Assessment of Current Human Resource Management Systems and Practices in the Ghana Health Service/Ministry of Health FINAL REPORT.

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1 Assessment of Current Human Resource Management Systems and Practices in the Ghana Health Service/Ministry of Health FINAL REPORT May 2005

2 Quality Health Partners is a bilateral assistance project funded by USAID/Ghana and led by EngenderHealth. JHPIEGO and Abt Associates are implementing partners on the project. Technical assistance is also provided by Initiatives, Inc. and Family Health International. Inquiries should be directed to: Chief of Party Quality Health Partners 25 Senchi Street, PMB KIA Airport Residential Area Accra GHANA (21) (21) The report will be available on-line at Suggested Citation: Quality Health Partners, Ministry of Health and Ghana Health Service (2005). Assessment of Current Human Resource Management Systems and Practices in the Ghana Health Service and Ministry of Health. (Accra : Ghana, Quality Health Partners). This publication was made possible by support from USAID/Ghana under the terms of Cooperative Agreement 641-A The opinions expressed are those of the authors and do not necessarily reflect the views of USAID Human Resources Management Systems Final Report 2

3 Table of Contents AUTHORS... 7 ACKNOWLEDGEMENTS... 7 EXECUTIVE SUMMARY... 9 I. INTRODUCTION Brief Overview of Health Human Resource Management Systems in Ghana Assessment Objectives and Study Rationale Assessment Conceptual Framework II. METHODOLOGY Key Informant Interviews (KII) Review of Key Documents Facility Baseline Assessment III. FINDINGS AND DISCUSSION Stakeholder Roles and Responsibilities in HRM Processes Personnel Policies, Plans and Procedures Human Resource Information Systems (HRIS) Staff Performance Management Staff Training and Development Pre-service Training Gender Issues Key Document Review IV. CONCLUSIONS V. RECOMMENDATIONS REFERENCES APPENDIX A. Survey Instrument to Assess HRM Components APPENDIX B. List of Regions and Districts Targeted in Assessment APPENDIX C. Key Informant Interviews APPENDIX D. Pilot Human Resources Information System, Eastern Region APPENDIX E. Health In-service Training Database, JICA and GHS Joint Project APPENDIX F. Percentage of Providers with Job Description, Supervision & IST APPENDIX G. Activities at Last Supervision Reported by Providers APPENDIX H. Percentage of Providers who Attended IST Last 12 and 36 months APPENDIX I. Top Ten Lists of Equipment Requested by Training Institutions APPENDIX J. Missing Data Elements in GHS Job Descriptions Human Resources Management Systems Final Report 3

4 List of Tables Table 1. Number of Full-time HR Personnel, by Organization and Level, Table 2. Districts with Formal Procedures for Discipline and Grievances...39 Table In-service Training Expenditure, Selected Regions...45 Table 4. Challenges and Potential Solutions for RIST Coordinators...47 Table 5. Categories and Grades of Staff in the Ghana Health Service...56 Table C1. Key Informant Interviews by Organization and Position Title...75 Table C2. Number of Persons Interviewed, by Agency/Function...75 Table C3. Health Training Institutions Targeted in Assessment...76 Table I1. Top Ten Requested Clinical Equipment...87 Table I2. Top Ten Requested Anatomical Models...87 Table I3. Top Ten Requested Audiovisual Equipment...88 Human Resources Management Systems Final Report 4

5 List of Figures Figure 1. Map of HRM Capacity Index Scores, by Region...19 Figure 2. Map of Welfare Benefits, by Region...28 Figure 3. Map of Staff Retention Data Availability, by Region...29 Figure 4. Map of Recruitment, Posting, and Promotion Procedures, by Region...32 Figure 5. Map of Human Resource Information Systems, by Region...35 Figure 6. Map of Personnel File Maintenance, by Region...35 Figure 7. District Level Personnel Records...37 Figure 8. Map of Orientation Programs, by Region...38 Figure 9. Map of Discipline and Grievance Procedures, by Region...39 Figure 10. Map of Availability of Job Descriptions, by Region...40 Figure 11. Map of Staff Supervision, by Region...41 Figure 12. Percentage of Providers Who Listed These Activities at Last Supervision...42 Figure 13. Map of Performance Appraisal Systems, by Region...43 Figure 14. Map of Staff Training, by Region...44 Figure 15. Trend in Pre-service Student Population...49 Figure 16. Number of Nursing and Midwifery Graduates, 2003, by Institution and Gender...49 Figure 17. Adequacy of Supplies and Teaching Equipment at Clinical Training Sites for Preservice Nursing and Midwifery Students...50 Figure 18. Number of Items Currently Needed to Fulfill Self-reported Needs, by School Category and Type of Equipment...51 Human Resources Management Systems Final Report 5

6 List of Abbreviations and Acronyms ADHA BMC C-AGD CHPS DDHS FBA GHS GIMPA HCD HR HRDD HRHD HRIS HRM HRMS IPPD IST JICA MDC MDA MDPI MOH MOFEP MTEP MTHS NMC OHCS PSC RCH RDHS SIST SSNIT T&T TIS Additional Duty Hours Allowance Budget Management Centre Controller and Accountant-General s Department Community-Based Health Planning and Services District Director of Health Services Facility Baseline Assessment Ghana Health Service Ghana Institute of Management and Public Administration Human Capacity Development Human Resources Human Resources Development Division Human Resources for Health Division Human Resources Information System Human Resources Management Human Resources Management Systems Integrated Personnel, Payroll Database In-Service Training Japanese International Cooperation Assistance Medical and Dental Council Ministries, Departments, and Agencies Management Development and Productivity Institute Ministry of Health Ministry of Finance and Economic Planning Medium Term Expenditure Framework Medium Term Health Strategy Nurses and Midwives Council Office of the Head of the Civil Service Public Services Commission Reproductive and Child Health Regional Director of Health Services Structured In-Service Training Social Security and National Insurance Trust Travel and Transportation Training Information System Human Resources Management Systems Final Report 6

7 AUTHORS Seth D. Acquah: Former QHP Senior Human Resources Management Specialist, JHPIEGO Dr. Kwadwo Mensah: Health Human Resources Management Consultant, JHPIEGO Catherine Schenck-Yglesias: Monitoring, Evaluation and Informatics Advisor, JHPIEGO ACKNOWLEDGEMENTS The authors would like to thank the following individuals who contributed to the writing and review of this report: Martha Serwah Appiagyei: Pre-service Training Specialist, QHP, JHPIEGO Philip Ampofo: In-Service Training Specialist, QHP Joyce Ablordeppey: Maternal and Neonatal Health Specialist, QHP, JHPIEGO Dr. Ken D. Sagoe: Director, Health Resources Development Division, GHS Prince Boni: Head, Human Resources Planning Unit, GHS/HRDD Dr. Yaw Antwi-Boasiako: Director, Human Resources for Health Division, MOH In addition to those listed above, the survey team for the Human Resources assessment consisted of the following individuals: Bright Adanfo, Stephen Darko, David Danjumah, Victor F. Ekey, Alex Mahamah, and Anthony Obiri Yebo. The Ministry of Health, GHS and Quality Health Partners would also like to acknowledge the following persons (listed in alphabetical order), who served either as survey team members for the concurrent GHS/QHP Facility Baseline Assessment, which also provided HR-related data that were used in this report, or as data managers or editors for the report. Dora Abbosey, Joyce Ablordeppey, Judith Addoquaye, Emmanuel Amakwandoh, John Amankwaa, Emmamuel Amawkwaah, Enos Amedo, Comfort Antwi, Emerson Kojo Arhia, Helen Aovare, Abraham Apetor, George Asante, Gifty Asante, Dinah Baah-Odom, Helen Mary Bainson, Dr. Edward Bonku, Lucy Bonuedie, Patience Darko, Joe Degley, Augusta Doe, Koomson Ebenezer, Victoria Akua Ed-Nignpense, John K. Essel, Veronica Araba Hemans, Dr. Julie Hoag, R.A. Inkumsa, Baidoo Joseph, Dr. Catherine Kannenberg, Dr. E.Y Klutey, Mary Amponsa Kodua, Evelyn Lamptey, Louise AE Mensah, Amin Muttalib, Agnes Nkumfo, Angela Oseit Kodua Nyanor, Grace Okine, Beatrice Omenako, Admire Owusu, Evelyn Owusu-Acheaw, Mends Kofi Quaning, Dr. Fulgence Sangber-Dery, T.K. Sifah, Thomas Weiredu, and Reverend Richard Yeboah. Sincere thanks go to the 174 key informants from the MOH, GHS and 38 pre-service nursing and midwifery schools who participated in the assessment and provided the information that forms the basis for this report. Ms. Marcia Mayfield of EngenderHealth gave feedback and guidance on the initial design of the assessment. Ms. Kerry Bruce deserves special mention for essential planning and data management contributions throughout this effort. Human Resources Management Systems Final Report 7

8 Human Resources Management Systems Final Report 8

9 EXECUTIVE SUMMARY The main objective of the assessment was to evaluate the human resources management (HRM) capacity of the Ministry of Health and Ghana Health Service (GHS) in terms of systems effectiveness and efficiency, identifying strengths and highlighting areas in need of improvement. The specific objectives were to: Review current HRM policies, plans and procedures. Assess HR data management systems, including personnel filing systems. Assess staff performance management capacity and systems. Assess the roles and responsibilities of stakeholders in the HRM systems and their impact on the efficiency and effectiveness of the management systems. Assess pre-service and in-service training systems including policies, plans and procedures for managing intake and outcomes, and assess the linkages between pre-service and in-service training. Assess the role of women in the GHS and their opportunities for job advancement. Provide recommendations for streamlining and strengthening HRM systems in the GHS. I. METHODOLOGY Central and regional key informants were interviewed and key documents reviewed. At the district and facility levels, the study focused on the 28 target districts of the Quality Health Partners (QHP) Project identified by GHS and USAID. District and facility-level personnel in these districts were interviewed. The data collection was based on three activities: key informant interviews, review of key documents, and a facility baseline assessment. 1.1 Key Informant Interviews (KII) The interviews made use of: Interview guides for exploring HR issues with policy makers and key informants at the national level, Semi-structured questionnaires for interviews with regional and district managers of health staff and managers of health training institutions, and Structured questionnaires for interviewing key managers at the Regional Health Directorates. 1.2 Review of Key Documents Existing documents on HRM policies, plans and practices in the Ministry of Health (MOH) and GHS were reviewed. The documents were examined for completeness, effectiveness in achieving set objectives, and constraints on their use, if any. 1.3 Facility Baseline Assessment The concurrent Facility Baseline Assessment (FBA) was carried out by GHS and QHP in collaboration with the CHPS-TA project. This involved interviews with a cross-section of field staff within health facilities in the seven QHP focus regions to determine operational consistency of HRM systems. These findings were considered in conjunction with those from the first two assessment components. Human Resources Management Systems Final Report 9

10 II. FINDINGS Three of the regions scoring lowest in overall HRM capacity house almost three-quarters of the 28 QHP target districts (Central, 12 target districts; Volta, 5; and Western, 3). 2.1 Personnel Policies, Plans and Procedures Key Informant Interview respondents indicated that MOH and GHS have national policy and guideline functions, while other key HRM activities are performed by regions and districts. A. Availability of Comprehensive HR Policy and Guidelines The document Human Resources Policies and Strategies for the Health Sector was developed by MOH/Human Resources for Health Division (HRHD) in However, the assessment indicates there has been insufficient consensus building on the document and that the GHS/Human Resources Development Division (HRDD) does not use it for practical guidance. Instead, a 1997 GHS policy document is still the reference point for many HR interventions. A more useful guide for management might emerge from an integration of the two documents. There are a number of draft policies and guidelines addressing issues such as recruitment, postings, promotions, training and development. Except for the policy on in-service training, on which some consensus was achieved, other policy documents that have consensus for HRHD and HRDD are not finalized and approved for implementation. B. Communicating HR Policies and Guidelines Communication of HR policies and guidelines to personnel is insufficient. From 1996 to 2000, an HR bulletin was published regularly and served as a means of disseminating information and soliciting staff input. The publication was discontinued in C. Monitoring Compliance with HR Management Policies and Guidelines There is a need for a stronger system for monitoring compliance with HR policies. For example, the 1997 In-service Training Policy directs that every health staff person should have at least one structured in-service training every three years. However, the available Inservice Training Information System that documents training in the regions has not been used to actively monitor or enforce compliance with the policy directive. D. Systems for HR Planning There is also a need to strengthen the system for review and projection of health sector HR needs in MOH/HRHD. Individual agencies and statutory bodies submit their staffing requirements and budgets to MOH annually. HR projections and budgetary requests for GHS are submitted annually to the Ministry of Finance. These plans and their implementation should be reviewed on an annual or biannual basis. This joint review should be part of the coordinating role of the MOH/HRHD. The Medium Term Human Resources Strategy and Plans for the Ghana Health Service discusses strategies for addressing the main HR problems of the GHS, namely: Shortage of professionally trained staff (e.g. doctors, pharmacists, nurses, health administrators, laboratory/diagnostic technicians, etc.) which is compounded by the high level of attrition from the public health service. Inequitable distribution of available staff, with urban/rural and north/south imbalances favoring the urban and southern sectors of the country. Low motivation of staff; slow promotions have led to low productivity and low morale among health workers. Centralized and inefficient staff management. Human Resources Management Systems Final Report 10

11 Only three of nine Regional Directors of Health Services interviewed said there were regional HR plans in place and that these had been costed out. However, none of them could produce the plans for verification. Of districts surveyed (n=28), 70% budget for HR and 89% make decisions on internal staff distribution. However, only a third of District Directors reported having HR plans. Districts lack capacity to prepare strategic HR plans as staff are not trained to perform HR functions. HR regional and district plans could provide a useful basis for projecting staff costs and ensuring that staff are assigned to areas of greatest need. All regions and districts should prepare and implement strategic HR plans. E. HR Budget Budgeting for the 2003 plan for the GHS/HRDD was based on the standard activity costing procedure using the Medium Term Expenditure Framework (MTEF). HR activities most commonly included in regional budgets were recruitment, salaries, training, promotions, insurance, and allowances. The GHS director reported that 21.4% of the budget was approved and 30% of the approved budget funds were released. The latter represents 8.6% more than the approved amount, but is still considerably less than the initial request. Only five of 19 Regional Directors of Health Services reported on the proportion of planned HR activities actually funded in This ranged from %, with a median of 70%. During the annual budgeting cycle for the pre-service training institutions, the MOH/HRHD meets with representatives of the institutions to prepare and submit their budgets to the MOH. The school budgets are then reconciled with the available resources and reprioritized. Finally, the number of students, level of infrastructure, maintenance of the physical plant, and status of teaching and learning materials in each institution are considered before budgetary allocations are made. F. HR Staffing The MOH/HRHD has six full-time HR staff: the director, three deputies and two schedule officers. The director was recently appointed from Acting to full-time status. The mandate of the MOH, as defined by Act 525 (1996), is policy formulation, resource mobilization, allocation and monitoring. Thus, since the MOH/HRHD is not supposed to be directly involved in operational activities, there may not be a need for additional staff. Instead, staff competence, in terms of policy formulation, analysis and monitoring, could be enhanced with technical assistance and training. The directorate is also limited by physical space; additional staff could not be accommodated with the present space available. The GHS/HRDD has four senior staff with varying degrees of competence in HR planning and management the director and three deputy directors as well as 50 additional staff. A large number of the staff were officers in personnel administration who were moved from the MOH to the GHS/HRDD with minimal structured orientation to their new roles and responsibilities. There is one staff member specifically designated for HR in each region, the Regional HR Manager, but various HRM functions are also performed by the regional director, other unit heads, and the training unit. Seven of the nine regional directors interviewed rated their HR personnel as satisfactory, but only three described the impact of the HR unit in HR decisions as significant. Those with significant influence (Eastern, Western and Central regions) noted recent improvements in appraisals, promotions, appointments, transfers and salary processing and in HR data systems. Upper West reported insignificant influence on HR decisions, stressing their lack of a proper HR database in place, in addition to lack of basic training for staff and low staff morale. Human Resources Management Systems Final Report 11

12 G. Compensation System and Performance Related Incentive Schemes Staff salaries are managed centrally. The rationale for this is that central controls are necessary to ensure that monies are provided as available. The national criteria for determining awards are not widely circulated and staff do not know them. Although local incentive schemes exist, they generally do not have objective criteria for selecting awards. 2.2 Stakeholder Roles and Responsibilities in HRM Processes A number of Ministries, Departments, and Agencies play various roles in the management of health staff. Some of the roles do not seem to add value to staff recruitment and appointment processes. Roles for some stakeholders could be better defined. Essentially the MOH manages the staff and services at the pre-service institutions and the GHS manages all facility level staff. 2.3 Human Resources Information System The GHS/HRDD personnel filing system has been reorganized and there are plans to extend the reorganization to the regions. The Integrated Personnel Payroll Database (IPPD) is the central HR information system for the civil service. However, the system is focused on distributing staff payroll rather than providing data for HR management. The GHS has a viable training information system (TIS) that has been developed with support of JICA and is linked to the IPPD. Data are imported from the IPPD into the TIS. As staff benefit from in-service training, this information is updated in their existing records on the IPPD. JICA is exploring how a second generation TIS and HRIS can be configured as part of one information system. 2.4 Staff Performance Management A procedure for staff performance appraisal was carried over from the civil service to the GHS. It is an ineffective tool for performance management because staff are typically appraised only when they are due for promotions. Both outstanding performers and poor performers are frequently evaluated as satisfactory. Program monitoring is more common than individualized staff supervision. Supervisory staff are lacking in skills for supportive supervision. 2.5 Staff Training and Development There are training opportunities for both tutors in training institutions and staff in the practice areas. The In-service Training (IST) Policy requires that every staff person have access to at least one in-service training every three years. However, resource constraints limit actual training opportunities. The IST Policy is not linked to pre-service training and TIS data are not used to monitor compliance with the IST policy. 2.6 Pre-service Training Most training institutions complained of high student-tutor ratios that compromise the quality of training. They reported having serious deficiencies in teaching aids and equipment. 2.7 Gender Issues Gender is not given due consideration in appointment of staff into management positions. Women appear to be underrepresented in senior management positions in the health sector, although this could be related to gender ratios in the higher level cadres. A number of recommendations have been drafted to address these findings. These recommendations are outlined at the end of the report. Human Resources Management Systems Final Report 12

13 I. INTRODUCTION 1.1 Brief Overview of Health Human Resource Management Systems in Ghana Strengthening the health sector has been the central focus of the Ghanaian government s development vision since independence. Like many other developing countries, Ghana has been undergoing health sector reforms and restructuring over the years. Though the health sector reforms in Ghana predate the independence era, the current period of accelerated reforms started with the preparation of the Medium Term Health Strategy (MTHS) document of The MTHS supports the broad framework of national development as outlined in the Ghana Vision 2020 document, which outlines the government s development agenda aimed at propelling the country into middle-income status by the year The MTHS provided a launching pad for reforms with the goal of: Improving quality of care Enhancing the efficient utilization of health resources (including human resources) Improving equity and access of the population to health care Increasing and coordinating the linkages between various sectors and communities contributing to health The program of work (POW) developed from the MTHS clearly outlined seven strategic objectives as a means of achieving the sector goals: 1. Improve access, quality and efficiency of primary health services. 2. Strengthen and reorient secondary and tertiary service delivery to support primary health services. 3. Develop and implement a program to train adequate numbers of new health teams to provide defined services. 4. Improve capacity for policy development and analysis, resource allocation, performance monitoring and evaluation, and regulation of service delivery and health professionals. 5. Strengthen national support systems for human resources, logistics and supplies, financial management and health information. 6. Promote private sector involvement in the delivery of health services. 7. Advocate for support of intersectoral action. All of these strategic objectives have implications for human resources capacity. Some specific HR management interventions proposed in the POW included: Decentralizing management of health staff. Developing and implementing reward and incentive systems that recognize superior performance in underserved locations. Promoting collaboration between public sector health providers and private practitioners. Developing and implementing continuous professional development programs. Training adequate numbers of competent professionals to serve in areas where their services are in most need. A review of the five-year POW was carried out in 2001 and highlighted a number of formidable challenges. Some of these challenges are in the management of human resources, key among which are excessive out-migration of trained manpower to other Human Resources Management Systems Final Report 13

14 countries that provide better salaries. Between 1996 and 2002, the number of doctors and nurses in Ghana decreased by 17% and 24%, respectively (Policy Project, May 2003). While the GHS sets staffing norms for each level of health care facility, no institution had ever reached its goal. Another challenge highlighted in the POW review was unequal distribution of health personnel within regions and between regions. Poor, remote areas were underserved and had inadequate incentives to attract and retain health professionals. Human resources management was very centralized, making deployment and staff management difficult. The Policy Project, in their 2003 report on HR management systems in the GHS and MOH, pointed out that the processes for regularizing the payment of salaries to newlyrecruited health personnel were cumbersome and frustrating. The report also indicated that many HR policies and plans had been developed but were not yet implemented. At a national HR forum for health professionals held in September 2003, these challenges were highlighted and the underlying causes were closely examined. The subsequent program of work ( ) catalogued these challenges and mapped out key strategies for addressing them. The same challenges have been outlined in the Ministry of Health (MOH) Human Resources Policies and Strategies, and the GHS Human Resources Strategies and Plans documents, published in 2002 and 2003 respectively. The key strategies adopted for addressing the HR management concerns were to continue using low-level health workers to provide preventive and basic curative services in rural areas through the CHPS initiative; train more medical assistants; recruit foreign health workers to fill critical gaps; and provide appropriate incentives for health professionals to serve in rural areas. These strategies are also highlighted in the 2002 document Health Sector Response to the Ghana Poverty Reduction Strategy. A number of ongoing interventions are aimed at simplifying and strengthening HR capacity in the MOH and GHS. For example, the HRDD of the GHS held a retreat in the third quarter of 2004 to review the status of implementation of HRM strategies and plans, assess the challenges and constraints to achieving targets and to plan for the program of work for the period. The MOH has also initiated some interventions aimed at improving pre-service training. Quality Health Partners (QHP) plans to collaborate with the GHS and the MOH in their efforts to strengthen capacity for HR management and development with a focus on systems for more effective recruitment, training, deployment and performance of staff. The current assessment of the status of HR management systems identifies strengths and highlights areas for improvement. 1.2 Assessment Objectives and Study Rationale The assessment used an integrated and holistic approach to assess the HR management and development issues in the GHS and MOH. The assessment team examined a variety of documents: products from the recent HR retreat, job descriptions, policies and guidelines for HRM practices, and descriptions of structures, processes and procedures for staff performance management at the national, regional and district levels. The team assessed the roles and responsibilities of various stakeholders in recruitment, placement, compensation, training and development as well as issues in the general organizational environment including policies, visions, plans, compensation and the labor market. Human Resources Management Systems Final Report 14

15 The Human Resources Development Division (HRDD) of the Ghana Health Service has been grappling with a number of interventions with the aim of improving HRM systems at all levels. Results from these interventions have been mixed. This report on the assessment of the HRM systems and factors that impact management functions will help identify areas for further work or suggest modifications of existing interventions. The main objective of the assessment was to measure the HRM capacity of the Ghana Health Service (GHS) and the Ministry of Health (MOH) in terms of systems effectiveness and efficiency, identifying strengths and highlighting areas in need of improvement. The specific objectives were to: Review current HRM policies, plans and procedures Assess HR data management systems, including personnel filing systems Assess staff performance management capacity and systems Assess the roles and responsibilities of various stakeholders in the HRM systems and how these affect the efficiency and effectiveness of the management systems Assess pre- and in-service training systems including policies and procedures for managing training activities and outcomes, and assess the linkages between preservice and in-service training Assess the number of women in the GHS and their opportunities for job advancement Provide recommendations for streamlining and strengthening HRM systems in the GHS 1.3 Assessment Conceptual Framework USAID s Human Capacity Development (HCD) initiative provided the conceptual framework for this assessment. The Human Resources Management (HRM) components of this framework are: Welfare benefits program Staff retention Recruitment, postings and promotion Orientation program HIV/AIDS workplace prevention program Employee manual Discipline and grievance procedures Labor law compliance Job descriptions Staff supervision Work planning and performance appraisal Staff training Management and leadership development programs Links to pre-service training Human resources information system Personnel filing system Each of the above components of HRM can be assigned a score from 1 (no or minimal system in place) to 4 (system in place and used optimally). Once each component is scored, an overall index score may be calculated. Survey instruments developed by Management Sciences for Health were adapted by QHP and GHS for use in this study (see Appendix A). Human Resources Management Systems Final Report 15

16 II. METHODOLOGY The data for the assessment, using both quantitative and qualitative approaches, were gathered from three activities: (1) Key Informant Interviews; (2) Review of Key Documents; and (3) a Facility Baseline Assessment. All 10 regions were included in interviews, including managers of training institutions. At the district and facility levels, this study focused on the 28 target districts for the Quality Health Partners Project, and interviewed district and facility-level personnel. These are considered the most deprived districts in the following seven regions: Ashanti, Brong Ahafo, Central, Eastern, Greater Accra, Volta, and Western (see Appendix B for a list of the districts). 2.1 Key Informant Interviews (KII) GHS/HRDD was involved in the design of the study and consented to this assessment. Informed consent was obtained from all respondents for the interviews. Respondents were assured that the information they provided was confidential and would be presented in an aggregate format Sample Characteristics and Size A total of 174 key informants were interviewed. Table C1 lists their titles and agencies, while Table C2 shows the number of respondents at each organizational level (see Appendix C). All 38 pre-service nursing and midwifery training institutions in the regions that offer courses in reproductive and child health (RCH) were included in the assessment. The institutions are listed in Table C3 (Appendix C) Data Collection and Analysis The following instruments were used: HRM Capacity Framework questionnaire, covering human resource policy, planning, management, training and development, was used to interview Regional Human Resource Managers and their immediate supervisors, the Regional Health Service Administrators Interview guides for: Director of Budget and the Desk Officer Health in the Ministry of Finance, Head of the IPPD Unit in the Office of the Head of Civil Service Director of Human of Human Resources for Health and the Deputy Director responsible for Training MOH Director and Deputies of Human Resources Development Division GHS Regional Directors of Health Services District Directors of Health Services Pre-service equipment checklist to assess need, availability and functional status At the end of the data collection period, coded and qualitative Key Informant Interview data were entered into SPSS (v. 13.0) for analysis. Data analysts produced frequencies, crosstabulations, graphs and/or maps for all coded responses and case summaries for all qualitative responses. Human Resources Management Systems Final Report 16

17 2.1.3 Response Rate and Interpretation of Results While all 10 regions completed the Capacity Framework questionnaire, only nine of the 10 regions responded to the Regional Directors of Health Services Interview (no response from Upper East Region). Similarly, for the Regional Training Coordinator Interview, nine regions were represented (no response from Western Region). For the District Directors of Health Services Interview, 27 of the 28 target districts responded (no response from Nkwanta District, Volta Region). 2.2 Review of Key Documents The second component of the assessment was a review of existing documents on HR policies, plans, and practices within Ghana s health sector. This qualitative review of documents obtained from the Ministry of Health and Ghana Health Service was aimed at assessing: (1) the completeness of the documents, (2) their relevance to achieving set objectives, (3) the extent to which they have worked in practice, (4) constraints on their use, if any, and (5) their approval and implementation status. The examination of documents also permitted qualitative comparison with interview data and facility survey results. 2.3 Facility Baseline Assessment The third component of the data collection was completed as part of the concurrent Facility Baseline Assessment (FBA) being carried out by GHS and QHP in conjunction with the CHPS-TA project. The focus was on examining HRM practices within health facilities in the seven QHP focus regions to determine consistency with designed systems and structures. This involved interviews with a cross-section of field staff. These findings were considered in conjunction with those from the first two assessment components Sample Characteristics and Size The FBA was a census of 171 facilities. The facilities included the 10 regional hospitals, all hospitals in the 28 target districts of the seven southern regions, all health centers in the 28 target districts, and selected other private facilities in the target area that provide reproductive and child health services. Up to five providers per facility were selected for interview. The first priorities for selection were those providers who were observed providing services; after that, the person in charge of the facility, then at least one midwife and one nurse. If five people still had not been chosen, the interviewers selected from among staff that provide RCH services. If there were fewer than five providers in a facility, they were all interviewed. A total of 527 providers in 171 facilities were interviewed Data Collection and Analysis The FBA instruments consisted of five pre-coded, quantitative questionnaires that were administered by trained surveyors. The data were collected between 29 November and 20 Human Resources Management Systems Final Report 17

18 December Coded FBA data 1 were entered from paper questionnaires into SPSS (v. 13.0) for analysis. Data analysts produced frequencies, cross-tabulations, and graphs for all coded responses Response Rate and Interpretation of Results A total of 94% of targeted facilities were included in the final analysis. Non-response occurred primarily in government-run health centers where there were few assigned staff and the key staff person was unavailable. A few private facilities were also closed on the day of the survey. While responses from facilities in all 28 target districts were included in the FBA, interpretation of the regional results reported from the facility survey must bear in mind that they are not representative of the region overall but only the selected districts within that region that were identified as priority districts by GHS and USAID. As such, FBA data are representative of the situation at health facilities in relatively deprived districts in the seven southern regions and for all regional hospitals. The notable exception is Central Region, where all 12 districts (now becoming 13 districts) were included due to their designation as target districts. 1 Further details on the methodology and findings for the FBA are available in the Ghana Health Service and Quality Health Partners Facility Baseline Assessment Report (2005), available from QHP in Accra. Human Resources Management Systems Final Report 18

19 III. FINDINGS AND DISCUSSION The findings from the three data collection activities are presented below within the USAID Human Capacity Development (HCD) conceptual framework described in the introduction (Section 1.3). Sections report on findings from the national, regional, district and facility surveys. Section 3.7 presents findings from the key document review. Using the HCD framework, several components of HRM were assessed in each region (see Appendix A). For example, only one of ten regions, Greater Accra, reported making efforts to review HRM policies on labor law compliance (one of the HRM components). Regional comparisons of other individual components are presented throughout this section. As described in Section 1.3, component scores may vary from 1 (no or minimal system in place) to 4 (system in place and used optimally see Appendix A for a copy of the instrument). These component scores are used to calculate an overall index score. The regional HRM Capacity index scores, based on ratings for the 16 HRM components, are shown in Figure 1 below. Three of the regions scoring lowest in overall HRM capacity contain almost three-quarters of the 28 target districts (Central, 12 target districts; Volta, 5; and Western, 3). Figure 1. Map of HRM Capacity Index Scores, by Region Human Resources Management Systems Final Report 19

20 3.1 Stakeholder Roles and Responsibilities in HRM Processes The Ghana Health Service employs about 70% of health staff in the public sector. Various stakeholders within the MOH, the GHS and other ministries and agencies outside the health sector also play roles in managing health staff in Ghana The Universities The universities train health professionals such as doctors, pharmacists, certain categories of nurses and administrators who are mainly employed by the MOH and its agencies, including the GHS. Their medical schools train doctors at the undergraduate and postgraduate levels. There are two well-established Ghanaian medical schools, in Accra and Kumasi. A third in Tamale has started training doctors, but is having difficulty mobilizing resources for effective training. Admission into these programs is insufficiently related to the needs of the health sector. Medical schools fall under the Ministry of Education. Medical training lasts seven years, followed by a one-year housemanship. At the national forum on human resources for health management held in September 2003, participants expressed concern about the long duration of medical training, especially at a time of critical shortage of doctors in Ghana. Participants stressed that the duration of training could be reduced without any negative effect. Yet there has not been a change of policy based on these recommendations. Even though regional and peripheral hospitals are designated as housemanship sites, house officers congregate at the teaching hospitals in Korle Bu and Kumasi. There is no arrangement for ensuring equitable distribution of newly graduated doctors among health agencies. Therefore, most new doctors are absorbed by the two teaching hospitals, to the disadvantage of the GHS, which has the widest distribution of health care facilities in the country. There is an urgent need for more equitable distribution of newly graduated doctors The Human Resources for Health Division (MOH) and the Human Resources Development Division (GHS) The tenets of Act 525 (1996) that established the GHS and teaching hospitals make the MOH and the divisions therein responsible for policy formulation, resource mobilization, allocation, and monitoring. Key staff at GHS/HRDD reported that the role of MOH/HRHD in providing overall HR policy direction has been weak. The document Human Resources Policies and Strategies for the Health Sector, developed by the MOH/HRHD in 2002 without the involvement of GHS/HRDD, has not been widely accepted or used by the latter. The MOH/HRHD has primarily managed health training institutions outside the universities. There is a lack of clarity in the roles of management of the training institutions around the country. There is also a lack of clarity in roles between MOH/HRHD and GHS/HRDD leading to duplication of effort. Regional Directors complain that even though they are given responsibility for managing the pre-service institutions, the MOH often gives conflicting instructions to the training institutions without the Regional Directors knowledge. Management of the training institutions needs streamlining as the conflicts and confusion undermine the morale and performance of staff. The Director of GHS/HRDD stressed that current procedures for selecting candidates into pre-service training are in conflict with policy directives. The policy states that District Assemblies are to be involved in sponsoring candidates for training so that upon completion of training such candidates can be posted to facilities within the districts. The intention was to allow regions to select trainees, but admissions are so centralized that regions and districts have little or no role. Human Resources Management Systems Final Report 20

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