Sufficient and Competent Health Workers for Expanded and Improved Health Services for the Mozambican People

Transcription

1 Ministry of Health National Directorate of Human Resources National Plan for Health Human Resources Development Sufficient and Competent Health Workers for Expanded and Improved Health Services for the Mozambican People 2008

2

3 TABLE OF CONTENTS Acronyms and Abbreviations... ii Introduction... 1 Challenges Posed by the HHR Shortage... 1 The National Health Human Resource Development Plan (NPHHRD)... 4 Objectives and Strategies of the NPHHRD... 7 NPHHRD Implementation The Cost of the National Health Human Resource Development Plan i

4 ACRONYMS AND ABBREVIATIONS APRAP CFS ESP HHR HHRO ICS MCH MDG MI MOH NHS NPHHRD PIS RCSD USD WHO Absolute Poverty Reduction Action Program Health Training Center Economic and Social Plan Health Human Resources Health Human Resources Observatory Institute of Health Sciences Maternal and Child Health Millennium Development Goals Monitoring and Implementation Group Ministry of Health National Health System National Plan for Health Human Resources Development Personnel Information System Regional Center for Sanitary Development U.S. Dollars World Health Organization ii

5 INTRODUCTION With this document, the Ministry of Health (MOH) of Mozambique intends to share with other sectors and its partners the most relevant aspects of its recently developed National Health Human Resource Development Plan (NHHRSP) This plan includes a series of interventions to overcome the serious absolute and relative shortage of health human resources (HHR) in the country. To achieve the health sector s objectives included in the Millennium Development Goals (MDGs) for the year 2015, Mozambique urgently needs a greater number of well-trained and supported health workers who are highly motivated and properly distributed. Health workers are the most valuable resources that will allow the MOH to improve accessibility to health services especially for the poorest populations living in rural areas; consolidate primary health care; strengthen the continuity of care through a well-coordinated referral system; and improve the operation, quality, and performance of the services provided at all levels. This plan and its expected results shall be the MOH s contribution to the Absolute Poverty Reduction Action Program (APRAP) and the Economic and Social Plan (ESP) instruments that guide the Government s action in the national effort to reduce absolute poverty, specifically focusing on rural areas; reduce regional imbalances; and promote sustainable economic growth. Therefore, the country will achieve a harmonious development based on peace consolidation, national unity, justice, democracy, and patriotic awareness. CHALLENGES POSED BY THE HHR SHORTAGE In the last few years, Mozambique has seen improvements in its health indicators. The neonatal mortality rate decreased from 147/1,000 live births in 1999 to 100/1,000 in 2005, and child mortality decreased from 219/1,000 to 178/1,000 in the same period of time. Maternal mortality decreased from more than 1,600/100,000 live births to 408/100,000 in Immunization coverage reached 95% in 2005 and has remained the same since then. The number of institutional births increased from 49% in 2005 to 54% in 2007, and the policy of free services for mothers and children under 5 years helped to increase access to these services even more. In addition, there has been a reduction in the mortality rate due to malaria, an expansion of TB treatment, and a significant increase in the number of persons benefiting from anti-retroviral treatment. These improvements were achieved through economic growth and stability and increased access to health services. However, the quantitative and qualitative deficits in the number of health workers represent the main barrier for the sustainability and expansion of these and other health outcomes that Mozambique has 1

6 achieved in the last few years. The absolute and comparative deficit of HHR in Mozambique is shown in Table 1. Table 1. Comparative Data for Some HHR Indicators, 2004 Doctors/ 1,000 Population Nurses/ 1,000 Population Birth Attendants/ 1,000 Population Pharmacy Staff/ 1,000 Population Mozambique Malawi Zambia , Zimbabwe Botswana South Africa Source: World Health Organization (WHO) Annual Report, Despite the MOH s effort to correct regional differences, improve the ratio of the population per health worker, and improve worker placement criteria, some differences still exist, as shown in Figures 1 to 3. This may be the result of an absolute lack of resources, difficulty in retaining workers, problems with the existing health network, and the lack of staffing definitions, among other reasons. The deficit in all HHR (Figure 1) is more evident in Zambezia, Nampula, Cabo Delgado, and Tete. The inequalities are more evident for doctors (Figure 2) than for nurses (Figure 3). For doctors, the most evident deficit is in Zambezia, Niassa, Nampula, and Cabo Delgado. For nurses, the deficit is most evident in Zambezia, Inhambane, Cabo Delgado, and Maputo Province. Figure 1. Population per HHR, by Province (June 30, 2007) 2

7 Figure 2. Population per Doctor, by Province (June 30, 2007) Figure 3. Population per Nursing Staff, by Province (June 30, 2007) The distribution of staff in the National Health System (NHS) per education level (from the university to the elementary level) points to a relative deficit of median and university staff (Figure 4). Figure 4. Percentage Distribution of NHS Staff per Education Level, 2000 and 2006 This deficit is more evident between provinces, particularly in Manica, Zambezia, Niassa, Tete, Cabo Delgado, and Nampula. The most underserved provinces in terms of priority competence cadres are Zambezia, Cabo Delgado, Nampula, Manica, Inhambane, Tete, Gaza, Sofala, Maputo Province, Niassa, and Maputo City (data not shown). In addition, there has been a greater increase in the non-clinical work force than in the clinical work force (Table 2). In other words, there is 3

8 a relative deficit in assistance staff that is not evenly distributed within the levels of care. Table 2. HHR Distribution per Job and Education Level, 2000 and 2006 Education Level Variation University Degree in medicine % Other % Sub-total 576 1, % Secondary level Clinical duties 2,132 3, % Other % Sub-total 2,489 4, % Basic level Clinical duties 4,128 6, % Other % Sub-total 4,651 7, % Elementary level Clinical duties 1,628 2, % Other 582 1, % Sub-total 2,210 3, % Other Assistant workers 1,631 2, % Source: MOH/DRH PIS Laborers 5,003 8, % Sub-total 6,634 11,077 67% However, the human resource challenges go beyond this deficit. Current health workers are unsatisfied with their jobs and perceive serious problems in the health service system. Among the problems highlighted by workers and managers are poor work conditions, nonimplementation of careers, an inadequate incentive policy for the many realities of the country, non-implementation of the incentive policy in force, a staffing deficit, lack of access to in-service training, weaknesses in bio-safety compliance, delays in processing staff documentation, inadequacy of the Personnel Information System (PIS), lack of access to private activities outside of the major urban centers, and inequalities between provinces and districts. Among clients, most complaints refer to long waiting times, lack of bio-safety, the poor condition of the health infrastructure, lack and/or cost of drugs, and lack of transportation to the health facilities. THE NATIONAL HEALTH HUMAN RESOURCE DEVELOPMENT PLAN (NPHHRD) The NPHHRD was developed to respond to these challenges and constraints. The plan contemplates the national priorities identified in the National Health Policy and the current Health Sector Strategic Plan and will continue the previous human resource development plans of , , and It is expected that the plan will allow: 4

9 A qualitative leap in the Mozambican health services system that is associated with significant improvements in the MOH s training system and management capacity (note that this document features only this purpose), by 2015; and A rapid expansion of all secondary and higher level professional resources by 2025 (Box 1). Box 1. Expected Expansion in Health Network by 2025 One rural health center (Type II) per 10,000 population (there is a deficit of approximately 750 in this type of structure), which shall be equipped with one ancillary worker, one medical agent, and one maternal and child health (MCH) nurse. One district hospital with surgical capacity (two rooms), per district. One general hospital per city. One additional provincial hospital in Maputo. One additional central hospital in Quelimane. Implementation of the plan will result in: An increase in the total number of health workers from 25,683 (1.26 per 1,000 population) to 45,904 (1.87 per 1,000 population) by This will be below the ratio of 2.3 per 1,000 population proposed by the World Health Organization (WHO), but it can still bring major improvements for the attainment of the health MDG. Mozambique will need another decade to achieve the ratio of 2.3. An increase in the number of health workers directly involved in clinical tasks from 1,896 to 4,572 (+141% increase), which will increase the ratio from 0.09 to 0.19 per 1,000 population or from 10,742 to 5,363 individuals per health worker. An improved definition of the regulating duty of HHR in the health service system. Table 3 shows the projected growth of HHR between 2006 and Table 3. HHR Projections in Difference Population 20,366,795 24,517,582 20% Total staff 25,683 45,904 79% Total staff per 1,000 population Population per health worker % Number of priority medical staff 1,896 4, % Number of priority medical staff per 1,000 population Population per priority health staff 10,742 5,363-50% Number of doctors 874 1, % Number of doctors per 1,000 population Population per doctor 23,303 12,803-45% Number of nurses 4,282 7,195 68% Number of nurses per 1,000 population

10 Difference Population per nurse 4,756 3,408-28% Number of trained birth attendants 2,906 4,856 67% Number of trained birth attendants per 1,000 population Population per trained birth attendant 7,009 5,049-28% Source: MOH, Mozambique Table 4. This plan is ambitious, but it is realistic in terms of the estimated numbers of health workers who may be trained in the country between 2008 and Beyond the cost, the major constraint for the increase of human resources in line with the objectives presented in the plan is the capacity to train new workers. For this reason, one of the main focus areas of the plan is to improve the capacity of the training institutions under the MOH. To illustrate one aspect of this strengthening in preservice training, Table 4 shows the projected investment in the MOH s training institutions during the period from 2008 to Summary of Annual Cost for Investments in Training Network Training Institution Estimated Annual Cost Total Cost (USD) CFS Lichinga $1,700,000 $1,700,000 CFS Cuamba $1,200,000 $1,200,000 CFS Pemba $1,650,000 $1,650,000 CFS Mocímboa da Praia $500,000 $500,000 $1,000,000 CFS Montepuez $800,000 $800,000 ICS Nampula $550,000 $1,000,000 $1,550,000 CFS Alua $350,000 $350,000 CFS Nacala $7,000,000 $7,000,000 ICS Quelimane $750,000 $750,000 $1,500,000 CFS Gorué $400,000 $400,000 $800,000 CFS Mocuba $500,000 $500,000 CFS Matundo $550,000 $1,000,000 $1,550,000 CFS Chimoio $1,300,000 $1,300,000 CFS Catandica $200,000 $400,000 $600,000 ICS Beira $600,000 $1,000,000 $1,600,000 CFS Nhamatanda $450,000 $450,000 CFS Inhambane $2,051,000 $2,051,000 CFS Chicuque $100,000 $100,000 $200,000 CFS Massinga $950,000 $950,000 CFS Vilanculos $200,000 $400,000 $600,000 CFS Chicumbane $550,000 $1,000,000 $1,550,000 CFS Chókwe $850,000 $850,000 CFS Marracuene $800,000 $2,000,000 $2,000,000 $4,800,000 ICS Infulene $750,000 $750,000 $1,500,000 ICS Maputo $600,000 $250,000 $850,000 TOTAL $17,400,000 $17,501,000 $2,000,000 $36,901,000 CFS = Health Training Center; ICS = Institute of Health Sciences 6

11 OBJECTIVES AND STRATEGIES OF THE NPHHRD The NPHHRD is based on the recognition that to achieve the desired results, the Plan must address the problems of lack of training capacity, difficulty in recruiting staff, low wages, lack of motivation, poor distribution of workers, loss of staff to the private sector, and limited management capacity. The plan therefore has the following eight objectives: Contribute to the achievement of the MDGs; Improve the MOH s training capacity; Reduce the HHR deficit; Reduce HHR inequalities among provinces; Correct the differences within provinces and districts; Improve HHR qualitative and quantitative performance; Retain the NHS work force; and Improve the definition of the regulating role for HHR in the health services system. Attaining these eight objectives will be facilitated by general and cross-cutting strategies, including: Build the capacity of individual managers, regulators, service managers, and providers, i.e., support procurement and improvement in terms of expertise, competencies, and attitudes; Strengthen organizational capacities, e.g., the operation of information systems; monitoring, supervision, and evaluation processes; the availability of management; decision support; and resource mobilization tools; Develop professional and financial subsidies and incentives packages to stimulate the performance of all cadres and to mobilize individual and institutional willingness to support the achievement of the proposed objectives and targets; and Create an adequate institutional environment through changes in the legal and regulating framework to facilitate attainment of the proposed targets. The NPHHRD identifies four strategic lines to advance toward the improvement in the health service system and human resources, which are identified and characterized in four packages: Organize NHS services and normative framework; Improve management capacity at all levels of the NHS; Improve HHR distribution, motivation, and retention; and Increase capacity of the initial production, post-graduate training, and in-service training networks. 7

12 1. Organize NHS Services and Normative Framework The general objective of this strategic line is to ensure that the health teams are adequate for the health facilities in which they are placed by: Harmonizing the structured organizational model at the level of care and the somewhat vertical programmatic approach, which contributes to the capacity of community health workers to work in the most peripheral levels; Implementing flexible organizational models with the mobility and capacity to adapt to the service packages provided; Developing an organizational model that formally includes community health workers; and Taking into account the epidemiological profile and organizational responses to ensure adequate HHR for these organizational models. The strategies to achieve these objectives include the following: Strengthen institutional and health facility management; Define the health facility staff; Design recruitment plans for the health facility on an annual basis; Regulate the interface between vertical programs and horizontal services; Update the human resource profile and ensure the adequacy of the training programs for such profiles; Systematize the advanced and proximity strategy; Ensure quality management; and Ensure the adequacy of incentives for the adopted organizational models. 2. Improve Management Capacity at All Levels of NHS Management, planning, and administration capacities will be strengthened according to the public administration reform in process and the reality of job decentralization. All appropriate steps will be taken to continually: improve the management practices, based on respect for the technical and regulating laws and norms in force for health staff professional careers and training; and decentralize the concentration of powers and competencies to ensure the development of facilitating instruments for management processes. The strategies will include: Training in management; Manipulating HHR management; Decentralizing HHR management to the provinces, municipalities, districts, and autonomous institutions; Developing an HHR Observatory (HHRO); Revising the Regional Center for Sanitary Development (RCSD) articles of incorporation to redevelop it as a Public Institute 8

13 responsible for training NHS staff in management and distance learning; and Developing regulations for multiple employment. 3. Improve HHR Distribution, Motivation, and Retention This strategic line is intended to contribute to an improved performance of the health service system through a better distributed and more motivated work force that contributes to the individual and institutional work objectives. Specifically, this strategic line intends to: Correct the poor distribution of staff throughout the country and between levels of care; Ensure adequate health careers for the current national context and advise on their effective management; and Develop a reference framework to justify a salary, subsidy, and incentive policy that acknowledges, within the public sector framework, the specificity of the HHR status. The identified strategies include: Review and correct blocks and dysfunctions in the recruitment, turnover, and retention procedures; Expedite staff retirement mechanisms; Review specific health careers to simplify and align them to the new institutional contexts, the greater demand for staff differentiation, and the new epidemiologic reality; Manage careers to allow HHR progression and promotion; Understand the capacity to intervene for HHR motivation; Differentiate a salary, subsidy, and incentive strategy specific to HHR within the public administration; and Improve working conditions of HHR, especially regarding biosafety conditions, and implement the principle of compensation based on incurred risks, difficulty and physical stress resulting from certain tasks, and the mandatory nature of shift work. 4. Increase Capacity of Initial Production, Post-Graduate Training, and In-Service Training Networks Properly trained health workers are required to expand and strengthen the health care provided to the population. Therefore, the general objective of this strategic line is to ensure the training of health workers needed in the NHS according to the identified needs. Specifically, it is intended to: Improve and expand training (both technical and ethical) of priority secondary level cadres; Improve and expand in-country and foreign post-graduation internships in medical specialties; Create conditions to train training institution managers on management and pedagogic training for its teachers; and Ensure implementation of in-service training as an integrated national program that is linked with career management. 9

14 The strategies include: Expand the training network and ensure adequate logistics; Expand the technical capacity of the training network; Improve the processes and quality of teaching; Create a teaching career within the MOH; Differentiate the training of health workers; Strengthen the training information system (in the scope of HHRO); Support the community mobilization and participation policy; Organize in-service training processes; Strengthen the planning and implementation capacity for postgraduates; Train managers (see Strategic Line 2: Improve Management Capacity at All Levels of NHS); and Coordinate with partners for the funding of local courses beyond those anticipated in the Provincial Common Fund. NPHHRD IMPLEMENTATION Implementation of the NPHHRD will be a laborious, complex and demanding process in terms of competencies. The following reference framework is proposed to ensure a well-coordinated, well-documented, transparent, accurate, efficient, and effective process. This reference framework requires the appointment of a NPHHRD Monitoring and Implementation Group (MI-NPHHRD) that will be responsible for 10 work packages necessary for successful implementation of the NPHHRD (Figure 5). Figure 5. NPHHRD Implementation 10

15 The MI-NPHHRD shall be a multidisciplinary senior group (including workers in the specific health careers, economists, human resource specialists, and information and expertise management specialists) under direct supervision of the National Human Resource Director. All positions shall be full-time, with permanent exclusivity and availability (no working hours). The MI-NPHHRD shall be appointed for a threeyear period, and its existence may be prolonged should any exceptional circumstances demand it. The following are some of the main tasks of the MI-NPHHRD: Design and execute a Communication Plan for the different NPHHRD audiences. This plan shall use various resources, such as newspaper, radio, television, brochures, and posters, as well as new Web-based technologies. Integrate the HHRO Installing Commission. The goal of the HHRO is to promote and incentivize evidence-based HHR strategies and interventions and develop capacity to evaluate and monitor the HHR situation. Promote and validate planning exercises in several provincial settings, maintaining a macro view of the Mozambican reality. Identify partners for different activities by establishing agreements and partnerships with public services to ensure access to necessary and adequate resources. Create a technical assistance plan for the NPHHRD, allocating parts of the management of this plan to different stakeholders involved in its implementation. Create a Mozambican HHR Research Plan and follow up the implementation of the plan. Develop and implement monitoring and evaluation mechanisms for the NPHHRD. Formalize an incentive package to be allocated to the national and provincial decision-makers for achievement of the activities anticipated in the plan. THE COST OF THE NATIONAL HEALTH HUMAN RESOURCE DEVELOPMENT PLAN The total cost of the NPHHRD is estimated to be $1.7 billion USD (Table 5), which includes the costs related to salaries, preand in-service training, subsidies and incentives, and management; costs related to the health care system; and implementation of the plan. The funding gap between the estimated available funds from the existing sources, assuming that health keeps its share of the government s budget, and the additional resources necessary for completion of the plan is $594.5 million USD over the seven-year period, reflecting the following elements: 11

16 The annual plan implementation costs increase from $158 million USD in 2009 to $350 million USD in The costs of salaries, subsidies, and incentives increase from $109 million USD in 2009 to $294 million USD in These costs include salary adjustments and a gradual increase in the number of qualified health workers, with the latter being responsible for the greatest part of the increase. Initial training costs (pre- and in-service training, scholarships) will be high, with a gradual decrease as soon as the expansion costs for the training facilities are covered. For 2009, the estimated cost is $30.4 million USD. For 2010, it is estimated at $18.8 million USD, and $14.4 million USD in The additional infrastructure investment to achieve the norm of one health post per 50,000 population was not included in the plan, but it will cost an additional $600 million USD over the period of 2009 to Training and placement of additional community health workers between 2008 and 2012 to expand services to remote areas will cost $8 million USD. Based on current trends, the total estimated expenses for HHR will increase from $129.5 million USD in 2008 to $158 million USD in 2009, $175 million USD in 2010, $209 million USD in 2011, $242 million USD in 2012, $273 million USD in 2013, $310 million USD in 2014, and $350 million USD in The funding gap, or the difference between the future available funds and the current funding levels, for the increase of the health work force will increase from an additional $70 million USD in 2009 to $112 million USD per year needed until It is important to highlight that the Mozambican Government is currently approving a new salary policy for the public service. As soon as this new salary policy is approved in 2009, the NPHHRD budget will be readjusted. 12

17 Table 5. Summary of Estimated Annual and Total Cost for Implementation of the HHR Development Plan (in thousand USD) Budgeted Items Total 1. Salaries and subsidies $87,360 $106,690 $133,000 $160,670 $184,760 $211,270 $238,390 $1,122, Additional salary and subsidy related costs, above and beyond the costs without salary reform $4,300 $10,210 $18,720 $23,170 $27,030 $31,300 $36,660 $151, Incentives $21,839 $25,564 $30,502 $36,965 $42,744 $49,180 $55,874 $262, Expatriate doctors $7,544 $6,478 $5,412 $4,346 $3,295 $3,561 $3,827 $34, Pre-service training $27,040 $14,909 $13,348 $8,908 $9,153 $9,263 $9,061 $91, In-service training $1,017 $1,329 $1,625 $1,625 $1,625 $1,625 $1,625 $10, Scholarships and post-graduate (specialization) $2,304 $2,515 $2,801 $3,094 $3,294 $3,493 $3,682 $21, Human Resource Management (including the Observatory) $779 $808 $850 $877 $832 $733 $761 $5, Training of Community Health Workers $1,234 $2,237 $ 2,237 $2,166 $7, Plan implementation $4,247 $4,247 $177 $177 $79 $79 $79 $9,085 Total $157,664 $174,987 $208,672 $241,998 $272,812 $310,504 $349,959 $1,716,596 Estimated funding gap (Total minus the estimated costs without the NPHHRD) ( ) $70,304 $68,297 $75,672 $81,328 $88,052 $99,234 $111,569 $594,456 Source: MOH, Mozambique

18 Figure 6 graphically presents the total composition of expenses. As shown, 90% of the estimated expense corresponds to staff expenses including salaries and remunerations (74.2%) and the incentives to be paid to workers (15.3%). The expense for expatriate doctors accounts for 2% of the total. The expenses for pre- and inservice training and scholarships and post-graduation internships account for 7.1% of the estimated total. The figure highlights that, despite representing significant values in absolute terms, the estimated expenses for human resource management and with community health workers are relatively low when compared with other expenses. Figure 6. Total Expense Composition Successful implementation of the plan depends on the mobilization of additional funding both at the national and international levels. Even if the Mozambican Government maximizes its commitment, there will still be a significant funding gap that must be filled by the donor community. As HHR increases, training-related costs will decrease but salary costs will continue to increase. The Mozambican Government is fully committed to implementation of the Health Human Resource Development Plan To demonstrate its support, the Government will ensure that health will at least maintain its part of the current State budget. Other long-term health partners in the donor community have expressed their willingness and availability to support the plan during the implementation period. There will still be a need for additional commitments of other partners for all or specific areas to fully fund the plan. Training, recruiting, and retaining/motivating health workers are long-term efforts that demand a major and continual financial commitment. The Mozambican Government and the MOH hope that their partners share this commitment and will help to ensure that all of its citizens have access to good quality health services provided by competent, motivated, and dedicated health workers. 14