SAMSS Newsletter, September 30, 2010
The Sub-Saharan African Medical Schools Study (SAMSS) tracks innovations in medical education in Sub-Saharan Africa. This Newsletter and the website http://samss.org are designed to raise awareness about issues related to medical education in Sub-Saharan Africa. Using this information, policymakers, donors and medical educators can make informed decisions that will strengthen their health systems.
In this issue the SAMSS newsletter will focus on planning and costing of human resource for health (HRH) in Sub-Saharan Africa.
The World Health Report 2006-Working together for health estimates a shortage of 4.3 million doctors, midwives, nurses and support workers worldwide with especially severe shortages in Sub-Saharan Africa. Recognizing this chronic shortage the World Health Organization (WHO) launched the Working Group on Tools and Guidelines to address how to finance the scaling up of Human Resource for Health (HRH) in developing countries. The working group developed the Human Resources for Health Action Framework to assist countries in planning, assessing, managing and monitoring their health workforce. In addition, the Global Health Workforce Alliance (GHWA) established the Task Force on Human Resources for Health Financing to strengthen the effectiveness of HRH financing policies. The task force, in collaboration with the World Bank, created the Resource Requirement Tool (RRT) to assist countries as they seek to estimate and project the resources needed for meeting their HRH plans as well as the affordability of these plans. The RRT estimates resource availability using variables such as economic growth, government capture of Gross National Income (GNI), share of government revenue allocated to health, and share of health spending allocated to HRH. RRT has been implemented in a number of pilot countries including Ethiopia, Ghana, Mozambique, Uganda, and Sierra Leone.
In “Finding Affordable Health Workforce Targets in Low-Income Nations”, Thomas J. Bossert and Tomoko Ono explored the HRH crisis and WHO’s suggested minimum target of 2.3 health professionals per 1, 000 people for all countries. The authors argued that this ‘one size fits all’ target will not be met by many countries, as it would require some countries to devote huge percentages of their gross domestic products (GDP) to health. For instance, Ethiopia would need to devote 53% of its GDP to health-related expenditures to reach the WHO target. A total of twenty countries would need to spend more than 19% of their GDP on health to reach the target, with 17 of those countries being in Sub-Saharan Africa. The article emphasized the importance of setting realistic goals and country specific targets. The authors further proposed designing a targeting mechanism that is in line with a country’s available financial resources and different skill mixes.
In “Costing the scaling-up of human resources for health: lessons from Mozambique and Guinea Bissau”, Tyrrell et al report on Human Resource Development Plan (HRDP) costing exercises conducted in Mozambique and Guinea Bissau. The authors used a case study approach to compare the two exercises and answer the questions: “(1) what to do and how to do it when undertaking HRH plans costing, and (2) what conditions need to be in place to enable a successful costing exercise.” While recognizing the value of a standardized software-based approach, the study shows some of the weaknesses of RRT such as lack of flexibility in HRH planning. The authors call for a simple, flexible bottom-up and country specific HRDP costing methodology that is integrated in the general HRH plan.
“Working in Health,Financing and Managing the Public Sector Health Workforce ”, authored by Marco Vujicic, Kalechi Ohiri and Susan Sparkes explored two key policy questions: “(1) What is the impact of government wage bill policies on the size of the health wage bill and on health workforce staffing levels in the public sector? (2) Do current human resource management policies and practices lead to strategic use of health wage bill resources in the public sector?” In addressing these questions the book examined relevant literature and analyzed cross-country data. Through case studies in four focus countries; Kenya, Zambia, Rwanda, and the Dominican Republic the book demonstrates that an analysis of wage bill budget trends, budget execution rates, vacancies, and unemployment levels among health workers can be used to determine if fiscal ceilings are preventing scaling up the health workforce. In all four focus countries, the study found a significant weakness in policies and practices related to recruitment, deployment, transfer, promotion, sanctioning, and payment methods of public sector health workers. For example, recruitment processes were delayed and did not target areas with severe staff shortages, while salaries and allowances were not being used as a strong incentive mechanism to increase rural practice and lower absenteeism. All in all, the analysis in this study suggests important issues related to the management of health wage bill in the four focus countries.
An analysis in "Financing and economic aspects of health workforce scale-up and improvement: framework paper” identified key considerations for policy-makers in planning the financing of their health workforce. The paper outlined all available information related to financial and economic issues around HRH in low-income countries and suggested what could and should be done with this information. The following seven key issue areas are discussed in great detail: (1) Employment costs and fiscal space constraints; (2) Pre-service training/production costs; (3) Equitable deployment costs; (4) Retention costs; (5) Efficiency/ productivity costs and savings; (6) Human resource management costs; and (7) Private sector engagement costs and savings. This paper is complemented by another document called “What Countries Can Do Now”, which outlines twenty-nine actions that policy makers could take to address the HRH issue in their countries, but must be tailored to country’s context.
Finally, the Human Resources for Health Observer series recently published “Models and tools for health workforce planning and projections”. The paper outlined the processes and resources needed for health workforce planning and projections. Different health workforce projection models are summarized including the WHO’s workforce supply and requirement projection model and the United Nations Development Programme’s integrated health model. Australia is used as a case study to illustrate an approach used to estimate workforce attrition at retirement age. The paper emphasized the importance of evidence-based planning in the development of HRH policies and strategic plans. On a similar topic, a technical brief by Martineau et al explored the importance of having a national HRH strategic plan. The brief highlighted the process of developing and implementing a detailed strategic HRH plan.
Francis Omaswa, MBCHB, MMed, FRCS, FCS
Executive Director, African Centre for Global Health and Social Transformation
Co-Chair, SAMSS Advisory Committee
Fitzhugh Mullan, MD
The George Washington University
Principal Investigator, SAMSS
Seble Frehywot, MD, MHSA
The George Washington University
Co-Principal Investigator, SAMSS
On behalf of the SAMSS Advisory Committee
Nurses in training at the hospital ward at the University College Hospital, Ibadan
SAMSS Advisory Committee
Magdalena Awases PhD, MA, HMPP, RN
Charles Boelen MD, MPH, MSc
Mohenou Isidore Jean-Marie Diomande MD
Dela Dovlo MB Ch.B, MPH, MWACP
Diaa Eldin Elgaili Abubakr MD
Josefo João Ferro MD
Abraham Haileamlak MD
Jehu Iputo MBChB, PhD
Marian Jacobs MBChB
Abdel Karim Koumaré MD, MPH
Mwapatsa Mipando MSc, PhD
Gottlieb Monekosso MD, DSc, FRCP, FWACP, DTMEH
Emiola Oluwabunmi Olapade-Olaopa MD,. FRCS, FWACS
Francis Omaswa MBCHB, MMed, FRCS, FCS
Paschalis Rugarabamu DDS, MDent
Nelson K. Sewankambo MBChB, M.Sc, M.Med, FRCP
SAMSS site visit team at Jimma University School of Medicine, Ethiopia