Human Resources for Health Strategic Plan ( ) Ministry of Healthcare and Nutrition Sri Lanka

Transcription

1 Human Resources for Health Strategic Plan ( ) Ministry of Healthcare and Nutrition Sri Lanka July 2009

2 Contents Background...1 Section 1: HRH Situation Analysis Introduction HRH Strategies in context of the Health Master Plan Conceptual framework Factors external to the Health sector affecting HRH Socio demography Epidemiology Geography Political profile Culture Government Economic policies Other sectoral policies Factors internal to the Health sector affecting HRH Existing Health sector policies and strategies Health care delivery system Supply Demand Demand for services Demand for Staff Expenditure on HRH Productivity Private Sector Planning Staffing norms Management of HRH Performance management The Health Ministry organizations ability for HRD Staff Satisfaction Adequacy Conclusion...27 Section 2: Analysis of Issues and Challenges in Human Resources for Health Introduction Analysis of HRH Policies and Planning...28 i

3 2.1 HR Development and Planning Inconsistencies in norms Deficiency in cadre determinations Uncoordinated policy and planning functions Human Resource Information System (HRIS) Policy dialogue Evidence based Planning Other stakeholders Private sector and HRH planning Analysis of Production/Training of HRH Quality assurance of training Training Staff Training Curricula Evaluation of training Management of training In-service training Post graduate training Analysis of HRH Management HRM capacity HRM staff development Coordination of HRM functions Delays in procedures and processes Work environment Deployment Motivation Devolution and decentralization Trade unions Performance appraisal Attitudes towards HRM Conclusion...65 Section 3: Formulation of Strategic Plan Introduction Scope Guiding Principles Establishment of a Vision and Mission Statements Strategic Framework Policy Directions...69 ii

4 Section 4: HRH Strategic Plan HRH Planning HRH Training HRH Management Assumptions and Risks Implementation of HRH strategies Financing the Strategic Plan Monitoring and Evaluation Conclusion...96 iii

5 List of Tables Table 1: Summary of HRD Policies...10 Table 2: Inputs and outputs from training schools for selected categories Table 3: Distribution of selected health staff by hospital and public health services Table 4: Health Ministry expenditure (in Rs millions) on selected major items, Table 5: Staff availability in countries of the Region per 100,000 population (2005)...27 Table 6: Problem Analysis on HRH Policy Development and Planning...33 Table 7: Problem Analysis on HRH Training and Production...41 Table 8: Problem Analysis on HRH Management...56 Table 9: Indicators for monitoring implementation of HRH strategy...92 List of Figures Figure 1: The Conceptual Framework...4 Figure 2: Trends in Key Health Personnel Figure 3: Distribution of Medical and Dental officers by province (2007)...18 Figure 4: Distribution of Nursing officers and midwives (field and hospital) by province (2007)...18 Figure 5: Distribution of selected categories of Health personnel by province (2007)...19 Figure 6: Trends in Doctor: Nurse ratio ( )...20 iv

6 Foreword The Ministry of Health is committed to improve accessibility and quality of healthcare in the country through a competent and productive health workforce. However the health sector is facing many issues and challenges in ensuring an adequate and equitable distribution of appropriately skilled and motivated health workers. In order to address the key issues, the Ministry of Health identified the need to develop a Strategic Plan for Human Resources for Health. I am pleased that such a plan has now been developed. This strategic plan outlines the broad objectives, strategies and major activities required to address the issues. The strategies and activities outlined in the Plan would provide a framework to direct interventions in the planning, management and development of human resources for health particularly for the government health sector. As highlighted in this document I strongly feel the absolute need to possess updated credible data and information on human resources for health for better planning and decision making. The release of HRH Strategic Plan can be considered as a milestone in the country s health system development. I strongly encourage stakeholder participation in reviewing this document and submitting their suggestions and comments. The successful implementation of this plan will pose many challenges, but I am confident that with the sustained support from stakeholders including professional associations, development partners, unions and the health workers, we can meet these challenges to achieve our goal of a health workforce responsive to the health needs of our people. Dr. Athula Kahandaliyanage Secretary Health Ministry of Health and Nutrition Sri Lanka v

7 Background Sri Lanka s health sector is facing a number of human resource challenges that are influencing effective delivery of services. There is a continuous mismatch of demand and supply of human resources over the years, which has resulted in maldistribution and shortages. These are further complicated by the disease burden and demographic changes. Although there are the discrepancies between numbers, types, functions, distribution, and quality of health workers, the Sri Lanka health system over the years has been performing well when compared to other developing countries. However the human resource issues it faces need to be resolved quickly, if it were to show any further improvement in its service delivery. Strengthening of the Human Resources for Health (HRH) in both public and private sector has been emphasised as one of major activity to be undertaken in the implementation of the Heath Master Plan (HMP) Though developing a Human resources strategic plan has ranked low in the past in the agenda of the Ministry of Health, the need for such a plan has been emphasised in many forums recently. Some attempts have been made in the past to produce HRH plans. The latter has not materialised as either the HRH issues were not addressed in a systematic manner, or the plans that have been formulated are divorced from the development of the overall health system. Relatively weak areas in the management of HRH are the fragmented nature of functions relating to HRH in the Ministry of Health, a sketchy database on HRH at information division of the Ministry, weak planning capacities throughout the system and the many gaps between policies and local implementation. A task force and a working group were appointed by the Secretary of Health to carry out this task of developing a strategic plan that would address the issues affecting HRH. This activity was conducted in collaboration with the World Health Organisation (WHO). In the process of developing the plan the working group organised several consultations which included discussions on HRH issues relevant to decentralization, private sector involvement and HRH in underserved areas. 1

8 Several consultations were also made with the trade unions and professional associations as well as with the senior staff of the National Ministry of Health and Provincial Ministries of Health. The HRH Strategic Plan is based on a thorough situation analysis (Section 1: Situation Analysis), followed by examination of the scale of the problem and the underlying causes and the effects on the delivery of health services. (Section 2: Analysis of issues and challenges in Human resources for Health). Based on the analysis, a draft strategic framework consisting of guiding principles, vision and mission statements and a set of strategic objectives were developed.(section 3: Formulation of Strategic Plan). The Strategic Plan was formulated around 7 interrelated objectives organised around three functional areas. (Section 4: Strategic Plan). The Situation Analysis described in Section 1 is a summarised version. The reader is requested to refer to the attached Supplementary document for detailed information from the Situation Analysis. The main document sets out strategies, outcomes and broad activities for 2009 to 2018 to address the human resources problems in the health sector in three functional areas namely HRH planning, HRH production and HRH management. Most of the activities will be implemented within the timeframe of national Health Master Plan (HMP). The main focus of the strategic plan is to strengthen human resource planning, production and management capacities at all levels. It aims at establishing a coordinated approach to Human Resource Planning, ensuring a trained, motivated and equitably distributed staff and at improving productivity and performance of health workers for provision of a service of high quality. 2

9 Section 1: HRH Situation Analysis 1 Introduction The purpose of the HRH situation analysis is to provide a baseline for the formulation of a HRH Strategic Plan, to review HRH policies in the light of identified HRH needs, and to identify issues and problems to be addressed in the Strategic plan during the period The contents of the strategic plan will be coherent with the strategic objectives of the Health Master Plan (HMP) for Sri Lanka. In the past there have been several studies on HRH with valuable recommendations. But there has been a gap in translating these recommendations into action.this section briefly outlines the present status of HRH, its influences and challenges. More details are available in the attached supplementary document. 2 HRH Strategies in context of the Health Master Plan The Health Master Plan for Sri Lanka has laid down the road map for development of the health sector after an extensive consultation process. The immediate objectives in the HMP in terms of HRH are as follows: 1) To expand functions and strengthen capacities of National and Provincial Ministries of Health in human resource development and management 2) To rationalize the development and management of human resources for health 3) To improve management, clinical and public health competencies of health staff The HRH strategies are aimed at achieving above objectives resulting in an effective workforce management. 3

10 3 Conceptual framework A conceptual framework 1 was constructed to capture the variables that need to be studied for situation analysis. This would help in a comprehensive understanding of factors that influence HRH. This conceptual model identifies the constructs within and external to the health sector that influence the demand and supply of human resources. Factors external to the health sector, affecting the sector is shown in the outer circle in Figure 1. Factors within the health sector influencing HRH is shown in the inner circle. Figure 1: The Conceptual Framework External Factors Epidemiology diseases patterns Internal Factors Socio Demographic Profile Culture health care seeking pattern Policies HRH policies Other Policies HRH Plans Norms and standards Labour relations Trade unions Professional Bodies Health System Organizations ability for HRD HRH Resources Expenditure Other Health resources governing HRH (Infrastructure Knowledge Technology) Actual Service output HRH Performance (Staff Quality Productivity ) Indigenous systems Performance Management of HRH HRH Demand Present Cadre requirement Utilization pattern at different levels of care Degree of Adequacy HRH Supply Education, training Migration, size of the workforce, Projections, Attrition, Deployment, distribution, skill Political Culture Economic policies and other non health policies Geographic Profile 1 A guide to rapid assessment of human resources for health World Health Organization

11 4 Factors external to the Health sector affecting HRH 4.1 Socio demography The demographic profile of the country influences health care demand. The differential growth that is required in different types of services is dependent on age structure of the population and their growth rates. Sri Lanka s population is ageing rapidly. People over 65 years of age comprise 8 per cent of the population in 2009 and this figure is estimated to reach 25 per cent (5.4 million) by, according to the demographers. The rate of growth of urban population is also another factor that determines how services should be made available. The shift of families to urban towns has left elders to care for themselves in rural areas. Thus there is a growing need to improve health care facilities for elders and health cadres that are trained in caring for elders in the community. The demand for free quality health care especially for chronic non communicable diseases (NCDs) and for rehabilitative care will increase within the next decade. Hence planning for a comprehensive primary health care delivery system supported by competent staff, targeting the elderly will be an imperative need. The socio-economic distribution pattern will be an indication of the purchasing power, which affects the growth of the private health sector in the country. The past conflict has lead to the need of rehabilitation of many young victims of war both mentally and physically, and health sector has an important role to play in that scenario. Reorientation of the health workforce to emerging challenges due to demographic transition is thus a key issue in the coming years. Therefore primary health care workers role in the field should be reformed to meet the challenges with proper guidance and training. Newer fields like rehabilitation medicine, geriatrics etc will be supplementary to the health services in the future. Physiotherapists, psychiatrists, counsellors, nutritionists and dieticians will be needed in bigger numbers in the next decade. 5

12 4.2 Epidemiology Morbidity and mortality trends also form an important means of determining health care demand and its required HRH. The need to manage the increasing trend towards noncommunicable diseases whilst maintaining an emphasis on communicable diseases, recognizing that globalization imposes special demands due to newly emerging communicable diseases, is obvious. Traumatic injuries have been the major cause of hospitalization during the past one and half decades. Hypertensive diseases also have crept into the main causes of hospitalization during last decade. Viral diseases continue to be a problem at hospital level needing admissions. New approaches in treating traumatic injuries, especially establishing ETUs at different level of hospitals with adequate skilled human resources may enable a reduction in admissions as well as the future burden of complications from traumatic injuries. Rehabilitation of trauma victims as productive and useful members of society will also be a responsibility of the health sector. Remodelling the existing primary level health care services which have been largely maternal & child health and communicable diseases oriented is important in the context of increasing disease trends for non communicable diseases, injuries & mental health conditions. 4.3 Geography Geography and its effect on health care distribution are important, particularly in understanding accessibility of services. Other factors that affect health care demand would be through climatic / location factors that could affect the health of communities in particular areas, e.g., high incidence of renal diseases in some locations, increased incidence of snake bites in agricultural areas, increased incidence of pesticide poisoning due to increased availability and use in farming areas. Urban Rural differences in HRH distribution exist. The difficulty in getting HRH to the facilities in underserved areas is a key concern. Difficult terrain, relative inaccessibility though the public transport system, lack of other resources such as suitable housing, 6

13 education facilities, and other social interactive environment for professional staff to reside in these areas, are some of the reasons. Residential facilities are available only for some categories. The development framework document of the current government (Mahinda Chintana 2 vision for a new Sri Lanka) has considered the geographical imbalances and has stressed the need to address the issues in the lagging regions. Availability of HRH in conflict-affected areas also needs special consideration. The gap here is more acute. Of the 50 estate hospitals managed by the private owners during the past 18 years, 27 of them have been taken over by the Ministry of Health. Although the emphasis is on bridging the gap for health outcomes between estate and other areas, the estate areas remain a lagging area when health outcomes and services are compared with other areas. A key issue is that there is a dearth of health care workers who can reach the Tamil-speaking population in the estate sector. In the Tamil-speaking conflict affected areas, this problem was overcome to some extent by lowering the entry education qualifications for midwifery training. 4.4 Political profile Successive Governments have realized the importance of continuing to provide free health care. Despite the difficulties in meeting this challenge, the present Government increased its commitment over the last two years by recruiting and training some required cadres. Although private sector growth for health care is encouraged, the Government is totally committed to ensuring that poorer, disadvantaged, displaced populations and other vulnerable communities are cared for. 2 Mahinda Chintana vision for a new Sri Lanka, A Ten Year Horizon Development Framework , Department of National Planning, Ministry of Finance and Planning 7

14 4.5 Culture Health care demand is greatly influenced by our culture. The prominent role played by females in the family unit and their level of education has improved health care access to the family unit, which is especially significant for pregnant mothers and children. It has been relatively easier to introduce health care programs which can be delivered through females in Sri Lanka. Another important societal value is that of extended families and caring for the young and old through this system. Some countries have had to adopt domiciliary health care systems to care for the elderly as most often elders live alone. Sri Lanka still has a high percentage of unmarried young adults who live with their parents, whereas many countries have societal values that encourage children to leave their family unit early. Men are seen to seek health services less frequently than women. Considering that the difference in life expectancy for female and men is widening, early attention to improving health-seeking behaviour of men is important. Although female cadres may prefer some specialties, a strong gender preference for the provider is not seen in Sri Lanka. Knowledge of cultural patterns and ability to speak the local language is an advantage. 4.6 Government Economic policies The macroeconomic policy vision of the government is to position Sri Lanka as a modern economy. The current global financial crisis has slowed the progress towards this and would have its effects on the human resources by way of job losses. The Government has received an IMF loan recently to help it to weather this crisis. One condition behind this loan is the reduction of budget deficit from an estimated 7-8% in 2008 to 5% by 2011 making it necessary to cut on expenditure and collection of more taxes. However government is committed to protect the heath sector by not cutting on the required funds for its development. The government will maintain a liberal foreign exchange policy environment with regulatory safeguards to promote a stable foreign exchange market and limiting the 8

15 outflow of foreign exchange. The monetary policy would be primarily designed to prevent demand fuelled inflationary pressures in the economy. Health care financing The healthcare financing policy has been based on a universal tax-based model. However the Government has encouraged growth of the private sector in providing healthcare, considering that some of the burden of health care can be shifted to those who can afford to access private health care, whilst the government can concentrate its efforts on those who are poor and less privileged. In 2008, the total health budget increased by 8.5 per cent to Rs. 75 billion which was about 1.7 per cent of GDP. Throughout the decade, government and private sources accounted for approximately 50 percent each of total financing. Recent research has shown that although private sector health care is an option, much coverage and equitable care cannot be achieved through its promotion. The private sector will develop only those aspects that are in demand by those who have the purchasing power. 4.7 Other sectoral policies Several policies outside the health sector also affect the HRH situation and its growth. The current emphasis on encouraging private sector growth and on decentralization, pose challenges in HRH determination. Education and infrastructure development policies have affected retention of health professionals in the government sector and also the availability of health staff in rural and difficult areas. Improved education facilities and infrastructure should at least in the medium term improve the availability of health staff in the remote areas. This is a key challenge in post conflict recovery. Health development in remote situations should take place together with development of other sectors to help the retention of health staff in difficult areas. 9

16 5 Factors internal to the Health sector affecting HRH 5.1 Existing Health sector policies and strategies Several successive workforce studies, task force recommendations and the Health Master Plan, Mahinda Chinthana policy statement and others have all given valuable recommendations on the need to improve HRD mechanisms, coordination between supply and requirements. But these have not fully materialized. Clear policy for development of HRD relating to proper workforce plans, projections, training, recruitment, and deployment are lacking. In the absence of such clear policy, the recruitment for basic training has been haphazard and has resulted in inconsistent supply of HRH. The Mahinda Chinthana recognizes that HRH supply must address the within country distribution imbalance of the government health sector staff, but also recognize the demands and opportunities for staff in the private sector and the opportunities arising in the context of globalization. Table 1: Summary of HRD Policies Policy area HRD policy area Current status National Mahinda Chinthana Staff recruitment Making more doctors and specialist doctors available Implementation of HRD relevant policy in the Mahinda Chinthana is not monitored specifically by any unit in the MoH. Staff deployment to underserved areas Staff motivation and provision of residential facilities to staff Training for the private sector Training for the global market 10

17 Sectoral policy Policy Formulation and implementation Decentralization and leadership Key HRD functions of the Line Ministry/Central Government are: HRH Policy formulation and issue of policy guidelines on HRD HRH planning & development staff recruitment, staff allocation, HRD planning, staff development and management, maintaining human resource information systems (HRIS) Basic and post basic training In-service training Training for skill development in management Preparation of quality assurance guidelines especially on technical competencies of staff HRH functions under Provincial Health Authorities are: Recruitment policy according to service minute or scheme of recruitment Provincial Policy Formulation and Statute making Functions in list 1 and concurrent list 111 of 9th Schedule of 13th amendment to constitution HRH planning cadre determination for the province, recruitment of minor categories, staff development and management, maintaining HRIS Awarding of scholarships for postgraduate education within Sri Lanka In-service training Training for skill development in management Implementing quality assurance programs Monitoring of staff quality Recruitment criteria for each category of staff exist. 11

18 Job descriptions Job descriptions are not available for most categories of staff. Although job descriptions are available for some categories of public health staff even these job descriptions are incomplete and do not cover the expected range of current functions. The curative sector does not have specific job descriptions given at the time of recruitment. More recently (2008) Directors of the Line Ministry of Health were given duty lists/ job descriptions. Benefits and entitlements Leave as in E Code. Health staff has special incentive schemes. Deployment/ placement policy Promotion policy No explicit policy for deployment. In general member of staff must earn his promotion by a satisfactory service and fulfilment of all the required qualifications prescribed in the Service Minute or the Scheme of Recruitment Seniority is considered an important criterion for promotion, rather than individual performance, special skills. Motivation and performance management Motivation of staff is low mostly from slowing down of implementation of performance management activities such as supervision. The main motivators next to remunerations (salary etc) are recognized as training, recognition and responsibility. Retirement policy The general rules for government servants apply Disciplinary action policies The general conditions as stated in the Establishment Code also apply to health staff 12

19 Transfer policy / schemes Transfers are referred to as in the Establishment Code for Public servants, where an appointment is given for a period of 4 years. A vacancy list is identified for each category of staff separately. Those eligible (i.e those who have served the minimum period of 2 years in the current station) can apply to this list where their prioritized preference is stated. Seniority is considered when identifying the next station. Dual Practice Government medical cadres are allowed private practice (dual practice) and hence the total availability in the private sector is much more than the registered number. Dual practice was introduced to compensate the low salaries given to those in Government services whilst encouraging them to remain in the country Training policies No explicit training policy 5.2 Health care delivery system The government is the key provider of healthcare in Sri Lanka. Both western and ayurvedic systems are practised. The western system is more popular; however there is a growing interest in ayurvedic care. Approximately 95% of in inpatient care is through government system while 51% of the out patients are seen in the private sector. Despite the gains achieved by the health sector in the past several years, the health workforce will face many difficulties due to the current organization and delivery of services being inadequate to face the new challenges described in the previous sections. 13

20 5.3 Supply The Health workforce in the Government sector comprises of 290 different categories. 3 These categories have been created over the past several decades and in the present context some of these may be redundant The workforce size In 2007, a total of 106,298 staff were deployed in the Government health sector. Of these, 48,839 are in position in the Provincial Health delivery system. The other 57,459 are in the Line ministry health institutions and include 10,096 who are currently under training. However, information of number of health workers currently employed is found to have many inconsistencies due to no maintenance of a proper HRIS. Therefore, the exact number of total workforce is difficult to assess. There is no updated information on migration for most categories. According to MoH records, 34, 44 and 39 nurses have migrated in the years 2008, 2007 and 2006 respectively. In year 2006, a total of 967 doctors graduated from training institutions in the country. Of these 100% was absorbed to government institutions for internship. 4 Generally there has been a long lag period between the time of graduation to internship appointments. In 2004 there was a work force of 9837 employed in the private sector including 156 doctors, 874 Consultants (including those in dual practise) 33 dentists, 3441 nurses. 5 The total availability of doctors in the private sector is much more than the registered number given here. The number of full time GPs is dwindling while there is an increasing number of part time private practitioners. There are approximately 20% full time practitioners against 80% of part time private practitioners, nearly all of whom are government doctors who are engaged in dual practice. 3 Censes on health manpower Annual Health Bulletin IPS Sri lanka 14

21 5.3.2 Trends in total workforce size Trends in the total workforce size result from the balance between attrition and increments. Empirical data on overall losses from emigration, moves to private sector etc. are not available to study the overall trends. However interesting trends are observed among some selected professional categories from (Figure 2) Figure 2: Trends in Key Health Personnel Rate per 100,000 Population Medical Officer Dental Surgeones Nurses PHI Public Health Midwives Hospital Midwives Years Source: MDPU, Ministry of Health 2009 The availability of Medical officers and nurses have increased over the period 1980 to The availability of dental surgeons, public health midwives (PHM), hospital midwives and public health inspectors (PHI) have not shown any significant growth. Of significance is the rapid rise of availability of nurses from due to increased recruitment for training from

22 5.3.3 Training and Recruitment The training of doctors takes place at eight medical schools functioning under Ministry of Higher Education while training schools for nurses and allied health professionals (AHPs) are managed by the Ministry of Health. Nurses are trained in 12 nursing schools which also conduct the first year of midwifery training. From recently nurses and AHPs are also following training courses in some universities. In the case of AHPs the recruitment for training has been irregular. Following table shows the training inputs and outputs from An accelerated recruitment drive to recruit nurses continued from Table 2: Inputs and outputs from training schools for selected categories Category Intake Output Intake Output Intake Output Intake Output Intake Output Intake Output Medical undergraduate Nurses* nil MLT nil nil nil nil Radiographers nil nil nil nil nil Physiotherapist s 18 nil nil nil nil nil nil nil Occupational Therapists 4 nil nil 3 21 nil nil nil nil nil Source: ET&R Ministry of Health The MoH has made ad hoc efforts to update training curricula. Further, significant investments have been made to upgrade the skills of health workers. In addition lower grade employees such as labourers have been promoted to higher categories like attendants on a regular basis. Opportunities for allied health professionals AHPs for post-basic training are minimal. A systematic review of these efforts and their impact, however, is lacking. 16

23 5.3.4 Deployment 907 new doctors, 111 dental surgeons, and 1216 nurses respectively were recruited by MOH in Among the other categories deployed in 2007/2008 are 1498 Public Health Midwives and 86 Public Health Inspectors. However there has been no regular intake of Public Health Midwives for training from There had been 26 PHM trainees recruited in 2007 to be deployed for North East province while 55 PHM trainees were recruited in 2008 for the estate sector Distribution of staff There are substantial variations in the geographical distribution of health personnel significant differences existed at the provincial level. Staff distribution by type of service The following table 3 shows that 91% of doctors were employed in hospitals and the public health services have 67% of total midwives. Table 3: Distribution of selected health staff by hospital and public health services 2007 Health Services Doctors % Nurses % Midwives % Hospital Services , Public Health Services Total 10, , Source: National Census of Health Manpower 2007 Staff distribution by provinces Staff patterns across provinces as shown in figure 3 indicate that there is inequitable distribution. 6 Performance progress report, Ministry of Healthcare & Nutrition 17

24 Figure 3: Distribution of Medical and Dental officers by province (2007) 70 Rate per 100,000 Population Administrative Grade MOO Specialist Medical Officers Grade Medical Officers (Gr.I, II & Pre.Grade) Dental Surgeons NCP NP EP NP Sab Province Uva CP WP SP Source: MDPU, Ministry of Health Uva province has the least availability for specialist and non specialist medical officers. Currently staff from other provinces are temporarily placed in the north for care of the internally displaced. Even Uva province is fostering one such welfare centre, despite their own shortages for staff. Figure 4: Distribution of Nursing officers and midwives (field and hospital) by province (2007) 160 Rate Per 100,000 Population Nursing Officers Hospital Midwives Gr.I, II & III Field Midwives Gr.I, II & III NCP NP EP NP Sab Uva CP WP SP Provinces Source: MDPU, Ministry of Health Uva province has the least availability for nursing officers. 18

25 Figure 5: Distribution of selected categories of Health personnel by province (2007) 6 5 Pharmacists Rate Per 100,000 Population Medical Lab Technologist Gr I, II & III Physiotherapist Gr.I, II & III Radiographer Gr.I, II & III Occupational Therapist Gr.I, II & III School Dental Therapist Microscopist (PHLT) 0 NCP NP EP NP Sab Uva CP WP SP Province Source : MDPU, Ministry of Health The differential availability of staff will affect the work outputs, especially for categories that work as teams. There are also distribution imbalances between districts in a province. Post conflict health service restoration in the North is likely to be affected if this staffing imbalance is not corrected as part of the resettlement plan. Many provinces are in need of for new cadre positions according to their requirements; this has been a barrier for staff deployment in the provinces Skill mix One aspect of quality of supply can be judged in terms of skill mix. Nurses are the largest category (22,586) within the health workforce followed by Doctors (grade medical officers, specialists and Administrative grade MOOs) 10,1537. The proportion of skilled categories as a proportion of total permanent staff was 48.6%, whilst the rate of Professional staff per 100,000 population was in year National Census of Health Manpower

26 The Doctor: Nurse ratio in 2007 was 1: 2.8 (figure 6). The trend for Doctor: Nurse ratio had shown a rapid decline from 1984 while an increasing trend was observed from year Figure 6: Trends in Doctor: Nurse ratio ( ) Doctors Nurses Ratio Year Source: MDPU, Ministry of Health 6 Demand The transition challenges have posed different demands for the types of services required. This also means that the required skills and skill mixes will be different in some situations. 6.1 Demand for services The situation in the North has caused a substantial demand for health services. This is acute in case of internally displaced persons (IDPs) of post conflict scenario, for whom an emergency plan is being implemented with a huge demand on health workers. The demand for human resources is increasing with the expansion of the private sector. By end 2008, 220 private health institutions with 8,850 beds have been registered with the Private Health Service Regulatory Council. 20

27 The private sector is largely dependent on the Government system for its Human Resources. Although nurses training facilities have emerged through the private sector, the question of their quality of training and recognition remains a concern. There is no comprehensive plan to accommodate needs of the private sector. 6.2 Demand for Staff If it is assumed that information on active supply reflects the demand for health staff, demand for health staff over the last decade remained static for all categories except nurses and midwives. The demand for health staff in the public sector continues to be above that in the private sector due to the larger health service network in the Government sector. Expansion of private sector organisations has led more health workers been absorbed to private sector and more government clinical staff engaging in dual practice. 6.3 Expenditure on HRH The demand for health staff depends on the availability of resources for health care, and in particular, personnel emoluments. The sector is expected to benefit from increases in both the absolute level of government spending on health and the relative share of the budget. The actual government expenditure on health has been increasing from In year 2007 the share of the health sector expenditure remained at 7.1% of the total budget. 8 A Medium Term Expenditure Framework is being developed now and would show trends of the personnel emoluments, as a share of recurrent expenditure in the sector. Out of the total investment on health, a large part is provided for recurrent expenditure, which includes salaries and wages both at national and provincial levels. This is to fund a total cadre of around 104,000, representing 18% of the total salary bill of the Government in Central Bank Report

28 Table 4: Health Ministry expenditure (in Rs millions) on selected major items, Total Recurrent Health Expenditure 43,081 51, 312 Total capital health expenditure 10,955 18,743 Total health Expenditure 54,036 70,055 Drugs (central) 7,100 10,100 Diets Salaries & overtime and other allowances central government Salaries & overtime and other allowances Provincial health authorities 14,625 18,899 11,969 15,758 Total expenditure on Salaries, overtime and allowances 26,594 34,657 % of total government health expenditure on salaries and overtime Source: MDPU, Ministry of Health 49.2% 49.4% In 2007 the Government expenditure on Salaries and overtime (Rs million 34,657.0) was 67.5% of the total recurrent expenditure and in 2005 this figure has been 61.7%. The percentage of expenditure on salaries, overtime etc. of the total government health expenditure was 49.2% in 2005, which remained almost the same in 2007 (49.4%). In Sri Lanka it has been shown that increasing staff availability does not show a reduction in expenditure for staff overtime. Overtime is considered as an additional income compensating for the low salary and has been subject to poor monitoring and management. However recently with the economic downturn there have been measures put in to place to reduce overtime expenditure. 6.4 Productivity The time health workers spent on patient care, outreach activities, administrative tasks, in meetings, in training activities, on cleaning, preparatory and maintenance activities, and 22

29 research have not been studied in a comprehensive way. Time and motion studies have to be carried out to measure staff productivity. The Ministry of Health has not developed a formal set of indicators to measure or compare staff productivity. However some hospital managers have developed productivity measures for their respective institutions. Preventive health system uses selective productivity measures for public health midwives. The current system does not have a clear functioning mechanism that recognizes performance, at individual level which can contribute to productivity. Thus there is a lack of a formalized reward system that recognizes good performance. Absenteeism affects productivity. But absenteeism rates cannot be measured due to lack of objective data. In general, public service regulations stipulate that cases of chronic absenteeism are reported to the respective employer who is authorized to take disciplinary action. However, no information on absenteeism was available. There is a growing proportion of women, approximately 60-70%, in the health sector. Their wish to combine their career and their role in the family as wife and mother has inevitably some influence on in the health workforce productivity. Many female doctors tend to work on fixed schedules, retire earlier and take time off more frequently than their male colleagues, factors that need to be considered in planning of the medical workforce. The existing policy is for recruitment of full time staff. The government health sector has not explored possibilities of part time employment for female staff as a measure of improving efficiency whilst taking into consideration their role in society and family development as an overall factor in improving health of the country. The private health sector however has adopted institutional policies of recruiting female staff on part time basis. 6.5 Private Sector The private sector is largely dependent on the Government system for its human resources. Although nurses training facilities have emerged through the private sector, the questions on of their quality of training and recognition remains a concern. There is no comprehensive plan to accommodate demands of the private sector. The demand for human resources is 23

30 increasing with the expansion of the private sector. By end 2008, 220 private health institutions with 8,850 beds have been registered with the Private Health Service Regulatory Council. 7 Planning There have been few attempts in the past to project HRH requirements. A HRH strategic plan with a staffing projection was done in 1999, for the period The process involved did not gain sufficient momentum for the strategic plan to be implemented. Similarly a strategic plan for nursing workforce projection took place in This too was not implemented due to lack of a coordinating mechanism within the Ministry of Health. 7.1 Staffing norms The latest revision of staffing norms was in year However, these norms are not accepted by the Salaries and Cadre Commission. Since then, the Provincial Health Authorities have had revisions of cadres off and on which have been approved by the respective provincial Public Services Commissions. The basis of norms used in these revisions is questionable. Currently staffing norms of medical officers and nursing categories are being revised. Revision of norms uses staff-population ratio and staff-staff ratio and staffbed ratio methods rather than workload methods. This can produce relative over or undersupply where bed strengths do not realistically reflect the need. 8 Management of HRH 8.1 Performance management The Ministry of Health has not adopted a suitable system for performance management of HRH. There is no objectively verifiable system that compares HRH performance across the country or within and between institutions. Performance management has to be introduced as a way of improving standards within health services and making services more responsive to citizens. Wider programmes of training and capacity building for staff on this aspect have to be undertaken. 24

31 A ceremony to reward performance was recently inaugurated by the Minister of Health with awards of excellence. The criteria and the mechanism to effectively reward excellent performance need to be reviewed. 8.2 The Health Ministry organizations ability for HRD Currently the many functions of HRD are scattered within the Health Ministry Organization. There does not seem to be any single unit that coordinates HRD functions within the Health Ministry. Many directorates are responsible for the management of different staff categories. This has lead to many recruitment, training and deployment plans for the different categories. These plans are not available at a given time in one location. Since planning activities too are held with the different management units there seems to be a lack of attention given to the skill mixes required in different work situations. An assessment of overall functions of Health Ministry with regard to Human Resources Development was undertaken using a self evaluation tool 9 developed by the Management of Health Sciences in Boston. The tool is structured to give 4 levels of development, in a progressive sequence, for each of the variables under study relating to HRD. A description is given for each of these levels. The tool was used to carry out a rapid assessment on the organizations ability for HRD through selecting the most appropriate levels that describe the variables (HRD component) under study. The assessment has highlighted the fragmented nature of HRD function in the MOH and inadequate HR managerial capacities and leadership. 9 Human Resource Management Assessment tool,management Sciences for Health Boston

32 8.3 Staff Satisfaction At focus group discussions and from interviews of trade union officials, it was revealed that the morale, satisfaction and motivation among government health workers are low. This is linked to staff shortages, low salaries, poor working conditions (equipment and housing), favouritism and lack of transparency in human resource management practices (e.g. transfers, selection for training and upgrading), limited supervision and monitoring; weak disciplinary procedures, limited and slow opportunities for promotion that are based only on seniority rather than merit, rigid employment management policies that discourage labour mobility, slow decision-making across the public service, and conflicting lines of accountability. The lack of clear job descriptions, lack of performance management, limited opportunities to participate in decision making, poor information flows between management and staff, poor supervision are attributing factors for low staff satisfaction. 9 Adequacy There are staffing imbalances in terms of numbers, skills/skills mix and geographical distribution as shown above. There has been a gradual increase in staff numbers for medical doctors and nurses over the last few years. However the staff availability using population rates are found to be inequitably distributed among the provinces. There is a skewed staff distribution in favour of urban areas. Availability of other staff categories too shows a stagnant trend for availability when population rates are considered. The causes behind these disparities are discussed in section 2. The staff availability (2005) when compared with some other Asian and middle income countries in the region cannot be considered adequate. 26

33 Table 5: Staff availability in countries of the Region per 100,000 population (2005) Sri Lanka Bangladesh India Nepal Pakistan Malaysia SE Asian Global average Source: Annual Health Forum 2007 When selected health outcomes (Maternal and child health and communicable diseases) are considered, Sri Lanka seems to have done well with its limitation in staff availability. However present staffing cannot be considered adequate at all if the present demand for services of non communicable diseases, elderly care and injuries are considered. Provinces with the high staff per population ratios were characterized by greater numbers of health facilities and the existence of a large Teaching hospital with significantly higher staffing levels than other hospitals. Significant staffing variations continue to persist. The lack of clear policies and operational plans has contributed to the inequitable distribution. 10 Conclusion Human Resources for Health play a crucial role in the attainment of health objectives. The changes over the years in the environment around the provision of health services in Sri Lanka have affected many aspects of HRH. These include devolution of health services to provinces, expansion of private health facilities, epidemiological and demographic transitions, increase in demand and expectations of people, introduction of high technology and increase of health service utilization. Many challenges and issues have been identified in which changes are required in the policy arena that is discussed in the next section. The new demands for health services cannot be dealt with in a short time frame. It should be understood that a substantial period of time is required to bring about needed qualitative and quantitative changes in the old categories of staff. There will also be a time lapse in recruitment and training of new categories of staff, as well as in rectifying the effects of some unplanned decisions taken in the past. 27