AFR/RC57/9 25 June 2007
REGIONAL COMMITTEE FOR AFRICA Fifty-seventh session Brazzaville, Republic of Congo, 27–31 August 2007 Provisional agenda item 7.7
ORIGINAL: ENGLISH
DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH IN THE WHO AFRICAN REGION: CURRENT SITUATION AND WAY FOWARD
CONTENTS Paragraphs BACKGROUND ............................................................................................................................... 1–7 ISSUES AND CHALLENGES ....................................................................................................... 8–15 ACTIONS PROPOSED................................................................................................................. 16–25
AFR/RC57/9 Page 1
BACKGROUND 1. In 1998 and 2002 Member States of the WHO African Region discussed and adopted resolutions1 to strengthen their capacities to optimize the utilization of their human resources for health (HRH) with a view to achieving the health objectives of the Region. These resolutions recommended priority interventions such as policy formulation and planning for the development of the health workforce, education, training and skills development, administration and management, research and regulation of health professions. 2. World Health Assembly resolutions2 also recognized the importance of human resources in health care delivery systems and proposed possible actions for reversing the negative effects of migration, strengthening nursing and midwifery, and scaling up the production of all categories of health workers. 3. WHO guidelines for policy formulation and planning were developed and disseminated in countries. Tools and guidelines to ensure quality and relevance of education and training were developed and used by countries. Five WHO collaborating centres for human resources for health were established, and five regional training centres continue to receive WHO technical and financial support. Nine medical schools and nine nursing schools were evaluated from 2002 to 2006 and supported to implement the recommendations. 4. Several approaches in health workforce management were implemented in some countries. For instance, new career profiles were established in Côte d’Ivoire and Mauritania; new contractual arrangements were set up in Benin, Kenya and Uganda; and human resource units were upgraded in South Africa. Various macroeconomic initiatives were used to recruit and motivate the health workforces in Cameroon, Cape Verde, Malawi and Zambia. 5. The status of the health workforce in the African Region was assessed in the 46 Member countries through surveys in 2003 and 2005; these resulted in the development of a database and country fact sheets. A regional health workforce observatory is being established, and Ethiopia, Ghana and Tanzania started the process of establishing national observatories. A total of 74 health workforce managers from 40 countries were trained from 2001 to 2004. 6. At the regional level, the African platform for health workforce development consisting of regional stakeholders was established to support countries in addressing the crisis. Collaboration with partners such as the African Union, the regional economic communities, the European Commission and the Global Health Workforce Alliance was significantly enhanced. More stakeholders and partners are willing to commit resources for health workforce development in countries.
1
2
Resolution AFR/RC48/R3, Regional strategy for the development of human resources for health. In: Forty-eighth session of the WHO Regional Committee for Africa, Final Report, pp. 6–8, Harare, World Health Organization, Regional Office for Africa, 1998; Resolution AFR/RC52/R5, Human resources development for health: Accelerating implementation of the regional strategy. In: Fifty-second session of the WHO Regional Committee for Africa, Final Report, pp. 13–14, Harare, World Health Organization, Regional Office for Africa, 2002. Resolution WHA57.19, International migration of health personnel: A challenge for health systems in developing countries, Geneva, 2004; Resolution WHA59. 23, Rapid scaling up of health workforce production, Geneva, 2006; Resolution WHA59.27, Strengthening nursing and midwifery, Geneva, 2006.
AFR/RC57/9 Page 2
7. Despite these actions and some encouraging results, the African Region is still experiencing an unprecedented crisis in the health workforce. The purpose of this document is to provide information on the progress made and propose a range of actions for the way forward. ISSUES AND CHALLENGES Funding for health workforce development 8. Over the past ten years, there have been many opportunities to invest in the development of the health workforce, but these opportunities have not all been used optimally. For example, countries are yet to fully explore the opportunities from the poverty reduction strategies; debt cancellation; the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria; and the Global Alliance for Vaccines and Immunization. On the other hand, ministries of finance are reluctant to endorse wage increases from external aid since such funds have been demonstrated to be unpredictable and unsustainable. 9. Low budgetary allocations to the social sector, in particular to health, are an impediment to strategies for training, recruiting and retaining health workers. Thus, the apparent high rates of recurrent expenditure (50%–70%) for remuneration of health workers for most public budgets in real terms translate to salaries as low as US$ 23–40 per month for a general medical practitioner and much lower for other cadres. Within this context, the main challenge is how to mobilize the requisite additional financial resources from both domestic and external sources and use them appropriately to reverse the current HRH crisis. Policy and planning for the workforce 10. Only 13 (28%) out of 46 countries have both a health workforce policy and plan while 33 (71%) have either a policy or plan.3 The policies and plans are often not evidence-based, costed or implemented. Most are developed without the involvement of the private sector and other important stakeholders. The challenges include how to fully involve other stakeholders to develop comprehensive and integrated policies and plans and ensure their implementation. Production of human resources for health 11. Training institutions are not producing a sufficient and consistent supply of health workers to replenish the dwindling HRH due mainly to attrition and years of underinvestment in institutional capacity. This underinvestment has resulted in dilapidated and inadequate health infrastructure, insufficient teaching staff and an inappropriate skills mix of graduates. Meanwhile, considerable funding is spent on training workshops for priority health programmes; however, such training is inefficiently linked with the training institutions and hence does not contribute to ensure sustainability in the production and continuing professional education of the health workforce. The challenge is how to coordinate and integrate educational activities for both priority programmes and training institutions. The other challenge is posed by the fact that training and education of health workers involves sectors other than health.
3
WHO, Status of human resources for health in the Africa Region: Survey report, Brazzaville, World Health Organization, Regional Office for Africa, 2006.
AFR/RC57/9 Page 3
Motivation and retention 12. A study4 on the migration of skilled health workers in 2002 in six African countries showed a decline in the number of available health workers. About two thirds of those interviewed expressed an intention to migrate, underscoring the gravity of the situation. Health workforce shortages have become acute in 36 countries in the African Region.5 This crisis continues to worsen with the attrition of health workers due to the impact of HIV/AIDS on the workers themselves. 13. Difficult working conditions characterized by heavy workloads, lack of equipment, poor salaries and diminished opportunities for advancement contribute to the state of de-motivation and poor performance of staff. These conditions are worse in rural areas, giving rise to inequitable staff distribution compared to urban areas. The outcome is increased migration from public to private sector, from rural to urban areas, or emigration. One strategic challenge is to change the inequitable distribution of health workers and thus serve both rural and urban areas. In addition, some countries are unable to recruit trained workers due to budgetary constraints. Management 14. Most health workforce divisions in ministries of health do not have the capacity to carry out their human resources functions, including stewardship and leadership. Furthermore, health workforce issues are complex and go beyond the health sector. Effective management of the health workforce therefore remains a key challenge and responsibility of not only the Ministry of Health but also the public service authorities. Though partnerships for health workforce development may have improved, there is not enough progress at country level due to fragmented efforts and insufficient coordination. Information and research 15. The existing information and research evidence show problems of inadequacy, inconsistency, duplication and poor linkages in the available data; in addition, countries lack systems to process and manage information to ensure easy access for decision-making. One of the main challenges confronting this crucial area is how to set up mechanisms to process and manage data to ensure easy access. ACTIONS PROPOSED 16. Given the current situation and challenges, it is proposed that countries should, for at least a decade, substantially invest in implementing sustained multiple actions to ensure that the required health workforce is in place and functional. The following proposed actions focus on six interrelated strategic areas.
4
5
Awases M et al, Migration of health workers in six countries: A synthesis report, Brazzaville, World Health Organization, Regional Office for Africa, 2004. WHO, The world health report: Working together for health, Geneva, World Health Organization, 2006.
AFR/RC57/9 Page 4
Create fiscal space 17. Countries should identify and implement innovative ways of creating fiscal space for health workforce development which should be institutionalized. These include implementing the decision to spend at least 15% of national budgets on the health sector and seize existing opportunities such as debt relief. Concerted efforts should be made to increase budget ceilings to allow governments to improve wage bills that allow for recruitment of more health workers or mobilization of donor funds to increase remuneration and incentive packages. Policy decisions should be made on using a negotiated percentage of development funding for priority health programmes, to support implementation of strategic components of health workforce plans. Advocacy at regional and global level should continue to solicit for substantial financial investment in health systems development that includes human resources. Accelerate formulation and implementation of comprehensive policies and plans 18. Effective planning is essential for future human resource needs based on current shortfalls and linked to the potential to recruit and retain an expanded health workforce. Therefore, countries are encouraged to develop and implement evidence-based comprehensive HRH policies and plans, with involvement from numerous sectors and stakeholders. The plans must forecast supply and demand for the whole health system, including priority programmes, and should be costed and operationalized for implementation. At the regional level, a multidisciplinary pool of African HRH experts should be strengthened to support countries in HRH planning and key workforce interventions. Produce more human resources for health 19. Increased investment is needed in preservice training to produce more health workers. Countries need to strengthen the capacity of training institutions for scaling up production of health workers, especially midlevel cadres to deliver promotive, preventive and curative health care in an integrated manner. Key actions for capacity building include reforming and upgrading training institutions, as well as exploring innovative ways of expanding training capacity, such as publicprivate partnerships. The process should start with evaluation of both private and public educational institutions to ensure an appropriate skills mix based on the health needs of the population. Accreditation mechanisms to certify academic institutions, education programmes and training performance should be prioritized. Utilization of WHO collaborating centres and regional training institutions should be optimized for training and research. Improve management systems 20. Countries are urged to give priority to improving the skills, equipment and status of health workforce departments to enable them to carry out their strategic functions. Professional bodies (regulatory and professional associations) should be empowered within national legislation to protect people’s health, including promotion of professional ethics, as well as the interests of health workers. In order to address skills and competency gaps for effective service delivery, continuing professional education should be promoted as part of in-service training, including distance learning. Technical support for strengthening health workforce management systems in countries should be provided from the regional level.
AFR/RC57/9 Page 5
Develop and implement retention strategies 21. Countries are encouraged to make policy decisions for attracting and recruiting more health workers as a matter of urgency within specific country contexts. The current employment and deployment policies and practices should be reviewed, and new opportunities for recruitment should be considered. Strategies to improve the utilization, performance, working conditions and retention of health workers should be considered. Strategies, including bilateral and multilateral agreements, for managing migration should be developed and implemented. Generate evidence 22. Countries are encouraged to strengthen effective collection and management of human resource information with core data sets and indicators useful for policy, planning and implementation. Countries should consider establishing national observatories as mechanisms for knowledge management, information-sharing and evidence for health workforce development. The regional HRH observatory will accelerate regional monitoring and evaluation, formulation of a research agenda and advocacy for research implementation. The observatory will also share best HRH innovative interventions such as management of salaries and incentives, evidence for sustainability of investment into HRH, and others. Foster partnerships 23. Countries are urged to strengthen, sustain and formalize mechanisms for intersectoral partnerships, including the private sector, NGOs and the diaspora, for health workforce development. One key role of these partnerships is to contribute to the planning, implementing and monitoring of national health workforce policies. The stewardship role of national authorities should lead the process and harness the contribution of all the players in the planning, production and utilization of health workers. 24. Regional level mechanisms for intersectoral partnerships should also be formalized and strengthened for coordinated support to countries. Institutions such as the Global Health Workforce Alliance and the African Health Workforce Observatory should be supported and strengthened for following up global, international and national commitments and resolutions. Such mechanisms should address the need for additional financial resources from both domestic and external investments. 25. The Regional Committee is requested to examine and adopt these actions meant to alleviate the human resources for health crisis in the Region.