Manuwa Lecture 2010-02

8/6/2019 Manuwa Lecture 2010-02

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THE CHALLENGES OF DEVELOPING HUMAN RESOURCES FOR HEALTH

IN WEST AFRICA*

The attainment of the highest possible state of health is a human right recognized by

many countries, guaranteed by law in some but neither recognized nor guaranteed in the

countries of the West African region.

Formal health care services were commenced in the colonial era in these countries to

cater primarily for the expatriates, civil servants and their families. With time, general hospitals

were established in state and provincial capitals to provide services for the general population.

At the onset, health care services were provided by expatriates and these were joined by a

handful of Nationals. Health workforce development started with the training of middle-level

professionals. The training of higher-level health professionals started after the Second World

War.

Post-independence, national governments extended services to more areas of the

countries with emphasis on infrastructures whose locations were driven more by political

imperatives than equitable distribution of health care services. As more hospitals and clinics

were built, there was need to train more health professionals. The Ministries of Education,

through the Universities, took on the responsibility for training doctors, dentists and

pharmacists whilst the Ministries of Health established institutions for training other cadres of

health workers. This dichotomy in responsibilities for education of health workers without a

mechanism for consultation and collaboration between training institutions and health care

provider institutions meant that training was not linked to service needs both in quantity and

quality. Each sector developed and implemented its plans without recourse to the other.

Major advancement in science and medical technology since the Second World War has

greatly impacted on health status globally. Even in developing countries, health indices had

improved and life expectancy had been elongated by a couple of years. Then came theeconomic crisis of the 80s and 90s and the imposed Structural Adjustment Policies and

Programmes (SAP). The prescribed health reforms froze recruitment and wages and

investment in education and training was capped1. The tottering health system in the region

became weakened, the training institutions stagnated and brain drain was catalyzed.

In Africa, especially Eastern and Southern Africa, the effect on the health system was

compounded by the HIV/AIDS epidemic, which took its toll on the lives of health workers and

increased their work load significantly.

The World Health Organization (WHO) defined health system as the sum total of all the

organizations, institutions and resources whose primary purpose is to improve health. Based on

this definition, health workers are people engaged in actions whose primary intent is to

enhance health.2

Since the health system is made up of the formal and the informal health

delivery services, which includes home care therefore traditional healers, mothers at home and

other carers and volunteers are part of the health workforce. However, because of difficulty in

being able to count and plan for this large workforce, human resources for health (formal

*Lecture delivered by Prof. Kayode Odusote at the 10

thAIM Inc. Public Lecture in honour of Sir Samuel Manuwa,

12th

November 2010.


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health workers) has been defined as paid workers that are engaged in organizations and

institutions whose primary intent is to improve health and those whose personal actions are

primarily intended to improve health but work in other types of organizations.2

This definition

has been adopted for this lecture.

At the Millennium Summit of the United Nations in September 2000, world leaders

signed up to the Millennium Development Goals (MDGs) as part of an ambitious global agenda

to reduce poverty and improve lives. Three of these are directly related to health viz., MDG4 toreduce child mortality, MDG5 to improve maternal health and MDG6 to combat HIV/AIDS,

Malaria and other major diseases. There was an overwhelming favourable response from the

global donor community to provide financial support for the agenda. Notable among these

were the Global Fund for HIV/AIDS, Malaria and Tuberculosis (Global Fund), Global Alliance for

Vaccines and Immunization (GAVI), US Presidents Emergency Plan for AIDS Relief (PERPFAR)

and Bill and Melinda Gates Foundation.

However by 2004, it became clear that the extra funding was not going to achieve the

desired goals due to insufficient human capacity to absorb and apply the newly mobilized

resources.3The progress report on the WHO 3 by 5 initiative stated that lack of doctors and

nurses to deliver anti-retroviral therapy (ART) was a major bottleneck to scaling up access totreatment.

4More than two decades of neglect has taken its toll on the key input to a system

that is labour intensive. There was global shortage, inequitable distribution, poor motivation

and demotivating working conditions, especially in the developing countries. A series of high-

level Ministerial meetings followed this realization and this culminated in the declaration of

2006 2015 as the decade of Health Workers by World Health Organisation (WHO). Gradually,

the health worker issue had moved from the back burner of global attention towards the front

burner.

THE CRISIS

Health workers are the keystone of the health system. In spite of technological

advancement and computerization in health, health care still depends heavily on human

resources. Human beings still require and demand to be cared for by other human beings. The

health workforce remains the glue that binds all the other resources together to deliver health.

The population ratio is the conventional method of assessing and measuring the

adequacy of the health workforce but there is no international agreement on a norm or

minimum standard. The often quoted WHO ratios for health workers appeared to be derived

from the global average many years ago. In the World Health Report 1993: Investing in Health,

World Bank recommended that public health and minimum essential clinical interventions

require 0.1 physicians per 1000 population and 24 graduate nurses per physician. This

recommendation appears empirical.

In an attempt to measure health workforce quantity as opposed to ratio of individual

cadres, the concept of health workforce density (aggregate sum of all health workers) was

introduced by the Joint Learning Initiative (JLI) analysis.5

The analysis showed a wide regional

variation in health workforce density between regions of the world, varying from 10.9 per 1000

population in North America to 1.0 per 1000 in Africa with a global average of 4.0 per 1000.

Furthermore, the analysis showed a linear correlation between health workforce density and


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the key mortality indices of MDGs 4 and 5 that is maternal mortality, infant mortality and

under-5 mortality. Countries with low-density of health workers had higher mortalities than

countries with high health worker densities. All countries in West Africa fall into the category

of low-worker density and high mortality. The obvious conclusion is that more workers save

lives or in the other words, the fewer the workers the more lives lost.

In an empirical attempt to relate health outcomes to health worker density, the JLI

analysis showed a correlation between specific health worker density (aggregate of numbers ofdoctors, nurses and midwives) and coverage of measles immunization and skilled attendants at

birth. Similar correlations have been shown with coverage of other immunizations, especially

the availability of nurses and midwives.6

Based on the analysis, a minimum threshold of 1.5

workers per 1000 population was computed for 80% coverage of measles vaccination and a

threshold of 2.5 workers per 1000 for 80% coverage of skilled attendants at birth. In an

updated analysis, the World Health Report 2006, observed a threshold of 2.28 health care

professionals per 1000 (range of 2.02 2.54/1000) for 80% coverage of skilled attendants at

birth and this threshold has been adopted globally as the minimum standard for health worker

density. Based on this it was estimated in 2006 that there was a global shortage of 2.4 million

health care professionals (doctors, nurses and midwives) which was extrapolated to 4.3 millionfor all health workers. The shortage of doctors, nurses and midwives in Africa was estimated as

817,992 and this was extrapolated to a shortage of 1,472,385 for all health workers. Using the

minimum threshold, the report noted that 57 countries in the world had critical shortage of

health workers and 32 of these were in sub-Sahara Africa. All the countries in West Africa fall

into this category. The average health care professional density for West Africa was 0.73 (range

0.05 to 1.97) per 1000. Our countries would still have shortage of health workers in 2015 based

on needs and current level of production.7

Table 1 shows the WHO statistics of health workers

in the countries of the region and Table 2 shows the updated total health workforce and

computed health care professionals density in some of the countries.

Apart from the critical shortage in numbers, the health workforce in the region as inmost developing countries is characterized by:

Inequitable distribution Inappropriate skills mix Poor performance associated with poor motivation and poor working conditions.

These have been compounded by:

Migration both internal and external Weak support systems.

The global mobilization in support of scaling up the human resources for health led to

the First Global Forum on Human Resources for Health. The vision for HRH as adopted by the

Forum and stated in the Kampala Declaration and Agenda for Action is that All people

everywhere shall have access to a skilled, motivated and facilitated health worker within a

robust health system.8

This along with the HRH goal as stated in the World Health Report 2006

to get the right health worker with the right skills in the right place doing the right thing,

have become the guiding beacons and targets for HRH development globally and in the region.


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TABLE 1. NUMBER OF SOME CATEGORIES OF HEALTH WORKERS IN WEST AFRICA*

COUNTRIES

(POPULATION) PHYSICIANS NURSES MIDWIVES PHARMACISTS

Benin (7.78m) 311 4,965 824 11

Burkina Faso (14.1m) 708 4.268 2.289 343

Cape Verde (0.47m) 231 410 0 43

Cte d'Ivoire (17.3m) 2,081 7,773 2,407 1,015

Gambia (1.42m) 156 1,168 263 48

Ghana (22.8m) 3,240 15,797 3,910 1,388

Guinee (8.97m) 987 4,061 347 530

Guinee-Bissau (1.6m) 188 912 160 40

Liberia (3.43m) 103 589 446 35

Mali (13.2m) 1,053 5,986 2,352 351

Niger (14.8m) 296 2,421 397 20

Nigeria (124.7m) 34,923 127,580 82,726 6,344

Senegal (9.90m) 594 2,606 681 85

Sierra Leone (5.40m) 162 1,211 1,299 340Togo (5.63m) 225 1,667 270 134

* Source: World Health Report, 2006

- Includes auxiliary and enrolled nurses and midwives in countries where they are recognized.

TABLE 2. AVAILABILITY OF SOME CADRES OF HEALTH WORKERS IN SELECTED COUNTRIES IN

WEST AFRICA*

COUNTRY POPULATION PHYSICIANS NURSES

MIDWIVES

HCP DENSITY

(/1000 POP.)+

Burkina Faso 14.731 921 3,645 1,016 0.38

Cte d'Ivoire 19.262 2,746 5,973 2,258 0.57

Gambia 1.709 49 111 72 0.14

Ghana 23.478 2,082 7,608 3,794 0.57

Guine 9.37 1,708 1,317 121 0.34

Liberia 3.75 51 338 280 0.18

Mali 12.3 960 1,033 628 0.21

Niger 14.2 427 1,050 471 0.14

Nigeria 148 55,376 128,918 90,489 1.86

Sierra Leone 5.866 95 245 111 0.08

Togo 6.59 622 1,006 469 0.32

* Source: WAHO Data 2009

- Includes only professional registered nurses and midwives.

+HCP - Health Care Professionals


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THE CHALLENGES

The challenges to developing Human Resources for Health in the region would be

discussed at three levels:

1. Operational2. Strategic3. Political

The Political is important in developing countries such as ours as over 70% of doctors and over

50% of other health workers are employed in the public sector and most of them, especially

the highly-skilled professionals are educated in public health institutions.

Operational:

For the purpose of this lecture, only the following would be considered:

Education Maintenance Retention

Education: Education and training have been the traditional approach to HRH development

globally and governments proffer production of health workers as the solution to health

workforce issues. The need for scaling up production was emphasized at the 59th

World Health

Assembly in 2006 and Resolution WHA59.23 of that Assembly urges member countries to be

more committed to training health workers. In spite of seaming years of experience of our

governments in the production of health workers, there are still challenges.

As stated earlier, all the countries in the region have critical shortage of workers. Using

the WHO statistics,

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we estimated that as at 2006 the region needed 255,000 more doctors,nurses and midwives and 204,000 more of other health workers. It is uncertain what the

current capacity for production of health workers in the region is, being that we do not have

the culture of collecting and using sound data for decision making, but in comparison with the

capacity of other regions of the world, we are unlikely to be able to easily scale-up our present

capacity to meet the needs. For instance, United Kingdom (UK) trains over 6,000 doctors

annually for a population of 60 million9

whilst Nigeria trains about 2,300 doctors annually

(Human Resources for Health Country Profile, Nigeria, 2008) for a population of over 150

million. The estimated annual production of medical schools in sub-Saharan Africa was 10-

11,000 in 2009.10

There is no doubt that we would need to build more institutions to train

health workers as existing institutions may not have room for expansion. Our experience from

a recent survey of training institutions in Burkina Faso showed that admission into most

government training institutions exceeded their training capacity and this may not be unique to

that country.

Though our governments have established institutions to train almost all cadres of

health workers that are required by our health system (but not for all medical specialists), we -

like most other countries - are not sure of how many of each category should be trained in

order to have the correct mix of skills at all levels. There are no gold standards and the skills


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mix varies widely between countries.11

Figure 1 shows the wide disparity in ratios of different

categories of health workers between selected countries in West Africa. In spite of this, we

should not continue to produce different categories without adequate information on the

optimal mix of the different categories based on the structure of our health system and the

service demands at every level. There are approaches available for determining these and new

models are being developed though some of these are complex and use data elements that are

not normally available in most developing countries.12

We could use of our limited trainingcapacity and resources more efficiently if we plan production based on the needs for optimal

skills mix in our health system.

Figure 1. Ratios of different categories of health workers in selected countries of West Africa. Data from

West African Health Organisation data 2009.

Who should be trained has become a challenge for our region as for many other

developing countries. The admission policy should assure equity and diversity so that all

languages, ethnic groups and cultures are represented in the health workforce. The current

selection criteria into training institutions for highly skilled professionals, such as doctors,

dentists and pharmacists, favour the children of the rich and highly educated city-dwellers.13

The children from the rural settings (and urban lower class) are disadvantaged by the

environment not by their native endowment. The Nigerian quota system for admission into

Universities was meant to address this but its application based on state of origin not state

of residence completely defeats the intention. I was fascinated by the title of a study from

Tanzaniawrong schools or wrong students.14

By the fifth year in the medical school, two


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thirds of the students, most of whom were children of city-dwellers, were demotivated in

comparison to their initial level of motivation on admission. All those who were motivated by

socio-economic considerations were demotivated by the low salaries, poor working conditions

and heavy workload of doctors. Only those who had primary interest in medicine at admission

remained highly motivated. If these findings are replicated in other medical schools in Africa,

then we need to take a fresh look at our admission criteria. May be the current experiment at

the Ghana Medical School will provide some empirical answers. The school has started aparallel programme that could be called Executive MBBS where graduates (adult students)

are admitted into an intensive four year programme and are all interviewed before admission.

It is assumed that most of these are joining the programme because of primary interest in

medicine and not socio-economic consideration and they would remain motivated throughout

their medical career.

What competence do we expect of the graduating health professional? At this point I

would like to at congratulate my old medical school, this College of Medicine of the University

of Ibadan for the development and approval of its new curriculum. I understand that this is the

first fully home grown medical curriculum and that it is based on the integrated approach to

medical education and the use of modern teaching methodologies. This is a departure fromthe traditional approach that is still the norm in medical education in Nigeria and other parts of

Africa.15,16

We hope that with the inclusive participatory approach in its development, the

management of change to an integrated approach would not be an uphill task. One recalls the

effort to introduce an innovative medical education in a Medical School in Nigeria a few

decades ago that failed after a number of years because of the resistance of the faculty to

change.

Are we training health professionals for our countries, our region or the International

market? In 2003, there were 643 medical graduates of the University of Ibadan, 429 of

University of Lagos, 394 of the University of Nigeria, 183 of the University of Benin and 156 of

the Obafemi Awolowo University, Ife, practicing in the Unites States.

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In these days ofglobalization, should our health workers not be competent enough to recognize and manage

health problems of visitors and migrant workers? If they are of International Standards, are we

not encouraging migration to high-resource countries? In a survey on migration, one of the

push factors identified was acquisition of knowledge and skills that could not be used at home

and are better used abroad where better technology and facilities exist.18

At the West African Health Organisation (WAHO), we have embarked on the process of

harmonization of the training curricula of nurses, midwives, pharmacists, doctors, dentists and

medical specialists and we hope to include other cadres in due course. Even though this would

facilitate the implementation of the ECOWAS protocol on free movement of goods and services

in the region and encourage internal migration, the objective is to ensure the same quality of

health care delivery through the region.

Health education is life-long learning. A graduate can know all for today but would be

lacking in knowledge tomorrow if he/she has not continued to learn. The current trend is for

graduates to know-how so that they would be able to indentify gaps in their competences

and know how to compensate for this throughout their professional life. I believe the design of

the new curriculum of this medical school was conscious of this challenge and had included

appropriate measures in its educational methods.


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Apart from the core competences of the health profession, there had been calls for

health professionals, especially doctors, to be trained in management before graduation. This is

justified as consumption of material resources in the health sector is controlled directly or

indirectly by the health worker and he/she should be conscious of his/her role in the effective

and efficient use of these resources. The doctor prescribing 10 drugs when three are adequate,

the X-Ray technician constantly under-exposing films or the nurse wasting dressing lotions and

sterile packs are all poorly managing the limited resources of the institution. Also, health careservice is a team work. Even though the doctor or dentist has the primary role of finding

solutions to the patients health problems, he/she cannot provide all the interventions and care

alone without the collaboration and support of other health workers. This should be

understood and built into the culture and psyche of the health professional before graduation.

Maintenance: After production, the health worker needs to be recruited, deployed and

sustained at work. These Human Resources management functions are part of the regular

activities of the Human Resources Department of an organization and are expected to the

performed by trained professionals. In the health system, especially in the public sector, these

functions are fragmented into different Ministries and those who performed them arepersonnel administrators who have been trained in the civil service system to handle routine

civil service procedures and policies.19

They are unable to perform the functions required to

support and motivate the health worker.

Except in countries where the government is decentralized and the health sector has

been given some autonomy, recruitment is carried out by the Civil Service Ministry or

Commission and this is based on vacancies in the established staff schedules. The number of

funded established posts has little bearing on the health needs of the people and has more to

do with the financial situation of government. Also the demand for health workers that is the

number that government is willing to recruit, has no relationship with the supply that is

number of fully qualified health workers willing to accept to work in the health sector. Thedemand by government is determined by the wage bills and the size of the budget allocated to

salaries20

regardless of the need to save lives. Even with our insufficient production capacity,

the demand for health workers is less than the supply in most countries especially for doctors

and nurses who are produced in larger numbers than other categories. This is an irony of

excess supply in the face of critical shortage. In one of the countries in the region, doctors offer

their services in hospitals without being officially recruited or being on the payroll. The

restrictions of SAP is a major factor in most of these countries and a President of a country

recently ordered the recruitment of 1,000 doctors in defiance of the creditors.

Inequitable distribution of highly skilled health workers is a continuous challenge to

HRH development in the region as in most parts of the world including the high-resourcecountries of Europe and North America. Figures 2 (A and B) show the geographical distribution

of doctors (A) and Registered Nurses, including Registered Midwives (B) in Nigeria in 2007.

Owing to the large socio-economic disparity between the urban and the rural areas in the

region, there is reluctance of health workers to be deployed to the rural and remote areas. The

rural areas, which have more health service needs than the urban areas, have fewer number of

health facilities and these are manned mostly by young inexperienced health workers who are

serving their mandatory period of rural deployment. This is what some call the inverse care


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law. Some countries are recruiting retired experienced health workers on contract to fill

vacancies in rural and remote areas. This is a strategy that should be considered by other

countries in the region if proven to be a best practice.

Figure 2a. The geographical distribution of doctors in Nigeria. Data from Ministry of Health, Country Human

Resources Profile, 2007. Ratios are per 1,000 population.

Figure 2b. The geographical distribution of Registered Nurses including Registered Midwives in Nigeria. Data

from Ministry of Health, Country Human Resources Profile, 2007. Ratios are per 1,000 population.


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Increasing feminization of the health workforce is contributing to the deprivation of the

rural areas. Whilst female health workers are less likely to emigrate abroad, they are also less

likely to work in the rural areas for long periods. The story is told of a class of midwives who

were single on graduation day but all arrived with certificates/attestation of marriage a few

days later when they were to be recruited and deployed. Studies have shown that selection of

students for admission into the medical school is an important factor in the willingness of the

graduate to accept deployment to the rural areas. Male students, who are older and haveparents living in the rural area are more likely to accept such deployment

14so are those who

had their primary or secondary education in the rural area.21

However rural exposure during

training has minimal effect and may have a negative effect if the students were all urban

dwellers from the upper class.

Effective performance on the job is the outcome of effective management of the

worker. This is the process of sustaining both the internal motivation and the external

motivation of the worker so as to be available, competent, responsive and productive. Low

salaries and allowances have featured in every survey on motivation of health workers and

they are the usual reason for going on strike. They are said to be responsible for absenteeism,

dual practice, informal charges and drug leakage in health facilities.22

However, basic principlesof human resource management states that low salaries demotivate but higher salaries do not

motivate. The effect of any salary increase last for as long as it takes to adjust to the increased

income level and for it to be depreciated by inflation, then the agitation for more starts. We

are all familiar with the unending cycle of strikes for increase pay in the health sector in Nigeria

and this situation is the same in most countries in the region. Whilst there is no doubt that

every worker is entitled to a decent living wage, motivating packages for workers should focus

on non-financial incentives good working conditions, training, career development, fairness

and transparency in promotion, recognition and fairness in performance evaluation, which

should be corrective not punitive.23

Retention: As mentioned earlier, there is global shortage of health workers. Whilst in the low-

income countries this is due to low production capacity and low attractiveness of the health

profession, in the high-income countries it is due to ageing population, increase feminization of

the health workforce and growing income.24

The migration of workers from the low-income

countries to high-income countries is favoured by push factors at home and pull factors

abroad.17,18,25

Push factors include poor remuneration, poor standard of living, insufficient

opportunities for post-graduate training, poor working conditions, socio-political instability and

poor management. Pull factors include better remuneration, better living conditions, well

maintained high-tech facilities, easier system of post-graduate education, safer environment

and prestige. In addition, there is the culture of migration. In 2000, about 65,000 African-born

doctors and 70,000 Africa-born nurses were working in developed countries.26 In 2003, 2,158

Nigeria doctors were working in United States (US), 1,922 in UK and 133 in Canada. In the

same year the number of Ghanaian doctors were 478 in US, 324 in UK and 63 in Canada.27

External migration is also a major contributing factor to the severe shortages of faculty in

medical schools in Africa.10

External migration encourages internal migration as post in urban

areas left by migrs are rapidly filled by health workers from the rural areas.


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STRATEGIC CHALLENGES

The development of HRH is multi-sectoral, multi-disciplinary and multi-dimensional and

it is complex. A strategic approach is required to achieve the goals of global access and good

health outcomes. There are three inputs into the health system human resources,

infrastructure and material resources. Of course, financial resources are required for all three.

In order to be focused and goal oriented, there should be a health policy to guide and drive the

health system. From this policy should derive the HRH policy that would guide and drive thedevelopment of HRH for achieving the goals of the Health Policy. The development of National

Health Policies in our countries started with the adoption of the Health for All by the year 2000

and the need to have a strategy for achieving it. To the best of my knowledge, the first National

Health Policy for Nigeria was developed and adopted under the leadership of late Prof. Olikoye

Ransome-Kuti as Federal Minister of Health. These National Health Policies have a small

section on Human Resources, are not adequate to meet the challenges of HRH development

today. An HRH Policy should address31

:

1. Planning for supply of personnel to ensure adequate numbers of different categorieswhich are equitably distributed geographically and to all levels of care.

2. Education and training to give different categories the skills required by the objectivesof the health policy

3. Management performance, which should include practice standards, evaluation andaccountability, strategies for maintaining and upgrading quality and staff motivation.

4. Work conditions, which should include guidelines for recruitment and retention, careermanagement, mechanism for mobility and methods and levels of remuneration and

incentives.

With the technical and financial assistance of WHO, Global Health Workforce Alliance (GHWA)

and WAHO, many of our countries have developed or are developing National HRH Plans.

Nigeria currently has a National HRH Strategic Plan (2008 2012) but I wonder how manypeople here present know about it and how many non-Ministry of Health stakeholders

participated in its development. Ideally, because HRH development is multi-sectoral, multi-

dimensional and multi-disciplinary, the Plan should be comprehensive and its development

should involve all stakeholders in the country Ministries of Health, Education, Finance and

Civil Service, training institutions, regulatory bodies, professional associations, labour unions,

partner organizations, labour unions and Civil Society.

The health sector is dynamic and it is influenced by local situations and socio-cultural

values. Also the production of health workers takes 2 6 years for basic qualification and many

more years for specialist qualification. Hence it is recommended that countries should have

long-term plans with short-term actions and regular review. In order to do this effectively,

countries need to have up-to-date information on the situation and what factors influence it.

The information base for HRH decision making is weak in all our countries. No single

country in the region has accurate and up-to-date information on its health workforce

number, distribution and skills mix. There is no accurate information on production and annual

supply level, rate of emigration or the age distribution and retirement projection. Most

countries depend on the payroll database for information on health workers employed in the

public sector with no information on health workers in the private sector. Nigeria depends on


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information in the database of registration bodies, and this information includes those who

have emigrated, retired or passed to the world beyond. Hence the computed health worker

density of Nigeria is most likely an overestimation. Figure 4 shows a trend in the density of

health care professionals in selected countries in the region. This should be interpreted with

caution as data collection instruments are not yet standardized and information provided to

different organizations may very particularly with regard to the definition of different

categories of health workers. Whilst some countries include enrolled nurses and midwives inthe category of nurses and midwives, others limit this category to registered nurses and

registered midwives only.

Figure 4. Comparison of density of health care professionals in selected countries between 2004 WHO (World

Health Organization) data and 2009 WAHO (West African Health Organisation) data.

Many organizations including WAHO are working with Ministries of Health to put in

place comprehensive HRH Information systems that would capture real time information on

the health workforce in the countries so that they can have sound data for monitoring their

HRH plans and make appropriate decisions. This is a challenge also as most countries lack the

skilled manpower to collect and analyze data as well as Information and Communication

Technology resources to manage data.

32

Research is necessary to determine the factors that are responsible for the observed

outcomes of the implementation of the plans and identify best-practices that can be replicated

elsewhere in the country or in the region. This is a rich mine for our public health specialists

and social scientists and we hope they would rise up to the challenge. We need to know what

factors influence intention to study medicine or any of the health disciplines and their effect on

deployment and migration after graduation. We need to know what factors motivate different

cadres of health workers to accept deployment to the rural and remote areas. Many more


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questions in HRH development require local answers because of the influence of individual and

socio-cultural values on health workers behaviour.

As mentioned earlier, HRH development involves many stakeholders outside the

Ministry of Health. Even though the leadership of the Ministry of Health is important, each

stakeholder has influence on the availability, maintenance and performance of health workers.

Coordination of all stakeholders behind the National HRH Plan is crucial if it is to achieve its

stated objectives. This is a major lacuna in the management of HRH in our countries. GHWA ispromoting the use of Country Coordination Framework (CCF) for getting the involvement and

commitment of all stakeholders in the countries to resolve the HRH crisis. WHO is promoting

the establishment of National Health Workforce Observatory (NHWO) for the coordination of

the information and knowledge on HRH in the countries. These two initiatives have created

some confusion in the minds of HRH Directors of the Ministries of Health in the region. At a

recent meeting organized by WAHO, it was proposed that both the CCF and NHWO should be

seen as approaches to be adopted by the Human Resource for Health section of the National

Health System Strengthening mechanism that are being established by the countries. This

would reduce the number of committees and meetings and would likely make them more

effective.

POLITICAL CHALLENGE

The coordinating mechanism for HIV/AIDS works in all countries in the region is

effective because of the leadership provided by the Presidencies. In some countries entire

Ministries had been established for responding to the HIV/AIDS epidemic whilst in others like

Nigeria, special institutions or agencies were established. Such a leadership at the top is

required to get all the major stakeholders such as Ministries of Finance, Education and Civil

Service behind the National HRH Plan. There is need for long-term investment in the education

of health workers, especially the highly-skilled ones. There is need for budgetary allocation for

financial and non-financial incentive packages. New positions need to be created in the staffestablishment whilst all existing ones need to be funded and filled. All these need high level

decision which may sometime be against the dictates and directives of creditors and donor

organizations. As mentioned earlier, there is an ECOWAS Ministerial approved plan for

retention of health workers in the rural and remote areas. The implementation of this plan

requires inter-Ministerial collaboration and approval of the Cabinet in each country. The 2001

(Abuja) promise of 15% of the National budget for the health sector remains an expectation in

all our countries.

We have the challenge to place the HRH issue on the priority list of the Presidents of

our countries and get their commitments and engagement if we are to have the health

workforce required to begin to significantly move towards achieving the MDGs which theysigned unto. All those who have interest in saving lives of mothers and children in the region

must join hands in the advocacy drive to get the ears of our Presidents on the HRH crisis. We

need champions to lead this advocacy crusade.


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BEYOND HRH CRISIS

Human Resources for Health is one of three major inputs in the health system. Whilst it

is a key input to effective health care delivery, the system needs the balance provision of other

inputs. Ongoing learning site interventions in Ondo State of Nigeria by CHESTRAD has shown

that health outcomes can be markedly improved without increasing health workforce by

effective management of material resources and listening to health workers (Dr. Lola Dare,

personal communication). There is need for a paradigm shift in our approach to Health Systemperformance in order to achieve desired health outcomes. It is a frequent commentary from

HRH Directors of the Ministries of Health that health workers were always on strike for better

wages but after getting what they want, nothing changes. Absenteeism, dual practice, informal

charges, unresponsiveness and poor patient satisfaction continue.

There is need for trained leadership at the facility level. It is traditional that the most

senior doctor in the facility heads the institution. It is recognized that he or she is not trained

as a manager and does not have the competence to do more than administer the institution

following civil service rules and procedures. Whilst it is recognized that he needs some

understanding of basic management human resources, financial and material resources,

he/she cannot be equipped with the competences of a professional manager except he/sheacquires additional certification. However, his/her primary role as head of the institution

should be that of leadership and he/she should be supported by administrators/managers who

are trained to perform management functions. The leadership functions, which can be learnt

through short courses, would include:

Inspire team work Mobilize resources Engage the community fully Have good relationship with local and central government Cooperate with other sectors.

The world including our region is undergoing socio-economic and cultural changes. The

consumer always has a choice of how and where to solve his or her health problems. The care

provider has a choice of where to offer his/her services or change profession completely. The

owners of health facilities (governments, faith based organizations, private investors and health

management organizations) have the choice as to how many health workers to demand for

with or without consideration for the health needs of the population.

If we recognize that every human being has a right to the attainment of the highest

possible state of health and are conscious of the changing socio-economic and culturalenvironment then we need a paradigm shift in the way our health system is view and

organized. We need to consider the health care industry as any other service industry providing

consumer-oriented solutions. Then we would be able use lessons learnt from similar industries

to remodel our health system at all levels to deliver responsive and satisfying solutions to all

who call with their health problems. This is with the realization that the nature of the health

problems and the characteristic of the consumers would be continuous variables and the team

of health workers (health care management team) must understand this and respond to it


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appropriately. The health workforce should have all the know-how competences to proffer

solutions to the problems and the management should have the flexibility to provide the

resources to deliver the solutions to the satisfaction of the customer at all times. The outcome

would not always be perfect as death and disability would still occur but the customer and

his/her relations would be satisfied with our genuine efforts to solve his/her health problems.

This approach has all the promises for us to retain and grow our share of the consumer health

market against competition from the informal health system and improve the health indices ofour countries.

CONCLUSION

Does God love Africans more than Japanese which is why he calls them to himself early

and leave the Japanese to live well above the Biblical three score and ten years? If we say that

he is a just God, then one can only conclude that he allows everyone to reap the benefit of the

use of the talent he has given them.

We need to use the talent and resources God has given us in the region better for the

health and well-being of ourselves. There is no reason why our mothers should continue to diegiving life a thousand times more frequently than in other parts of the world. Our children

need not die before they can contribute to the growth and development of our region. Neither

can we continue to let our best brains emigrate to other countries to serve their rural and

remote areas.

The challenge is for all of us government, training institutions, private health

providers, Partners, Professional Associations, Labour Unions and Civil Society. We all need to

be committed to achieving the goal of having the right health worker with the right skills at the

right place doing the right things.


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Manuwa Lecture 2010-02

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Transcript of Manuwa Lecture 2010-02