Review of HRH-Related Bank Activities in Africa

Oscar F. Picazo, AFTH1Marko Vujicic, HDNHE

October 28, 2004

HRH in World Bank Projects

Part I: HNP Projects (O. Picazo) Past projects (ICRs): review by E.Elmendorf,

et al Current projects (PADs): AIDS, other specific

disease interventions, health sector

Part II: Macro Programs (M. Vujicic) HIPC and PRSP documents PRSCs (PADs): current and recently closed

Part I: A. Past HNP Projects(n= 63 ICRs from 1974-2002)

Wide range of activities, but highly concentrated on training Construction and equipping of training facilities Pre- and in-service training; ToT; distance ed;

curriculum dev’t Some HR planning & management

HR activities represent only about 10.3 percent of aggregated project cost of US$902 million

B. Current HNP Projects(n=17 PADs)

HIV/AIDS projects (MAPs) 9 out of 30 projects

Specific disease interventions 3 out of 9 projects

Health sector projects 5 out of 17 projects

1. HRH in HIV/AIDS Projects

Administrative structures & processes Multisectoral coordination and partnerships NACs and new institutional arrangements Subgranting to NGOs and CBOs

Capacity building At communities (CHWs) and subnational

levels (‘focal points’ and local AIDS committees)

In specific fields (epidemiologic surveillance; behavior change; blood screening/testing; treatment, care and support)

2. HRH in Specific Health Interventions

Eritrea Early Childhood Development Cross-sectoral linkages and coordination Capacity building for program management

and zonal implementation

Nigeria Polio Eradication No major institutional support Focuses only on providing financing gap for

vaccines

Senegal Nutrition Enhancement Capacity building for M&E and program

management

3. HRH in Health Sector Projects

Analysis and planningProductionDeployment and retentionPerformance management and supportAdministration and HRD systemsRegulation and quality assuranceElements of “new public administration”

3a. HRH Analysis & Planning

Chad: Recognizes HR problem as “catastrophe,” but sets modest HR goalsEthiopia: Recognizes gaps in staffing and supervision; links facility expansion to staff availability and deploymentGhana: Recognizes medical brain drain, unequal distribution of staff, and declining number of practicing nursesNigeria: Recognizes personnel shortage and fragmentation of responsibilities of various tiers of government as cause of suboptimal provision of servicesTanzania: Recognizes shortage (numbers, skills) and “aging” of district health staff due to freeze in public employment, under-investment in tertiary education, HIV/AIDS and migration; proposes long-term manpower planning

3b. HRH Production

Chad: Targets graduation of 700 new paramedical personnel by June 2005; proposes reform and decentralization of paramedical training systemEthiopia: Plans for development of a large number of few new cadres of frontline workers and mid-level health service providersGhana: No specific strategyNigeria: Aims to improve quality of training in State nursing, midwifery, and health technology schools; training of trainorsTanzania: “More strategic use of zonal training centers”

3c. HRH Deployment & Retention

Chad: Paid particular attention to recruitment of women; no strategy on retention as suchEthiopia: Gov’t issuance at project inception of new guidelines on career structure and appropriate incentivesGhana: Intension to restructure health sector’s personnel size, distribution and skill mixGhana, Nigeria and Tanzania: All expressed intention to use decentralization as mechanism for staff retention, but provided no details on how to go about it

3d. HRH Performance Management & Support

Chad and Nigeria: Not clear or specificEthiopia: Project management component addresses personnel management and supervisionGhana: Identifies need for continuous professional staff development and staff performance management system, but wanting in specificsTanzania: Spells out roles of central and regional levels in HRH, but not local authorities

3e. HRH Administration and

Systems

Occupational safety Unclear whether “universal precaution” for HIV/AIDS is

practiced No mention of ARVs for health workers In Tanzania PAD, the risk of AIDS on hospital staff is

recognized, but proposed solution is unclear (“mitigated through HR strategies”)

Industrial relations No discussions on the role of professional societies, councils, or

unions Unclear whether these were involved in project design or

policy formulationHR systems

Little, if any, discussion, since much of these systems are outside the purview of MOHs (ie., with civil service or DHRMD)

3f. HRH Regulation & Quality Assurance

HRH training standards Marketability of locally-trained doctors and nurses imply

‘acceptable’ standards But available evaluations underscore rote learning, lack of

practical training, Western orientation, and low rate of passingHRH norms and standards of care

Workloads and provider/patient ratios have not been updated in a long time to take account of AIDS and resurgent epidemics

Accountability being enhanced by increasing community involvement in managing and financing local health facilities, and introduction of user satisfaction surveys

Regulation Relationship between MOH as major employer and professional

councils as regulator of HRH not underscored in Bank projects Increasing HRH needs of NGOs/private sector not taken into

account

3g. Elements of New Public Management

Implicit contracts with mission facilities well-established in Ghana, TanzaniaIncreasing size of private sector/NGOs well recognized, but contracting is ‘grudgingly’ endorsed and slowly implemented in sample countriesAutonomous management of central hospitals proposed, but actions and timelines not specified Decentralization of health services has been slow

No ‘innovative’ HRH recruitment/deployment measures identified

Observations

Number of health sector projects declining; narrowly-focused HIV/AIDS and broadly-pitched PRSCs increasing. Implications of this trend on HRH?Governments promise higher budgetary allocations to cover for additional recurrent costs of Bank projects, but mostly for ORT, not personal emoluments (PE). Not clear whether increase in PE consistent with WB/IMF macroeconomists’ positionPADs clearly recognize HR as problem but offer little lasting solution for increased deployment and retention. Use of Bank funds for personal emoluments strictly prohibited.

Observations

Capacity building revolves around immediate project requirements. Large-scale capacity building inhibited by lack of resolution on key sector issues (decentralization, autonomy of tertiary hospitals, public/private partnerships).Capacity building heavily focused on general institutional requirements (planning, procurement, financial management), and less so on specific HNP technical areas. Unstated assumption that “other donors” provide technical management skills not always true.

Observations

Training focused on frontline and sometimes mid-level workers; little attention on technical managersThere is a focus on numbers: little attention on HR management, incentive schemes, productivity, leadership, performance management Overly focused on short- or medium-term results related to specific initiatives; little cognizance of long-term strategic needs of the health sector

Part II: HRH in PRSP, PRSC and HIPC Initiatives in

Africa

Key Questions:To what extent are HRH issues acknowledged in PRSP and HIPC documents? To what extent do PRSP and HIPC documents describe country strategies to address HRH issues?Are the cross-sectoral linkages relevant to HRH taken into account?

Findings

PRSPs and HIPC documents reviewed for 28 countries in SSA by WorldBank and in 6 countries in DfID studyIn most countries HRH is mentioned as a constraint to improved health system performance (17/26 documents)However, strategies to address the HRH constraints are described in very few of the PRSPs and HIPC documents (3/26)

Findings

While disease-specific strategies and objectives are identified frequently, implications for HRH associated with initiatives are rarely discussed

HIPC Initiative

HIPC funds provide donor support for education and health sectorsSome countries are using HIPC funds to directly address HRH constraints15% of HIPC funds going to the health sector in Benin were used for recruiting staff to fill vacancies in primary health care facilities 8% of salary payments in Burkina Faso are from HIPC sources

PRSCs

Are there specific objectives or targets within PRSCs that relate to HRH? In Ghana, decentralization of PE and incentives

for recruitment and retention are mentioned as health sector objectives in PRSC3

In Burkina Faso PRSC4 specifies decentralizing HRH functions to Regions and implementing incentive schemes consistent with budgetary allocations in MTEF

PRSCs

Tanzania and Uganda PRSCs do not have HRH-specific objectives outlined

Key finding: Specific, measurable targets or triggers related to HRH are not present in PRSCs

Cross-Sectoral Linkages

There is almost no linkage between HRH and reforms outside of the health sector that influence HRH policyThis is a key shortcoming since broad reforms such as decentralization, public sector downsizing, privatization initiatives, pay reform have an important impact on HRH policyCivil service reforms were prominent in 50% of the countries examined yet the impact on the health sector was ignored

Cross-Sectoral Linkages

E.g. in Tanzania, PRSP noted strengthening salaries in the public sector as part of civil service reform but in health section it was explicit that salary budget would not increaseE.g. Mauritania was only example where civil service reforms incorporated the needs of the health sectorWorld Bank operations not harnessing cross-sectoral linkages related to HRH

Recent Global Initiatives in HRH in Africa

Joint Learning Initiative High Level Forum on MDGs World Bank and WHO collaboration Country briefs on HRH in 9 SSA countries Overview report

Bank’s Role Moving Forward Joint partnership between WHO, WorldBank

and JLI successor moving agenda forward after High Level Forum in December

Conclusion

Past HNP projects provided little support to HR; mostly in-service training and small piece-meal interventionsCurrent HNP and MAP projects do not focus on HR, but ESW/AAA and CSRs are providing early analysis of the problem

Conclusion

HRH issues and recognition of HRH problems have a presence in PRSP and HIPC initiativeHowever, information on policies to address the HRH problems is largely absent Countries are not ‘making the case for HRH’There is an opportunity to increase the role of HRH policy in World Bank operations World Bank policy on lending for recurrent costs Suitability of each instrument for HRH issues