Priority Areas in Human Resources for Health Research in Sudan

Priority Areas in Human Resources for Health Research in Sudan Dr. Amel Abdu Abdalla Research and Publications Department-NHRHO October-2009 Page 1

Table of Contents: Item Page Executive Summary 3 Introduction: - Situation of HRH Research in Sudan 5 - Objectives 6 Methodology: - Approach &Priority Setting Process 7 - Methodologies Taken Towards Prioritization 8 Result: - HRH Concerns & Problems. 13 - Current Situation of HRH Research 14 - Research Priority Issues 14 Conclusion 19 References 20 Annexes 21 Page 2

Executive Summary: Introduction: Human resources for health are the main asset for the health system. In Sudan with it is huge land and diversity of health problems and low resources; it became a nessacity to have evidence-based policies, plans and means of management. HRH research is believed to be of great importance and will have a crucial role in improving the overall HRH picture in the country. A lot of unresolved questions are there and this document was designed to facilitate pritorization of these questions and to figure the HRH concerns and obstacles to proper HRH research. Methodology: The main goal of the paper was to develop a list of HRH research priorities, and to achieve that we follow three stages. The first was to identify the HRH stakeholders and key informants and their priority unresolved HRH research questions beside the concerns and main problems from their point of view that facing HRH. The second was to identify the gap and the obstacles that hinder the proper HRH research. The third stage was to develop a list of HRH research priority issues. A questionnaire was developed to gather the information from the key stakeholders and informants. Besides, literature was revised to identify the research done. Results: A list of twenty-eight priority HRH research issues was materialized from the key stakeholders and informants. They were also put in broad categories that represent the HRH domains. Number of concerns and problems in regard to health workforce were also identified including the weak policies and management systems; issues of production and quality and skill mix problems; issues related to distribution of the health workers between rural/urban and public/private sectors; and the health workers performance and the factors affecting the best practice. Page 3

By reviewing the literature and the current situation of HRH research; it was evident that the HRH research is a neglected and weak area. A few studies were conducted addressing issues that related mainly to that institute and add little if ever to the HRH concerns. Poor research capacity and low funds were mentioned as the main barriers to best research practice. Back to the list of priorities, after ranking, the top ranked HRH research issue was the health workforce migration, and the role of the unions and professional associations in the development of the health workforce was at the bottom of the list. Conclusion: By pritorizing the HRH research issues we aim at increasing and raising the awareness towards research in regard to health workforce issues to provide the evidence that help improving the policy, planning and decision making. This list was emerged from those really concerned of HRH issues at the different levels, and domains. And we hope that, this list will be used as guidance for what research should be conducted and for donors support. Page 4

Introduction: Human resources for health research is a largely ignored but increasingly important component of the overall sustainable strategy to improve the quality, quantity and stability of human resources for health in developing countries and a key component of successful sustainable health system improvement 1. The last years witness an increasing concern regarding human resources for health in Sudan that brought it strongly to the decision and policy-makers agenda. In spite of that; still there are gaps and shortages considering the availability of clear priority issues and human resources for health research list; the capacity and personnel needed to conduct such researches; and the defiantly allocation and/or mobilization of resources for funding and conduct these researches. Regarding the area of human resources for health research (HRHR), prioritization is as important as conducting the research it self. So taking in account the scarcity fund, it is important that the health workforce research to be based on a rational priority setting process to identify the priority issues that will make the greatest contribution to the development and stabilization of human resources for health and consequently improving the community health. Situation of HRH Research in Sudan: In Sudan as in many other developing countries the health sector research is very limited and few in contrast to its useful benefits due to the poor funding. The majority of the research studies conducted is largely skewed to quantitative research focusing on disease control and clinical medicine. Focus on health system research, especially in its qualitative domain is largely missing in the country. Within this context, it is not surprising to learn that human resources for health area is still virgin in terms of investigations and research. Most of the current impressions about the health workforce were based on personal impressions and not supported by evidence e. g. research findings or solid data. These issues include among others, distribution of health workforce and reasons of preference to work in urban areas versus rural areas; dominance of female, role of financial incentives in retaining the health workforce, reasons behind migration, issues of skill mix, and quality of health workforce education and training. Page 5

Following on that, one would find it difficult to define priorities for HRH research in the country given the pressing need for evidence in all components of HRH. However, it would also be a good chance to set the broad agenda for HRH research and try to propose a sequencing process to go about addressing the huge HRH research gap in the country. Objectives: By prioritizing the issues in human resources for health we aim at the following: 1. Better understanding of the problems facing the human resources for health in Sudan and identify the concerns and research priorities of the key stakeholders; 2. Identify the gaps and the unresolved questions in regard to human resources for health research issues; and 3. Develop a national human resources for health research priorities; Page 6

Methodology: To achieve our objectives three main stages were taken (Figure-1): - Identify the key stakeholders and informants in regards to the different HRH issues; - Situation analysis for the HRH research in the country and identify the gaps and unresolved questions; and - Develop a list of HRH research priorities by making use of the findings of the previous two steps. Figure-1: Priority setting process Stage-1 Identify the HRH stakeholders and the key informants and their concern. Stage-2: situation analysis of the current HRH research and identify the gaps Stage-3; Develop list of priority HRH research questions. Out puts Policy makers Areas with the Ranking of Final main unresolved the HRH approved HRH related bodies questions. research document. questions. National Expertise's Researchers and academicians. Approach for Prioritization & Priority Setting Process: We are guided by the concept of Essential National Health Research (ENHR) which was advanced by the Commission on Health Research for Development in 1990. It is a systematic approach for organizing and managing the country-specific and global health research in order to promote health and development on the basis of equity and social justice 2. Page 7

The main principles of this approach are: 1. Involvement of stakeholders (decision-makers at various levels, health services providers, researchers and donors), and 2. Multidisciplinary approach. 3. Defining the criteria for selecting the research questions, and we apply the following criteria: i. Magnitude of the problem and expected impact of the research; ii. iii. iv. Feasibility of doing the research and avoidance of duplication; Focused; Add to knowledge and bridging of information gap; and v. Politically and ethically acceptability. Methodologies taken towards prioritizing include: The steps taken to wards developing the final document include the following: 1. Identification of the key stakeholders and the key informants: In Sudan the human resources for health are managed by various stakeholders in regards to the different domains (Table-1) shows the HRH stakeholders and their roles and responsibilities. Table-1: HRH stakeholders in Sudan Stakeholder Current role in HRH Federal Ministry of Health (FMOH) - HRH policy and planning - HRH mass training (chances and funding) - (training paramedics) - HRH management - HRH data and information Ministry of Health, Government of Southern Sudan (MOH- GOSS) (since 2005 responsible for health sector governance of the 10 states in the geographical area of Southern Sudan) - HRH policy and planning for the ten States in the South within the framework of National policy - Monitoring and supervision of the 10 state Ministries of Health in the South. - HRH training (availability varies from State to State) - (training paramedics) - HRH management down to the locality of staff, Page 8

Stakeholder Current role in HRH including the deployment of staff to locality health facilities - HRH data and information collection and storage State ministries of Health (SMOHs) - HRH policy and planning at the State level and within the framework of National policy - HRH training (availability varies from State to State) - (training paramedics) - HRH management down to the locality of staff, including the deployment of staff to locality health facilities - HRH data and information collection and storage Ministry of Higher Education (MOHE) - policies on production of HRH - licensing, monitoring and supervision of medical and health training institutions - teaching staff development and training - data and information on admissions, enrollment, graduates and staff Ministry of Labor (MOL) Chamber of Civil Service (CCS) - employment and condition of service for health staff - salary structure and promotion of health workers - approval and funding of health workforce training National Council For Training (NCT) Ministry of Finance (MOF) - provision of salaries for public sector staff - regulating the range of incentives for health staff - funding the allowances and incentive packages for staff placement Sudan Medical Council (SMC) - licensing and registration of physicians, dentists and pharmacists - accreditation of medical, dental and pharmacy schools - ensuring safety of practice by doctors and dealing with related public complaints Council for Allied Health Professions (CAHP) Sudan Medical Specialization Board (SMSB) - licensing and registration of nurses, technicians and paramedical staff - postgraduate training for doctors, dentists and pharmacists - CPD for doctors Page 9

Stakeholder Army Medical Corps (AMC) Current role in HRH - employment of HRH on military terms - planning, distribution, management and training of affiliated staff Police Health Services - employment of HRH on Police forces terms - planning, distribution, management and training of affiliated staff - provision of basic medical and health cadre education Health Insurance Fund - top-ups for health staff providing insurance services - employment and management of some staff categories Sudan Doctors Union (SDU) Sudan Health and Social Professions Trade Union (SHSPTU) Sudanese Technicians Association (STA) - Professional development for doctors (conferences, etc ) - support for doctors in condition of work and some general services - condition of services and trade union activities for all health workers (with a focus on nursing and paramedics) - professional development of technical staff - condition of work and scope of practice for technicians Private sector - production of HRH (basic and postgraduate training) - employment and management of staff - toppings for public sector staff working on part-time basis International agencies and donors - technical support in HRH policy and management - training and CPD chances - toppings for public sector staff Beside those stakeholders another group of key informants were identified. This group includes some researchers and national expertise in the area of human resources for health and health system and operational research. 2. Identification of the stakeholders concerns and HRH priority research questions: Each and every stakeholder institute has it concerns and problems in regards to health workforce that related strongly to its mandates and objectives and defiantly its roles and Page 10

responsibilities towards health workers. To collect their opinions and define their priority unsolved research questions in this domain; a self filled questionnaire was developed and distributed among all the key persons identified as key stakeholders/informants. The questionnaire is attached as an annex and it covers the following: - The main HRH concerns and problems facing the stakeholders institutes and the country from their point of view; - The situation of HRH research at the level of stakeholders institutes; - HRH research priorities. 3. Situation Analysis of the current HRH research: A situation analysis was done to highlight the problems and shortcomings in HRH different areas and domains. In this regards a literature review including documents from the government, federal ministry of health (FMOH), WHO reports and documents were visited. Also the general situation of health workforce was reviewed including: - Number and types of health workforce. - Trends of distribution and densities. - Availability of policies and level of implementation and constrains. - Training and training capacities. - Motivation of health workforce. - Managerial system and principles. To assess the current situation of HRH research, part of the questionnaire was designed to satisfy this issue, and it investigates the following: - HRH research conducted; - The benefits gained from the research results and its uses; - The funds for the research; and - Availability of partners and future plans for HRH research. 4. Reviewing the Literature: The literature was reviewed including published and non published documents in order to figure out the current level of health workforce research conducted, and to evaluate to what Page 11

level they satisfy the priorities defined by the key stakeholders/informants. Unfortunately, our review was limited to those published only because it was difficult to gather those drafted or not published. 5. Approval Workshop: The final document will be presented in a workshop for consensus building and approval. The attendees of this workshop will be the higher authorizes of the health sector, the HRH stakeholders' institutes representatives, HRH related bodies' representatives, national expertise, and researchers. Page 12

Results: HRH Problems and Concerns: Certain health workforce concerns and problems were rose by the different stakeholders' institutes and HRH related bodies. These concerns include: HRH policy and management capacity: Improve the HR functions at the decentralized levels (states, localities). Lack/weak HR management system and policies and poor advocacy for them at the different levels. Coordination between the different HRH related bodies. HRH supply and production: Low supply of certain categories of health workers (skill mix problems). Issues related to migration and emigration. Retention of health workforce. HRH performance: Quality of health workers training and lack of continuous professional development programs. Incentives (financial and non-financial) and performance and the relation to promotion. Work environment problems (vertical and inter-personal relations). HRH distribution: Health workforce misdistribution (rural/urban, public/private). Gender issues and relation to misdistribution of health workforce. Absence of rules and regulation that control the practice in the nongovernmental sectors and dual practice. These concerns were rose across the different stakeholders' institutes and the HRH related bodies. And as mentioned before there are different federal bodies involved in the overall Page 13

HRH management; and that raise the issue of coordination between those partners as an important mean for collaboration and efficient use of resources. The National HRH Observatory is expected to play an important role in this regard; it s a platform for coordination between those stakeholders. Current Situation of HRH Research: The HRH research is a neglected area and received little attention across the different stakeholders' institutes. It appears that a few studies were conducted but still not satisfying the major concerns. Financial shortage and limited resources and poor research capacity were the main obstacles facing the conduct of proper HRH research. Most of those researches done were extremely limited to internal issues of the specific institute but added nothing to the overall picture of HRH policy, planning and management. On the other hand there are no future plans for HRH research, but some institutes and academia started a partnerships and collaboration with an international institutes including issues of research that benefit the HRH concerns and problems. Research Priority Issues: According to the analysis of the questionnaire and ranking priorities expressed by the key informants; and with application of selective criteria mentioned before for the HRH research questions; the priority HRH research issues include: 1. Health workforce migration issues. 2. Evaluation and development of human resources for health policies in Sudan. 3. Study the HR information systems problems and related issues. 4. Problems of in-service training and lack of continuous professional development programmes. 5. Lack of strategic planning and HR projections plans with the health system. 6. Work environment and it effects on performance of health workers. 7. Issues of higher studying and specialization in the different specialties for the different cadres. Page 14

8. Relation between the medical and health training outcome and the health sector needs and the labor market. 9. Problems of deployment and retaining of the health workforce. 10. Salaries and incentives and rewording systems for the health workforce. 11. Health workforce and decentralization of the health system. 12. Health workforce misdistribution issues and related problems. 13. Policies for financing training and health workforce development. 14. Assessment and development of health training curricula and improve of the institutional capacity of the medical/health training institutes. 15. Assessment and evaluation of the country experience of medical education and health professions training. 16. The skill mix of the health team and the provision of better health services. 17. Training needs assessment for the different categories of the health workforce. 18. Productivity and quality of the health workforce for the health system. 19. Problems and related issues of coordination between the different HRH stakeholders and the HR related bodies. 20. Assessment of the accreditation system and recognition standards for the medical/health training institutes. 21. Evaluation and assessment of the institutional and management capacity of the human resources for health in the country. 22. Health workforce problems at the hospital and health facility level. 23. Issues of job description and performance of the health workers within the health system. 24. Increase number of females at the medical/health training institutes intake and dominance of female in the health workforce and the effects on the health system and health services provision. 25. Evaluation of the effect of training programmes on the health workforce performance. 26. Role of external financial support and technical expertise in improving the health workforce in Sudan. Page 15

27. Role of the private sector in improving and developing the health workforce and chances for collaboration between the public and private sectors. 28. The role of the unions and professional associations in the development of the health workforce. If we divided them into domains without considering the ranking the list will take the following frame: HRH Policy: Evaluation of the current implemented policies: Carrier Pathway Policy which was implemented three years ago to identify the positive and negative impacts, constrains and difficulties for proper implementation. Reasons and constrains behind immature policy making process in the area of human resources for health in Sudan. Production of health workforce in Sudan, is there a clear policy? Evaluation of the current policies. HRH Management: Capacity of central and state health authorities to manage the workforce. Importance of information system and human resources for health data bases in management current problems its role in policy making and planning for HRH Inequitable distribution of health workforce in Sudan, reasons behind and predisposing factors, the resulting problems and impact on health services utilities Effects and impact of decentralization on HRH management What impact do the changing policy environment and other pressures have on the mechanism by which health authorities exercise Page 16

supervision and control? Effects of fragmentation of authorities on health workforce stability. Incentives and motivation of health workforce in Sudan evaluation of current principles used the link between health workforce stability and types of incentives problems resulting as a consequence of low motivation Brain drain of health workforce in Sudan the reasons and causes, the effects on health workforce availability on health services on future planning for HRH Effects and impact of increasing number of females in the health workforce on the managerial roles regarding HRH HRH Development: Training of human resources for health in Sudan the capacities and role in the production of qualified personnel the past, present and future prospects Need/production relationship How to make use of the health personnel trained out side Sudan Evaluation of Malaysia experience outcome Do we need continuous/in-job training?? Do the current health workforce qualifications meet our health system needs?? Role of working environment and working conditions on health workforce performance Page 17

Conclusion: Health workforce in Sudan faces a serious concerns and problems, including issues related to policy formulation and management capacity at the different levels. The HRH research is still weak area though it's important for better use of resources and needs more attention and support from the different parties involved and collaboration in the first place between the main HR stakeholders. Weakness of the research capacity was a major concern -beside poor funding for research- that hinder the improvement of this area. A list of twenty-eight priority research issues was expressed by the main stakeholders as the unresolved questions that need to be addressed in the coming future. This list needs to be endorsed and approve by the higher authorities and after that it could be used with donors for funds and grants. Page 18

References: 1. Ijsselmuiden, C. The key to successful sustainable health system improvement: Human resources for health research. MMS Bulletin 104/2007 22-27. 2. Commission on Health Research Development (1990) Health Research: Essential link to equity in development. Oxford University Press: New York, USA. 3. Badr, E. The HRH Strategic Plan 2010-2015-Sudan. Not approved. Page 19