Addressing the Human Resource in Health Crisis: Empowering the Private Not for Profit Health Training Institutions

to Play their Role

The Views and Experiences of Uganda Catholic Medical BureauPresentation to the Christian Connections International Health

2006 Annual Conference May – June, 2006

Authors: Marieke Verhallen, Daniele Giusti, Nancy Bolan.

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Structure of the Presentation (1)

The Country Context Relevance of the Private Not for Profit Sector

(PNFP) The Importance of Nurses and Midwives The Human Resources for Health Crisis The PNFP Research & Development Question Findings:

Obstacles to Increasing Training Output Obstacles within the PNFP Sector Complex and Confused National Environment

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Structure of the Presentation (2)

Conclusions and Priority Actions needed The Strategy to strengthen and empower the

PNFP Health Training Institutions (HTI) The Partnership of the PNFP Health Training

Institutions The Setback and the Alternative Strategy Results so far Recommendations

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Uganda in East Africa

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Context: Uganda in Figures

Population: 27 million people Living below poverty line: 38% Infant Mortality Rate: 88 / 1000 Under five Mortality Rate: 152 / 1000 Maternal Mortality Rate: 505 / 100,000 live

births Life Years Lost

due to preventable diseases: 75%

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Relevance: PNFP Sector (1)

Faith Based Organizations : autonomous Civil Society Organizations

Voluntary choice to contribute to Public Social Aims: Essential cost effective services

Percentage of Health Facilities in rural areas: 80%: 47% of hospitals in the country and 23% of Primary health care centers

Overall 25% of the national health facilities 60% of the Nurse Training Schools

National Coordination and Technical Support: Medical Bureau per denomination

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Relevance: PNFP Sector (2)

Health Service output:

30% of the national total Allocated budget:

7% of the national budget (government and donors)

Nurses & Midwives graduated in 2005: 60% of national total

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Present HR Problems in PNFP

PNFP Shortage of Nurses and Midwives: 1,843 = 36% of current norm (national 32%)

Annual Attrition rate nation: PNFP 20% (national 3%)

In Nurse Training Schools shortage is relatively larger

Main obstacle to recruitment = Financial But: this year PNFP shortage rapidly

increasing: Attrition in PNFP 25% in first quarter 2005!

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Importance of Nurses and Midwives

Total current health work force: 24,380 Qualified Nurses and Midwives: 8076 = 33% Nursing Assistants (auxiliary nurses): 6345 = 26% Nurses & midwives in average hospital:

60% of medical / clinical team In Primary Health Care Centers:

80% of the team Many Additional the responsibilities in PHC

centers

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The Human Resource Crisis

National and International consensus: Human Resources essential to attaining health outcomes Shortage of HR is THE OBSTACLE To achieve the Millennium Development Goals (MDG’s):

Health worker/population density needed: 2.5 per 1000 people: Increase in Nurses and Midwives needed: 18,000

PNFP: 6,000 NB: “Brain drain” to developed countries accelerating

2005: 200 nurses lost in one recruitment drive Training Capacity / Output will have to be increased

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Human Resource Crisis in Figures

Present available

Present shortage

New required

New shortage

HR/pop density

0.8 / 1000 4,909 2.5 / 1000 43,120

Nurses & midwives- Including Nurse Assistants

0.5 / 1000

0.7 / 1000

3,715 1.5 / 1000 21,714

PNFP N&M

2,829 1,843 7,843

Nr of N&M training places

1600 - 1800 3500 - 4000

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The PNFP Research and Development Question Initial question: how to improve utilization

of schools?

Actual Question to be answered: How can the PNFP HTI be enabled to

assist in resolving the HR crisis?

Research and development method: Participatory Approach

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Findings: Obstacles to Increasing Training Output Present training capacity inadequate Existing Curricula not adjusted to health

needs Range of cadres trained too limited Entry criteria based on secondary school

results continuously raised

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Findings: Obstacles within PNFP Sector Lack of coordination and cooperation

among the PNFP HTI No influence on national training policies,

plans, nor programmes Loss of innovative capacity and daring

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Findings: Complexity and Confusion at National Level (1) Lack of Leadership Absence of HR Strategic plan Funding inadequate and inequitable

Focus of Development Partners too narrow

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Findings: Complexity and Confusion at National Level (2) Who decides and who should decide?

Existing Legislation: The Professional Councils But MOES responsible for training?

Entry criteria and curricula: contradictory directives

Academic and Professional Certification: duplication of exams

Regulation of professionals after entry into the system under developed

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An Example to Illustrate

To improve PHC train a multipurpose nurse: The Enrolled Comprehensive Nurse

Decision taken in 2000 but still not fully implemented Reasons:

Curriculum developed by technical team MOES without effective consultation

Nurses and Midwives Council never really endorsed it Unresolved dispute about the entry criteria Rural candidates cannot access the course Hospital managers: hospital nursing not covered PHC center managers: midwifery part inadequate Investment and recurrent costs proved too high

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Conclusions from the Findings

Nurses and midwives form the backbone of the Ugandan health system

To achieve the MDG’s the number of nurses and midwives needs to be increased THREEFOLD

Increasing training capacity is essential to increasing availability of HR

The PNFP HTI have a large potential to increase the training output

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Priority Actions to Increase HR Availability National level: clarify and strengthen

Leadership and Planning PNFP HTI: organize and strengthen

themselves The Development Partners: support

both partners and joint development

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Preamble to Strengthening the PNFP HTI (1) Internal consensus: PNFP Health Training

Institutions need to be enabled to:

To respond to opportunities and threats in the external environment Build strong cohesion and unified voice

To address the required huge increase in nurses and midwives Participate in national policy and planning

process

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The Partnership of PNFP HTI (1)

Choice of the PNFP HTI:

An Interdenominational Organization Legally established and recognized Formed and Governed by the member HTIs:

Taking charge themselves High level of participation and commitment Strong expression internal cohesion Employ professional capacity to support and

enhance implementation

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The Partnership of PNFP HTI (2)

Mission of the PNFP HTI: To train an optimal range of health care staff

of high professional and moral standard for the PNFP and national health care institutions

Partnership: Enhance attainment of HTIs mission through: Internal: coordination and cooperation External: advocacy and cooperation Addressing common challenges

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The Setback

When Constitution and Memorandum of Association ready to be signed by the Owners

One denomination realizing the full extent of the plan requested to stay the process

Decision: Too early to set up a legal organization First exhaust existing structures and internal /

external dialogue

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Alternative / Incremental Strategy

Incremental step towards the Partnership The PNFP Medical Bureaux set-up a structure and

capacity to support and represent their HTI: A Participation Forum / Standing Committee Annual assembly of affiliated HTI HTI & Training desk with a professional coordinator

Mission, strategies, and objectives the same: Per denomination

One additional assignment: Foster interdenominational dialogue and pursue the

installation of the Partnership at later stage

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Results So Far (1)

Externally: Increased national awareness PNFP HTI

capacity indispensable Move to include PNFP HTI in

development of plans Increased interest Development Partners

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Results So Far (2)

Internally: Increased assertiveness of school teams

and group Stronger cohesion among PNFP HTI Interdenominational cooperation

accepted and pursued Innovations starting

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Recommendations

For the PNFP HTI: The key to contributing more effectively lies

in united active participation and cooperation

The structure and professional support should aim at empowering each HTI and the group as a whole

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Recommendations

To address the HR Crisis effectively: National and International Stakeholders

have an interest in: Fostering Public – Private Not for Profit

Partnership in training health workers Assuring adequate and equitable funding of

training in all HTI

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Recommendations

For CCIH participants:

The church health institutions represent a huge heritage that our forefathers left us:

As stewards:

We need to assure that we hand them over to those that come after us in better shape than they are now!

We may not succeed if we follow the fashion of the day!