Reforming the Health Work Force
to support Universal Health
coverage in Africa.
Dr Patrick KADAMA
Executive Director of the Platform on Human Resources for Health
at the
African Centre for Global Health and Social Transformation
(ACHEST)
Presentation Outline
• PHC experience & the emerging concerns with
Inequality in health outcomes
• The case for new direction & HRH Challenges
• Need for New thinking and effort
• Competency Based Education
• Way forward
From WHR 2008 - PHC Now More than Ever
UHC – the means to manage Concerns with INEQUALITIES
The world health report 2008 identified as one the four broad policy
directions for renewal of primary health care the need to Deal with HEALTH
INEQUALITIES by moving towards UNIVERSAL COVERAGE in three aspects at
the very minimum:
1. Extend of health-care networks (INFRASTRUCTURE) to where they are
not available;
a) Implications for reform of HRH policies
b)
c)
Implications for Health Infrastructure
Implications for essential medical products, commodities and a supply chain
2.
Shift from reliance on user fees levied on the sick to the solidarity and
protection provided by pooling and prepayment;
a) Implications for reform of Health Financing Mechanisms
3.
Develop of mechanisms of social health protection.
a)
Implications for Governance to contribute to cross-sectoral development of policy for
Social Security (?pensions / terminal benefits for employees as well as child and
unemployment support for indigents).
Human Resources for Health
require Reform
(WHR 2000)
Why New Directions?
• Global shortage: 4.3m,African shortage 1m.
• Globalized connected world with inequities
• Tensions: Health Professionals vs Population
expectations: vocation or jobs, distribution,
commercialization, working environment
• Changing scope of practice; unmet skills
needs: Nurse Practitioners, Task Shifting,
Needs based training etc
Education: Critical Solution
• Underlying global HWF crisis is failure to train
and retain enough
• Education Institutions are factories: good
factory = good product; bad factory = bad
product
• Sub Saharan African Medical Schools Study:
faculty shortages, infrastructure, private
sector
Environment in Africa
• Large population
• Limited resources
• Human Resource
shortages
Population
Physician workforce
• Big Disease burden
www.worldmappers.org
Disease Burden
HS definition
African HWF spectrum
Contributing
factors:
•Good governance, law and
order
•Gender
•Social justice
•Social and economic
development
Nat'l
referral
Regional
referral
General
Practitioners
Mid-level
Sub-district level
Household & community
CHWs
SHARED
District level
Super-specialists
Specialists
11
AU Health Strategy & WHO Road Map
Focus not only on numbers but on skill mix and quality
• Determine the categories of professional, auxiliary (mid-level)
and community health workers that will provide an
appropriate human resource mix for their needs.
• Develop costed national human resources development and
deployment plans, including revised packages and incentives,
especially for working in disadvantaged areas.
• Fund the establishment of the training capacity required to
produce the desired number of health workers.
• Build multi-purpose trained staff as the nucleus of health
care delivery.
Scale-up framework
INDICATOR:
MDGs
GOAL: HEALTH OUTCOMES
Integrated Health Service Delivery
Networks
PRIORITIZED SKILL MIX
"CLOSE-TO-CLIENT HEALTH TEAMS"
Defined within country context
EXISTING CAPACITY
TECHNICAL
- Training
- Institutions
- Infrastructure
- Connectivity
- Partnerships
DEVELOPMENT OF NEW CAPACITIES
POLITICAL
- Supportive
environment
- Leadership
- Commitment
- Legislation
- Policy
- Partnerships
FINANCIAL
- Resources
- Incentives
- Partnerships
13
Critical success factors for scaling up
Study of GHWA Task Force on Education and Training
•
9 country experiences across regions
Critical factors identified:
• Political commitment and good governance
– Sustained high level support, 'one' country-led health plan, significant
financial investment
• Enabling environment
– Multi-sector participation, Good information systems, effective management
and leadership, labour market capacity and policy
• Workforce planning
– Plan long term, act short-term and update regularly, commitment to
production / appropriate skill mix integrated teams, needs based, expansion
of pre-service programmes
New directions
Needs Based
Education
Competency/
Outcome
Based
Education
Key issues with the Health Work Force to meet needs
1.
2.
3.
4.
5.
6.
Mismatch of competencies to needs
Weak teamwork
Gender stratification
Hospital dominance over primary care
Labour market imbalances
Weak leadership for health system
performance
Summarized from the report on the Health Work Force for the 21st Century
Evolution of Medical Education reforms
from the report on the Health Work Force for the 21st Century
Moving toward a Health Work Force
Fit-for Purpose
What is fit for purpose:
• good enough to do the job for which it was
designed
• Possess attributes required to achieve
intended objective
• Experts, Professionals, Leaders
What FFP is Not
•
•
•
•
Low quality HWF for the poor only
HWF with restricted market
Origins of FFP HWF: Africa first missionaries
FFP HWF: UK (Surgeons); USA surgical
technicians
Competency Based Education
• Education aimed at imparting underlying
characteristics related to job performance
• Encompasses knowledge, traits, skills and
abilities.
• Fit for Purpose
Required Competencies
• Prepared to work where services are most
needed.
• Able to respond to health needs of
community.
• Able to deliver quality care with available
(limited) resources.
• Able to be leaders and change agents
• Continuous self directed learners
• Effective communicators
Achieving Competencies
• Selection process for candidates
• Right attitudes, belong to community (underserved areas)
• Training in real life practice environment
• Mentorship
• Team Based Learning
• Strong linkages with communities
Kampala Declaration and Agenda for Global
Action
•
Key elements:
– Building coherent national and global leadership for health workforce
solutions
– Ensuring capacity for an informed response based on evidence and
joint learning
– Scaling up health worker education and training with needs based
skill mix
– Retaining an effective, responsive and equitably distributed health
workforce
– Managing the pressures of the international health workforce market
and its impact on migration
– Securing additional and more productive investment in the health
workforce
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Implications for Countries
•
•
•
•
Prioritize Education and Training of HWF
Link with National Development Plans
Plan long term, act short and review frequently
Link E &T to Population health needs & health
systems
• Create Country Multi-stakeholder Alliances (CCF)
• Establish HWF Information Systems (Observatories)