World Health Organization (WHO) · Technical Documents

Guidelines for the health manpower development process within country health programmes and national health plans

December 31, 1979 World Health Organization

The full text is hosted by the publishing organisation. lawenc.com indexes the metadata and links to the official source.

Full text

ICP/HMD/025

29 AulUet 1979 POLISH OILY

GUIDELINES FOR THE HEALTH MANPOWER DEVELOPMENT PROCESS WITHIN COUNTRY HEALTH PROGRAMMES AND NATIONAL HEALTH ~8

Preliminary Edition. (Unedited) WHO Regional Office for the We.tern Pacific Manila

CONTENTS

CHAPTER 1 - INTRODUCTION CHAPTER 2 - RELATIONSHIP BETWEEN COUNTRY HEALTH PROGRAMMING (CHP) AND THE HEALTH MANPOWER PROCESS ....................... CHAPTER 3 - THE PLANNING PROCESS CHAPTER 4 - USING THE CHECKLISTS CHAPTER 5 - NEEDS FOR CONSULTATIVE SERVICES IN THE HEALTH MANPOWER PROCESS ...........................••• LIST OF TABLES AND FIGURE TABLE 1 - THE THREE SUB-COMPONENTS OF HEALTH MANPOWER PROCESS TABLE 2 - NINE CONSIDERATIONS AFFECTING THE HEALTH MANPOWER PROGRESS COMPONENT ••.........................•.•........ TABLE 3 - THE MANPOWER PLANNING PROCESS .....•.....•..•.......•.... TABLE 4 - CHECKLIST: HEALTH MANPOWER PLANNING COMPONENT OF HMP ..............•......................... TABLE 5 - CHECKLIST: HEALTH MANPOWER PRODUCTION COMPONENT OF HMP ........................................ TABLE 6 - CHECKLIST: HEALTH MANPOWER MANAGEMENT COMPONENT OF HMP ........................................ FIGURE - A FRAMEWORK FOR SITUATION, ANALYSIS OF THE HEALTH MANPOWER PROCESS (HMP) . '................................ . ANNEX CASE STUDY: DEVELOPING WORKERS FOR PRIMARY HEALTH CARE .....................................

2 10 27

4 6 14 32 39 50 31

FOREWORD

This document has been prepared with the collaboration of three consultants working with the staff of the WHO Regional Office in Manila in October/November 1978. 1 The goals of the consultancy were: (1) To develop a statement of the objectives for health manpower planning, whenever possible within the context of the country health programming process. (2) To develop a set of guidelines to be used by nat;'onal staff and WHO staff to collaborate with them in the process of health ~npower planning within the context of countr health ro rammes and national health lana. The guidelines should address such areas as the data requ rement., methodology, process and linkages at all levels of the planning process. The guidelines were to be simple and as non-technical as possible as they are to be used by a variety of workers both familiar and unfamiliar with planning methodology . (3) To develop a statement of the requisite skills for staff and consultants involved in health manpower planning. The document was reviewed and finalized after the consultancy by a multidisciplinary working group on health manpower planning established in the Regional Office. I t is hoped that this preliminary edition of the guidelinea will be found applicable to a variety of situations where one has to develop health manpower as part of the health system.

The methodology proposed can be applied whether or not a detailed country health programme has been developed.

IR. Wainwright, WHO Medical Officer, attached to FIJ/HMD/OOl project. Beverly Dugas, Health Manpower Consultant, Vancouver, British Columbia, Canada. Paul Gross, Special Adviser, Welfare Research and Evaluation, Social Welfare Policy Secretariat, Canberra, Australia.

CHAPTER I - INTRODUCTION

"Health is one of the components of living which influences the socioeconomic system. Health is affected by and, in turn, affects other conditions of the socioeconomic system. ,,1 Health planning must, therefore, be considered an essential component of overall development planning in a country. Because health care is basically a service provided by people for other people, the development of health manpower must go hand in hand with the design of the health system and the development of health care services. The health manpower planning process then must be integrated within national health planning and country health programming as an essential part of the total process. The purpose of these guidelines is to provide countries with an approach for improving the health manpower process, whatever the entry points into this process. The guidelines also identify the linkages of the health manpower process to the country health prograrmning process. This "health manpower process" includes three identifiable components; viz., health manpower planning, health manpower production, and health manpower management. Among the several possible approaches for reviewing the health manpower process, the one used takes the reader through the three components of the process at two levels of analysis, viz: identifying the steps of the process involved in the three components, i.e. describing what is generally done in each step of the process; and identifying a list of questions that should be asked at each step of this process, i.e. specifying the content of the analysis associated with each step (checklist). The document is therefore divided into four major chapters: Chapter 2 - Relationship between Country Health Programming and the Health Manpower Process An overview of the scope of the country health programming (CHP) effort, the relationship betweenCHP and the health manpower process; and a definition of the health manpower process.

Chapter 3 - The Planning Process An analysis of the steps in the health manpower process.

1Angara, A.A. et al. Health Planning in the Western Pacific, Public Health in the U.P. No.2 p. 41.1

- 2-

Chapter 4 - Using the Checklists An analysis of the types of questions asked In the health manpower process, i.e., the content of the process.

Chapter 5 - Needs for Consultative Services in the Health Manpower Process A listing of the type of future consultant skills that are likely to be required in if countries in the region want to develop the health manpower process component of CHP. CHAPTER 2 RELATIONSHIP BETWEEN COUNTRY HEALTH PROGRAMMING (CHP) AND THE HEALTH MANPOWER PROCESS

2.1

The country health programmIng (CHP)

CHP process is the instrument to develop national strategies and plans of action to implement in the countries the overall primary health care strategy 1n order to achieve the objective '~ealth for all by rhp year 2000". It consists of five stages: Policy basis, data collection and analysis This stage is referred to as pre-planning, policies are examined, data collection and preliminary analysis are done; the product is terms of re ference for the planning/programming proce'ss; Situational analysis and broad planning Problems are identified, objectives set and strategies developed, some broad indications of programmes are given; Detailed programme formulation - detailed plans are developed, tested for feasibility, constraints and obstacles; alternatives are sought; Programme implementation - programmes/plans are implemented according to detailed plans prepared in previous stage; Programme evaluation - progress, effect and impact of the plan/programme are assessed. 2.2 The health manpower process

As mentioned earlier, the '~ealth manpower process" to include three identifiable sub-components, viz., health manpower planning, health manpower production, and health manpower management. The contents of each of these three sub-components of "health manpower process" are listed in Table 1.

• Focusing solely in the "health manpower planning" sub-component would be to ignoring the critical influence of the other two sub-components on the health manpower planning process and on the country health programming process.

,,, :.. ,/4 -

[

TABLE 1 THE THREE SUB-COMPONENTS OF HEALTH MANPOWER PROCESS Source: Modified version of Table 1 in Hall and Mejia (eds), 1978, p. 36. Overall Goal: 1.

To provide the health personnel and other human resources needed for health care Health Manpower Hcacement To manage and develop the manpower available for health care services, management and research 1. Recruitment and management of personnel in individual heal th services 2. Coordination of groups of health service by level (e.g. primary care; institutional care) and by region 3. Evaluation of the appropriateness of supply, utilization, productivity and distribution 1. Health personnel recruitment (and community) ~raining for self-help) 2. Staff supervision

Goal

Health Manpower Planning - _._-- . Health Manpower Production To. tell us What manpower we To produce the manpower have and What manpower we need required for health care to produce or retrain for health care 1. Forecasting future manpower needs 2. Analysis of existing manpower supply, utilization, productivity and distribution 3. Development of planning documents for individual projects, regions or nations 4. Evaluation of plan impacts 3. Recruitment into education progrlUllllles

Strategies

t. Plan education institutions and programmes to educate or retrain manpower for health care 2. Develop specific curricula and teaching methods for specific types·of training and education at the basic, post-basic and continuing educfttion level

Activities

1. Long range and short-term forecasting 2. Data collection for specific purpose 3. 4. Data analysis Project and programme planning

Student recruitment

2. Education progr_ developaent (including ad.i.sions ~ocedures, syllabus, curriculua planning teaching methods) 3. Evaluation of process and products of education and training

3. Career development planning (including continuing education) 4. Staff deployment

5. Har.onizing the impact of different planning prqcesses 6. Research and development

5. Information systems development for human resource management and evaluation of organization performance

- 5 -

A systematic review of the health manpower process can be undertaken by using the checklist referred to in Section 1.3. This checklist should cover at least the nine (9) sets of questions ("considerations") listed in Table 2 if one of our objectives is to undertake a systematic review of the health manpower process, viz., (1) (2) (3) (4) (5) (6) (7) (8) (9) the minimum data set describing the sub-component problem area for which a plan or plans is being developed; how the sub-component is organized; how it how it 1S 1S

financed; staffed;

what facilities and technologies it uses; the scope of the present planning effort; the legal, constitutional or regulatory factors influencing the problem area; the level of consumer involvement in the problem area; and the extent of present evaluation activities in the problem area.

It should be noted that within the three sub-components, some of these considerations are far more important than others. It should also be obvious that the first checklist item - the ,minimum data set describing the problem area - will vary in detail depending on the scope of the problem faced, the data available for analysis, and the urgency of the planning effort (see Section 2.6, following). Tables 4, 5 and 6 in Part 4 of this report contain the preliminary versions of checklists covering the three sub-components of the health manpower process.

,,,

- 6 -

... ICD/HMD/025 Pa,e'l of 2 "

TABLE 2 NINE CONSIDERATIONS AFFECTING THE HEALTH MANPOWER PROCESS COMPONENT

Consideration L

Indicators 1.1 Data on manpower a} supply b) distribution c) productivity d) utilization e) costs of} production quality and quantity Data on health status indicators and trends Data on health care costs and trends Humbers of organizations and coordinating agencies involved in the process Their functions and size 1. 1.

Relevance to Health Manpower Process Baseline data for identifying, describing and assessing the scope of the problem

What minimum data describes the manpower process under review?

1.2

1.3 2. Bow is it (Le. the

2.1

health .anpower process) or,.dzed 2.2

May identify the coalitions who could facilitate the ft selling" of the final plan developed Identification (e.g. in situation analysis) of the organization barriers to solutions involving coordinated or integrated approaches Baleline data on the financial relources affected by the planning decision

How is it financed?

3.1

Sources and uses of public and private leeton funding

c·

,. - 7 -

...

. Icp/mm/025 Page 2 of 2

Consideration

Indicators

Relevance to Health Manpower Process

3.2

Methods of financing, budgeting and payment

ldenti fication of the major organizations whose future would be affected by different plan "solutions" Baseline data on the human.resources affected by the planning decision

How is it staffed?

4'.1

Numbers, qualifications, experience and location of 1II8npower involved Patterns of staff grouping Numbers and monetary values of materials consumed by or used

4.2 5.

What facilities, equipment and technologies does it use?

5.1

Baseline data on physical resources used Indicative data on the sophistication .of the technology available to the problem area Baseline data on limitstions of existing planning process and its i._paCL on problem resolution in the nation

What is the scope of the present planning process?

6.1

Indicators of the scope, sophistication and process of planning used (e.g. data collection, analysis, linkage with other. types of economic planning) Listing of the organizations involved

6.2

.. -8 -

•

. ICP/HMD/025 Page 3 of 2

CC)nsiderati!lJl

Indicators

__ ~_~

---'ele~anc~

to_!lealth Manpower Process

What are legal, constitutional or regulatory factors?

7.1

List of laws/regulations/statutes/ administrative decisions affecting the roles of different organizations/ manpower / fac Hit ies, etc. List of all processes of consumer involvement (e.g. national advisory committees, hospital boards, etc.) Listing of all past or ongoing evaluations

Baseline data on possible constraints in implementation of any single planning "solution"

What is the consumer involvement?

8.1

Baseline data on possible methods of "selling" the final plan "solutions" to the pub 1ic Baseline data for situation analysis, and for evaluation of possible plan "solutions"

What evaluation activities now take place?

9.1

- 9 -

2.3

The HSMD concept

It is essential that the health manpower development activities be responsive to health service requirements in order to fulfil the health needs of the community. The growing awareness of the fact has led to the concept of "health services and manpower development (HSMD)". ' It calls for the integration of the components of the health manpower process with the functional elements of the health services systems into a unified system providing health care relevant to the health needs of the population. One of the many ways to achieve such an integration may be through the country health programming process discussed in Angara et al., 1977 .

2.4

The objectives 0f the health manpower process within programming

c~untry

health

The broad objectives of the health manpower process are: 1. To develop and apply a rational, systematic process for the production and deployment of health manpower so as to achieve a balance between the supply of health workers and requirements for their services. 2. To develop alternative health manpower strategies for the implementation of health programmes. 3. To coordinate basic, post-basic and continuing educational programmes for health manpower with the development of health services. 4. To provide health manpower educators and health service managers with a methodology and criteria for the evaluation of performance and productivity of health manpower. 2.5 Entry points into the health manpower process - some samples

Different nations enter the health manpower development process with different needs, different levels of data availability or technical analysis skills, and different levels of sophistication in planning for economic development,. health care, or health manpower. The stages at which the health planning process and more broadly health manpower process might begin varies in di fferent countries. A number of countries have developed a national commitment to planning and have developed a relatively sophisticated structure and methodology; they have also trained individuals in a number of disciplines relevant to planning. These countries have thus committed significant financial resources to the planning process. Other countries in the Region are in the early stages of developing their capacities for planning. They have not as yet sought or committed significant resources to their planning process.

- 10 -

The availability of accurate data and the ability to answer difficult questions posed in the planning process is also quite variable. Some countries have large amounts of data accessible in computer-based information systems. They have available skilled computer technicians, data analysts and other specialists who can assist in data analysis and in the design of studies to answer complicated planning questions. In other countries, data are either not available or are scattered in various locations, making access to these data either difficult or impossible. The CHP process has attempted to recognize these variables in its flexible approach to health planning process. Entry into the planning process can occur at many points, and provision is made for returning to earlier steps to clarify problems (for example, by analysis of data which ideally have been collected and analysed at the earlier stages). The health manpower process outlined in this document should be viewed as a flexible series of steps. The process outlines in general terms the linkages, interactions and activities which are considered important in the improvement of the health manpower process in country health planning. CHAPTER 3 THE PLANNING PROCESS

3.1

General description of the planning process Situational Analysis Detailed 'Forumulation Implementation Evaluation

Pre-planning

Any planning process follows five stages depicted schematically above, regardless of whether we are developing a country health plan, or a national manpower plan for supply of specific professions, or a specific plan to provide a community with basic health services. This process is, in particular, used for country health programming (CHP). The five stages listed below are in sequence of development and each stage requires appropriate preparatory activities. In general, each stage requires the completion of the previous stage (the product of one stage serves at the input, starting point, for the next one). The input in the first stage is a policy statement, a requirement to introduce change, or the result of evaluation of ongoing activities. Stage 1 - Policy basis, data collection, analysis The stage often referred to as pre-planning sets the stage, deals with the developing of the planning structure, includes preliminary data analysis and problem identification. The policy basis is included in the terms of reference of the planning group.

- 11 -

It is desirable that indicators which are variables to measure changes and are relevant for planning, programming and evaluation are specified at this stage. Indicators can measure change directly or indirectly, they should be valid, objective, sensitive and apecific. Validity implies that the indicator actually measures what it is supposed to measure. Objectivity implies that even if an indicator is used by different people at different time and under different circumstances, the results would be the same. Sensitivity means that the indicator should be sensitive to change in the situation or phenomenon concerned. Specificity means that the indicator reflects changes only in the situation or phenomenon concerned. Stage 2 - Situational analysis and broad programming Definition of priority health problem/s is followed by assessment of current activities and resources devoted to the solution of the identified problem/so Overall objectives are set and strategies for achieving these objectives identified. Quantified targets are part of health strategies, strategies are translated in broad priority programmes. Stage 3 - Detailed programme formulation Selection of detailed programme is based on their relevance to the problem policy statement and priority identified. Programme formulation itself will include the listing of resources required, procedures to be developed, manpower to be trained, time schedules, organization for programme implementation, criteria and indicators for evaluat~on. Indicators specified on the first phase - policy basis, data collection, analysis - are relevant for this phase as well. In addition, criteria for evaluation have to be developed during this phase. Criteria are standards against which plans and actions can be compa~ed. Criteria are social, technical and administrative. Social criteria are to establish relevance of an activity or programme to the social standards, norms and goals of a society. Technical criteria are to compare the activity or the programme with technical standards set for that activity or its outputs. Administrative criteria will help to measure the success of the programme or activity against the organizational structure and administrative support it requires. Stage 4 - Implementation Implementation requires development of specific procedures and organizational structures and securing the resources. These are: detailed operational plans programme budgeting information systems development procedures for monitoring and control of implementation replanning/programming as required.

- 12 -

Stage 5 - Evaluation Although it is listed as the last stage of the planning process evaluation, with its components it should be built in all stages of the planning process and is also an integral part of the implementation. Instruments for evaluation are indicators and criteria. They are also used in planning and programming and as already mentioned in stages 1 and 3, Indicators and criteria are used 1n the following components of evaluation: (1)

(2) (3) (4) (5)

Relevance Progress Efficiency Effectiveness Overall impact

(1) Relevance relates to the rationale for having programmes, activ1t1es, services or institutions, in terms of their response to social and health policies and priorities (use of criteria),

(2) Progress is concerned with the comparison of the actual with the scheduled delivery of the programme activity, (3) Efficiency is an expression of the relationship bet~een the results obtained from a programme/activity and the efforts to achieve them in terms of human, financial and other resources, processes, technologies and time. (4) Effectiveness is an expression of the desired programme, service or institution in reducing a problem or improving an unsatisfactory situation. It measures the degree of attainment of the predetermined objectives and targets. Wherever feasible, the extent of attainment should be quantified (use of indicators). (5) Impact is an expression of the pos1t1ve effect of programme, service on overall development (health and on related social and economic development). While a programme may be effective in that it has attained its objecti~es, the attainment of these objectives may in fact make little or no contribution to overall health and related socio-economic development. Setting of criteria and indicators is a part of the planning process. All components of the evaluation should be considered during the planning process; the plan of evaluation, its frequency, methods and mechanisms are planned in relevant stages of planning. The planning can also be evaluated 1n the following terms: Do the planned programmes deliver the planned outputs; What is their ability to obtain resources;

- 13 -

What is their ability to obtain political and administrative support; What is the level of demand for and the consumption of outputs; What is the feasibility to monitor the above and revise the programme as necessary. 3.2 The manpower planning process

The health manpower process follows the same five stages as outlined for the planning process above. In each of the stages, there are several steps and activities that may have a significant impact on health manpower. Table 3 lists the steps which might be undertaken in pach of the stages and then further lists a number of activities important to each step. It also link responsibility in terms of overall areas of concern, e.g. health manpower planning, health manpower production, etc., and in term of specific groups, e.g. ministries, professional groups, institutions of higher education, etc. As an example, an annex to this document describes a case study making use of the five stages for the development of workers for primary health care in a developing country.

- 14 -

Page I of 9 TABLE 3 THE MANPOWER PLANNING PROCESS I . . Pre-Planning Steps A. Recognition of need for heal th manpower planning Responsibillty Highly variable possible sources of recognition include economic planning/ development groups, educators. health officials. manpower planning groups. professional societies. Economic planning/ Health/Education Ministries or Departments, of Economic Planning, Health, Education, Professional societies. Economic planning/Health planning/Education planning MinTstries or Departments of Economic Planning, Health, Education, Higher Education Institutions, Professional Societies Actfvit1es (1) Inform relevant group and of individuals concern for possible manpower problem. (2) Generate interest in further evaluation of the problem.

B. ·Develop commitment to planning process

(1) Bring together relevant policymakers. (2) Establish relevance of planning to their sector.

Establish structure for health manpower planning within the overall planning process of the country

(1) Determine possible alternatives for structure of health manpower planning. (2) DesigDate focus for manpower planning within the overall planning structure. (BMP* focal group) (3) Establish financing mechanism for health manpower planning. .

*HMP - Health Manpower Planning

. Responsibility Health Planning/ Health Manpower production/Health manpower manage~nt lIMP focal group

- 15 Page 2 of 9

Steps D. Design and organize heal th manpower planning activities

Activities (1) Designate/provide heal th- manpower planning staff. (2) Review established approaches to health manpower planning. (3) Select or methodology. d~velop

(4)

Develop plan of work.

(5) Establish time frame for inttial planning activities.

·"

- 16 -

Page 3 of 9 II. Situational Analysis Steps Responsjbij1ty Health Plannirg/Health Manpower Production/ Hea I th Man power Management lIMP focal group Aedvities (1) IdentifY an initial basic set of data.

A: Information gathering

(2) (3) (4)

IdentifY sources of data. Collect information. Tabulate. Select methodology.(*)

Develop health manpower projections based upon present resources and services IdentifY other constraints

Health Manpqwer Production/Health Manpower Management lIMP focal group Health Manpower Planning lIMP focal group

(1)

(2) Prepare projections of supply and requirements.

. (1)

Review statutory

~equirements.

(2) Review standard set by professional groups. (3) Review existing health manpower policy and plans. (4) Review personnel commission rules and regulations. (5) Review budget limitations.

(*)See Hall and Mejia,Health Manpower Planning

- 17Page 4 of 9

Steps D. Problem identi fication

Responsibility Health Planning/ Health Manpower Production/Health' Manpower Management Health Planning group HMP focal group

Activities (1) Identify shortages, excesses and maldistribution. (2) Identify discrepancies between task preparation and job description. (3) Identify discrepancies between job description and health services requirements. (4) Identify disc,repancies between health manpower polices and plans and manpowerl requirements. \ (5) Assess impact of new programme on the manpower process.

- 18 -

Page 5 of , Ill. Plan Formulation SUps A.' Evaluate health . problems as to priority _ Responaiblity Health Planning/Health Manpower Plaaning Health planning group Activities (1) Transmit priority health manpower related problems to health manpower planning focal group. (1) Transmit decision to health manpower planning group.

Decision to deal with prollleDIS

Health Planning/Health Manpower Planning Health planning group Health Manpower Planning HMP focal group

Develop and evaluate alternative . strategies to deal with problelllS .

(1) Identify health manpower implications of problem .

(2)

Review relevant data base.

(3) ·Develop alternative st:}:ategies. (4) Undertake studies and/or operational research to evaluate strategies. (5) Submit alternative proposals and recommendations to health planning groups. D. Selection of strategy Health Planning/ Health Manpower Planning Health planning group (1) Transmit strategy selected to health .anpower focal group.

- 19--

.., Page 6 of 9

Ste~___

Responsibility Health Hanpower Planning/Professional Societies lIMP focal group Professional groups

Activities (1) Review existing and proposed programmes in area of concern.

Develop programme plan to implement strategy

(2) SpecifY manpower tasks need to provide services. (3) Aggregate task and assign to health IllAnpower category or level.

(4) Determine training levels of health manpower aggregates. (5) Estimate resources required.

(6)

Develop estimated

t itiie frue. (7) DevelOp linkages between IllAnpqwer and health services development.

Formulate projects

Health Manpower Plaaning/ Health Manpower Produc.tion BlIP focal group @ealth Planning Health planning grouP.

(1) Disaggregate progrSllllle plan into ~pecific projects.

Incorporate progr..plan and projects into health plan

- 20 -

Pale 7 of 9 ·~V.

Implementation Steps ----.~

Responsibility·

UACHvit}es (l) Transmit approved project to health manpower focal group implementatioD. (1) Identify specific educational programme objectives. (2) Estimate specific demand using norms or operational research. (3) Set targets - numbers and time. (4) Specify length of programmes.

Approval of project

Health Plannitlg Health planning group

Development of Educational Programme Objectives

Rea 1 th Man.power Production/Health Hanfower Management ·HiDutries of Health and Education, health manpower educators

Define educational process and situation

Heal th Manpower Production/Health Manpower Management

(1) Select location of facilities. (2) Determine faculty qualifications and numbers. (3) Determine other resource requirements, e.g. equipment and sup.pl iea, - student support. (4) Develop institutional objectives for the project. (5) Recruit faculty.

(6) Prepare faculty (teacher training).

- 21 Page 8 of 9

Steps

Responsibility Heslth Manpower PToduction Faculty

Activities (1) Identify specific terminal behaviours.

Curriculum development

(2) Review and approval of behaviours by health manpower focal group. (3)

Write curriculum. Specify entry

(4)

competencies. (5) Determine educational methodology.

Recruit students

Health Manpower Production Faculty

(1) (2)

Advertisement. Assessment of applicants. Selection of students.

(3)

Conduct training progr_es'

Health Manpower PToduction I"aculty Heal th Manpower Production Faculty, Ministries of Health and Education (I) Curriculum content evaluation.

Evaluation of training programmes

(2) Evaluation of teachers and methodology. (3) Individual student evaluat io'l.

- 22 -

Page 9 of 9 V. Evaluation

Steps A. Assess the achievement of manpower objectives Assess the achievement of health service targets Monitor health status indicators

Responsibility Health Manpower Planning/ Production lIMP focal group Health Manpower Planning/ Management H)tp foed group (1) Re-enter situational analysis with new health manpower.

(1) Re-enter situational analysis of new health services.

Health Manpower Planning/ Health Planning lIMP focal group

(1) Re-enter situational analysis to assess possible input of new health services/ .manp.ower on health status.

- 23 -

3.3

Interrelationships within the planning process

There are several categories of interrelationships within the health manpower planning process which should be considered. These interrelations form the network upon which the health services manpower development concept can be developed and expanded. The following table detailing the interrelationships is from Mejia l and lists the many linkage categories and some of the specific areas of overlapping interests. Linkage category National Health Planning and health manpower planning Interest area - problem identification - cost/benefit analysis and the study of alternatives - formulation of priorities, objectives and plans plan implpmentation strategies - policy mak ing - resource allocation Health manpower planning and health manpower production - manpower category definition (health team composition - task reallocation - manpower requirements projection training capacity assessments - definition of learning objectives educational planning and programming - educational technology - educational research and development - recruitment and student selection and admission procedures

lMejia, A. "The Health Manpower Process," Hall, T.L. and Mejia, A. ed.

Health Manpower Planning,

- 24 -

identification of areas 1n need of support evaluation of educational outputs Health manpower production an d hea 1 th man powe r management - job description and work designs - task assignments - supervision and continuing education - per formance evaluat ior.s - community resources utilization for education and training - career development patterns Health manpower planning and health manpower management distribution of manpower and services - manpower utilization and productivity - job description - costs bf serV1ces and maripower - coverage identi fi.cntion of areas in need of support To illustrate the manner in which entry into the planning process may occur, three case studies may be helpful. /Example I :/ The nation has a five-year plan for economic development, and a country health plan for a similar five-year period. Policymak~rs in the nation have noted that the migration patterns of medical manpower are changing as a result of either the impending or actual restrictions on the entry of the foreign medical graduates to industrialized nations (e.g. United States of America, Canada, Australia and New Zealand). Its problem is to plan its future intakes to its own medical schools to anticipate: (a) (b) (c) the likelihood that doctors who have gone overseas on graduation will now be forced to return to the nation; the likelihood of an increasing oversupply of nurses in the nation; the possibility that, even with such a reverse migration, the nation's medical school graduates will not find their way into rural areas that still lack docto~s, and that, as a result, an oversupply of practitioners will develop in urban areas;

- 25 -

(d)

the effects of a change in the numbers of individuals who are now eligible for coverage of their health costs through the nation's social security system (this expanded coverage will generally increase the total demand on the nation's health services); the effects of a new national initiative to develop primary care services in health centres in rural areas and in deprived urban areas; the effects of a parallel initiative to develop self-help initiatives in remote villages, perhaps through a community development programme that develops the capacity of villages to provide their own services for first aid, nutri t ien, family planning, sanitation and water supply.

(e)

(f)

This nation may choose to go through all five stages of the planning cycle for future medical manpower supply and distribution. Depending on whether a single focal group exists to plan medical manpower requirements and supply, the nation may adopt the following approach: create a national steering committee to formulate the terms of reference of a national planning study (i.e. stage 1); initiate a situation analysis (stage 2) using project groups to study the different facets of the problem; formulate a single national medical manpower plan for the next decade; recommend to the government that specific action be taken to restrict future intakes to the different health professions now and in the future; and, finally, handing over implementation of the plan to officials in the health and education ministries and the relevant academic institutions.

On the other hand, it may choose a second approach which avoids the pre-planning stage and detailed situation analysis. The government may simply instruct its Ministry of Health to urgently prepare a new amendment to the five-year plan and a new country health plan so as to adequately recognize the signals noted above (d-f). Or it may opt for a third approach in which the Ministry of Health convenes a meeting of all medical school deans at which it indicates its intention to reduce the intakes to medical schools by 30% by 1981, while also indicating its parallel intention to cut foreign medical migration to a net of 100 doctors per year by 1981. The medical school deans are then given their quotas. A detailed planning process is not required with this option; the government's advisers have decided on a plan formulated on their own experiences and on the experience of other similar nations that have tried the more sophisticated planning approaches without great success.

- 26 -

Obviously, the checklists attached to this report are more likely to be useful in the first approach, and less relevant in the third approach. /Example 2:/ This nation does not have a five-year plan, nor does it have a country health programme. It has a small planning unit in the Ministry of Health, and not much data are available on the capacities or distribution of existing institutions training the health professionals. The deans of one of the medical schools, influential in medical education and in national politics, return from a two-week course on trends in medical education. He convinces the Ministry that what the nation really needs is a centre to train teachers of all health personnel. The planning problem initially posed is to assess the feasibility of such s centre. . The nation could adopt different approaches in Bolving this problem. First, it could convene a steering committee of all influential health professions; then, it could enter the pte-planning stage and agree on the terms of reference of a planning study; then it could undertake a detailed situation analysis of existing methods of education, teacher qualifications and experience, existing process of programme development and curriculum development, and evaluate the outcomes of these processes; finally, it could prepare an analysis of the gains and losses in a Teacher Training Centre. Thus, the feasibility study team would not enter into detailed plan formulation (stage 3 of the planning process), and it would cease its activities with a feasibility report to both the Ministries of Health and Education at the end of situation analysis (stage 2). A second approach might see the Ministry of Health request its Director of Training and Manpower to prepare, within two weeks, a short report on whether such a centre is feasible or desirable. There is no pre-planning stage. Situation analysis consists of a few telephone calls to a few selected influentials in the education sector, and a draft report is written within the deadlines set. /Example 3:/ A small island-nation has received external funding to improve its drinking water supply in the next 10 years. It decides that it needs a study of its manpower requirements to achieve this goal, to ensure that adequate maintenance workers are available to maintain whatever equipment is installed, and that health inspectors and sanitarians are available, along with adequate services and supplies. This nation has no five-year plan, no country health plan (but a situational analysis is available), and no health manpower planning staff or a manpower plan. The health manpower process could take several forms. The Ministry of Health could be asked to estimate how many health inspectors and village sanitarians are required if the decision is taken to build, say, ten new water supply systems in five regions. The Ministry of Public Works mayor may not be asked to link its plans to the availability of these manpower. The pre-planning and situation analysis stages could vary depending on the extent of inter-ministry collaboration, the present availability of health inspectors, sanitarians and the other manpower categories in the region, and on the education programmes already in existence in local colleges and other institutions.

- 27 -

The checklists included to this document may be of some value in this situation if outside consultants were called in to review the situation de novo. Parts of the checklists might also be useful for the Ministry staff undertaking such a review.

CHAPTER 4 USING THE CHECKLISTS The purpose of chapter 3 was to describe the stages, steps and activities involved in the health manpower planning process. The objective of this chapter is to outline the contents of the checklists that apply the nine considerations listed in section 2.2 to the three components of the health manpower process viz., health manpower planning, production and management. It is hoped that the use of those checklists will diminish the effects of three traditional obstacles to the acceptance and use of planning documents, viz., the inability either to use available data or to collect a minimum of new data to analyse the problem situations that are faced in the health manpower processj the lack of attention to coalition formation, i.e. the process of bringing together influentials whose involvement can bring about a plan's acceptance and usej and the lack of attention to the processes of advocacy, communication and marketing of the finished plan that are necessary to achieve implementation of its recommendations. The last section of this chapter suggests approaches which could be used to refine these checklists and adopt them to specific needs. 4.1 ~,al1tical

framework for a checklist

Figure 1 illustrates a framework suggesting the disaggregation of the structure and the three components of the health manpower development process. It suggests that any problem area can be reviewed by identification of five components, viz., the inputs to the problem area under review (such as students entering the health manpower production process, or ideas entering the health manpower planning process)j

- 28 -

the environment(s) affecting the inputs, structure and process of the problem area (such as the health status of a population which causes sufficient concern that a new method of primary care is proposed, along with a health manpower production procesl to train appropriate health workers); the structure that influences the organization, financing, staffing and operations of the problem area (i.e. the last eight considerations listed in Table 2; the process applied in the problem area (in this case, the three componentR of HMP)j the outcomes of those processes (e.g. was the process efficient, acceptable and coordinated, and what were the economic costs of the process?). It should be noted that while Figure I gives examples of only three broad classes of outcome, we have already indicated in Section 3.1 that there are at least ten broad types of criteria for evaluating the outcome of the processes. The following tools could therefore be used in the HMD process: a list of nine considerations for reviewing the structure affecting a problem area (i.e. the categories listed in Table 2,and in Figure 3); a listing of the three separate components that are embedded in the health manpower process (with some o.f the components disaggregated into up to three sub-components); a list of ten criteria for evaluation of the outcome of any of these processes (i.e. those criteria listed 1n Section 3.1). 4.2 Relationship with the planning process

The ~ontents of the checklists are organized according to the various components (and sub-components) of the total health manpower development process on one hand and according the nine considerations listed above, on the other hand. These contents are made of questions to be asked and answered at various stages of the planning process or cycle described in chapter 3. Tables 4, 5 and 6 included in this chapter contain the preliminary versions of checklists covering the three sub-components of the health manpower process. These checklists are meant to illustrate the potential value of systematically derived checklists, rather than an endorsement of the relative value of all the questions listed. The checklists are put forward for discussion, review and amendment in the light of different national needs and experience in the health manpower process in the Region.

- 29 -

4.3

The health manpower planning component

Table 4 contains a list of questions covering this first component of the health manpower process. A comment is made on the minimum data set describing the problem area: The traditional listing of all possible types of data that would be required to solve a range of planning problems have not given; it would make little sense to do so, since a minimum data set should be specific to the given problem. It could be desirable to identify a few common problem areas that reappear time and again in health manpower planning and define what minimum data sets are appropriate to each of these problem areas. Some problem areas that come to mind include the following: estimating the size and nature of changing patterns of migration of doctors and nurses and the resulting impact on health manpower production in the next decade; estimating the effect of a national primary care initiative on the requirements for different levels of health manpower (including lay health workers involved in self-help initiatives); evaluating whether a reduction is feasible in the number of overlapping categories of nurging manpower with different levels of education and training; and - estimating the likely demand for a new type of health professional. 4.4 The health manpower production component

Table 5 contains checklists for three major sub-components (education recruitment, education programme development (EPD) and curriculum development (CD». It is fully recognized that the last two sub-components are not separable since CD is part of the broader process of EPD; also considerations of recruitment can never be fully separated from the related planning of education programmes. The rationale for their separate treatment here is that they regularly emerge as problem areas in their own right, particularly the last sub-component. 4.5 The health manpower management component

Table 6 contains the checklist for three sub-components of health manpower management. Once again, the disaggregation is illustrative rather than based on any detailed considerations of what is a suitable disaggregation. Three factors however - recruitment into health care institutions and services, the continuing education of health manpower and health information system development - consistently emerge as key problems in the Region. Of these three sub-components, the last has significant effects on the future data base for health manpower planning and for other aspects of health services planning. The health manpower information system (HMIS) provides the data base for planning, evaluation, research and development.

- 30 -

One major problem in past HMIS activities is that their conceptualization has not been based on an adequate review of what is the minimum data base (as distinct from the desirable data base) needed for planning in specific problem areas. This concept of "minimum data base" is critical in those nations where the available data are of pOor quality or non-existent, or where the numbers of trained staff available for planning and analysis are few. 4.6 Development of specific checklists

From the foregoing comments, it is obvious a very large premium is placed on the conceptualization of a minimum data base for ~ll three sub-components of th~ health manpower process. It would be des irab Ie to re fine the checklists in Tablt:s 3, ~ and 2into versions that meet the needs of nations at different stages of development in the health manpower process. Some nations are conceptually very advanced in their manpower planning, others are intent on systematic improvements in health manpower production, and yet other nations face significant problems in the years ahead unless they are able to rationalize their manpower supply and its redistribution to ill served areas. Detailed consideration of the health manpower process needs of these three types of nations might be useful.

In these future studies, there is a need to more carefully review the specific processes of "coalition-formation" (Le. in the pre-'planning stage) and "plan-setting" (mainly in the plan formulation and plan implementation stages). Planning is first and foremost a political process, and whatever "process" and "content" charts are used to depict the rational nature of a desirable planning process, the fact remains that very few plans are not affected by an often-Iess-than-rational political process. Thus, future actions to improve the acceptance of a rational health manpower process must include some systematic study of the paths to acceptance or rejection of various manpower plans, including studies of the relative importance of "coalition formation" (Le. are there key individuals and organizations in given situations whose participation is mandatory) and "plan cetting" (how the plan is packaged, communicated and marketed by different methods of advocacy).

- 31 -

FIGURE A FRAMEWORK FOR SITUATION ANALYSIS OF THE HEALTH MANPOWER PROCESS (HMP)

THE Health Status Social

E N V I RON MEN T Economic Technological

H M P

Political

Institutional (education & health care)

THE STRUCTURE affecting THE PROCESS OF HMD The INPUTS to HMD 1. 2. 3. What organizations are involved? How are its different components financed? How is it staffed? What technologies dops it use? Wh<lt 1"

Planning

Production

HM Mgmt. 1.

The OUTCOMES* of HMD CLIENT Outcomes (e.g. did it meet the needs of students equitably and effect ive1y?) PROCESS Outcomes (e.g. is the process efficient and acceptable to providers, clients and sponsoring bodies; is it coordinated with other processes? ECONOMIC Outcomes (e.g. what were its unit costs, and total costs) 3.

4. .).

the scope

of any planning effort involved? 6. What legal/ constitutiona1/ regulatory factors influence its inputs, process and outcome? 7. What levels of consumer involvement influence the same factors? 8. How ~s the problem area influenced by any ongoing EVALUATION activity?

*A more detailed list of evaluation criteria are given

Section 3.1.

- 32 ICP/HMD/025

Page I of 7 TABLE 4 CHECKLIST: HEALTH MANPOWER PLANNING COMPONENT OF HMP

Consideration 1.

Questions Affecting Health ManpowerPlannin~ Component 1.1 What broad descriptive data are easily available for analysis (e.g. data on supply; distribution; productivity; utilization; costs of manpower training and employment in specific categories; production quality and quantity; selected relevant health status indicators; health care costs).

Relative Importance of Question in the PlatlnillA Cycle Important in Stages 1 and 2.

Minimum data set describing nature of problem area

1.2 What additional data are required and which are essential to solution of· the specific problems being posed? 1.3 What minimum data set down from existing data and from other studies is essential for future planning in this same area (and thus should be collected beyond this present planning effort)? What groups, regions, professions, etc. are involved in different planning processes or in plan implementation? What are the organizational linkages between differe~t planning agencies (e.g. Divisions in the Ministries of Health, Economic Planning, Education, etc.) health facilities, education facilities, etc.) to ensure completeness, quality and cost-effect1veness in any data collection efforts required in the planning process? (This question emerges again in reviewing the existing planning mechanisma - see Factor 6 below).

May be important in Stage 2 and beyond. May be important beyond this present study.

2 Organizations Involved

2.1 2,.2

Both questions important in formation of planning committees in Stage 1 to avoid possible dissention at later stages.

'.-,-33 -

ICP/HMD/025 Page 2 of 7

Consideration 3.

QUstioRs Affecting Health Manpower Planning Component 3.1 What are the budgets for any existing HH planning activities by the public or private sector agencies or outside bodies? atat proportions of this financing are from ''hard'' 8l\d"soft "Ii1oney?

Relative Importance of Question i~_ t!le Planni.llgCycle NOt essential gives some-idea of cOllDllitment to planning at- different levels. Not essential - gives some indications of lively performance of planning process if '''oft'' money dries up. Iaportaat,ia atage 1 if a88e88ing nation's ability to undertake sophisticated planning studies. As in 3.2. Not e88enti.I .... relev·ant to long-term review of career structures for planners. Not essential - relevant to long-term Teview of c.reer development patterns and nat iona11ll8npower planning.

Financ ing Methods

3.2

Staffing ME!thods

4.1

libat are the nUlllbers, qualifications and experience of staff in the major HM planning organizations? What proportions of these numbers are permanently employed in planning positions? What career structures exist forHM planners? libat education programmes are available in the nation for baeic, post-baeie andcoctinuing education.in 11M planning (and in related health and economic planning) methods?

4.2 4.3 4.4

- 34 -

ICP/IflIID/025 Page 3 of 7

Consideration 5• Technology uud in th"eplamiing process

QuestionsAfficting Health Mut.pow~~ PlanningCOIIIponent 5.IWhat technologies are used at different stages? 5.2 5.3 What technology limits the present technical detail of the planning p~ocess? What techniques are used in analysis within the planning effort (e.g. cost-benefit analyses; costeffectiveness analysis; operations analysis studies; task analysis studies; computer-oriented analysis of conceptual models, etc.)?

m__

Relative lliiportanci~cif QUestion in the Planning Cycle

Not essential. Not essential. All in 4.1 above.

5.4

Row sophisticated are the data collection procedures used (e.g. available data; special surveys; national surveys, etc.)?

Not essential.

5.5

What technology is used to present the results of the planning process (e.g. to the public, to politicians, to institutional administrators, etc.)? of sophistication in the different aspects of the planning process? (This question could also be asked under factor 3 above.

Important in Stages 2 and 3.

5.6 Row experienced are the planners and to what levels

All in 4._1.

- 35 -

ICP/HMD/025 Page 4 of 7

Consideration _ 6.

Scope of the Planning Effort

6.1

Are the objectives of the HM planning process a) clearly documented?b) understood by all important groups affected by the Plan? How systematized is the planning process- in tl!qas of a) its potential use as an instrument of soundly-based _ b) c)

Relevant in Stages 1 and 2.

6.2

Not critical. Relevant in Stages I and 2. Relevant in Stage 4. Relevant in Stages 1 and 2.

e) f) g) 6.3

social action or reform? involving all relevant groups, professions, regions, etc.? over-coming entrenched social customs tbat militate against changes in e.g. health care or health manpower supply and utilization? adequately relating considerations of supply, demand, productivity and distribution in assessing the impact of decisions to. implt!1llent new heflth services? its relationship of private and public sector planning? its relationship to other types of planning (e.g. health planning, education planning, national manpower planning, national economic planning)? being based on soundly conceived nonlS, standards, needs and evaluative research?

Relevant in Stages I and 2. Relevant in Stages 1 and 4. Important at all stages, but part:'cularly Stage 2.

BDv subatantial are the processes of .anpower forecasting and research which underpin the planning effort, e.g. the adequacy of these processes for assesaaent of present and future a) health profiles of cOllBllUnities (to provide insights into new health manpower requirements)? Important in base-line dat. collection

- 36 ICP/HMD/025 Page 5 of 7

Conlideration b) c)

Queltionl-Affecting- HealthManpower Planning Component levell of lupply, demand, diltribution and productivity of major health manpower categories? curricula for the education and training (E & T) prograDDe for these categories? costs of E & T (as affected by health service effectiveness, acceptance by consumers and providers, and productivity? migration and movements between and within specialties?

Relative Importance of Queltion in t!t~ Planning Cycle Same al 6.3a. Not critical. Not critical. As in 6.3a. As in 6.3a.

6.4

How adequate and comprehensive is the data base (or information system) available for a) research, planning and analysis affecting health manpower policies? b) specific research into health manpower productivity, task delegation, working conditions, salary, unit costs and the quality of health care provided by different manpower categories? c) "quick and dirty" analysis rather than the analysis of all relevant variables (i.e. is a minimum data set available?) Bow adequate is the level of technical advice and aaeittance available from the planning grotip(s) to a) health facilities which provide training place I and _ployment? b) educational institution. involved in 8M education and training?

As in 6.3a.

6.5

Important in Stage 4.

As in 6.5a

- 37 -

ICP/IIfD/02S Pase 6 of 7 .

Con.ideration

Que.tions Affecting Health Manpower Plaonins Component c) . other national pliplning groups (e.g. in the . koncildc Planninl alencies)'l d) other IOvernment a"acies having direct impact on ''health'' (e.g. Environment. Rousing. Manpower. Education, Coa.unity DeYeiopaent, etc.)'l

Relative Iaportance-of Question in the Pl~nn~ns eycle· As in 6.Sa • As in 6.Sa.

Le,al, Constitutional or Reelatory ractors

7.1

• •t are the legal and. constitutional prPVlsions

affecting health care and health .anpower

developaen~'l

laportant in Stagea 2 and 4. Asin7.!.

A'ffectins the .Planning Process

7.2

~a~

specific regulatory factors influence the planning proceas, health care delivery and health .anpower deve~opaaDt (e.g. in.titutional and .anpower.lieensure, accreditation. reimbursement. etc.)

7.3 • •t specific factor. influence aanpower .upply. di.tribution and productivity (e.g. task delegation, .upervision, etc. 'l 7.4

. As in 7 ~1.

What' .pecific factor. influence consuser involvement in the planning process (.ee also factor 7 below)'l

%aportanee varies ·with type of consuaer involvement.. ' As· in 7.4.

eoo....r

Extent of I~lve.eat

8.1 See factor 7.4 above. 8.2 What is the actual extent of con.uaer participation

in health services evaluation. e.urricul. c;leveloplle1lt, "tioul health plannina. etc. (e.a. hospital bosrds of trustee., health centre coaaittees, com.unity develo,..nt activities, a.lf-belp initiatives, .tc~)

Can 8011eti.a be iaportant in ca.aunity-o~ient.d plannina.

-39 ICP/HHD/025 Page 1 of 11

TABLE 5 ,CHECKLIST: HEALTH MANP~lt,PROl)IlCTION C~N!NTOF

BMP

Health Manpower Education Recruitment (V.l )

Education Progr8lllDe Development

curriculum Development

(V.2)

(V.3)

<v .1)

,Health Manpower Recruitment 'Sub-component Cfiecklist ..,~

QuestlOns ~AffectingHealth Question Consideration 1. Minimum data set describing natUre of problem area

,~~,er

Relative Importance of in th~lanning

Education Recruitment (lIMER) Sub-component 1.1 1.2 what descriptive data are available on the problem 'area and trends? What additional data are needed benmd the~ br,oad broad aggregates (e.g. qualifications; experience; recruitment process/standards/costs; poasible biases in re~ruitment affecting the equity of access of population sub-groups; etc.) What organizations are involved in spec.Hic of E. e.g. . a) e)1trance requirftlents? b) . recruitment/sefection? cOll~tS

Cycle

Important in Stages 1 and 2. Ilay b.e important in Stage 2 and beyond. .

Organizations involved

2.1

Important in Stages I and 2.

- 40 -

ICP/RMD/025 Page 2 of 11

Consideration 2.2

Questions Affecting Health HADpoWer Education Recruitment (RMER) Sub-component What organizations or policies influence HMER, e.g. a) b) c) duration of primary school and secondary school? assessment procedures in secondary education? relationships of basic, post-basic and continuing education?

Relative -Importance of Question - in the Planning Cycle Important in Stage 3 and beyond.

Financ ins methods

3.1

What are the sources and uses of all financing of the area of concern (e ..g. MOH. MOE, Public Service COIIIlIialion, etc.; private sector organizations; professional bodies involved in outreach and screening activities)? What part of it is financed with fees/public budgets/etc.? What staffing methods are used (recruitment, career structure, etc.) a) b)

Important in Stages 1 and 2;

3.2

May be important in Stages 2 and 4.

Staffing aethOds

4.1

Which government agencies staff different components (e.g. MOB, MOE, Civil Service Commission. etc.)? What other publically funded organizations (e.g. universities, other educational institutions. etc. ) provide staff for this fUnction? 1ibat p).'ivate institutions and independent bodies staff this function?

May be important in Stage 2 and "eyarid. Aa in 4.la.

Aa in 4.la.

- 41 -

ICP/HMD/025 Page 3 of 11

Consideration 5.

Questions Affecting He-81th Mlinpower Education Recruitment (HMER) Sub-component 5.1 What are the organization procedures for recruitment (e.g. policies, objectives setting, policy implementation, evaluation)? What specific techniques are used in different stages .of the activity (e.g. advertising, outreach, contact, interview, selection, placement)? What specific facilities or equipment is used at different stages (e.g. in data proceuing)? Are there identifiable goals and objectives for different stages of the recruitment process? Bow systematic is the overall planning proc,ss i~ terms of involVing relevant bodies, involvement of both public and p!'ivate sector organizations, data collection, etc.)?

Rela"Hve Importance of Question in the Planning Cycle Nay be important in Stage 2 and beyond. M

Technologies used

5.2

in 5 •. 1.

·5.3

in 5.1.

Scope of the planning effort affecting HMER

6.1 6.2

Important in Stages 1 and 2. As

in 6.1.

6.3 What specific linkages exist between this aspect of health manpower production and other planning processes (e.g. other areas of BMP, health planning, employment planning and national economic planning)? 7.. Lead, constitutional

in 6.1.

7.1

or reel.tory factors influencing BNIR

What statutes, ministerial responsibilities and otherquasi-legal factors influence both 'the BHEB. process and outca.e?

Nay be important in Stages 3 and 4.

ICP/HMD/025 Page 4 of 11

Consideration 7 .2

Questions Affecting Health Manpower Education Recruitment (HMlR) Sub-component

u_ ---

. Relative-

Importance of QUeltlon in the Planning CyCle

What o.ther external factors (such as national policies on ethnic composition, equality of access and opportunity, or consumer involvement) influence recruitment? . What consumer involvement takes place at any stage (e.g. outreach, selection or placement of the intakes)? How is this involvement facilitated (e.g. by law, by statute, by common agreement, by evaluation, etc.)? What evaluation activities influence different parts of the recruitment process? What partes) of this evaluation is(are) more important or effective than others in determining' the outcome of the recruitmebt process?

AfJ in 7.1.

EXtent of consumer involvement influencing RHER,

8.1 8.2

May be important at all stages. May be important in Stage 2.

Extent of evaluation of HMER processes

9.1 9.2

Important in Stages 1 and 2. As in 9.1.

•

- 43 ICP/HMD/025 Pale 5 of 11 (V.2) EDUCATION PROGRAMME DEVELOPMENT SUB-COMPONENT CHECKLIST

Consideration 1. MinilllUm data set describiDi""iiat'ii're C!f problem area 1.1

Questions Affecting Health Manpower Education PToAT&aDe Development (~D) Sub-cOlljlonent What descriptive data are easily available on existing numbers in education md· training at relevant institutions and at relevan.t levels (basic, post ....basic) CE) affecting problem area?

Relative Importance of Question in the PlanllillLCycle Important in Stages 1 and 2.

1.2 Wbat other data are required for coapletenes. of analysis (e.g. class sizes; pass/fail rates; teacher nu.bers; qualifications and. experience; teaching . .thods used, etc.)? 1.3 What minimum data set should be collected to facilitate continuing analysis of the problem area beyond plan implementation? 2. Oraanizations involved 2.1 What are the types, nuabers and locations of the maJor institutions producing health manpower in this problem area? Who has managerial responsibility for these institutions (e.g. MOB, MOE, universities, private sectors, etc)? What I118jor organizations are involved'· in Teacher Training (rT) theae ..u.power cateaori..? Who bas managerial responsibility for tbese Tl' organizations? What other organizations are involved in otber aspects of iPD (e.g. researchers, evaluators, planners, administrators, etc.)?

Important in Stage 2.

Important beyond this planning cycle.

Important in Stages 1 and 2.

2.2

May be important in Stages 1 and 2. Same a8

2.3 2.4 2.5

2.3.

Same

as 2.3.

Same as 2.3.

- 44 ICP/lDfD/025 Page 6 of 11

Consideration

Questions Affecting Health Manpower Education Progr_ Development (!PD)S~))-component 3.1 Mbat are the major types of funding' in !PD?

Relati:ie-taportance of Quel!tion in the Planning Cycle S.- as 2.1.

Financing methods

3.2

What are the major sources of funding for these activities (e.g. public sector budgets, fees, private foundations, external aid, etc.)? What are the major!!!!! (or recipients).of these funds? lihat are the types, numbers, qualifications and location of the staff in different education programmes a) b) c)

s..

as 1.2.

3.3

Saae as 1.2.

Staffing methods

4.1

s..

as 2.1.

basic? post-basic? continuing? Same as 2.1.

4.2Wbat other staff are located. in government agencies, private sector institutions, universitydepartmentl or research centres, etc.?

Technologies used

5.1

What educational technologies are in use or under development in different !PDs (e.g. class, modified classroom, saall group, progra.med instruction, CAl, experiential, etc.)? What&,.cific dicacipli_ry. cross-4iacipliDary. multidisciplinary or other approaches are in use or under develo~t in various 1PDs?

May be important in Stages 2 and 4.

5.2

May be t.,ortant in Stages 2 and 4.

- 45 ICP/HMD/025 Page 7 of 11

Consideration 6. Scope of the existing planning process for different EPDs 6.1

Quest10ns Affecting Health Manpower Education Programme Deve1opme.nt (EPD) Sub-component Who plans, develops, tests and evaluates new EPDs and their different components (objectives, course or programme content, curriculum, teaching method, etc.)? What is the organization of the planning processes for different EPDs (MOH, MOE, other public sector agencies listed in consideration 2 above; external advisers, foreign experts, etc.)? How comprehensive is the planning of existing EPDs (e.g. sophistication of ongoing data collection and analysis; linkages with other planning processes in health and manpower planning; level of consumer, provider and student involvement, etc.)? What is the impact of the existing process and how is it measured? What minimum data base for future planning is available from EPD? What specific factors influence the scope and functions of the different organizations involved in EPD in educational institutions and how? Which such factors influence the ~ructure, costs and outcome of EPD located in health care institutions (e.g. supervision of training posts, institutional aC.creditat ion requirements, etc.)?

Relative Importance of Question in the}>lallning Cycle Important in Stages 1 and 2.

6.2

As in 6.1.

6.3

May be important in Stage 2.

6.4 6.5

May be important in all stages As

in (6.4)

Legal, constitutional and regulatory factors influencing different EPD

7.1

May be important in Stage 2

7.2

in (7.1)

- ,46 -

fCP/HMD/625 Page 8 of 11

Consideration 7.3

QUestiO'lS Affecting Health Manpower Education Progr.... Development (EPD)_ Sub_-<l~ent Which specific requirements of professional accreditation influence the nature, .costs and outcome of EPD at the basic and poat-baaic levels of EPD? What is the level of conaumer involvement in EPD ,planning, deaign, implementation or evaluation? What positive or negative iapaeta of consumer involvement in EPD are identifiable? What evaluative research activitiea are ongoing or completed. on the appropriateness to needs, effectiveness, efficiency, cost, quality or acceptability of EPDs? What specific organizations are involved in EPD evaluation?

Relative Importance of.Queation in the Plannip,g Cycle As in 7.1.

Level of conaumer involvement in·EPD

8.1 8.2

May be important in Stages I and 2. As.

in 8.1.

IValuation of EPD

9.1

As in 8.1

9;2

9.3 .What gaps exist in evaluative reaearch that are critical to future changes in EPD?

- 41 ICP/HMD/025 Page 9 of 11 (V. 3) CURRICULUM DEVELOPMENT SUB-COMPONENT CHECKLIST

£ons iderat ion 1.

Questions Affecting HealthM4npower Education Recruitment (ltHER) Sub-co.ponent 1.1 What available data describe present _thods of CD (e.g. range of methods used, number of staff and qualifications, etc)? What other data are required for comprehensive· analysis of the CD problem area? What organizations determine the contents of the· curriculum in the major health manpower education programmes in basic, post-basic and continuing education: public sector agencies (e.g. divisions of manpower in MOH; MOE) b) individual schools of health professions c) independent CD organizations (e.g. centres for learning reSOl,1rces, 1'l"l'C). d). professional as.ociatiorts e) accreditation bodies f) service delivery organizations a)

-Iterative Importance-of QueeHon in the Plannil\g Cycle May be important in Stag-e 2

Minimum data set describing natUre of problem area .

1.2

May be important in Stage 2

GrmizatiOns involved

2.1

As in

1.1

Financing methods

3.1 3.2

What are the sources and uses of all funding of CD? What proportion of each of the are financed fro. a) b) c) abov~

in 1.1

activities

public .ector agencies (e.g. MOIl. MOE) private .ector budgets (e.g. training programmes for nurses in private hospitals) external sources (e.g. deve10paent assistance, international foundations, etc.)

- 48 ICP/lDID/025 Pae 10 of 11

Consideration 4. Staffing ~thods

Questions Affecting Curriculum Development (CD)Sub-cOllPonent 4.1 4.2

Relati.e Importance of Question . _ in the PlannJng C':!cle As in 1.2

. a t numbers and qualifications of staff are in.olved? How are the different CD processes sta·ffed, and

with what levels and qualifications of staff a) indigenous staff b) indigenous plus external advisory stafr c) RTTC and other s imitar centres If) other combinations involving accreditation agencies.

Technologies used

5.1

What CD techniques are (a) developed

(b) applied?

As in 1.2

5.2 What combination of education and -.nageaent technologies do the different CD processes apply - e.g. a) functional analysis, task analysis, organization analysis? b) teaching materials (lectures.• AV-TV. other visual aids, etc.)?

Scope of planning processes

6.1 6.2

Which organizations are involved in foraal and informal planning processes affect in, CD? How sYltematic is the planning procus (in terms

As in 1.1 As in 1.2

or or,ani.ation involved. sopbiaticatioe of planning tec:hDique.; relationlhip to specific objective. and purpos.s)?

- 49 ICP/HMD/025 Pa,e 11 of 11

Consideration 7. Leld, conltitutional or "lUlatog fact()rs influenci~g CD . '

QUestIOns Affectin, Cuqicul3B'lOfN,lo,...t <CD) Sub ..c.OIIIponent

Relative I.pOt-tanee of QUestion in the Planning Cycle As in 1.2.

7.1

....:.-.

Which specific L/C/R factors affect the scope of practice of individual health profes.ions and the cOntent of their training? Wha1:,,,specif.i:c' limitations on CD occur-as a resl,1lt of accreditation of health. prof.saionals by external asencies (e.g. Society of Radiographers, ft; lloya1 Society of Health; Royal Colleges of Physicians, Surgeons, etc., .V8 "",ciaity·boaE'\fs, .etc.)? What iilipact does the"Conswler have on CD through traditional advi8Qrys~Aotures (e.a.academic advisory boards, facult.y senatelt. IiQspital advisory boards, village committees)1 . What other types of cOnsumer involvement influence CD? Does formal evaluation follow curriculum implementation (e.g. student performance, teacher performance. teaching process~' e.fficieney/ ,.cceptability/coordination, etc.)? What types of infprmal evaluation"occ_ :and bow s~tic is' the iapact 'o"t .'ui:b'evaluaHon? . What is the impact ofthe81S dilfeuht:evaluation efforts?

7.2

As in 1.1.

Extent of consumer involvement in CD

8. I

As in 1.1.

8.2

Extent of evaluation of CD

9.1

May influence all stages.

9.2 9.3

.. iJI (1.1). As in (1.1).

-so ICP/mm/025

Pa,e 1 of 5 TABLE 6 CHECKLIST: HEALTH- KAMPOWER MANA(;!IIQT COMPONENT OF HMP

\' Consideration 1.

Questions Affecting B e - . l t h - Relativ-eimportance of QUestion Manpower Han"'Aem~llt ~C)11Ip()nent__ __ in the Planning Cycle 1.1

Minimum data set describing nature of problem area

What minimum available data provide a descript ive pi~ture of problem area and trends? What other data are required to give a comprehensive picture of the problem or solutions? ~lich

Hay be important in Stage 2. Hay be important in Stage 2.

1.2

Organizations involved

2.1

organizations have the major respon.ibility for recruitment into and deplOyment of health personnel in the nation's health services, particularly in activities such as: establishments (classification of posts and numbers) stafring patterns (i.e. mixes of manpower categories) salaries conditions of service (both health personnel and teachers of health personnel)1

As in 1.1.

a) b) c)

d) 2.2

Which organizations have major responsibility for at.'Laoupervilion and staff c1evelOJ!!!!Dt once staff are _ ployed, e.g.: a) b) c) public agencies responsible for approving adainistrative and supervisory structures reaulatory boards (who license particular personnel cateaories following basic and post-basic training) organizations with responsibilities for institutional accreditation?

As in 1.1.

- 51 ICP IJOIII;/ft2 5 Page 20£ 5

Consideration 2.3

Questiona Affec:ting Health Manpower Management COBIponent Which organizations have _jar r.esponsibilities for the data collection and health information systemdevelo~nt activities which provide data .on: a) . supply (posts approved; vacancies; establishments; qualifications) b) distribution (geographical, professional; functional) c) prod.uctivity (individual profeasions; health te"') d) utilization (by patient probl . . catelory ~d by provider attributes) e) quality of care (both technical quality and the art~of-care c~ponent that influences lifeatyle changes)?

Relative Importance of Question . in !he Planning Cycle . As in 1.1.

Financing methods

3.1

What are the sources and uses of all budgets in tbeproblem area? . 'llbat are the numbers and qualifications of manpower involved in these activities, e.g. in: a) b) c) c1) public sector alencies· (HOB, MOE, Civil .Service Com-iasion. etc.) private sector organizations iad.pendent orpoi.adons elEternal advisers? AI in 1.1.

Staffing methods

4.1

4.2

specific training progr..- andc~reer d.veloJlllent paths .dst for individuals invoived in the third activity, i.e .. health unpower data collection and manpower research?

in 1.2.

--.

- 52 ICP/HMD/025 Pale 3 of 5

Consideration 4.3

Questions Affecting Health Manpower Management ComfOnent Are existing scholarship, fellowship and continuing educat.ion adequat·ely targeted towards professional developaent for the professions involved in all three activities? What physical facilities and other equipment are used in each of the areas (e.g. records, space, filing/retrieval facilities)?

Rerative~-tlllpOrtaDce of Questlon in the Planning Cycle As in 1.2.

\ 'I '

5·.

Teehnologi.,es used

5.1

As in 1.2.

5.2 What data processing technoiogies are used in each of the three activities (e.g. manual, punched cards, EDP, microfiche, etc.)? 6. Scope of planning

As in 1.2.

6.1

lihat specific planning processes affect the area? Is there evidence of systematic attempts to plan and evaluate the supply and utilization of the health professions (e.g. have there been attempts to develop and use information systems in MOB; MOE; National iconomic Planning Unit; interagency caa.ittees; multisectoral planning projects funded by external aid, etc.)? Ie there evidence of systematic att"pts to plan and paluate patterns of career developlHllt in tile key bealth .professions (including the effects of MDpower .iatation changes; new health services, new health professions. etc.)1

in 1.1.

processes affecting activity

6.2

As in 1.2.

6.3

in 1.2.

-~ .....- - -..... ---'-OW'.

---------~ ~

-~- - - - - - - - - -

-53 ICP/HMD/025 Page 4 of 5

Consideration

Que.tion. Affecting Health Manpower Management Component

..~ - - " - - ' .

blative Importance of Question in the Planning Cycle As in 1.2.

6.4

Is there any evidence of action to meet current training needs in key professions (such as evaluators. researchers, heal th institution managers, nurse educators, etc.? Is there any evidence of a systematic attempt to review the aclequacy of all the nol'1ll8 and stanelards applied in any ongoing planning effort (e~g. doctor or nurse,populat ion ratios)? What specific factors influence the problem area? Which of these factors most adversely affect the management of individual health professions a) in institutional care b) in cOlllBUDity care . c) in government administration? lIlichsuch factors affect the completeness of or sece.. to an adequate health _power information system (e.g. national concerns about individual privacy; statutory responsibilities of certain agencies to collect data)? Which traditional methods of conSUller in"olvement influence the precess and outcome of til... three activities (e.g. representation on goverDll8llt adviaory bodies, hospital boards, cOIIIBUDity action committeeB, villale committees, etc.)?

6.5

AIl in 1.1

Legal, constitutional and regulatory factors affecting the process and 'outcome of these activities

7.1 7.2

AIl in 1.1. As in 1.2.

7.3

A. in 1.2.

Bxtellt

of cocauaer

,ac'tivities?

E$l"E;t eae ree

8.1

AIl in 1.2.

- 54 -

ICP/mm/025 Page 5 of 5

Consideration 8.2

Questions Affecting Health Manpower Management Component

- - - - - -

-Re1i-tive Importance of Question in the Planning Cyc Ie As in 1.2.

Which other methods of consumer involvement significantly influence these activities (e.g. political and professional influences on recruitment, selection and career development paths in certain health professions)? See questions 6.1, 6.2 and 6.4 above. Is there any evidence of attempts to evaluate the long-term impact of existing overlaps in the roles and responsibilities of: a) b) c) d) e) f) certain health professions (e.g. medical graduates, medical assistants, nurses, nurse aides) incentives fpr redistribution of manpower international trends in migration of manpower ongoing activities that influence work force· productivity (e.g. through health tea. development, role changes, etc.) new service delivery system changes in the methods of financing of health care (including changes in social security coverage)?

Extent of evaluation of these activities

9.1 9.2

As in 1.2.

- 55 -

CHAPTER 5 NEEDS FOR CONSULTATIVE SERVICES IN THE HEALTH MANPOWER PROCESS

5.1

Overview

This last section is an attempt to summarize some of the implications of Chapters 3 and 4 for future consultants. A number of individual consultant skills would be required. It should also be noted that countries are roughly at one of three stages of commitment and development of the health manpower precess and country health programming" .e.: - countries which are well advanced in their conceptualization and development of the HMP (in such nations, consultants might well study the process of innovation that led to these developments); - countries which have partly developed HHPs and whose commitment to HHP is beyond doubt (in these nations, specific consultant skills may be applicable in the less developed components of their HMP); - countries which have obvious problems in their HMP, and which seem unable or unwilling to devote resources to the solution of these problems (in these nations, a larger number of consultant skills might,be required). Consultant skills could be applied to the solution of some recurring problems in the three components of HMP, viz., HMP planning: 1. Skills related to bringing together coalitions to plan in the HMP.

2. Skills related to plan preparation (e.g. data collection and analysis; forecasting future requirements; operational research studies). 3. Skills related to "selling" of the final plan.

HM produc t ion 1. Skills related to recruitment of students to educational institutions (e.g. psychometric skills; personnel administration processes in an education institution). 2. Skills related to educational programme development (e.g. educational planners with expertise in the related aspects of economic and country health programming processes). 3. Skills related to curriculum development (e.g. educational technologists; experts in curriculum objectives-setting).

- S6 -

HMP management: 1. Skills in health information system design to improve the management of different health care institutions (e.g. information systems design for financial, manpower and programme budgeting). 2. Skills in human resource development for staff employed in health care institutions (e.g. short-stay and long-stay hospitals; health centres; home care, etc.). S.2 Consultants for health manpower planning component

Three types of consultant input may be desirable. The first of these inputs (Project l) might involve a short-term consultant j~ the review of the impact of "coalition formation" on the success or otherwise of the planning process in a selected group of countries. The objp.ctive of this project might be to identify those factors in coalition-formation that facilitated acceptance and implementation of the final plan. The type of consultant required would have had considerable cooperation in the study of political processes in developing nations, and the background qualifications could be those of a political scientist, sociologist or anthropologist. The work of Dr Anthony Ugalde (University of Texas) in Iran and in Colombia illustrates the potential of such a consultancy.l A second set of consultant activities would involve a more technically oriented consultant in projects whose objective would be the aevelopment of appropriate manpower skills in the plan preparation phase. One short-term project (Project 2) could attempt to inventory which nations have developed effective (i.e. usable) methods of data collection and data analysis, forecasting and operational research that are appropriate to the level of planning carried out in the nations. A second set of projects (Project 3) might help particular nations solve specific problems in each of these technical areas. A third project (Project 4) might review the state-of-the art in minimum data set development and usage. A fourth project (Project S) might identify training needs to upgrade specific health manpower planning skills that are in short supply in the Region, reviewing the adequacy of existing educational programmes which now produce graduates with such skills. Finally, it might be appropriate to focus on a third general problem area in health manpower planning, i.e. how the final plan is "sold" to different audiences. This project could be usefully linked to Project 1 above. The objective of such a project is to identify successful mechanisms by which plans (both adequate and less so in the technical sense) have been accepted in different nations. The project would include a specific study of the processes of advocacy and communication used in an effective "selling" process.

1See A. Ugalde (1977), Social Science and Medicine, reference to be provided.

.' 5.3

57 -

Consultants for health manpower production

The Regional Office for the Western Pacific has already initiated a number of projects directed on specific components of HH Production (e.g. curriculum studies, environmental manpower etc.). One project (Project 6) might review successful methods of linking educational planning with both economic planning, country health programming and health manpower planning. The objective of such a project would be to link functional area planning (e.g. health, education, public works, etc.) within the broader framework of national economic planning. A second project (Project 7) might review the ways in which education and health planners are brought together at the national, state and sub-state level. l 5.4 Relative priorities in future consultancies

Among the ten projects identified, special attention will be given to those projects which focus on: (a) (b) minimum data base development in the health manpower planning component (projects 4 and 10); and "coalition formation" and "plan selling" (projects 1 and 3).

In the area of recruitment into educational programmes, there are few countries that have developed robust instruments for selection of students. Few countries in the Region would have the time or money to sfend on development of the equivalent of the United States MeAT for selecting medical school students. But there could be some value in a project (Project 8) to review the instruments presently used to select students into key professions in different countries of the Region. 5.5 Consultants for health manpower management

One pre-occupation in this document has been the adequacy of the data base available for the health manpower process. One project (Project 9) might review existing methods'of collection of data in health care institutions and in non-institutional health care with a view to identifying which countries have successfully developed components of a HMIS which are also used in their health manpower process.

IAn example of the potential of such a review is The Future Planning and Development of Health Manpower in Australia, Canberra. Hospitals and Health Services Commission, Research Management Monograph No.6, June 1978, 33 pp.

- 58 -

A second project (Project 10) might attack the same problem from the conceptual end to postulate what minimum data bases are required in countries of the Region for health manpower management in specific services. Such a project would be a natural extension of Project 4 above; but with particular emphasis on methods of linkage of manpower data (from institutional data collection processes such as budget data; payroll data; personnel record data) with data on manpower utilization and productivity from specific studies of these phenomena.

- 59 -

ANNEX

CASE STUDY: DEVELOPING WORKERS FOR PRIMARY HEALTH CARE

BACKGROUND INFORMATION

Country B is a developing nation of approximately 10 million people. Its economy is based primarily on agriculture and roughly 80 per cent of the population live in rural areas. There are, however, three ~arge urban centres located in a triangular area in the southern part of the country, where the seat of government and most industry, shipping and CaaDerce are situated.

PREPLANNING

With the aid of an external agency, a planning unit had been established within the Ministry of Health. Health manpower planning was identified as an important function of the unit, and one staff member had been delegated responsibility for coordinating activities involved in this function. A Health Manpower Working Group had been called together as a focal group to undertake an analysis of the health manpower situation in the country, to advise on health manpower policy ,formulation and to develop plans for health manpower programmes.

SITUATIONAL ANALYSIS

Analysis of the current manpower situation and projected estimates of supply and requirements, based on present manpo\?er policies and resources, identified the following problems: 3.1 Present and anticipated continuing shortages of professional nursing personnel, particularly to staff general hospitals. 3.2 A tendency to over-production of hospital-trained nursing auxiliaries and insufficient production of community based auxiliaries.

3.3 A gross maldistribution of services and qualified health personnel, with concentration of both in the urban areas, leaving the rural areas seriously underserviced.

- 60 Annex

3.4 A grossly inequitable distribution between hospital and community services. 3.5 Insufficient present and anticipated supply of environmental health workers, plus disparity between training programmes and task requirements the field. 3.6

Extreme shortages, existing and continued, of trained dental personnel. increasin:~

3.7 A potential problem of the country's inability to a:fo·.. d the number of physicians being prepared. 3.8

A serious shortage of qualified teachers for all training programmes. 4. PLAN FORMULATION

4.1

Health problems

An assessment of the health status of the population had shown excessively high maternal, infant and child mortality rates, a very high birth rate, widespread malnutrition and the prevalence of many preventable communicable and infectious diseases. The incidence of measles, for example, was high in children, and water-borne infections in both adults and children. Malaria was prevalent throughout the country and tuberculoais common. Assessment of health services and of health manpower had both pointed out the gross disparity between urban and rural areas, with the people living in the villages and rural communities (who comprised approximately 80 per cent of the population), having very little access to services and very few qualified health personnel beyond the district hospital level. 4.2 Deci~ion

to attack specific problems

A decision was made by government to attempt to attack the major health problems in the country through extension of health services in the rural areas. A target date was set for 1990 to complete the programme. 4.3 Exploration of alternative manpower strategies

The Health Manpower Working Group established a subcommittee on Primary Health Care to assess the implications of the government decision, to explore the possibilities of alternative strategies to provide these services, and to develop a proposal for submission to Government to implement primary health care services throughout the country by 1990.

- 61 -

Annex -----

Two experimental projects, both undertaken with external collaboration, were already underway (one almost completed) in the country. One was a pilot project to deliver primary health care services in a rural district near the capital city. The second was an integrated rural development project which included health care as a major component. In both projects, training programmes had been inaugurated for traditional birth attendants, and for village health workers (vaw). The training programmes for VHWs were similar, but they functioned in ~he villages differed. th~

way in which

One project included a rural health training school, which had been established originally by the Ministry of Health to prepare male nurses to administer health centres and provide basic medical services in under-doctored rural areas. This school was used to train community (village) clinic attendants, nutrition workers and community disease workers for the project. Representatives from the staff of both projects were seconded to the Health Manpower Working Group's Sub-committee on Primary Health Care. 4.4 Development of a programme plan

The Sub-committee on Primary Health Care used the combined experience from both projects to develop a plan for: (1) (2) (3) (4) the structure of rural health services determination of the categories of workers needed at each level of service identification of their respective tasks recommendation of guidelines for the training of personnel

Three levels of primary health care services were planned: (1) (2) (3) village level health post level - for several villages health centre level - major sub-district

The next level of service·was the district hospital and the district public health services which were already staffed with existing categories of health personnel. The tasks needed to be done at each of the three primary health care levels were identified, and these were aggregated to determine the different types of workers needed.

The number of workers needed (by type) to implement the plan fully, that is, covering every village in the country, were estimated. These estimates were based on the number of districts in each state and the number of villages in each district. It was recognized that a careful analysis of each district would be required as the plan was phased in, to more precisely quantify requirements. Education programmes to prepare the required manpower were recommended. These included: (1) (2) (3)

programmes to prepare village health workers programme3 to upgrade traditional birth atteneants (a) an amalgamation of the existing training prograaaes for hospital and community auxiliary nurses (b) revision of the curricula for the programmes, to include midwifery and basic diagnostic and clinical management skills

(4) (5) (6) (7)

possible expansion of the existing programme for the physician assistant type of male nurse expansion and revision of the training prograllllles for environmental health workers a tutor-training programme (multidisciplinary) training programme for district level health personnel (including the district MOH, PHN, environmental and nutrition workers)

Estimates were made of the resources needed to phase in the primary health care programme, starting with one district in each state. The programme plan was submitted, and if approved, detailed planning would be undertaken in the districts selected for initial imple&entation. 5. IMPLEMENTATION .A. PREPARATION OF HEALTH MANPOWER

The first step in implementing the primary health care programme was intended to bring together the state medical officers to discuss the plans and ensure their cooperation. The next step was preparation of the district level health teams, one team from each district selected by their respective states to initiate the programme. A 3-month programme was being planned for these people to orient them to the primary health care programme and their role and responsibilities in coordinating and supervising it (The PHC sub-committee was to act as advisory committee to the programme).

- 63 -

Meanwhile, the national nursing education committee was looking into revision of curricula for the auxiliary nurses to amalgamate the two programmes in line with the recommendations of the sub-committee on primary care. The curriculum for environmental health workers was also to be revised and the intake enlarged to prepare the necessary number of workers. An advisory committee for a multidisciplinary teacher-training programme was being established, the course to be developed at one of the universities.

A common (national) curriculum was agreed upon for village health workers based on th~ WHO guidelines but adapted to the specific needs of the country. Similarly, a course for upgrading TBA's was being developed. This, too, was based on the WHO guidelines but modified (as in the experimental projects) to meet local needs. These programmes were to be instituted at the local level, with training done by the district PHN assisted by district hospital staff. The programme preparing male nurses as physician assistants was expected to be expanded, with a modified curriculum that included more emphasis on community health. 6. IMPLEMENTATION E.: DEPLOYMENT

A detailed analysis of each district was to be undertaken prior to the inauguration of primary health care services~ This analysis would include socioeconomic and cultural aspects of communities as well as basic data on the population, existing health workers in the area (traditional and other). In both pilot projects, the village leaders had been brought into planning and implementation of the programmes from the beginning and it was expected that this process would continue, e.g. the village leaders selected candidates for both the TBA and VHW training programmes and were responsible for paying them.

Key facts

Organisation World Health Organization (WHO)

Document type Technical Documents

Adoption date December 31, 1979

Source World Health Organization