The Distribution and Mix of Human Resourcesfor Health in Nepal

Presented by : Basanta ChaliseMHPE (1st batch)

Outline

• Introduction• Objectives• Methodology• Findings

– Pre-service training– Distribution and shortage of Health workforce– Mix of Human Resources for Health

• Conclusion• Recommendations

Introduction

• Nepal has been identified by the World Health Organization as one of 57 nations with a critical shortage of health workers.

• This creates a huge deficit in the requirements for high coverage of essential intervention, including those necessary to met health related MDGs.

• MOHP has also identified major challenges in HRH : Specially in shortage, distribution and skill mix of health workers.

Objectives• To analyze the current production,

distribution and skill mix of the health workforce.

• To provide recommendations to MoHP and other concerned stakeholders for improvements in HRH policy and strategic plans and its implementation

Methodology• A cross-sectional descriptive study was conducted

using mixed method with observation checklist.• A multi-stage cluster sampling method, Fifteen

districts representing eco-developmental regions of Nepal were selected.

• 747 health workforce from 375 health institutions were interviewed using the Probability Proportionate to Size method as per WHO guideline.

• Observation was carried out in 256 health facilities. Further, secondary review was carried out for triangulation of findings.

Production (PRE-SERVICE TRAINING) OF THE HEALTH WORKFORCE IN

NEPAL

Production (Pre-service training of basic level health workforce)

• It includes the production of TSLC level Health workers

• Primarily produced by affiliated institutions of CTEVT

• Annual capacity of about 6,500 basic-level health workers (June 2011)

• Enrolled in 2009 : Only about 3600• 91,000 basic level health workers were

produced (1993 to June 2011)• Among them 60 % were CMA and 22% were

ANM

Production (Pre-service training of mid level health workforce)

– Includes PCL level course in health science– Primarily produced by affiliated institutions of

CTEVT• Current (June 2011) annual capacity of

about 8,582 mid level health workers.• Enrolled in 2009 : Only about 4250• About 12,355 mid level health workforces

were produced from CTEVT (by June 2011)• Among them 57 % were PCL Nursing and

22% were PCL in GM

Production (Pre-service training of High level health workforce)

• Includes Bachelor and above level in Health science

• Master level: – Total current annual production:

507( including: MD/MS : 369; MDGP: 20; MPH: 30 and other)

• Bachelor Level: – Total current annual production: 3100

( including MBBS: 1255; BN: 499; BPH: 455 and other)

Ratio of Health Workers to Population (Doctors,

Nurses/Midwives)• The WHO 2006 report shows that in Nepal, there

are 7 Nurses/midwives and doctors per 10,000 population

• The latest cumulative statistics of registered personnel from Nepal’s medical and nursing councils suggest : 16 per 10,000 population.

• The ratio in public sector based upon current sanctioned position and population census data is only 2.9 health workers per 10,000

DISTRIBUTION OF HEALTHWORKFORCE IN NEPAL

Distribution of Health workers in Nepal

• Latest Cumulative registration data from Medical and Nursing Councils revealed low ratio of Doctor and nurses with population than WHO recommended: Categories

Total Registration to

June 2011Ratio/10,000 Population

Working in Public Sector

until mid 2010

Medical Doctors 10,753 4 1,628 (15%)

Nursing staff including ANMs 32,948 12 11,637 (35%)

Total 43,701 16 13,265 (30%)

Total Country Population 26,620,809

Distribution of HRH (Fulfilled % Vs Sanctioned)

Distribution of current HRH• Doctor:

– Filled: 62% (lowest in hill, PHC and private and NGO run hospital)• Nurses including ANM:

– Filled: 90% (lowest in Mountain, CDR and I/NGO run clinic or hospitals)

• HA and AHW: – Filled 94% (lowest in Mountain, EDR and I/NGO run clinic or

hospitals)• Technicians:

– Filled 79% (lowest in Hill, CDR and I/NGO and private clinic or hospitals)

• All cadres: - Filled 86% (Lowest: Hill, EDR, NGO run clinic and private

Hospital)

Distribution of all Types of HRH Cadres in Nepal

• Among the total filled positions,– the government contributed to 86.7% – local recruitment (DDC/VDC, I/NGO, private

sector and management committees : 13.3%• The survey data includes staff recruited

through DDCs/VDCs– in the Health Posts (9%) and – Sub-Health Posts (10%), and

• Management Committees, who made the highest contribution in Hospitals (11%).

Distribution of Health workers in Nepal

• Sanctioning positions is not a solution to HRH shortages, a FCHV from Bardiya said that despite all other positions in the PHCs being filled, the absence of a doctor was the major problem in health service provision. – One FCHV explained that “Doctors and nurses

mandated to perform their night duties are also not found and at night, the office assistant is found performing the doctors’ duties.”

• Key informants from manager of private hospitals stated that posts are vacant because of dual practice of health workforce and there is no job security, no career opportunities, a high workload and low pay to become fulltime worker.

Skill Mix of Human Resources for Health

Skill Mix of Human Resources for Health

• The sanctioned positions are based largely on the 1991 NHP and there is high pressure for all cadres of HWs to serve an increased population (more than 45 percent increase since 1991), with an increased burden of disease and an increased number of health programmes from central to village level.

• One of the DPHO from hilly district said that health workers should have comprehensive training that covers emerging health problems and makes them capable of providing a range of quality services.

Skill Mix of Human Resources for Health

• The criteria for an effective HRH mix for this survey included the availability of at least one Doctor, one Nurse/ANM, one AHW/HA and one Laboratory Assistant in a filled position and available workforce at the time of survey.

Cadre of HRH Surveyed PHC (n=17)Government Hospital

(n=14)

At least one Doctor 18% 100%

At least one Nurse 41% 86%

At least one ANM 82% 93%

At least one HA 59% 64%

At least one AHW 82% 71%

At least one LT/LA 77% 93%

Radiographers 50%

Skill Mix of HRH at PHC* and Hospital level**Spatial

CharacteristicsNo. of HF Observed No. of HF with a

*Mix of all cadres among filled post

No. of HF with a *Mix of all cadres available at the time of survey

At PHC level*Mountain 4 0 0

Hill 5 4 1Tarai 8 4 2Total 17 8 3

At Hospitals**

Mountain 4 0 1**

Hill 5 3 2

Tarai 5 4 3

*PHC Level: At least one Doctor, Nurse, AHW/HA, LA, in filled position and available at the time of survey** At Hospital: At least one Doctor, Nurse, AHW/HA, Radiographer, LA, in filled position and available at the time of survey

The qualitative data from different stakeholders also mentioned about the issue of Skill mix during FGD and KII

A Senior District Health Manager from the Hill belt of the EDR stated in a KII“…Overall, the sanctioned posts are not enough to give required health service to the people. The technical human resources are not enough in the health institutions similarly, the number of available Laboratory Technicians, Radiographers and staff nurses is very low…….”.A journalist from Doti stated that :“……If the health centre is carefully observed, we will find ANM, MCHW working in the health centre as doctors, if doctors are really not available in the communities, community health workers should be trained properly……..”

Conclusion and Recommendation

Conclusion

• The hypothesis that the spill-over effect of over-production of health workers would positively affect the availability of HRH at remote service delivery stations has not been realized.

• The uncontrolled growth of private HRH production Institutes led to relatively uncontrolled production of health workforce including doctors who do not join the public health sector and often migrate to western countries.

• Population has increased by 45 percent in the last two decades, the number of sanctioned positions still based on the 1991 Health Policy.

• Overall, 14 percent of sanctioned positions for all HWs were vacant, with a deficit of 38 percent of doctors and a 10 percent of nurses.

Conclusion……

• Greater shortage of health workers in rural health facilities compared to urban areas

• PHCs and hospitals with a complete mix of filled sanctioned posts was particularly low in the Mountain belt compared to other belts, where staff had to be locally recruited to fill the gap.

• Qualitative data highlighted that absence of one category of health workers negatively impacted on the performance of other health workers which affects health delivery system as a whole.

Recommendations:

• There should be strong coordination between the MoHP and MOE to ensure that HRH pre service training is based on the needs of the population and addresses the current imbalance between supply and demand.

• To improve the consistency of HRH data in Nepal, the MoHP should strengthen the HuRIS covering public, private for-profit and private not for-profit health facilities. Creating a database that includes private academic institutions and high level health cadres should also be considered.

• The MoHP and the respective Councils should strengthen the monitoring systems for private sector to ensure that sanctioned positions are filled and there are consistent quality services.

Recommendations..

• The MoHP should encourage the hiring of health workers at local level through district health system as a part of devolution considering the local needs, so as to the health sector partners (EDPs, I/NGOs and private sectors).

• The MoHP should increase the current number and revise type of sanctioned positions to address the issues of skill mix and shifting disease burden and population growth.

• The MoHP should create a pool of health staff at the Regional level who can be transferred to rural health facilities to fill gaps.

THANK YOU