 9
SUCCESS AND FAll..URE FACTORS ... ... . . ... ..... ..... .. . .. ... .. . . ... .......... 10 CONCLUSION .. . .......... . .............. .... • ... .. .............. . .......... .. 10
AFR/RC48/ 10 page 1
INTRODUCTION In all countries of the world, human resources constitute the most valuable asset because, in addition to their economic impact, they enhance the value of all the other resources by converting them into socially useful products. Thus, in the health sector, efforts have been made for many years to better integrate human resources development into the health for all objectives. Further, for the last live years, at least, programmes for enhancing and developing human resources have been proposed and implemented in many African countries, within the framework of bilateral and multilateral cooperation activities, in order to cope with the chronic problems affecting the development ofhuman resources for health. These problems include lack of integration between human resources development and development of the sector; poor numerical, spatial and qualitative distribution of personnel in the public and private sectors; the mismatch between training on the one band, and needs and job profiles on the other; non-identification of the health team appropriate to each health care delivery level; inability to retain and optimally utilize existing staff in a manner as to guarantee stability which is required for achieving medium- and long-tenn objectives, such as health for aIl. Investments in training at the national level and within disease control programmes have rarely produced the expected results, probably due to compartmentalized, isolated and uncoordinated implementation approaches to all aspects of the development of human resources for health. Indeed, developing human resources for health means attempting to provide: the health personnel we need, in suflicient numbers, with the right competence, motivation and experience, in the desired institutions, and at appropriate posts, at the right tirne, and at an affordable cost, so !hat users may have quality health care adapted to the state of health of the individual and the community. Human resources development is therefore directly associated with planning, training and managerial capacities ofhealth personnel at alllevels of the health system, especially at the policy and strategic levels, on the one band and on the other, with guaranteeing career prospects to heaIth personnel.
JUSTIFICATION Situation analysis The development of human resources for health depends on a number of factors, sorne of which relate to the overall national situation while others relate to the health sector. The targeting of one or the other of these factors instead of a systematic approach is the source of the many problems compromising the optimal utilization ofhealth resources and the implementation ofhealth policies.
Factors related to the overall national situation Refonns are ongoing in all the sectors of nationallife in the majority of African countries. These refonns are being encouraged and supported by the international community. Despite this favourable environment, the rhythm of refonns remains slow due to a number of social, economic and political reasons. For example: (i) The population, by its demographic characteristics, behaviour in the face of disease and death and the epidemiological profile, exerts sorne influence on the demand for and utilization of health services, including the type of personnel.
AFRIRC48/10 page 2 (ii) The socioeconomic crises of the 80s and 90s, in arresting economic growth and social progress, had serious repercussions on the health services, particularly on personnel, whose training and recruitment were suspended in many African countries. (iii) The political situation certainly impacts on the organization, fimctioning and management of the hèalth sector. Nonetheless the following facts must be mentioned: Poor understanding by policy makers and health officiaIs of the importance of human resources in the implementation oftheir hea1th policy rarely led to the inclusion ofhuman resources development for health on the priority policy agenda of these countries or to the allocation thereto of the resources needed. The "medical model" as the dominant health model continued to influence to a large extent the health and development policies related to human resources, despite the movement begun almost two decades ago in favour of community health and despite the adoption ofprimary health care as the strategy for achieving the social objective ofhealth for aIl.
Factors related 10 Ihe heallh seclor The capacity to plan, produce and manage health personnel and guarantee them career prospects is a determinant factor in human resources development for health. Yet not much importance is always accorded to this. The result, in the majority of the countries of the Region, has been iII-suited structural, technical and regulatory arrangements. For example: (a) The department responsible for human resources for health is hardly ever structured or given the tools with which to carry out the principal fimctions of modem-day human resources management, narnely, planning (qualitative and quantitative determination ofstaffing needs, identification, projection and programming of those needs); production (training related to needs and job profiles); management (routine, forward-looking and performance evaluation). The activities of these departments are limited essentially to routine personnel management.
(b) Sorne laxity and politically-oriented measures characterising health personnel planning exclude the private sector and neglect its planning and personnel training needs. (c) Initial and specialist training in the health sciences is still elitist and focused on hospitals, despite the recognized reform needs or the reorientation of medical training and practice. Continuing training, virtua\ly inexistent in the private sector, is carried out almost exc1usively within specific-disease control programmes or for the purpose of promoting specific drugs. These training efforts must necessarily be accompanied by an organizational change of the health system in order to have any chance of success. Conversely, isolated reforms without changes in the knowledge base of the personnel will stand Iittle chance of success. (d) Training in human resources management, in the institutions where this is a training discipline, seems to have rarely received privileged treatment; the expertise needed for such training, especially for training permanent trainers adept in human resources management, are often lac king; there is no inventory or needs assessment and partnerships between the authorities concemed; training institutions are also practically non-existent. (e) The tools to help act on the behaviour of staff or to influence their retention are generally few or non-existent, and not adapted to the sector or to ongoing reforms, be they in the area of legislation or existing regulations, including the legislation applicable to professional practices, living conditions, incentives or to the professional environment.
AFRJRC48/ 10 page 3
Goldiog prioeiples Policy basis The Alma Ata Declaration attaches special importance to the role.of health personnel in the implementation of the primary health care strategy, and requires !hat the personnel adopt a more holistic approach, in conformity with WHO's Constitution and the definition ofhealth.
In 1995, the report of the working group on WHO 's response to global changes caUed for a revision of the heaith for aU strategy, speciaUy emphasizing the development ofhealth care systems based on the principles ofhuman dignity, equity, solidarity and professional ethics. The sarne year, in ils resolution WHA48.8, the World Health Assembly urged Member States to undertake coordinated health system reforms, in other words, reforms in training and the practice of the health professions. The importance of the role of the other categories, particularly nursing and midwifery, was reaffirmed and addressed in a specifie resolution in 1996 (WHA 49.1) and in a special report in 1997.
Social justification Health costs to the society, especiaUy those relating to health personnel (70% of the operational budget of the health sector in many countries), associated with the scarcity ofresources, brain drain both within countries and the continent and outside them, are additional arguments for improving the efficiency ofhea1th care services and, hence the competence and motivation ofhealth personnel at aU levels of the health system.
Programmatic justification The ongoing changes and reforms both in the countries and at the level of WHO offer both an opportunity and an obligation to tie in the issue of human resources development for health with the expected changes in the organization, functioning, financing and management of the health system on the one hand, and on the other hand, with technical cooperation with the countries of the Region.
REGIONAL STRATE GY FOR THE DEVELOPMENT OF HUMAN RESOURCES FORHEALTH Reforming the health system means setting a number of objectives, narnely, guaranteeing equity of access to health services and care to aU citizens; improving the quality and effectiveness of health services; controlling health expenditure increases and ensuring efficient management of available resources; increasing the degree of satisfaction of users and health personnel. Faced with such objectives, the insufficiency of staff, their poor distribution, the absence of continuing training and of quality assurance mechanisms, and the low productivity and morale of the personnel are urgent problems requiring solutions.
Atms and objectives This strategy aims to contribute to the achievement of the health objectives of the Region by strengthening the capacity of the countries to optimize the use of their human resources for health.
Strategie objectives The strategy aims to ensure that each Member State: (i) defines a human resources development policy, supportive of the implementation ofits health policy.
AFRlRC48/1 0 page 4 (ii) possesses the required capacities for diagnosing the problems ofhuman resources development for health, for formulating relevant policies, mobilizing actors and implementing, monitoring and evaluating the policies.
Targets The targets for the period 1999-2008 are as follows: (i) By the year 2004, the 46 countries of the Region will have developed a policy for human resources development for health. (ii) By the year 2007, the 46 countries of the Region will have acquired the capacity to implement their policy ofhuman resources development for health.
Principal thrusts This strategy comprises six principal thrusts. They are: a policy framework, in other words, the commitment of decision makers and health officiaIs to consider the development of human resources for health as a necessary condition for achieving the objectives of the national health policy; planning ofhuman resources development for health based on three elements: the environment and its trends, the needs and aspirations of the population, and employees' expectations; training-education of quality personnel, based on needs, the absorption capacity of the sector and job profiles; administration-management or creation of working and living conditions that enhance the satisfaction ofboth the users and personnel; research in key fields ofhuman resources development for health with a view to clarifYing the choices of policymakers and health officiais; regulation of the medical profession in order to proteet the sick and the communities against risks and professional malpractice.
Priority interventions Policy formulation and development The formulation and adoption of a policy for the development of human resources for health in accordance with health objectives is a fust step !hat is both difficult and delicate but indispensable, due to the nature of the resource concerned and its impact on the preparation of strategies and sectoral plans. In the countries, advocacy before policy makers and healthofficials will be required to bring them to insert human resources development for health on the list of national policy priorities, and to identifY, mobilize and support institutional actors. This political will should be reflected in restructuring and the strengthening of the institutional capacity of ministries of health, in the establishment of coordination mechanisms, in the adoption of appropriate human resources development tools, and in the allocation of additional resources for the implementation, monitoring and evaluation of the human resources development policy.
At the regionallevel, the measures to be taken will focus on the following: adoption of a resolution on the development of human resources for health; leadership to support the inclusion of human resources development for health among the priority policies; coordination of the programmes concerned and; mobilization of resources.
AFR/RC48/10 page 5 Planning tbe development of buman resources for bealtb
Human resources planning consists of analysing the factors !hat influence the supply of and the demand for health personnel, with a view to improving performance. The essential raIe of such planning will he to: (i) make operational the strategy or strategies by clarifying them, identifying implications and the actions to he taken to achieve the set objective; (ii) facilitate coordination; (iii) orient ail actors to the desired direction; (iv) stimulate the creativity of the officiaIs in valid data analysis and heighten awareness regarding the acceptability and feasibility of envisaged solutions. Enviranmental uncertainty, the nature of the resources to he planned and the necessity to take cognizance of the values and motivations of the personnel in realizing the selected plan make the task both complex and difficult.
In the countries, the measures to be taken are as follows: (i) Preparation of a realistic plan for the development ofhuman resources for health. This plan must be compatible with the health objectives and in harmony with changes in the organization, ftmctioning, financing and management of the health system. Il must take cognizance of the values and motivations of the personnel and include the raIe and place of the private sector. The plan must also: (a) define qualitative and quantitative criteria for the production and distribution ofhealth personnel, such as to correct inequity in access to health services; ensure efficient utilization of personnel; assure the effectiveness of health care and services; as weil as ensure users' satisfaction; (b) adopt strategies to be implemented to achieve set objectives in the following areas: production and distribution of personnel, education or training, performance evaluation, working an living conditions; (c) identify the necessary resources; (d) indicate the scheduIe of implementation; (e) define the mechanisms for monitoring, evaluating and adjusting objectives and strategies. (ii) Acquisition of requisite capacities for diagnosing problems relating to human resources development for health, formulation of a relevant policy and plan, mobilization of the institutional actors, and implementation, monitoring and evaluation of the plan. At regionallevel, the envisaged arrangements will aim al: (i) designing activities !hat will strengthen the capacity of countries to reach the levels indicated above; (ii) making an inventory of lessons leamt and innovative experiences in the field of human resources development for health and disseminating such information. Education and training and skills development
To ensure the success of current health sector reform, comprehensive efforts must he made"to reorient training and update the knowledge base of the staff. Il is necessary therefore to redefine the roles of these staff and the missions of health institutions in which they work. Il is also necessary to adapt basic training programmes, both for specialist and continuing training, to the spirit of the Cape Town Declaration and to global recommendations and strategies aimed at this reform.
In the countries, it will be necessary to: (i) undertake advocacy action vis-à-vis policy makers and training institutions;
AFRlRC48/ 1O page 6 (ii) define the job profile of each professional category to be trained; (iii) defme the missions and fimetions of health eare facilities; (iv) evaluate the training given in faculties ofmedicine and health schools in order to bring about the neeessary changes in training, research, serviees offered to the eommunity, and in cooperation with other institutions; (v) put in place structures to guide the reform at" the national level and within the training institutions; (vi) train the personnel in the teaching ofhealth sciences and research; (vii) train the personnel in the management ofhuman resources for health; (viii) combine training by example and the teaching of professional ethics and deontology in health; and (ix) programme fellowships in aceordanee with the objectives of the plan relating to human resourees development for health.
At the regionallevel, il will be necessary to : (i) make available to the countries guides on and methods for the evaluation and revision of training programmes; (ii) organize evaluations and revisions of programmes and disseminate their results; (iii) select, every two years, two countries for assistance in their implementation of a eoordinated reform of health practice and training. Administration and management
To improve health personnel productivity and performance, personnel managers must have relevant legal and regulatory texts : texts relating to health personnel funetions; texts regulating the geographic distribution of health workers; lexts relating to training and supervision of health personnel; texts relating to working conditions; texts relating to initial and continuing training and maintenance of skills; texts relating to the procedures, mechanisms and modes of fmancing; texts relating to career plans; and texts relating to professional ethics and deontology in health. In responding therefore to multiple objectives, the application of policies relating to the efficient distribution and utilization of health personnel can he facilitated through legislation. In the countries, actions to he implemented will aim at:
(i) (ii) (iii) (iv)
restructuring and strengthening fimctions for the development of human resources for health; training and recruiting competent managers; preparing appropriate legislative and regulatory instruments; setting up an information system and a system for managing hurnan resources for health;
AFRlRC48/10 page 7 (v) (vi) (vii) distributing, equitably, the available staff based on population distribution, health care levels, health services models or types of institution; evaluating the performance ofhealth workers in relation to job profiles and posts; adopting rules and regulations goveming the profession and draWing up progressive career plans;
(viii) conducting studies and analysing the eva1uation of jobs, reqUlslte qualifications, organizational modalities, the professional environment and staff remunerations; (ix) (x) (xi) creating merit-based systems of incentives and rewards; putting in place al alllevels quality assurance programmes; and estimating costs (salaries and employer expenses) and linancial capacities.
At the regional level, it is necessary to study and evaluate country experiences, disseminate the results thereof and provide support to national programmes. Researcb
Issues such as policy formulation planning of the health professions and the training and utilization of health personnel deserve in-depth studies. For the countries, this signifies: introducing research on human resources development for health as a component in national health systems research programmes; conducting studies and research on priority themes; giving feedback to policy makers and health officiaIs regarding research results and encouraging them to use these results to improve the health system and the health situation. For the regionallevel, this signifies: promoting research on the development ofhuman resources for health; defining priority themes in the above-mentioned areas; encouraging institutions, groups and individual researchers to draw up research protocols; identifying sources of funding and encouraging policy makers and health officiaIs to utilize research results to develop human resources for health; promoting exchanges of information and data on experiences in the field of human resources development for health; creating a databank for collecting and disseminating information and knowledge on strategies and methods in human resources development for health. An inventory of the regional institutions for training and research in public health and in management, especially health management, could be made from which sorne institutions could be selected and supported with a view to making them real collaborating centres for the development of human resources for health, to the benefit of the Region.
AFRlRC48/10 page 8
Regulation of the health professions Respect for professional ethics and deontology in health will guarantee provision 10 the population (patients, communities) of quality care by qualified health personnel who comply with professional rules. ln the countries, and for each health profession, a legal status, compulsory registration and a control system governed by corresponding professional boards or bodies should he established, a national ethics committee created and made functional, and a patient chlirter promulgated.
At the regionallevel, an awareness drive for good health care practices and the drafting of a Charter for the African Patient will be necessary.
Mobilization of resources
(a) Actors in the countries A number of actors are involved. These are so-called institutional aclors, and are grouped as follows: the State and national institutions and agencies responsible for health issues; employers who pay salaries or national public or private health insurers; health sciences training and research institutions; the health professions; bodies that regulate the health professions; professional associations; users ofhealth care services; external partoers and donors. The identification, definition and recognition of their respective roles, their mobilization and coordination will be determinant factors in the implementation and success of the national strategy for the development ofhurnan resources for health. (b) Actors at the regionallevel
The aim of WHO and the other partoers (bilateral and multilateral) will be to support the efforts of the country in the formulation, adoption and implementation of the coordinated reform of training and practice in the health professions. This support, considered an asset, should promote overall assistance to meet the needs of the health sector. Il should also stimulate the allocation of sufficient funds to the health sector, and enhance the equitable distribution and efficient use of these public funds thereby guaranteeing their sustainability while avoiding dependence on assistance.
(c) The period covered The period concerned (2000-2012) sits astride!hat of the Tenth and Eleventh General Programmes ofWork of WHO.
(d) Financing Funding will he principally by the countries. WHO will work with other health development partners and other institutions to mobilize additional resources at the internationallevel and to support the efforts of the countries of the Region.
AFRlRC48/10 page 9 Managerial framework The viability and effectiveness of the proposed strategy will depend heavily on the importance given to political will and support of policy makers and health officiaIs; ownership of the concept; orientation and implementation of country-specific strategies at the different levels of the health pyramid; effective partnerships among institutional actors; the quality of training and ofhealth services and care; the judicious use of available resources and of research results; and formation of real health teams. Monitoring of implementation
(a) ln the countries A national advisory committee of ail institutional actors will assist ministries ofhealth to guide this coordinated reform of the system of health care and human resources development for health. Every year, it will examine the state of progress of the following six components: Policy: legislation and regulatory instruments, resource allocation and coordination of actions. Planning: formulation of a plan; level of implementation annually; adjustrnents. Education or training: analysis of annual results, quality of training administered, number of graduates, educationists, researchers and managers trained. Administration or management: user and health personnel satisfaction. Research: publication, feedback and utilization of results. Regulation of the professions: the creation of regulatory bodies, much discussed in the media.
(b) At the regionallevel WHO will coordinate the implementation of this strategy. A regional multidisciplinary group of experts in health policy, health planning, and hurnan resources development for health will be created with a view to assisting the Regional Office in this strategy. Partnerships and collaboration arrangements with other institutions involved in the development of human resources for health will be sought. A follow-up report will be submitted every year by the regional programme concemed. Principal monitoring indicators are the number of support missions organized for the formulation of policies and plans, the number of fellowships granted for training in human resources management and the number of managers trained.
Evaluation In the countries, evaluation will be conducted every Iwo years by the orientation committee and will analyse the reports relating to the different components.
At the regional level, evaluation will be done every Iwo years with the collaboration of the multidisciplinary groups created; the indicators to be used will be: percentage of countries that have a realistic policy and plan on human resources development congruent with their health objectives; percentage of countries that have put in place coordinated reform of the health system and of training in health sciences; percentage of countries that regulate the health professions.
AFRlRC48/10 page 10 SUCCESS AND FAILURE FACTORS The necessity for long-terrn political commitment, the duration of this programme on the national priority agenda, its orientation to assure intemalization of the process within the countries (health care system and institutional actors, ministries and departments responsible forhuman resources, national institutions for· training and research in administration or management, especially ofhealth), scarcity or lack ofresources, are all major problem areas. The commitment of Memher States and ·other pamiers to the health sector, and hence, to the development of human resources for health, demonstrated by the proportion of national budgets allocated to the social sectors such as education or training and health, will need to he encouraged and sustained. CONCLUSION Health personnel constitute the most important resource in health, on account of its cost and the value it gives to the other resources. Attaching value to and developing this resource is a challenge that the countries of the Region, WHO and other partners must face. The achievement ofhealth for all depends on it.