The Evidence Issue 2: 2January 2012 HUMAN RESOURCES FOR HEALTH - Identified Policy Gaps In this issue: Words from an international collaborator Situation of HRH in Sudan, FMOH Spotlight on HRH strategy Public Health Institute critical appraisal of HRH policy and research Spotlight on HRH policy research on retention. Follow up from the previous issue of the newsletter PHI News Contacts Editorial Committee of the Newsletter The Advisory Committee: Dr. Elmuez Eltayeb Ahmed Dr. Igbal Al Bashir Dr. Muna Abdel Aziz Dr. Bahaa Eldin Mohamed Dafaala Dr. Isam El-Din Mohammed Abdulah Dr. Mustafa Saleh Dr. Muna Hassan Editorial Secretariat: Dr. Nazik M. Nurelhuda Israa Mustafa Director of the Human Resources General Directorate Public Health Institute General Director Public Health Institute Acting Director Public Health Institute- Head of Consultancy Department Federal Ministry of Health Federal Ministry of Health Faculty of Medicine- African International University Knowledge Plus Coordinator Evidence for Health Program Coordinator Chairman of the Comittee Member Vice President Rappoteur Member Member Member Member of the Editorial Editor in Chief 1
Letter from the editor The Evidence for Health (E4H) program, public Health Institute is very pleased to introduce its second evidence for promoting the public health situation, by reflecting the significant role that the Human Resources for Health-HRH play. As a follow-up to the previous issue, this newsletter also contains a brief report about the ehealth seminar that held in the PHI and its recommendations. Our evidence series will be available for free download on our website www.phi.edu.sd. We will be very happy to receive our reader s comments, suggestions and queries through the newsletter email the.evidence@phi.edu.sd. Israa Mustafa -E4H coordinator- PHI Words from an international collaborator Dr Amir Hassan University of Liverpool The working experience at the Public Health Institute, Federal Ministry of Health, Sudan, in delivering the Epidemiology In Action Course, was considered by all our staff working there as a positive one. The counterparts in Sudan with whom we worked were seen to be both competent and excellent in undertaking their duties and of special mention were Dr Hayat Khogali, Dr Muna Abdel Aziz and Ms. Nahed Abdelgadeir Ali. The facilities provided by the Institute were of a sufficiently good quality including the computer lab and library. The students of the courses also need to be commended. They were notably from different states and came with differing backgrounds and were keen to learn, punctual and polite. Having been asked to comment, we would note some of challenges in developing toward a centre of excellence are to focus on establishing core academic and quality standards in approving and delivering teaching courses. The most urgent steps which may be considered would be toward both institutional and capacity development. However, it is evident that the institute has progressed excellently and it is well positioned given that it is only two years old. 1 Situation of HRH in Sudan, FMOH: Health system performance and health indicators have always been of paramount importance in assessment of the health workforce training and practice in Sudan. Studies and researches conducted has revealed that figures and outcomes to be poor and lagging behind the (MDGs). Tracing back the health system profile and trends in Sudan, educational and management work over years has culminated into a health workforce that is composed of more than 100 thousands health workers making over 20 different professions. The picture of Sudan health workforce today shows slight dominance of females representing 51 percent but with increasing trends. The age structure points to a rather young health workforce probably due to the recent expansion of medical education and health training leading to increased number of young university graduates available. The civil service under the ministry of health employs majority of health workers, with the lower numbers in the army, police, universities and health insurance fund. Exclusive private sector staff represents only 9 percent, taking into account that dual practice is very common. Analysing the Geographical distribution of health workers shows very clear bias towards urban setting especially Khartoum state where 62 percent of specialist doctors and 58 percent of technicians are found. HRH issues in Sudan are supported by various stakeholders. The Federal Ministry of Health and the state ministries of health are the major employers responsible for human resource management and in service development. The Ministry of Higher Education is responsible for pre-service training and production of health workers through a total of 145 medical schools and health training institutes affiliated to different universities. The Sudan Medical Council is in charge of registration and licensing of doctors, pharmacists and dentists; while the Council for Allied Health Professions is dealing with the rest of the health workforce. Other Stakeholders and health providers that employ a share of the country workforce are the Army Medical Corps, the Police Health Services and the Health Insurance Fund in addition to the private sector. Professional associations for doctors and other categories of health workers are mainly playing roles in trade union activities and continuous professional development.
Evaluation of HRH systems in Sudan has revealed a record of some successes, shortcomings and challenging issues. In the domain of HR policy, a group of policies focusing on training, career pathways and staffing norms were developed and introduced over the last ten years. Problems were encountered in implementation of some policies; while consensus over policy development and sound implementation mechanisms remain as two challenging areas. As for HR planning, the outcome is not satisfactory reflecting poor focus and clear distinction between HR planning and overall health planning. When HR planning was adopted during the last five years, the plan produced has focused on staff projections to the neglect of other important HR dimensions. Institutionalization of HR planning at national, state and locality levels are a challenge that needs to be addressed. The capacity for HRH production has been extensively increased over the last two decades, in particular for medical education. Despite the favourable aspect of effects brought by educational expansion, the lack of coordination between health service and academia has resulted in many forms of skill mix imbalance, in significant numbers. Human resource management systems were the least developed and emphasized among HRH systems. Despite the existence of routine practice of setting job descriptions, deployment, personnel administration and performance appraisal, but still these need reinforcement for revival, re-adjustment and successful implementation. Among the HRH main issues highlighted, were developing capacity for HRH planning and policies, augmenting equitable geographical distribution, improving individual performance management systems as well as improving health workforce production, education and training and Strengthening HR functions at the decentralized levels. Within the current context, opportunities exist for productive work on addressing HRH issues. Political commitment and health system focus on health workforce front is an important cornerstone to build on. Promising funding opportunities from national sources and donors are now financed. In addition to that, the talent of the country workforce together with the huge potential of educational institutions and migration are factors positively counting towards human resource development. More benefits and attention towards HRH issues can be gained from the global movement and international focus on HRH issues, particularly in the continent of Africa. Spotlight on HRH strategy The Strategic plan for HRH in Sudan 2012-2016, based on a thorough situational analysis, is aimed at developing human resource plans at different levels of the health system in a comprehensive approach. The plan defined the priorities of HRH and subsequently defined the following objectives: Support health service needs through adequate HRH planning. Develop policies/systems to ensure more equitable geographical distribution of health workers especially doctors and nurses. Improve individual performance management systems. Improve production and orientation of education and training towards health service needs. Strengthen HR functions at the decentralized levels. Critical appraisal of HRH policy and research PHI are involved in developing the national Health Strategy (HRH component), the National HRH Strategy for Sudan 2012-16, State HRH strategies and also leading the HRH research on retention, migration and gender. Key partners in these processes are within the HRD Directorate, FMoH Planning Directorate, FMoH Research department and Connecting Health Research in Africa and Ireland Consortium (CHRAIC). PHI is working on national priorities for research and especially for HRH, a critical appraisal was undertaken based upon the CHRAIC methodology. This is a key document for the HRH research situation analysis, priority setting, and strategy development. The CHRAIC process to identify priority research areas for HRH includes four key steps. These are: 1. Agreeing on terms definitions used around the thematic areas of governance, human resources, and equity and access. 2. Collecting data about current health system concerns and knowledge gaps in the three thematic areas through: a. Key informant interviews/group discussions 2
b. Review and appraisal of the following types of documents: i. Policy document ii. Reports of published and unpublished local research including review articles- in the three thematic areas 3. Overview of research report and literature reviews to identify research completed to date that provide data to fill knowledge gaps identified in step 2 above 4. Inputs from steps 2 and 3 are then to be discussed at a workshop of stakeholders for ranking of the research issues, and brainstorming around the topranked issues. There is much that is known in the field of HRH. There also remains much that is not known. Policy gaps did emerge and some unanswered research questions are summarized below. Policy gaps: Institutionalization of HR planning at national, state and locality levels are a challenge that needs to be addressed. When human resource planning is attempted, it usually addresses the projection of staff numbers leaving uncovered important areas like HR policies and management systems. Harmonization of HRH planning within the overall health planning process is another problematic area. It is important to ensure HRH planning is in line with needs and with burden of disease. Not uncommonly, expansion in health care infrastructure and facilities occurs without paying enough attention to the need for health workers both in terms of numbers and qualities. This was shown in terms of service targets for facilities but not for the corresponding staff needs. It is highlighted that in addition to planning for facilities, HRH need equipment and technologies to undertake the job. This issue was not clear in the strategy, and policy initiatives are needed to ensure investment in new/assistive technologies as well as HRH. These policies should consider the need for educated trained health workforce who are able to meet the challenges of society need as well as new technologies. Strengthening educational system in its three facets (basic, post-graduate and in-service) is both a policy requirement as well as a required strategy. The policy gap that emerged clearly is that roles and responsibilities remained subdivided among a number of different institutions outside MoH such as Ministry of Higher Education and Ministry of Labour and the newly developed Ministry of Human Resource. Similarly to HRH production, regulatory functions are needed to be streamlined in a policy that enhances the capacity to regulate and track staff health professionals, especially to meet MDGs. As retention is key to ensuring skilled HRH in rural and distant areas, HRH policy is required to address the issue of sponsoring and sustaining a package to deploy and retain health workers in states and underserved areas, and enhancing capacity for health professions regulation. Decentralization policy has important implications to HRH strategy. The devolved health system of Sudan now gives more emphasis on the role of state and locality levels with important HRD functions such as employment, deployment and management transferred to states in all service grades. With this come the challenges of resources and capacity needed for the decentralized institutions to play their roles. The policy appraisal of HRH revealed that much of planning for HRH have been developed at Federal level with lack of information and systems to support planning at State levels. Initiatives like the Academies of Health Science and Continuing Professional Development at State levels are to be evaluated and sponsored. In conclusion, for human resources for health to flourish in Sudan these areas need to be explored and policies to resolve these outstanding gaps need to be in place. Research gaps: There is much that is known in the field of HRH; however, the appraisal exercise highlighted the following questions as important areas for research. The research questions are allocated as per the HRH strategic objectives: Strategic Objective 1. Support health service needs through adequate HRH planning. What is the role of HRH in meeting MDGs 4 and 5, and are we tracking progress against workforce skills and numbers? What is the ideal staffing ratio (HRH targets) per health facility and per population? 3
What is the current and expected level of attrition in the workforce (by cause, place, level and profession)? Is there retirement planning/ succession planning in relation to age profile of staff and in relation to rate of attrition? Strategic Objective 2. Develop policies/systems to ensure more equitable geographical distribution of health workers especially doctors and nurses. What are the existing mechanisms of motivation/ incentivisation at Federal, State and programme levels (not just financial)? Are there any issues related to implementing this? How are salaries and incentives (remuneration packages) determined? Are there retention policies? How is attrition managed? (Policy and managerially). How is internal migration managed (rural to urban, public to private)? Which incentives seem to work? How is overseas migration managed? How are diasporas encouraged to return or contribute? Strategic Objective 3. Improve individual performance management systems What are the issues regarding performance appraisal? Are there different models of staff supervision being used? Are there any issues related to implementing this? How is staff health and safety preserved in the workplace? What should be the ideal development of an occupational health service? What is the impact of stress and workload on health among the HRH workforce? How is workload balanced? Are there systems in place to support staff who need support eg not coping due to workload &/ or stress related? Are there any issues related to implementing this? Strategic Objective 4. Improve production and orientation of education and training towards health service needs Are staff working in jobs matching their skill and qualification? What are their training needs? Where are they overqualified? How are training needs identified? How can the existing partnerships be strengthened between higher education and health service needs? How does the experience of the Academies of Health Science orient training to health service needs (evaluations study)? Strategic Objective 5. Strengthen HR functions at the decentralized levels What is the effect of decentralisation on HRH? Are there clear HR management structures in States? Do they include recruitment plans and how are staff selected? Are points of overlap clear between States and Federal? What is the ideal structure and competence for the HR management function in each state? (Number, qualifications, and functions). Are there clear SOPs for hiring and distribution? Who manages the process? Are they guided by context, historic, current or future needs? What evaluations have been done for HRH initiatives federally or in States or programmes? What are the current M&E capabilities in HR depts. or initiatives in States/programmes? Spotlight on HRH policy research on retention. Regarding research and policy gaps, PHI is working on a research that should identify the logical or conceptual framework behind HRH equitable distribution and burden of disease. This is essentially an ecological study of HRH and disease indicators. Current HRH distribution will be mapped geographically using existing data i.e. secondary data analysis, and as far as possible current migration patterns will be deduced. It is expected to map this further for a specific programme domain (e.g. provision of maternal health services and the referral system as a contributor to the Millennium Development Goals -MDGs). Further research is also underway to develop options for financial and non-financial incentives that promote retention in rural areas. Gender and migration issues are emphasized. From all these researches, options and evidence based recommendations will be developed in the form of policy briefs. 4
Follow up from the previous issue of the newsletter: PHI ehealth Seminar day, An event under the title of ehealth in Sudan revisited was held on the 5th of December at PHI to launch the Evidence newsletter and Knowledge Plus. It brought together in one forum, diverse stakeholders to discuss ehealth issues in Sudan. Speakers included Dr. Salah Hussein Mandil, Prof. Abdelmoneim Sahal Elmardi, Engineer Ali Naseem and Dr. Muna I Abdel Aziz. Member of the panel were Dr Abdalla Seed Ahmed- National Consultant PHI, Dr Isam Eldin Mohamed Abdalla- Undersecretary FMOH, Dr Iqbal Ahmed Basheer- Director PHI, Representatives from National Health Information Centre. The program included Briefing from PHI situational analysis Nazik M Nurelhuda mhealth promising future? - Dr Muna I Abdel Aziz Tele-education - Prof Abdelmoniem Sahal Elmardi Briefing on ehealth project Eng Ali Naseem Perspectives and the way forward: Specific actions Dr Salah Mandil Seminar recommendations: ehealth is a very important tool, and we in Sudan have an excellent vision of the future, however, implementation of priorities need to be from downwards up, that is from a national health information network, national health care management information system towards telemedicine project expansions. Aafya net (National Health Information Platform that networks all the Sudan health sector institutions and supports all forms of communications between them) is under the last steps delayed due to digital security issues. This network should solve issues related to access, equity and improvement of services. 5 There is an emphasis on the obstacles facing the ehealth arena in Sudan as being primarily due to a managerial crisis rather than economic or technical difficulties. Previous programs such as the telemedicine project should be evaluated. Both managerial and technical experiences should be documented. Health should be viewed, by the government, as an economic necessity rather than a social duty. The ehealth project established by National Information Cooperations ehealth project, which was designed by a Turkish consultancy group is well acknowledged. However, steps to move forward include: It is the duty of everyone to collaborate with them. However, NIC cannot be responsible for health in Sudan coordination and responsibility should be in the hands of the Ministry of Health. The 2005 strategy is not cast in stone, but departing from it needs to be on strong grounds. The strategy described a system based upon the needs of the people. What we have today is the other way around. Both ways work. The policy can be amended. There is a need to ascertain that the system obtained is complete. We need to know whether the system is operational elsewhere, outside Turkey. If present, channels of communication should open with them and the Sudan should learn from their experience. With respect to the price of the installed system, it should be precisely clear what features are covered e.g. costs of customization, updates, maintenance and training users. There should be a joint cooperation between the health sector, NIC, and interested stakeholders to establish requirements. The presentations from the ehealth seminar can be accessed on the Public Health Institute official website: www.phi.edu.sd.
PHI News We are delighted with the appointment of Dr Igbal Ahmed Bashir as the new Director of PHI. The PHI together with the Liverpool School of Tropical Medicine (LSTM), affiliated to the University of Liverpool, in the United Kingdom, has signed an MOU aiming toward achievement of mutual benefit and objectives for both parties. The core areas of collaboration will be in program development, curricula, staff, training, teaching, learning, research work and technical assistance. PHI received the second batch of master of the Disaster Management in June 2011. The public health institute, federal ministry of health held the following courses and workshops: In collaboration with Liverpool School of Tropical Medicine provided Epidemiology in Action course. In collaboration with Liverpool School of tropical medicine provided - Planning Monitoring and evaluation course. HINARI gate is now available through the PHI website: www.phi.edu.sd, on E- library tap on HINARI icon. For PHI students and Staff. The consultant Mrs Annette Bool senior expert, PUM visited the institute to help in improving the quality of the curriculum and improvement of the teaching qualities of the instructs as well as increasing the quality of educational programs. PHI was honored with the visits of: Academy of Royal Collage (AoRC) and British-Sudanese Academy of Medical specialty. Salah H Mandil, PhD, Senior Expert Consultant To the International Telecommunication Union and WHO On ehealth & estrategies and, Former Director Health Informatics & Telematics World Health Organization Geneva, Switzerland. DR. Nageeb Shorbagi, knowledge management director, World Health Organization, Geneva. Sudan Health Consultancy group- United Kingdom. Mr. Bahar Idriss Abu Garda Federal Minister of Health. In collaboration with MERLIN and WHO- provided Analysis of Disrupted health systems workshop. 6