Assessing and Determining Capacity challenges in Health

Dr Lilian DudleyHealth Systems Trust

13 October 2005

Definitions• Human resources for health (HRH)

persons engaged in any capacity in the production and delivery of health services. These persons may be paid or volunteer, with or without formal training for their functions, and in the public or private sector. HRH encompass “all individuals engaged in the promotion, protection, or improvement of population health, including clinical and non-clinical workers.” (JLI, 2004)

• Human resources development (HRD), as applied to human resources for health (HRH), includes the planning, production, and management of health personnel.

Policy Framework

• National Health Act, 2003– Establishes National Health Council

to develop “policy and guidelines for, and to monitor the provision, distribution, development, management and utilization of, human resources in the national health system”.

– Human Resources Planning required by Provinces & Districts

Strategic Framework for HRH Plan (Aug 2005)

Pillars proposed:• Human Resource Policy and Planning• Human Resource Production • HRH Management / Leadership

(Capacity Development)• HR Information System• HRH research• Monitoring and Evaluation

Human Resources for Health, Overcoming the Crisis, JLI 2004

– Global crisis in HRH• HIV &AIDS • Shortages, maldistribution of HRH and migration• Chronic underinvestment in HRH• Poor work environments• Weak knowledge base on HRH

– Five pronged strategic approach• Engaging stakeholders• Planning human investments• Managing performance• Develop enabling policies• Learning for improvement

SAHR 2005

HST commissions and conducts research in support of strengthening health systems, including human resource aspectsSAHR produced annually by HST since 1995This year theme on Human ResourcesCommissioning of chapters & research to expertsReviewing- Peer (Internal & External)- NDoH & PDoH

Main Users

DoH – national, provincial and district, municipalities and parliamentsAcademic institutions, NGOs, Corporate sector, international community including foreign missionsOften accessed through the web(www.hst.org.za)

Key HRH issues in SAHR• International Context• National Strategic priorities (2004 -9)• HR Policies • Financing of HRH (incl projections for ART &

PHC)• Nursing profession• HRH at District Hospitals• HRH for District Health System• Mid-level workers• Community Health workers• Information for HRH• Chapter on Health and related indicators

International Context

• Focus on HRH a.r.o HIV &AIDS and MDG’s• SSA has lowest ratios of health workers to

population• HRD deficiencies

– Lack of planning results in recruitment from other countries– Production not in keeping with needs (no.s, skills, PHC)– Management poor resulting in low morale, and poor

performance• Migration

– Push & Pull factors– Role of Nepad (Health strategy and HRD doc)– Resolution on intnl recruitment and migration of HRH at

WHA, May 2005

Review of 10 Point plan (2004 -09)

Backdrop of SA as developmental state.Balanced review with many things being achieved (e.g. smoking reduction, health act) and less success in other areas (e.g. HRH, TB, cervical cancer screening) HRH a critical constraint to achieving other targets – 40% of PHC facilities have trained PHC nurses

Recommendationsa Politicians & managers communicate a vision/mission that

resonates with front line health workers. Followed by clear operational strategies.

a A programme of action that is developed with and that captures the imagination of implementers.

aAn effective governance and management system. aA critical mass of skilled and motivated health managers and

health workers at all levels.

District Health System

Health Act v positive and big step forwardChallengesaLack of clarity of assignment/delegation to LGaCooperative governanceaHow district health team will functionaDemotivation of health workers – HR

management needs attentionaSingle public service

Human Resources: District Hospitals & PHC

Rural and scarce skills +ve feature. Needs PHC nurses included, also standardised definition of rural.

Appropriate training & support of hospital managers required; balancing financial mgt with service care & quality.

Recruitment and retention of professional staff (especially nurses and doctors) needs private sector approach.

Strengthening community- based and mid-level health workers is needed; cooperation of all professional bodies and unions required.

Continuing Education is an enormous but vital challenge that needs support and supervision to accompany it.

ART and PHCFinancing and HR needs

ARTaConditional grant funding (R325m) covers current 50,000 on

ART.aBy 2009, full coverage of 1,000 000, cost will be R6.5baHR requirements: 3100 doctors, 2300 nurses, 765 social

workers, 765 dieticians, 2000 data capturers.

PHC (2009) – full package of servicesaCurrent 2.5 visits p.a. to increase to 3.85aCurrent spending needs to double to R308 per person.aTranslates into R13.5b requireda If PHC continues in hospital OPDs an extra R4.5baR1.8 billion needed for CHW programmes by 2009/10

NursingDuring the period 1996-2004 the growth in the no. of all nurses was < than increase in population growth.At same time increase in demand (HIV) & migrationProduction of new professional nurses declined from 2682 (1997) to 1553 (2003).Nursing colleges produce over 80% of all professional nurses.All universities together have total graduation of 400 p.a. (e.g. 3 universities in W.Capeproduce 50 nurses p.a.)Over 40% of all professional nurses produced via bridging course

Nursing (Cont)

Enrolled nurse training increased off low base. Private sector now producing more p.a. than public sector nursing colleges; (>90% of private in KZN & Gauteng).Private sector responsible for bulk of auxiliary nurse training (75%). This is concentrated in Gauteng and KZN (90%)Public Sector training also not equitably spread. Eastern Cape producing very few enrolled & auxiliary nurses

Mid-level Health Workers

Pharmacists’ Assistants – v successful case study but still challenges remain.Rehabilitation workers – initially successful but then fizzled out for number of reasons.Dental assistants did not achieve goals.Ground prepared for medical assistants but number of outstanding issues (hospital/clinic; scope of practice vs nurses)All need full stakeholder buy-in & career planning

Information for HR

PERSAL has primary function to manage salaries. Rest of info not accurate. Improve the completeness and accuracy of non-salary information (e.g. staff establishment) on PERSAL to increase the use of information.

Routine info system for HR mgt would create a culture of info & appreciation for importance of info.

The Goals & Indicators for 2001/05, (NDOH) is good starting point for information requirements for HR management.

Indicators

New NIDS will provide wide range of indicators from facility level to national.Population estimates below provincial level uncertain; district indicators (e.g. immunisation coverage) unreliable.Utilisation rates PHC steadily improving over past 5 years.Large amount of information on HRNew section on MDGs. International comparisons difficult as different data sources used.

Research & Info Needs(Strategic Framework)

• Norms and Standards/ Staffing establishments/workload

• Availability and Distribution• Impact of retention strategies incl. special

allowances• Health Education and Training

– Funding– Interface between DOH & DOE– Rethinking settings of training (AHC or DHS)– Nursing education reform

• Continuing Professional Development

Research Agenda cont..

• Career progression• New Health Worker Cadres • Role of CHW’s• Structures and systems for effective

HRH planning and management• Impact assessments of HRH

planning

Summary

• Priority is for implementation of effective policies, planning and management of HRH,

• Which is informed and supported by research, reliable information systems and routine M&E in HRH