HUMAN RESOURCES FOR HEALTH. – HUMAN RESOURCES FOR HEALTH. –

SOME ISSUES CALLING FOR POLICY CHANGESOME ISSUES CALLING FOR POLICY CHANGE..

Professor Lalitha MendisProfessor Lalitha Mendis

Annual Health Forum 2007Annual Health Forum 2007

Adequacy of NumbersAdequacy of Numbers

DOCTORS PER 100,000 POPULATIONDOCTORS PER 100,000 POPULATION

2005 Sri Lanka 2010 Sri Lanka2005 Sri Lanka 2010 Sri Lanka Non specialist doctors Non specialist doctors In Govt In Govt 8060 (+5500) 13560 8060 (+5500) 13560 Specialist doctors Specialist doctors 829 2087 829 2087 GPs + PNHs 1784 1784GPs + PNHs 1784 1784 -------------------------------------------------------------------------------------------------------------- Total 10,643 17431Total 10,643 17431 ------------------------------------------------------------------------------------------------------------

Drs per 100,000 55.2 90.5Drs per 100,000 55.2 90.5

Global average Global average 170 / 100,000 population 170 / 100,000 population South Asian average South Asian average 40 +40 + Sri LankaSri Lanka 55.2 55.2 BangladeshBangladesh 2323 IndiaIndia 5151 NepalNepal 0505 PakistanPakistan 6666 MalaysiaMalaysia 67.267.2

Non Specialist and Specialist Doctors and General Non Specialist and Specialist Doctors and General Practitioners per 100,000 populationPractitioners per 100,000 population

55.2 Drs per 100,000 pop’n55.2 Drs per 100,000 pop’n (2006) - one per 1811 (2006) - one per 1811 personspersons

90.5 Drs per 100,000 pop’n90.5 Drs per 100,000 pop’n (2010) one per 1100 (2010) one per 1100 personspersons

ISSUE - MIGRATIONISSUE - MIGRATION

4.8 spec’s per 100,000 pop’n(2006) one per 23000 4.8 spec’s per 100,000 pop’n(2006) one per 23000 personspersons

10.8spec’s per 100,000 pop’n(2010) one per 9000 10.8spec’s per 100,000 pop’n(2010) one per 9000 personspersons

Singapore 63 , New Zealand 82, South Africa Singapore 63 , New Zealand 82, South Africa 8.88.8

1504 Specialists Board Certified by PGIM up to December 20061504 Specialists Board Certified by PGIM up to December 2006 Approx 43% more than current specialist cadre of MoHApprox 43% more than current specialist cadre of MoH ISSUE - MIGRATIONISSUE - MIGRATION

Migration of both newly qualified doctors of Migration of both newly qualified doctors of Board Certified specialists and specialists Board Certified specialists and specialists in training is an issue to be addressed.in training is an issue to be addressed.

Issue of coordination.Issue of coordination.

General PractitionersGeneral Practitioners

2.8 GPs per 100,000 pop’n – one 2.8 GPs per 100,000 pop’n – one

per 35,000 personsper 35,000 persons

What policies will reverse this What policies will reverse this trend?trend?

Do we know how many doctors we Do we know how many doctors we need for Sri Lanka?need for Sri Lanka?

Lack of coordination, dialogue and Lack of coordination, dialogue and policy between the production line policy between the production line (MoHE) and the consumer (MoH) .(MoHE) and the consumer (MoH) .

No clear government policy on the No clear government policy on the opening of private medical colleges? opening of private medical colleges?

MALDISTRIBUTIONMALDISTRIBUTION

ProvinceProvince

Non Non SpecialistSpecialist DrDr /100,000 /100,000

PopPop

SpecialistSpecialistDr/Dr/100,000 100,000

poppop

Number of Number of GPsGPs

PopulationPopulationdensity density persons per persons per

sq. KM sq. KM (2002)(2002)

Rural & Rural & EstateEstate

Doctors per Doctors per 100,000 100,000

PopulationPopulation

WesternWestern 1,5151,515 68%68%

SouthernSouthern 3636 3.73.7 3232 427427 88.5%88.5% 43.843.8

Sabara’Sabara’ 29.429.4 3.23.2 1212 367367 34.834.8

CentralCentral 44..244..2 44 2525 437437 88.6%88.6% 52.452.4

N.WestN.West 32.132.1 2.52.5 3636

(6.5%)(6.5%)291291 95%95% 37.437.4

UvaUva 30..230..2 33 22 142142 92.5%92.5% 35.535.5

N.CentrN.Centr 3636 3.53.5 22 115115 95%95% 40.440.4

NorthNorth 3131 3.23.2 22 126126 90%90%

EastEast 24.524.5 2.32.3 22 154154 7979

Sri lankaSri lanka 38.538.5 4.34.3 554554 302302 ???? 55.255.2

51.4 7441

79.6%71.3

30.7

30.5

What policy directions will be What policy directions will be able to improve the distributionable to improve the distribution

of HRHof HRH

TRAININGTRAINING

DOCTORS (Ministry of Higher DOCTORS (Ministry of Higher Education)Education)

AHPs (Ministry of AHPs (Ministry of Health)Health)

RecruitmentRecruitment RegularRegular Some categories have Some categories have not been recruited not been recruited regularlyregularly

Training Training facilitiesfacilities

PhysicalPhysical

EquipmentEquipment

Teaching staffTeaching staff

CurriculumCurriculum

Quality ControlQuality Control

SatisfactorySatisfactory

SatisfactorySatisfactory

Adequate. Teacher training Adequate. Teacher training opportunities in 5 of 8opportunities in 5 of 8

Satisfactory. Traditional-modernSatisfactory. Traditional-modern

Yes through UGC and SLMCYes through UGC and SLMC

c/o poor facilitiesc/o poor facilities

InadequateInadequate

Insufficient trained teachersInsufficient trained teachers

Lack of regular curriculum Lack of regular curriculum review and revision. review and revision.

No mechanisms for QCNo mechanisms for QC

Attrition rateAttrition rate LowLow High – partly due to High – partly due to delays in recruitment delays in recruitment processprocess

Adequacy to Adequacy to meet service meet service demanddemand

adequateadequate inadequateinadequate

Avenues for Avenues for post basic post basic trainingtraining

adequateadequate NoneNone

There is the issue of an urgent There is the issue of an urgent need for clearer career paths for need for clearer career paths for AHPsAHPs

Problem of policy implementation Problem of policy implementation

lack of monitoring the time based lack of monitoring the time based implementation of policy decisions. implementation of policy decisions.

No target oriented approach.No target oriented approach.

Summary of Main problemsSummary of Main problems

Specialists and AHPs are in short supply.Specialists and AHPs are in short supply. HRH planning and implementation appears to lack a target HRH planning and implementation appears to lack a target

oriented approach e.g. there are no projected targets for oriented approach e.g. there are no projected targets for AHPs and doctors .AHPs and doctors .

There is a lack of coordination, dialogue and policy There is a lack of coordination, dialogue and policy between HRH producers, the Ministry and other users between HRH producers, the Ministry and other users such as the private sector. such as the private sector.

Migration is a problem in all categories- doctors, Migration is a problem in all categories- doctors, specialists and AHPsspecialists and AHPs

There is maldistribution of doctors, General practitioners, There is maldistribution of doctors, General practitioners, Specialists and AHPsSpecialists and AHPs

AHP training is not state of the art.AHP training is not state of the art. There are no avenues for post basic training in the case of There are no avenues for post basic training in the case of

AHPs.AHPs. There are issues concerning policy implementation and There are issues concerning policy implementation and

monitoring of a time based plan. monitoring of a time based plan. No mechanisms for monitoring performance and quality of No mechanisms for monitoring performance and quality of

care of the health personnel.care of the health personnel.

Suggested policies to address Suggested policies to address these problems:-these problems:-

• To set up a comprehensive To set up a comprehensive knowledge and information knowledge and information systemsystem to support decision making. to support decision making. This would include research findings This would include research findings which would provide an evidence base which would provide an evidence base for decision making.for decision making.

• To develop an efficient state of the art To develop an efficient state of the art workforce management systemworkforce management system that will maintain a firm grip on that will maintain a firm grip on recruitment, training, discipline and recruitment, training, discipline and distribution. The sheer size of the distribution. The sheer size of the health health workforce being about workforce being about 90,00090,000 demands this.demands this.

• To establish an adequately staffed and To establish an adequately staffed and separate HRH unit/directorateseparate HRH unit/directorate

preferably under the dedicated service of a preferably under the dedicated service of a Deputy Director General of Health Services. Deputy Director General of Health Services.

• There should be feeder units/committees in There should be feeder units/committees in the provinces. The unit should search for a the provinces. The unit should search for a model to work with the provincial councils, model to work with the provincial councils, who are important stake holders. who are important stake holders.

• The unit could also coordinate the production The unit could also coordinate the production of HRH and set targets and coordinate and of HRH and set targets and coordinate and monitor achievements of targetsmonitor achievements of targets

• To set up a To set up a National Human National Human Resource for Health CommitteeResource for Health Committee that that would work with this unit and monitor would work with this unit and monitor progress. progress.

• This committee could also commission This committee could also commission research studies into emerging issues as research studies into emerging issues as and when necessary.and when necessary.

FUNDINGFUNDING

To stem migration of doctors, specialists and AHPs.To stem migration of doctors, specialists and AHPs. E.g. E.g.

reduce the gap between qualifying and internship. reduce the gap between qualifying and internship. Consider granting MBBS certification after internship and Consider granting MBBS certification after internship and not before as is done now. not before as is done now.

Re-introduce the five year service bond that was in Re-introduce the five year service bond that was in operation in the 60s and 70s. operation in the 60s and 70s.

High salaries, more satisfying working conditions, and High salaries, more satisfying working conditions, and better educational prospects for children .. An investment better educational prospects for children .. An investment in housing by the Ministry for peripheral hospital in housing by the Ministry for peripheral hospital personnel.personnel.

Forward planning of placements for specialists who are to Forward planning of placements for specialists who are to return from overseas training. return from overseas training.

(Lack of facilities in the stations they are sent to frustrates many who (Lack of facilities in the stations they are sent to frustrates many who return with every good intention of putting into practice the skills they return with every good intention of putting into practice the skills they have acquired.)have acquired.)

To provide To provide state of the art basic training in state of the art basic training in the case of nurses and AHPsthe case of nurses and AHPs and and opportunities for opportunities for post basic trainingpost basic training and and upward educational mobility.upward educational mobility.

To this end To this end Boards of StudyBoards of Study of experienced of experienced persons in the field including consultants in persons in the field including consultants in universities and the Ministry of Health could universities and the Ministry of Health could review, revise and oversea study programmes review, revise and oversea study programmes and examinations. and examinations.

Post basic trainingPost basic training could be provided for AHPs could be provided for AHPs selected on defined criteria on a selected on defined criteria on a block release block release basis. basis.

To plan measures to increase productivity and To plan measures to increase productivity and inducements to serve at the periphery. e.g.inducements to serve at the periphery. e.g.

IIntroduce a scheme of performance based promotions ntroduce a scheme of performance based promotions and salary increments for all categories of HRH.and salary increments for all categories of HRH.

Introduce effective grievance handling mechanisms. Introduce effective grievance handling mechanisms.

Creating a work environment where people can develop Creating a work environment where people can develop their full potential and lead productive, creative lives in their full potential and lead productive, creative lives in accord with their needs and interests. accord with their needs and interests.

Providing a work conducive environment especially at the Providing a work conducive environment especially at the periphery for all categories of HRH. periphery for all categories of HRH.

Special incentives for those posted to the periphery, e.g. Special incentives for those posted to the periphery, e.g. special allowances, housing ,and arrangements for special allowances, housing ,and arrangements for schooling of children, limited service period at the schooling of children, limited service period at the periphery. periphery.

• To look for policy changes that will To look for policy changes that will provide a backbone of good provide a backbone of good primary health care and primary primary health care and primary care.care.

• To create in HRH a To create in HRH a confidence that confidence that the system is fair to all.the system is fair to all.

Ultimately HRH in the system should be appropriate Ultimately HRH in the system should be appropriate in relation to :-in relation to :-

Numbers,Numbers, right quality, right quality, distribution, distribution, skill-mix, skill-mix, competency, and competency, and motivation,motivation, working with moral principles and satisfaction to working with moral principles and satisfaction to

provide care responsive to local and national health provide care responsive to local and national health needs.needs.

Thank YouThank You

Following to receive Diploma Certificates at the end of the 2 Following to receive Diploma Certificates at the end of the 2 year period:-year period:-• MLTsMLTs• Ophthalmic TechnologistsOphthalmic Technologists

Radiographers to receive a Diploma at the end of a supervised Radiographers to receive a Diploma at the end of a supervised period of internshipperiod of internship

The following to receive a Certificate of proficiency at the end The following to receive a Certificate of proficiency at the end of the training period.of the training period.

MicroscopistsMicroscopists

CardiographersCardiographers

Curriculum to be reviewed, redrafted and qualification Curriculum to be reviewed, redrafted and qualification determined for EEG recordistsdetermined for EEG recordists

Criteria for post basic trainingCriteria for post basic training• Performance at previous examinationsPerformance at previous examinations• Record of performance at workRecord of performance at work• Attendance at workAttendance at work• Conduct at workConduct at work

Post basic training on a Block Release basisPost basic training on a Block Release basis

PGIM model for training AHPsPGIM model for training AHPs

Medical Laboratory

Technologists

Radiographers Physiotherapists ECG Recordists EEG Recordists

No. Rate No. Rate No. Rate No. Rate No. Rate

871 4.6 342 1.8 219 1.2 158 0.8 37 0.2

Rate per 100,000 population

Source : Annual Health Bulletin 2002 Medical Statistics Unit

Allied Health Professionals in SL, September 2002

Dhaka Declaration Dhaka Declaration aimed at…aimed at… Developing national policies Developing national policies

and regulationsand regulations Developing and implementing Developing and implementing

national HRH strategic plansnational HRH strategic plans Increasing training capacityIncreasing training capacity Strengthening HR P&M capacityStrengthening HR P&M capacity Involving global and regional Involving global and regional

networksnetworks Mobilizing adequate resourcesMobilizing adequate resources

ProvinceProvince Chest Chest PhysiciaPhysicia

ns ns

Genito Genito Urinary Urinary SurgeonSurgeon

ss

Plastic Plastic SurgeonSurgeon

s s

RheumaRheumatologists tologists

NeonatolNeonatologistsogists

NephrolNephrologistsogists

ChemicaChemical l PathologPathologistsists

WesternWestern

SoutherSouthernn

XX XX XX XX

SabaragSabaragamuwaamuwa

XX XX XX XX XX XX

CentralCentral XX XX XX

N. WestN. West XX XX XX XX XX

UvaUva XX XX XX XX XX XX XX

N. N. CentralCentral

XX XX XX XX XX XX

NorthNorth XX XX XX XX XX XX XX

East East XX XX XX XX XX XX XX

ProvinceProvince CardiologIsCardiologIststs

VenereolgVenereolgistist

Dermatolo.Dermatolo. Neuro’sNeuro’s Orth.Orth.SurgeoSurgeo

nsns

Vascul.Vascul.SurgeoSurgeo

nsns

NeuroNeuroSurgeoSurgeo

nsns

Paed.Paed.SurgeonsSurgeons

CadioCadioThoracicThoracicSurgeonsSurgeons

CancerCancerSurgeoSurgeo

nsns

Oncol’sOncol’s

WesternWestern

SouthernSouthern XX XX XX

Sabara’Sabara’ XX XX XX XX XX

CentralCentral XX

N.WestN.West XX XX XX XX XX XX

UvaUva XX XX XX XX XX XX

N.CentrN.Centr XX XX XX XX XX

NorthNorth XX XX XX XX XX XX XX XX XX

EastEast XX XX XX XX XX XX XX XX XX XX XX

NURSING IN PRIVATE SECTORNURSING IN PRIVATE SECTOR

Private sector tends to neglect Private sector tends to neglect planningplanning for for nurses in different categories during setting up nurses in different categories during setting up private sector institutionsprivate sector institutions

The many training programmes presently The many training programmes presently available available vary in qualityvary in quality and duration of training and duration of training

Criteria and standardsCriteria and standards should be set for should be set for nurse’s training courses in the private sector e.g. nurse’s training courses in the private sector e.g. Indian Nurses Council CriteriaIndian Nurses Council Criteria

CommitteeCommittee should be set up for this purpose. should be set up for this purpose. E.g. Senior nursing personnel and Medical E.g. Senior nursing personnel and Medical personnel with interest in nursingpersonnel with interest in nursing

MEETING DEMANDS FOR NURSES MEETING DEMANDS FOR NURSES TRAININGTRAINING

Nursing Teachers-Nursing Teachers- • insufficient.insufficient.• Only qualified nursing teachers should be used in public and Only qualified nursing teachers should be used in public and

private sectorprivate sector• Regular teacher training programmesRegular teacher training programmes• Those teaching special areas should be sent for training Those teaching special areas should be sent for training

abroad in addition to local training.abroad in addition to local training. School School for nursing teachersfor nursing teachers Teaching of Teaching of English language skillsEnglish language skills should improve should improve Better library facilitiesBetter library facilities Medical equipmentMedical equipment for training for training Only Only hospitals with specified standardshospitals with specified standards to be used for to be used for

nurses training e.g. at least 150 beds and specified nurses training e.g. at least 150 beds and specified specialtiesspecialties

CAREER LADDERCAREER LADDER

Career opportunities limited in both Career opportunities limited in both private and public sectorprivate and public sector

Public sectorPublic sector• Grade 11Grade 11• Grade 1Grade 1• Special GradeSpecial Grade• Director nursingDirector nursing

Suggested- Suggested- clinical nursing specialistsclinical nursing specialists and and clinical teachers in specialized areasclinical teachers in specialized areas..

OTHER ISSUESOTHER ISSUES

Lack of involvement of nurses in decision Lack of involvement of nurses in decision making and policy planningmaking and policy planning

Controlling body for nursing matters. Act Controlling body for nursing matters. Act of Parliament for Nurses Council passed in of Parliament for Nurses Council passed in 1989 but not yet operational1989 but not yet operational

No regular updating of nursing curricularNo regular updating of nursing curricular Inadequate opportunities for senior nurses Inadequate opportunities for senior nurses

to be exposed to newer trends in to be exposed to newer trends in managementmanagement

OTHER ISSUES (CONTD)OTHER ISSUES (CONTD)

Inadequate Continuing Professional Development Inadequate Continuing Professional Development (CPD) programmes for all levels of nurses(CPD) programmes for all levels of nurses

Distribution of nurses not equitableDistribution of nurses not equitable Provision of adequate supplies for good nursing Provision of adequate supplies for good nursing

carecare Nurses burdened with many non-nursing dutiesNurses burdened with many non-nursing duties Doctor:Nurse relations show room for Doctor:Nurse relations show room for

improvementimprovement WelfareWelfare

• Better working conditionsBetter working conditions• Salaries commensurate with their responsibilitiesSalaries commensurate with their responsibilities• More opportunities for post basic education in the country and More opportunities for post basic education in the country and

overseasoverseas

BackgroundBackground A technical consultation was held in Washington, DC, A technical consultation was held in Washington, DC,

on December 14-15, 2005, to develop an HRH Action on December 14-15, 2005, to develop an HRH Action Framework to support Framework to support "an effective and sustainable "an effective and sustainable health workforce” health workforce”

Sponsored by WHO and USAID, the consultation Sponsored by WHO and USAID, the consultation consisted of multilateral and bilateral agencies, consisted of multilateral and bilateral agencies, donors, partner countries, NGOs and members of the donors, partner countries, NGOs and members of the academic community.academic community.

WHO included the WHO included the frameworkframework in The World Health in The World Health Report 2006: Working together for health.Report 2006: Working together for health.

HAF : action fieldsHAF : action fields

Policy

Leadership

Partnership

Education

Finance

H R M Systems

HRH Action Frameworktools for an effective and sustainable health workforce

BETTER HEALTH

SERVICES Equity

EffectivenessEfficiency

Accessibility

BETTER HEALTH

OUTCOMES

other healthsystem

components

country specific context

including labour market

Improved Health

Workforce Outcomes

Situation analysis

Preparation & Planning

Implementation

M & E

Policy

Leadership

Partnership Education

FinanceH R M

Systems

Go to CD-Rom / Internet

Critical Success Factors

How components link to each How components link to each other: illustrative exampleother: illustrative example

Situation analysis

Preparation & Planning

Implementation

M & E

Policy

Leadership

Partnership Education

FinanceH R M

Systems

What policies or next steps are needed to maximize training

capacity at the country level and within the

region?

How to maximize effective utilization of available funding for health

through better harmonization and alignment of partner funding behind

national plans?

Illustrative indicatorsIllustrative indicators•Ratio of graduates of pre-service training programs to projected demand by type of health worker.•Attrition of students in pre-service education programs.•Number of certified lecturers/tutors employed by pre-service institutions by cadre and geographic location.

•Agreements in place between MoH and other health providers to supplement the delivery of health services.•Mechanisms in place to mobilize community support for health services.•Mechanisms in place for coordination of key stakeholders (including donors)

Situation analysis

Preparation & Planning

Implementation

M & E

Policy

Leadership

Partnership Education

FinanceH R M

Systems

Health Workforce in Health Workforce in SEAR CountriesSEAR Countries

The First Conference of the Asia-Pacific The First Conference of the Asia-Pacific Action Action

Alliance on Human Resources for Health Alliance on Human Resources for Health (AAAH)(AAAH)

28-31 October 2006, Thailand28-31 October 2006, Thailand

Dr Myint Htwe Dr Myint Htwe WHO/SEAROWHO/SEARO

WHO’s Response WHO’s Response Resolution WHA57.19 (2004): ‘Challenge posed by the

international migration of health personnel’ Resolution WHA59.23 (2006): ‘Rapid scaling up of

health workforce production’

Resolution WHA59.27 (2006): ‘Strengthening nursing and midwifery’

World Health report 2006: ‘Working together for Health’ highlights importance of health workforce

WHO launched Global Health Workforce Alliance (2006)

SEARO’s Response (2006)SEARO’s Response (2006)

““Dhaka Declaration”Dhaka Declaration”, August 2006, August 2006

SEA/RC59/R6: SEA/RC59/R6: “Strengthening the “Strengthening the Health workforce in South-East Health workforce in South-East Asia”Asia”

SEA/RC59 endorsed SEA/RC59 endorsed “SEA Regional “SEA Regional Strategic Plan for Human Resource Strategic Plan for Human Resource Development”Development”

Regional Strategic Plan for Regional Strategic Plan for Human Resource DevelopmentHuman Resource Development

Goal:Goal: A health workforce responsive to the health A health workforce responsive to the health

needs of the population needs of the population

Vision:Vision: Achieving optimum health outcomes Achieving optimum health outcomes

through effective health services… balanced through effective health services… balanced distribution of sufficient, competent & distribution of sufficient, competent & highly motivated health workforcehighly motivated health workforce

Mission:Mission: Strengthen capacity in planning, training, Strengthen capacity in planning, training,

developing and managing HR to meet the developing and managing HR to meet the increasing health demandsincreasing health demands

Guiding PrinciplesGuiding Principles

Decision-making based on sound Decision-making based on sound evidenceevidence

Aiming equitable distribution for HRAiming equitable distribution for HR Targeting poor and unreached Targeting poor and unreached Considering socio-cultural, political Considering socio-cultural, political

and economic contextand economic context Minimising gender imbalances Minimising gender imbalances Creating healthy work environment Creating healthy work environment

Strategies Strategies Strengthening data collection, analysis,

interpretation and utilization Policy development, regulation and

legislation Scaling up HR production Knowledge generation and management Capacity building on HRH management Regional partnership building Quality assurance in training Increasing investment

Way Forward..Way Forward..

Finalizing Regional Strategic Plan Finalizing Regional Strategic Plan for HR Development with country for HR Development with country consultation in December 2006consultation in December 2006

NATIONAL OBJECTIVES FOR HRH to NATIONAL OBJECTIVES FOR HRH to 2010 and 20202010 and 2020

VietnamVietnam

TargetsTargets 20102010 20220200

Ratio doctor/ nursesRatio doctor/ nurses 3,53,5 4-54-5

Ratio doctor/ 10,000 inhabitants Ratio doctor/ 10,000 inhabitants 77 88

Ratio pharmacist / 10,000 Ratio pharmacist / 10,000 inhabitants inhabitants

11 2-2-2.52.5