This paper outlines the severity and complexity of the Human Resources (HR) crisis in sub-Saharan Africa and criticises donor neglect of the issues. The document was prepared as a background document for a World Bank/World Health Organization meeting on Building Strategic Partnership in Education in Health in Africa.
Human Resources
The Health Sector Human Resource crisis in Africa: An issues paper
Support for Analysis and Research in Africa (SARA), USAID
The health worker recruitment and deployment process in Kenya: An emergency hiring programme
Adano U: Human Resources for Health, 16 September 2008
Despite a pool of unemployed health staff available in Kenya, staffing levels at most facilities are only 50% and maldistribution of staff has left many people without access to antiretroviral therapy (ART). It typically takes one to two years to fill vacant positions, even when funding is available, so an emergency approach was needed to fast-track hiring and deployment. A stakeholder group was formed to bring together leaders from several sectors to design and implement a fast-track hiring and deployment model to mobilise 830 more health workers. The recruitment process was shortened to less than three months. By providing job orientation and on-time pay checks, the programme increased employee retention and satisfaction. Most active roadblocks to changes in the health workforce policies and systems are 'human' - not technical - stemming from a lack of leadership, a problem-solving mindset and the alignment of stakeholders from several sectors. Strengthening appointment on merit is a powerful, yet simple way to improve the image and efficiency of the health sector and governments. The quality and integrity of the public health sector can be improved only through professionalising human resources (HR), reformulating and consolidating fragmented HR functions, and bringing all pieces together under the authority and influence of HR departments and units with expanded scopes. HR staff must be specialists with strategic HR functions and not generalists who are confined to playing a restricted and bureaucratic role.
The health worker shortage in Africa: Are enough physicians and nurses being trained?
Kinfu Y, Dal Poz MR, Mercer H and Evans DB: Bulletin of the World Health Organization, 87(3):225-30, March 2009
This paper set out to estimate systematically the inflow and outflow of health workers in Africa and examine whether current levels of pre-service training in the region suffice to address this serious problem. Most data came from the 2005 WHO health workforce and training institutions' surveys. The study was restricted to 12 countries in sub-Saharan Africa. It found that the health workforce shortage in Africa is even more critical than previously estimated. In 10 of the 12 countries studied, current pre-service training is insufficient to maintain the existing density of health workers once all causes of attrition are taken into account - it would take 36 years for physicians and 29 years for nurses and midwives to reach WHO's recent target of 2.28 professionals per 1,000 population for the countries taken as a whole - and some countries would never reach it.
The health workforce crisis in TB control
Human Resources for Health 2005, 3:2
"Human resources (HR) constraints have been reported as one of the main barriers to achieving the 2005 global tuberculosis (TB) control targets in 18 of the 22 TB high-burden countries (HBCs); consequently we try to assess the current HR available for TB control in HBCs...(The study concluded that) There were few readily available data on HR for TB control in HBCs, particularly in the larger ones. The great variations in staff numbers and the poor association between information on workforce, proportion of trained staff, and length and quality of courses suggested a lack of valid information and/or poor data reliability. There is urgent need to support HBCs to develop a comprehensive HR strategy involving short-term and long-term HR development plans and strengthening their HR planning and management capabilities."
The human resource for health situation in Zambia: Deficit and maldistribution
Ferrinho P, Siziya S, Goma F and Dussault G: Human Resources for Health 9(30), 19 December 2011
In this paper, the authors describe the way the human resources for health (HRH) establishment is distributed in the different provinces of Zambia, with a view to assess the dimension of shortages and of imbalances in the distribution of health workers by province and by level of care. They used secondary data from the "March 2008 payroll data base", which lists all the public servants on the payroll of the Ministry of Health and of the National Health Service facilities. Results indicate that workers are maldistributed across Zambia. This case study documents how a peaceful, politically stable African country with a longstanding tradition of strategic management of the health sector and with a track record of innovative approaches dealt with its health worker issues, but still remains with absolute and relative shortages of health workers. The Zambia case reinforces the idea that training more staff is necessary to address the health worker crisis, but it is not sufficient and has to be completed with measures to mitigate attrition and to increase productivity.
The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe
Chirwa Y, Witter S, Munjoma M, Mashange W, Ensor T et al: BMC Health Services Research 13(197), 28 May 2013
This study aimed to examine the links between human resources for health (HRH) and changes in health policy on user fees in Zimbabwe, with particular respect to reproductive, maternal and newborn health (RMNH). The authors used secondary data and small-scale qualitative fieldwork (key informant interview and focus group discussions) at national level and in one district in 2011. They found that past decades have seen a shift in the burden of payments onto households. Implementation of the complex rules on exemptions is patchy and confused. RMNH services are seen as hard for families to afford, even in the absence of complications. Health workers face challenges in managing demand, including from migration, and low pay. In four provinces they found that there are not enough doctors to provide more complex care, and only three provinces could provide skilled personnel for deliveries taking place in facilities. The authors argue that that there is a need to jointly address user fees that place financial burden on clients of RMNH services and to improve the terms and conditions of health staff.
The impact of a supportive supervision intervention on health workers in Niassa, Mozambique: a cluster-controlled trial
Madede T; Sidat M; McAuliffe E; et al.: Human Resources for Health 15(58), doi: https://doi.org/10.1186/s12960-017-0213-4; 2017
Studies have shown the contribution that supportive supervision can make to improving job satisfaction amongst over-stretched health workers in in resource-constrained settings. The Support, Train and Empower Managers study designed and implemented a supportive supervision intervention and measured its’ impact on health workers using a controlled trial design with a three-arm pre- and post-study in Niassa Province in Mozambique. Post-intervention interviews with a small sample of health workers were also conducted. The quantitative measurements of job satisfaction, emotional exhaustion and work engagement showed no statistically significant differences between end-line and baseline. The qualitative data collected from health workers post the intervention showed many positive impacts on health workers not captured by this quantitative survey. Health workers perceived an improvement in their performance and attributed this to the supportive supervision they had received from their supervisors following the intervention. Reports of increased motivation were also common. An unexpected, yet important consequence of the intervention, which participants directly attributed to the supervision intervention, was the increase in participation and voice amongst health workers in intervention facilities.
The impact of an emergency hiring plan on the shortage and distribution of nurses in Kenya: The importance of information systems
Gross JM, Riley PL, Kiriinya R, Rakuom C, Willy R, Kamenju A et al: Bulletin of the World Health Organization 88(11), November 2010
This study analysed the effect of Kenya’s Emergency Hiring Plan for nurses on their inequitable distribution in rural and underserved areas. It used data from the Kenya Health Workforce Informatics System on the nursing workforce to determine the effect of the Emergency Hiring Plan on nurse shortages and maldistribution. Of the 18,181 nurses employed in Kenya’s public sector in 2009, 1,836 (10%) had been recruited since 2005 through the Emergency Hiring Plan. Nursing staff increased by 7% in hospitals, 13% in health centres and 15% in dispensaries. North Eastern province, which includes some of the most remote areas, benefited most: the number of nurses per 100 000 population increased by 37%. The next greatest increase was in Nyanza province, which has the highest prevalence of HIV infection in Kenya. Emergency Hiring Plan nurses enabled the number of functioning public health facilities to increase by 29%. By February 2010, 94% of the nurses hired under pre-recruitment absorption agreements had entered the civil service. Preliminary indicators of sustainability are promising, as most nurses hired are now civil servants. However, continued monitoring will be necessary over the long term to evaluate future nurse retention.
The impact of an emergency hiring plan on the shortage and distribution of nurses in Kenya: The importance of information systems
Gross JM, Riley PL, Kiriinya R, Rakuom C, Willy R, Kamenju A et al: Bulletin of the World Health Organization 88:798, November 2010
This study sought to analyse the effect of Kenya’s Emergency Hiring Plan for nurses on their inequitable distribution in rural and underserved areas, using data from the Kenya Health Workforce Informatics System. It found that, of the 18,181 nurses employed in Kenya’s public sector in 2009, 1,836 (10%) had been recruited since 2005 through the Emergency Hiring Plan. Nursing staff increased by 7% in hospitals, 13% in health centres and 15% in dispensaries. North Eastern province, which includes some of the most remote areas, benefited most, with nurses increasing by 37%. By February 2010, 94% of the nurses hired under pre-recruitment absorption agreements had entered the civil service. The study cautions that, despite promising preliminary indicators of sustainability, continued monitoring will be necessary over the long term to evaluate future nurse retention.
THE IMPACT OF HIV/AIDS ON CIVIL SOCIETY: ASSESSING AND MITIGATING IMPACTS
This report is the result of research into the current impact of HIV/AIDS on NGOs and CBOs in KwaZulu-Natal, the worst-affected province of South Africa. A survey of organisations found that most were aware that they eventually would have to grapple with HIV/AIDS among their own staff and volunteers, and they knew this could have serious consequences for their organisations' effectiveness and sustainability. This report aims to provide not just information on the status of the surveyed organisations, but also tools to help organisations in South Africa and elsewhere plan for and manage the epidemic among their own staff and volunteers.