Assessing and Determining Capacity challenges in Health

1
Assessing and Determining Capacity challenges in
Health
Dr Lilian Dudley Health Systems Trust 13 October
2005
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Definitions

• Human resources for health (HRH)
• persons engaged in any capacity in the
  production and delivery of health services. These
  persons may be paid or volunteer, with or without
  formal training for their functions, and in the
  public or private sector. HRH encompass all
  individuals engaged in the promotion, protection,
  or improvement of population health, including
  clinical and non-clinical workers. (JLI, 2004)
• Human resources development (HRD), as applied to
  human resources for health (HRH), includes the
  planning, production, and management of health
  personnel.

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Policy Framework

• National Health Act, 2003
• Establishes National Health Council
• to develop policy and guidelines for, and to
  monitor the provision, distribution, development,
  management and utilization of, human resources in
  the national health system.
• Human Resources Planning required by Provinces
  Districts

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Strategic Framework for HRH Plan (Aug 2005)

• Pillars proposed
• Human Resource Policy and Planning
• Human Resource Production
• HRH Management / Leadership (Capacity
  Development)
• HR Information System
• HRH research
• Monitoring and Evaluation

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Human Resources for Health, Overcoming the
Crisis, JLI 2004

• Global crisis in HRH
• HIV AIDS
• Shortages, maldistribution of HRH and migration
• Chronic underinvestment in HRH
• Poor work environments
• Weak knowledge base on HRH
• Five pronged strategic approach
• Engaging stakeholders
• Planning human investments
• Managing performance
• Develop enabling policies
• Learning for improvement

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SAHR 2005

• HST commissions and conducts research in support
  of strengthening health systems, including human
  resource aspects
• SAHR produced annually by HST since 1995
• This year theme on Human Resources
• Commissioning of chapters research to experts
• Reviewing
• - Peer (Internal External)
• - NDoH PDoH

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Main Users

• DoH national, provincial and district,
  municipalities and parliaments
• Academic institutions, NGOs, Corporate sector,
  international community including foreign
  missions
• Often accessed through the web
• (www.hst.org.za)

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Key HRH issues in SAHR

• International Context
• National Strategic priorities (2004 -9)
• HR Policies
• Financing of HRH (incl projections for ART PHC)
• Nursing profession
• HRH at District Hospitals
• HRH for District Health System
• Mid-level workers
• Community Health workers
• Information for HRH
• Chapter on Health and related indicators

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International Context

• Focus on HRH a.r.o HIV AIDS and MDGs
• SSA has lowest ratios of health workers to
  population
• HRD deficiencies
• Lack of planning results in recruitment from
  other countries
• Production not in keeping with needs (no.s,
  skills, PHC)
• Management poor resulting in low morale, and poor
  performance
• Migration
• Push Pull factors
• Role of Nepad (Health strategy and HRD doc)
• Resolution on intnl recruitment and migration of
  HRH at WHA, May 2005

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Review of 10 Point plan (2004 -09)

• Backdrop of SA as developmental state.
• Balanced review with many things being achieved
  (e.g. smoking reduction, health act) and less
  success in other areas (e.g. HRH, TB, cervical
  cancer screening)
• HRH a critical constraint to achieving other
  targets 40 of PHC facilities have trained PHC
  nurses
• Recommendations
• Politicians managers communicate a
  vision/mission that resonates with front line
  health workers. Followed by clear operational
  strategies.
• A programme of action that is developed with and
  that captures the imagination of implementers.
• An effective governance and management system.
• A critical mass of skilled and motivated health
  managers and health workers at all levels.

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District Health System

• Health Act v positive and big step forward
• Challenges
• Lack of clarity of assignment/delegation to LG
• Cooperative governance
• How district health team will function
• Demotivation of health workers HR management
  needs attention
• Single public service

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Human Resources District Hospitals PHC

• Rural and scarce skills ve feature. Needs PHC
  nurses included, also standardised definition of
  rural.
• Appropriate training support of hospital
  managers required balancing financial mgt with
  service care quality.
• Recruitment and retention of professional staff
  (especially nurses and doctors) needs private
  sector approach.
• Strengthening community- based and mid-level
  health workers is needed cooperation of all
  professional bodies and unions required.
• Continuing Education is an enormous but vital
  challenge that needs support and supervision to
  accompany it.

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ART and PHCFinancing and HR needs

• ART
• Conditional grant funding (R325m) covers current
  50,000 on ART.
• By 2009, full coverage of 1,000 000, cost will be
  R6.5b
• HR requirements 3100 doctors, 2300 nurses, 765
  social
• workers, 765 dieticians, 2000 data capturers.
• PHC (2009) full package of services
• Current 2.5 visits p.a. to increase to 3.85
• Current spending needs to double to R308 per
  person.
• Translates into R13.5b required
• If PHC continues in hospital OPDs an extra R4.5b
• R1.8 billion needed for CHW programmes by
  2009/10

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Nursing

• During the period 1996-2004 the growth in the no.
  of all nurses was lt than increase in population
  growth.
• At same time increase in demand (HIV) migration
• Production of new professional nurses declined
  from 2682 (1997) to 1553 (2003).
• Nursing colleges produce over 80 of all
  professional nurses.
• All universities together have total graduation
  of 400 p.a. (e.g. 3 universities in W.Cape
  produce 50 nurses p.a.)
• Over 40 of all professional nurses produced via
  bridging course

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Nursing (Cont)

• Enrolled nurse training increased off low base.
  Private sector now producing more p.a. than
  public sector nursing colleges (gt90 of private
  in KZN Gauteng).
• Private sector responsible for bulk of auxiliary
  nurse training (75). This is concentrated in
  Gauteng and KZN (90)
• Public Sector training also not equitably spread.
  Eastern Cape producing very few enrolled
  auxiliary nurses

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Mid-level Health Workers

• Pharmacists Assistants v successful case study
  but still challenges remain.
• Rehabilitation workers initially successful but
  then fizzled out for number of reasons.
• Dental assistants did not achieve goals.
• Ground prepared for medical assistants but number
  of outstanding issues (hospital/clinic scope of
  practice vs nurses)
• All need full stakeholder buy-in career planning

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Information for HR

• PERSAL has primary function to manage salaries.
  Rest of info not accurate. Improve the
  completeness and accuracy of non-salary
  information (e.g. staff establishment) on PERSAL
  to increase the use of information.
• Routine info system for HR mgt would create a
  culture of info appreciation for importance of
  info.
• The Goals Indicators for 2001/05, (NDOH) is
  good starting point for information requirements
  for HR management.

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Indicators

• New NIDS will provide wide range of indicators
  from facility level to national.
• Population estimates below provincial level
  uncertain district indicators (e.g. immunisation
  coverage) unreliable.
• Utilisation rates PHC steadily improving over
  past 5 years.
• Large amount of information on HR
• New section on MDGs. International comparisons
  difficult as different data sources used.

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Research Info Needs(Strategic Framework)

• Norms and Standards/ Staffing establishments/workl
  oad
• Availability and Distribution
• Impact of retention strategies incl. special
  allowances
• Health Education and Training
• Funding
• Interface between DOH DOE
• Rethinking settings of training (AHC or DHS)
• Nursing education reform
• Continuing Professional Development

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Research Agenda cont..

• Career progression
• New Health Worker Cadres
• Role of CHWs
• Structures and systems for effective HRH planning
  and management
• Impact assessments of HRH planning

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Summary

• Priority is for implementation of effective
  policies, planning and management of HRH,
• Which is informed and supported by research,
  reliable information systems and routine ME in
  HRH