Understanding the Human Resources for Health Crisis

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Understanding the Human Resources for Health
Crisis

• Eilish McAuliffe,
• Centre for Global Health, Trinity College Dublin

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Burden of disease
Share of population
Share of health workers
Our Common Interest 2005184 The Commission for
Africa Source Sanders, D. (2005) Making Public
Health Matter Research, Training and Advocacy to
Addesss Africas Health Crisis
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HR Crisis in SSA

• Africas health workforce is insufficient and a
  major constraint in attaining the Millennium
  Development Goals (MDGs)
• WHO has estimated that to meet the ambitious
  targets of the millennium development goals,
  African health services will need to train and
  retain an extra one million health workers by
  2010 (WHO 2004).
• Beyond the national level shortages, imbalances
  in geographic distributions especially - between
  rural and urban areas exacerbate the crisis

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Addressing the human resource crisis

• Attracting home the migrants
• Attracting retired professionals back to the
  workforce
• Increasing output from training institutions
• Developing reciprocal agreements with richer/or
  oversupplied countries
• Maximising the existing in-country resources
  (skill mix and performance)

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Human Resource Actions
Health Outcomes
Health System Performance
Workforce Objectives
Coverage Social physical
Numeric adequacy Skill mix Social outreach
Equitable access
Motivation Systems support
Satisfactory remuneration Work environment Systems
support
Health of the population
Efficiency effectiveness
Competence Training Learning
Appropriate skills Training and
learning Leadership and entrepreneurship
Quality responsiveness
Figure 1 Managing for Performance Source Human
Resources for Health Overcoming the Crisis (2004)
Joint Learning Initiative
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Health Workers Perceptions of their Work
EnvironmentHealth Professionals Work Index (mean
score)
Differences are significant at .001 level In
Lesotho staff in decentralised districts more
positive Staff in urban areas more negative about
management support and working relationships
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Health Professionals Work Index

• Significant differences
• staff in decentralized districts are more
  positive about the availability of adequate
  resources
• Those working in urban areas tend to be more
  negative about management support and working
  relationships with colleagues than those in rural
  areas and than those in peri-urban areas
• Perceptions of health workers in Lesotho were
  more negative than in Malawi.

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What are the implications for attrition?

• multivariate analysis indicated that such
  negative
• perceptions of the work environment predicted
  staff
• motivation and attrition measures such as
• emotional exhaustion, job dissatisfaction,
• dissatisfaction with the profession, and plans to
  leave
• current post.

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Burnout of sample scoring high, medium or low
in each of the subscales.
Malawi
Lesotho
Significant difference in emotional exhaustion
(plt.005) Also mid-level cadres lower emotional
exhaustion Staff in decentralised districts lower
emotional exhaustion, higher personal
accomplishment
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Burnout

• In Lesotho
• Health workers in urban centres score
  significantly higher on the emotional exhaustion
  with a higher level of personal accomplishment
  than those in peri-urban or rural areas and those
  in peri-urban areas score higher than those in
  rural areas.
• Staff employed in decentralized districts scored
  significantly higher on personal accomplishment,
  lower on emotional exhaustion and lower on
  depersonalization scales than those in the
  non-decentralized districts

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Job satisfaction

• Significant correlation between working
  relationships, poor management, inadequate
  resources, control over practice and satisfaction
  with the job
• The more dissatisfied they are with their working
  environment the less likely they are to recommend
  their jobs to others

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Attrition

• Health workers who reported poor management,
  inadequate working relationships and lack of
  control over practice are more likely to report
  job dissatisfaction, have thought about leaving
  their jobs or are actively seeking other
  employment
• Lesotho
• More than half of the respondents said they are
  actively seeking other employment
• Malawi
• I consider leaving this job on a daily basis
  especially since after our former DHO left. I
  have even thought of going to sell in the
  market.
• Medical Assistant
• almost a quarter of the sample (23) said they
  are very likely to leave their job within the
  year

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• I have been in this position for the past 13
  years without promotion or increment. People that
  went for their diploma after me now earn more
  salary than I do. I am so frustrated by this that
  I have considered resigning even to sell
  something.
• Medical assistant, Malawi
• I have been in this position for the past 11
  years, it seems I have been forgotten, the worst
  of all is that I do not have any opportunity for
  continuous education.
• Ophthalmic technician, Malawi
• basing promotion on qualification is very wrong,
  sometimes you have to wait for 10 years to get
  further education that means you remain in the
  same position for about 10-15 years.
• Enrolled nurse, Malawi

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• I also think that donors should be aware not to
  separate us this thing of giving some of us
  allowances while we are all working together
  pushes us to hesitantly do our work with a
  complaint that it will be done by those who get
  allowances. When a donor is bringing some
  equipment, it should be seen that is not going to
  discourage us and separate our team spirit
  especially when we are working in one ministry
  because of one person who is a patient.
• Registered nurse, Lesotho

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Why respondents think of leaving their present job
56.3
56.2
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Age profiles of Health worker samples in Malawi
and Lesotho
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Why are Malawi and Lesotho different?

• Proximity to South Africa influencing
  expectations.
• Profile of health workers differs. Possibly
  lower expectations from mid-level cadres.

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What we know

• Our research has shown
• Staff are de-motivated, emotionally exhausted and
  seriously considering leaving
• Better resourced facilities could improve
  motivation
• Improved management infrastructure at the
  district level could have a positive impact on
  motivation
• Governments have developed good HR strategies and
  policies but inadequate management means policies
  do not get implemented
• Health workers do not all share common
  motivational needs (pay is not the only issue)
• Recruitment or increasing numbers alone will not
  solve the problem
• Experienced health workers are in short supply

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Implications

• This research gives a clear indication of the
  inadequacy of
• adopting a strategy of training and employing
  health workers in the
• absence of strategies to strengthen and improve
  other aspects of
• the work environment in resource poor settings.
  The importance
• of good HR management systems and appropriate
  staff mix in
• allowing staff to practice to their full
  potential is highlighted.
• eilish.mcauliffe_at_tcd.ie

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Motivation Project

• Many countries have developed initiatives aimed
  at incentivising health workers e.g top-up of
  salaries, housing allowances, rural posting
  allowance.
• Focus on case studies of human resources
  initiatives in Tanzania, Malawi and South Africa
• Discrete choice experiments to establish relative
  importance of different incentives.
• Funded by Irish Aid and HRB
• PI Prof Charles Normand

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HSSE

• Based on
• evidence that mid-level cadres e.g enrolled
  nurses and clinical officers are providing much
  of the obstetric services in these countries.
• Already some published evidence of their
  effectiveness.
• Some evidence from our research that they are
  more tolerant of the shortcomings of the health
  systems
• A belief that they have the potential to become
  an important part of the solution to the HR
  crisis

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HSSE

• Centre for Global Health
• Averting Maternal Death and Disease, Columbia
  University
• Realizing Rights, Ethical Globalisation
  Initiative
• Regional Prevention of Maternal Mortality Network
• In-country research and advocacy partners in each
  of 3 countries
• Funded by Irish Aid and Ministry of Foreign
  Affairs Denmark
• Project website www.midlevelproviders.org

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HSSE

• Research and Advocacy project in Tanzania, Malawi
  and Mozambique
• Expand the evidence base in use and effectiveness
  of mid-level health workers and identify leverage
  points for improvement
• What is the a relationship between performance
  and job satisfaction?
• Research that links motivation and satisfaction
  with objective measures of quality of care
• What are the most salient factors in the work
  environment influencing job satisfaction?
• Research that distinguishes the relative power
  of different types of incentives
• What are the critical factors that cause MLPs to
  leave their jobs?
• Critical analysis of the decision making process
  and the factors that influence health workers
  decision to leave their post/migrate
• How do we overcome the barriers to MLPs?
• Advocacy work with professional organisations and
  governments and also with health professionals
  networks in the countries

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Future Research

• What is the optimum skill mix?
• How can we fill the expertise gap in the
  short-term?
• Do initiatives focused on most powerful
  incentives retain staff?

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Some publications

• Eilish McAuliffe, Cameron Bowie, Ogenna Manafa,
  Fresier Maseko, Mac MacLachlan, David Hevey,
  Charles Normand, Maureen ChirwaMeasuring and
  Managing the Work Environment of the Mid-level
  provider The Neglected Human Resource. Human
  Resources for Health 2009, 713
  (19 February 2009)
• Susan Bradley, Eilish McAuliffeMid-level
  providers in emergency obstetric and new-born
  healthcare factors affecting their performance
  and retention within the Malawian health system.
  Human Resources for Health 2009, 714
  (19 February 2009)
• Mc Auliffe, E. Tackling Malawis Human Resources
  Crisis, HD 21 Insights, Health Insights No12.
  May, 2008.
• Mischa Willis, Posy Bidwell, Stephen Thomas,
  Laura Wyness, Duane Blaauw, Prudence Ditlopo,
  Improving Motivation and Retention of Health
  Professionals in Developing Countries A
  Systematic Review , BMC Health Services Research,
  8 247, 2008
• Troy, P.H., Wyness. L. Mc Auliffe, E. (2007)
  Nurses' experiences of recruitment and migration
  from developing countries a phenomenological
  approach, Human Resources for Health, 5 15.
• Negusse, H, Mc Auliffe, E. MacLachlan, M.
  (2007) Initial community perspectives on the
  health service extension programme in Welkait,
  Ethiopia, Human Resources for Health, 5 21
• Hongoro C, Normand C Building and Motivating the
  Workforce. In Disease Control Priorities in
  Developing Countries. Second edition. Edited by
  Jamison D, Breman J, Measham A, Alleyne G,
  Claeson M, Evans D, Jha P, Mills A, Musgrove P.
  Oxford Oxford University Press 2006