Original: English Supporting countries for HRH development: from dialogue to action Methodological note Geneva 2004 World Health Organization The World Bank
Supporting countries for HRH development:from dialogue to action. Methodological note World Health Organization 2004 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. 2
Contents Objectives...6 Scope of the work...6 Country selection...7 Process for country work...7 Phase I. Preparation...8 Phase II. Assessment and policy development...9 Phase III. A costed HRH development plan...9 Phase IV. Implementation and monitoring...10 Organizational arrangements...10 National-level arrangements...10 Partnership arrangements...10 Budget and financial arrangements...10 Timetable...10 Annex 1. Health workforce context and influencing factors...11 Annex 2. HRH lens...12 3
Abbreviations CMH: HSDP: JLI: MBB: MTEF: PRSP: SWAps: Macroeconomics and health Health sector development programme Joint learning initiative Marginal budgeting for bottlenecks Medium-term expenditure framework Poverty-reduction strategy papers Sector-wide approaches 4
Supporting countries for HRH development: from dialogue to action Methodological note 1 Human resources for health (HRH) are increasingly recognized as a crucial element in improving health systems and health services and attaining Millennium Development Goals (MDGs) and 3 by 5 targets. Acknowledging this, the World Health Assembly in 2002 also identified HRH as a major challenge. In most African countries HRH development is a major concern of health systems. Members of the New Partnership for Africa's Development (NEPAD) have declared 2004 the year for HRH development. The World Health Organization, through its Regional Office for Africa, has developed collaborative plans with the countries to support this initiative. An Extraordinary Summit on Human Resources in Africa will be held early in 2005. In addition, collaborative initiatives such as the Joint Learning Initiative (JLI) have been developed to address HRH challenges, offering partners in this field an efficient way to work together. At the beginning of 2004, the High Level Forum proposed actions to improve HRH in countries so that MDGs can be reached. In consequence, in-depth examination of HRH will be undertaken. The resulting analysis of HRH constraints and the nature and costs of measures to address them will better permit countries and their partners to take action to meet priority health objectives. This methodological note proposes a strategy to work with countries. The underlying principles are that the strategy will: be country-led impose no extra burden on countries build on existing information and policy processes in the country. An essential part of the country work is that it will go beyond studying HRH issues alone and will take into account broader development and macroeconomic policies, strengthening health systems accordingly. This will require agreement on how to engage with governments and the different processes currently under way, such as PRSP or MTEF. The HLF asked the secretariat to put together a working group to address three key questions at the country level: What are the human resource requirements to attain the MDGs? What feasible strategies can be developed to reach MDGs? What are the cost implications of attaining the MDGs? 1 Developed by the World Health Organization in consultation with the World Bank and the Joint Learning Initiative. 5
Objectives to support and facilitate the development of HRH policies and costed HRH development plans to attain MDGs and to implement development policies; to mainstream HRH solutions into health and broader development initiatives and tools (e.g. PRSP, MTEF, SWAps); to establish mechanisms to identify common challenges and lessons learnt in various countries; to build technical capacity in countries to support HRH analysis and solutions. Scope of the work It is important to consider health workforce development in a broad perspective, taking account of the influences of globalization and national and subnational political, sociodemographic, economic, geographical and cultural factors. Acknowledging the recommendations of the HLF that HRH issues are strongly linked to non-health policies and should be dealt with in the context of development and macroeconomic policies, the planned HRH work will operationalize the HRH conceptual framework shown in Annex I. The dynamics of the health care system and labour market will also be taken into account. The work will include assessment and analysis of the current situation, identification of requirements and cost implications; policy reform; formulation of costed HRH development plans; implementation; and monitoring in the selected countries. The HRH requirements and cost implications will be identified, including key dimensions of health workforce performance, incentive structures and their impacts. Policy frameworks and ongoing national activities and commitments will be identified that have an impact on HRH such as CMH, PRSP, MTEF, SWAPs, public-sector reform and MBB. The aim is to facilitate a consultation process in the countries to agree on and support appropriate actions to develop HRH capacity. The consultation process will identify the following: What kind of dialogue must take place? Who must be involved in the dialogue? What information is needed so that participants in the dialogue have a common knowledge base? What instruments and processes can assist the dialogue in that setting? The process will drive action-oriented products, focused on solutions. The intended output is a short-, medium- and long-term, costed HRH development plan that the country can use. The sequencing of the solutions and actions is of utmost importance: understanding how to implement changes optimally is central to facilitating development processes, while failure to understand the critical path for implementation can, in itself, be a barrier to successful change. Translating investment plans into successful implementation will depend on the political, technical and managerial capabilities of the country and will determine the sequencing of the plans. Therefore, a Sequencing 6
and Capability Analysis (SCA) will play a crucial role in deciding plans of action. This tool will assist countries to reduce barriers, enhance strengths and maximize resources. The work will bring together different actions that affect HRH and explore the links (an illustrative framework is given in Annex 2). The process will provide mechanisms that view the different processes through an HRH lens, identifying interventions and policy processes of common benefit and shared challenges. Country selection Initially, up to 10 countries will be invited to collaborate in this work. Provisional criteria for inclusion are: the presence of serious health workforce shortcomings; commitment of the national government; opportunities to build on work already undertaken or ongoing that would provide background to accelerate progress; an ongoing or planned policy process (development/macroeconomic/health); opportunities for concerted action among the international/bilateral/ngo partners; diversity among selected countries (including language balance). Ethiopia is a candidate for inclusion. HRH is a priority in its political agenda. The Government is committed to PRSP, MTEF and development plans. Health-sector policy is led through the HSDP, which covers HRH. The government, the WB and WHO have already done some work on HRH. CMH has already started working in Ethiopia. WB PER includes a component on the costs of feasible strategies to improve HRH, linked with the achievements of MDGs. The WB CSR has built a model to estimate the services required to reach MDGs, including HRH. A WB facility survey conducted last year included health workforce analysis. Data from the WHO World Health Survey are already available and give broad estimates of HRH. The country has undertaken decentralization and several civil-service reforms but still faces many problems. Several bilateral agencies are also committed to supporting HRH development by pooling funds. Ethiopia is a priority country for the 3 by 5 initiative and faces serious HRH constraints in scaling up. Process for country work A government-owned and -led process is crucial in ensuring successful implementation. The process will therefore emphasize participation of stakeholders in the country in order to ensure wide ownership and sustainability and to contribute towards national capacity-building. It is envisaged that the process will be closely linked to other ongoing policy processes and policy dialogue in the countries. 7
Phase I. Preparation The Government will be contacted and asked for its agreement and commitment to the work and the process. This discussion will be carried out jointly by WHO/AFRO, WR/Ethiopia and the WB representative in the country. After the agreement of the country is obtained, the preparatory work will cover activities to be undertaken in parallel. Communication with and involvement of other partners Information on the HRH process will be conveyed to all other relevant international/bilateral/ngo partners, including CMH, JLI, Belgium, Ireland, the Netherlands, Norway and Sweden. The partners will discuss and agree upon their participation and roles in the process. Organizational arrangements at the country level Organizational arrangements at the country level will be initiated for example, identifying where meetings can be held, where information can be obtained and where collaborating institutions can be found. Shared communication at country level Information on the work and process will be communicated to all stakeholders in the country through various mechanisms. Information documents will be widely distributed; workshops will be used as opportunities for communication and publicity. Desk review There will be a comprehensive review of relevant documents and studies. A briefing note will be developed compiling the HRH-relevant aspects of this information and will set the context, identify the information gaps and set the stage for the work in the ensuing phases. Identification/development of tools For this exercise, it is necessary to bring together different tools and agree on and harmonize them. The following will be included: tools for political mapping, stakeholder analysis tools for dialogue at country level 2 tools for HRH assessment tools for costing that are consistent with the government s mid-term financial plans. It should be noted that some of the tools such as tools for dialogue at country level may need to be country-specific. 2 Such as Social dialogue in the health services: A tool for practical guidance. Geneva, International Labour Organization, Sectoral Activities Programme, 2004. 8
Expected products: defined contribution and roles of partners briefing note on Ethiopia tools for further work agreement on a process of dialogue. Phase II. Assessment and policy development In this phase, information gaps in HRH will be addressed, political mapping in the context of health and broader development initiatives undertaken, and solutions and policies proposed. The country experts and participating partners will identify a team likely to include at least the following specialists: policy analyst, HRH management specialist, health economist, education specialist and political analyst. A mission will be organized for a rapid assessment of the HRH situation in order to complete the situation analysis initiated through the desk review. In addition to assessment of the HRH situation, the terms of reference of the mission will include initiation of the policy dialogue, determination of the appropriate forum for discussion, organization of one or more workshops to discuss the initial findings at a wider forum, and identifying and seeking agreement on further actions in the process. The initial mission will be followed by one or more further missions, depending on the consultation process agreed with the Government. The process will explore the solutions for HRH issues in the short and long term and identify ways to mainstream HRH policies into broader health and development initiatives. A Sequencing and Capability Analysis will be undertaken to foster realistic, feasible, costed HRH development plans. Expected products: current issues, gaps and requirements identified HRH policies providing solutions to gaps and requirements Sequencing and Capability Analysis. Phase III. A costed HRH development plan On the basis of the discussions and policies identified in Phase II, the development of action plans will pave the way to operationalize solutions. The detailed, costed HRH development plans will also identify the HRH implications of broad development policies (PRSP, MTEF, HSDPII). Different scenarios with costings and implications for trade-off will be explored and discussed with all stakeholders. In addition to the conditions for sustainability, the support required for successful implementation (financial and technical) will be identified, as well as the contribution and role of different partners. Expected product: costed HRH development plans. 9
Phase IV. Implementation and monitoring This phase will aim to translate the policies and HRH development plans into action. Any implementation process faces challenges. In this case, the development plan presents HRH implications for other interventions; coordination is a further challenge. The implementation phase will tackle technical, financial, coordination and monitoring aspects, identified in earlier phases of the work, and capacity strengthening will be crucial in response to the capability analysis. The main responsibility in implementation rests with the Government; support will be provided when needed. Coordinated implementation will be a major challenge; appropriate coordination mechanisms will have to be established and facilitated. A monitoring framework will be developed and regular monitoring will be ensured. This framework must be incorporated into ongoing monitoring processes and cycles for the National Development Plan, PRSP, MTEF and HSDP. Expected products: coordination mechanisms for implementation progress reports on implementation monitoring framework and monitoring reports defined feedback mechanisms for monitoring and evaluation. Organizational arrangements It is crucial for ownership and sustainability that the work and the process be led and managed by the Ministry of Health. WHO/WB/JLI and other partners will provide support to the Ministry of Health to coordinate and manage the process and will provide advice on technical issues. National-level arrangements A secretariat will be established, consisting of a counterpart identified in the Ministry of Health and a small support team. The secretariat will coordinate and facilitate the work at the operational level. The work must be steered technically and politically. The mechanisms established for these purposes should reflect the multisectoral nature of the work. Partnership arrangements As this is a joint effort, it is necessary to establish coordination/communication mechanisms to link to the external partners. For each country, one agency can facilitate external coordination. Budget and financial arrangements To be discussed. Timetable To be discussed. 10
Annex 1. Health workforce context and influencing factors Socio-demographic Policies Health Care System Health Labour Demand Cultural Non-health Health - Financing -Stewardship/ Health planning - Provision - Resource generation Market failures Stakeholders Regulations Time lag Potential market power Utilization of health care Education/training Labour participation Migration Shortage Equilibrium Oversupply Geographical Health Labour Supply Financial /Physical/Knowledge Resources Economic This will form the basis of a policy framework that can be used in each country. 11
Annex 2. HRH lens Interventions and processes HRH policy Health labour market Education/ training Recruitment Retention Migration Incentives Regulation Distribution/ equity Development plan PRSP MTEF Public sector reform Civil service reform SWAps Health investment plan (CMH) Health policy Health information system Child survival MPR HIV/AIDS Malaria TB Other