UNIT
3
Managing and
Supporting Health
Workers
INTRODUCTION
We have now discussed the planning aspect of health workforce
development, as well as some of the key aspects related to education and
training. In WHO’s Working Lifespan cycle, these aspects are captured in the
first circle entitled “Entry”. The other two circles are headed “Workforce:
Enhancing worker performance” and “Exit: Managing Attrition”.
The two latter circles are incorporated into this last unit – which also provides
a very brief introduction to, and overview of, monitoring and evaluation in the
human resources sector.
This is a lot of content for one unit, and may be slightly intimidating. However,
this is an introductory module, so it will provide an overview of the many and
quite complex aspects of what traditionally is called human resource
management, and it will leave many gaps. Later this year, or next year, you
Master of Public Health: Introduction to Health Workforce Development – Unit 3
83
will do a module dedicated entirely to the topics covered in this unit, so will get
a chance to engage with them in much more detail.
There are five study sessions in this unit:
Study Session 1:
Issues in Human Resources Management Today.
Study Session 2:
Establishing a Supportive Supervisory System.
Study Session 3:
Skills session: Writing a policy brief
Study Session 4:
Managing health workforce attrition
Study Session 5:
Introduction to monitoring and evaluation in HRD
This Unit looks at some of the major challenges facing HRM today, both within
and beyond organisations. These challenges are numerous, and our
engagement with the subject will be far from comprehensive. The areas
chosen are those considered to be the most crucial, including issues of
motivation, brain drain and HIV/Aids. Study Session 1 offers an introduction to
these themes. Study Sessions 2 and 4 again focus very selectively, but in
greater detail, on two particular issues, supervision and attrition, both of which
are central to the improvement of human resource management at an
organisational level. Session 3 is a skills session, and session 5 gives a very
preliminary introduction to monitoring and evaluation in the context of HRH.
The topics chosen for closer investigation clearly indicate our own sense of
priorities, based on the literature and our own experience of working with
health services at different levels across Africa. While the list may well look
different from yours, it is assumed that all believe the topics below are
important and warrant closer study.
LEARNING OUTCOMES FOR THIS UNIT:

By the end of this unit you should be able to:
Demonstrate a contextual understanding of health human resource
management;

Discuss the major challenges facing health human resource management
today;

Explain the elements of a responsive supervisory system;

Understand the purpose and elements of a policy brief;

Write a policy brief;

Demonstrate an understanding of the key reasons for workforce attrition;
and

Understand and discuss some of the strategies used to address and
remedy workforce attrition.

Demonstrate an insight into the rationale and scope of monitoring and
evaluation of HRH;

Develop some M&E questions in the context of your organization.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
84
Unit 3 - Session 1
Issues in Human Resource
Management Today
INTRODUCTION
Session 2 in Unit 1 introduced some of the greatest challenges facing human
resources internationally in the health sector today. We discussed the
challenges of health workers shortages, maldistribution, and the HIV/AIDS
crisis. The first session in this unit is, in effect, a follow-up session. It picks up
many of the themes raised in Unit 1 Session 2, but from a district and subdistrict perspective.
1
LEARNING OUTCOMES OF THIS SESSION
By the end of this session you should be able to:
 Demonstrate a contextual understanding of health human resource
management;

Discuss the major challenges facing health human resource management
at district and sub-district level.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
85
2
READINGS
You will be referred to the following readings during this session.
Details
Beardsley, S., Johnson, B., Manyika, J. (2006). Competitive advantage from
better interactions. McKinsey Quarterly. Issue 2.
Sanders, D., Dovlo, D., Meeus, W. & Lehmann, U. (2003). Ch 8 - Public
health in Africa. In Beaglehole, R. Global Public Health - A New Era, pp 135155. Oxford: Oxford University Press.
Kolehmainen-Aitken, R.-L. (2004). Decentralisation’s impact on the health
workforce: Perspectives of managers, workers and national leaders. Human
Resources for Health, 2(5): 1-11.
Lehmann, U. & Zulu, J. (2004). “You feel like you are fighting a losing battle”.
How nurses in Cape Town clinics experience the HIV epidemic. Manuscript:
11 pages.
Kober, K. & van Damme, W. (2004). Scaling up access to antiretroviral
treatment in Southern Africa: Who will do the job? The Lancet, 364: 103 107.
WHO. (1993). Motivation. In Training Manual on Management of Human
Resources for Health. Section 1, Part A. 8 pages. Geneva:WHO.
Van Lerberghe, W., Conceicao, C., Van Damme, W. & Ferrinho, P. (2002).
When staff is underpaid: Dealing with the individual coping strategies of
health personnel. Bulletin of the World Health Organisation, 80(7): 581 - 584.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
86
3
REMEMBERING THE “HUMAN” IN HUMAN RESOURCE
DEVELOPMENT
The frequently shifting nomenclature in this field (‘health manpower’, ‘human
resources’, ‘health workforce’) reflects the complexity of, and sometimes
ambivalence in, the sector. Human resource or health workforce development
is about getting the best possible value and enhancing the performance of the
key resource in the health system, in the same way as we want to get the best
possible value from other resources. But, at the same time, human resources
are fundamentally different from all the other resources we manage. As we
said in the introduction, HRD is about people – citizens, family members,
neighbours. This may sound like a truism, but it is something that can be
forgotten in the talk about productivity, efficiency and cost effectiveness.
Management sciences and practices (often much earlier in the private sector
than the public sector) are increasingly recognizing that effectiveness and
productivity in areas which rely heavily on interaction are strengthened when
hierarchies are flattened and workers feel competent, acknowledged and in
control.
Beardsley et al (2006) summarise this development as follows:
Managing for effectiveness in tacit interactions is about fostering change,
learning, collaboration, shared values, and innovation. Workers engage in a
larger number of higher-quality tacit interactions when organizational barriers
(such as hierarchies and silos) don't get in the way, when people trust each
other and have the confidence to organize themselves, and when they have
the tools to make better decisions and communicate quickly and easily.
While we will not go into management theory in this module, I thought it would
be of interest at the beginning of this unit to reflect on our own HR
management practices and requirements in the health sector against some of
the insights from new management sciences.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
87
Self study
TASK 25: Reflecting on the application of New Management
Sciences to HRH
Please read Beardsley et al (2006). Their article talks about
management changes in the industrial sector where, what they call
“complex interactions” are becoming more and more important. The
health sector is different in that it has always relied on complex
interactions for its productivity. But it has not always been very good at
fostering such interaction. The public sector in many countries is
characterised by steep hierarchies, insufficient capacity development,
lack of independence in decision making – often at great expense to
productivity and effectiveness. Many studies of staff motivation assert
that workers who are involved in decision making and are able to make
decisions are substantially more motivated than workers who are only
recipients of instructions.
While reading the Beardsley article, make notes on what they consider
to be the key ingredients to “better interactions” (e.g., trust and
confidence).
 Has your institution taken aspects of these management practices on
board?

What aspects do you think would be of particular importance, or, if
they are being practices in your institution, what aspects make the
greatest difference to the productivity of the organisation?

What are, or would be, key helping and hindering factors in
implementing some of these practices?

Can you think of any suggestions that would be relatively easy to
implement in your immediate context? What might these be?
Again, I would like to encourage you to share and discuss some of your
experiences and ideas on the Google discussion group.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
88
4
Key issues in HR management at district and sub-district
level
This section starts with a task.
Self study
TASK 26 (Self-study): IDENTIFY KEY HR MANAGEMENT ISSUES
You have come across many of the issues that will be discussed here in
Unit 1. Re-read, in particular, the texts by Kolehmainen-Aitken and
Sanders et al, and extract the central management issues discussed by
these authors. Supplement the emerging list with issues from your own
professional experience.
Can you prioritise this list? What, in your opinion, are the three key issues
bedevilling HRM today? Your priorities will obviously be informed by your
own experiences and they will differ depending on the level of
management (i.e. challenges at district level may look very different to
those at national level).
You could develop a table of priorities which could be then discussed with
colleagues in your organisation, if appropriate.
4.1
HIV/AIDS: A Key HR Issue
The HIV/AIDS epidemic presents the greatest challenge yet to health systems
in many developing countries. Its impact feeds the brain drain: health workers
leave services, exhausted by caring for rapidly growing numbers of very sick
patients, and access to fewer resources. And it drains those remaining in the
service, until they eventually also leave or get sick.
The following two articles in Task 27 both make the case for urgent attention
to the needs of health workers, who are shouldering the main burden of the
epidemic.
The first article was written by staff members of the SoPH and accepted for
publication by the South African AIDS Bulletin. It focuses primarily on the
strains caused by mainstream HIV service. However, the article by Kober and
van Damme’s, raises the question of who will staff the anti-retroviral roll-out in
Southern Africa. Both articles strongly agree that if the planning and
management of human resources, particularly at primary care level, does not
receive urgent attention, any treatment programme will have little chance of
success.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
89
Self study
TASK 27 (Self-study): STAFFING THE FIGHT AGAINST HIV/AIDS
Please read Lehmann& Zulu (2004) and Kober and van Damme (2004).
After reading these two research reports, consider these issues.
 Do the experiences reflected in the two articles resonate with your own? If so,
in what ways?

These articles are a few years old. In your opinion, has the situation changed
in your own environment? For better or for worse? In what ways?

Is initiative being taken in your professional context to assist and support
health workers? If so what strategies are being used - and are they making a
difference?
 4.2
WhatMotivation:
suggestions could
you make toHR
yourIssue
managers to strengthen health
An Important
workers?
What possible
interventions
could
you yourself
initiate?
Today,
whenever
you open
a training
manual
or a publication
on HR
motivation
has which
a prominent
place
in theimmediately.
discussion.
 management
Think aboutproblems,
at least one
intervention
you could
initiate
All publications concerned with management issues in the public health sector
indicate that motivation of health workers has been declining, often leading to
serious deterioration in the quality of care and causing many health workers to
leave the sector (one aspect of the ‘brain drain’). There are many obvious
reasons for this: deteriorating pay, poor working conditions, work overload,
lack of recognition, lack of supervision, the phenomenon of “the grass is
always greener on the other side”. But management theory looks at what
motivates people to work, not to work, or to work harder. The following
reading, another WHO publication, briefly summarises and discusses this
theory.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
90
Self study
TASK 28 (Self-study): ASSESS YOUR ORGANISATION IN TERMS OF
MOTIVATIONAL FACTORS
Please read WHO (1993) on motivation then consider the following:
A set of basic needs, that each of us has in some combination or other, have
been identified. These are:
SURVIVAL
RECOGNITION
SECURITY
SELF ESTEEM
COMPANIONSHIP
SELF FULFILMENT
STATUS
PERSONAL GROWTH
a) Your own organisation will satisfy these needs to a greater or lesser extent.
Rearrange the list to show in reducing order, from best satisfied to worst
satisfied, the extent to which you feel these needs are met by your
organisation.
b) Given the circumstances of the health service of your country, identify which
of these needs could feasibly and most easily be better met than they are
now.
c) How could this be done?
Self study
TASK 29 (Self-study) - ANALYSE DEMOTIVATING FACTORS
In many organisations, it is likely that certain actions or procedures create a
negative impact on individual staff members.
a) Identify those actions or procedures, at national and local level, which you
feel have a negative impact on a large number of staff in the service.
b) Order the list given in Task 28 to show those you believe to be the most
damaging down to those that are the least damaging.
c) How does your list compare with the demotivators suggested in the text?
Master of Public Health: Introduction to Health Workforce Development – Unit 3
91
4.3
Individual coping strategies
How health workers cope with their living and working conditions is not a topic
which receives much attention in academic writing. However, such coping
strategies can potentially have a crucially important impact on how health
services function. In recent years, a small group of authors started the debate
on the inter-relationship between individual health workers’ behaviour and
health service performance. Some of the issues have already been raised in
the above section on HIV/AIDS. The following reading addresses the issue of
coping strategies, and their impact on health services.
Self study
TASK 30 (Self-study): DEALING WITH INDIVIDUAL COPING STRATEGIES
Read the article by van Lerberghe et al. (2002) carefully. It is not particularly easy to
read, but its contents justify close attention. The authors describe a number of
“predatory” and “non-predatory” coping strategies, such as under-the-counter
payments (predatory) and moonlighting (non-predatory).
 Do you recognise any of these behaviours as happening in your organisation or
district?

If so, how widespread are they? Are they being spoken about or are they
acknowledged but ignored?

How do you feel about such behaviour? Is it a crime or a necessity?
On page 582, the authors talk about the impact of coping strategies on public
health service delivery, in particular about predation, competition for time and
conflict of interest. They paint quite a negative picture of the impact an
individual’s behaviour can have on the ability of health services to render
services.
 - Do you agree with this assessment?

- Have you seen it happen or are your experiences different?
Lastly, the article contains a number of suggestions to ameliorate the negative
impact.
 Can you think of other suggestions suitable for your own context you could make
recommendations to your line manager or staff meeting?
Master of Public Health: Introduction to Health Workforce Development – Unit 3
92
5
SESSION SUMMARY
This session has provided a broad sweep of some of the key HR
management challenges at district and sub-district level. In sessions 2 and 4
we will expand on two specific themes: on supervision in session 2 and on
managing health workforce attrition in session 4.
6
FURTHER READINGS & REFERENCES
There are many readings available under each of these headings. To pursue
any of the above topics in more detail, you should consult the references in
the readings used in this session. They all have bibliographies which refer to
additional relevant articles and books.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
93
Master of Public Health: Introduction to Health Workforce Development – Unit 3
94
Unit 3 - Session 2
Establishing a Supportive
Supervisory System
INTRODUCTION
[This session has largely been taken from the Children’s Vaccine Programme
website of PATH (Programme for Appropriate Technology in Health) and has
been slightly adapted.]
In all likelihood you are supervising colleagues, and you may well be
supervised by someone yourself. If you think back in your career, you may
have experienced really good supervision during which you were guided and
mentored - and you may have had very poor supervision which focused on
inspection and provided you with no feedback. You may also have had
experience of not being supervised at all: not knowing what is expected of
you, whether you are on the right track, where you are messing up, etc.
Whatever your experience of being supervised has been, you will know that
supervision is crucial. In fact, it is an essential and indispensable ingredient to
good health system performance. Good supervision can determine whether
staff are motivated or not, whether they are performing well or not, whether a
programme is growing and sustainable or not.
In the context of the current HR debates, and particularly given the increasing
practice of task shifting, supervision becomes even more important than it has
been, as we increasingly entrust health workers who have limited skills with
sometimes quite complex aspects of health care delivery. The literature
confirms that health workers with limited training can perform a range of tasks
very satisfactorily IF THEY ARE SUPERVISED REGULARLY AND
APPROPRIATELY.
In this session you will engage with PATH’s approach to what they call
Supportive Supervision and you will study the case studies they provide. At
the end of the following session (session 3 in this unit) you will be asked to
write a policy brief to your minister or permanent secretary, arguing the case
for improved supervision structures and practices for community health
workers in your country.
1
LEARNING OUTCOMES OF THIS SESSION
By the end of this session you should be able to:
 Explain the elements of a supportive supervisory system.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
95
2
READINGS
You will be referred to the following readings during of this session.
Details
Children’s Vaccine Program at PATH. Guidelines for Implementing Supportive
Supervision: A step-by-step guide with tools to support immunization. Seattle: PATH
(2003). Available at URL
http://www.path.org/vaccineresources/files/Guidelines_for_Supportive_Supervision.p
df [21 Feb 2010]
3
THE CORNER STONES OF SUPPORTIVE
SUPERVISION
The PATH document identifies several elements which are essential to
establishing and/or maintaining good and supportive supervision. A central
tenet is that supervision should NOT be punitive but developmental. It should
be a learning experience both for the individual being supervised, but also for
the supervisor and the organisation who are able to identify areas of concern,
emerging problems, service gaps, etc., before they become serious problems.
The PATH document furthermore talks about the following cornerstones of a
supervision system:
a) Understanding the country context and mobilise national support for
supervision: This involves understanding and building on existing
supervision systems; advocating for financial support and ensuring that
supervision becomes part of health and human resource planning and is
considered in job descriptions and work load considerations; and working
towards the institutionalisation of supportive supervision within the
government system. It is here that policy briefs and other advocacy tools
are important.
b) Involving supervisors in training: To ensure that identified training
needs are addressed, and to facilitate the re-enforcing of training in
supervision.
c) Ensuring that supervisors have the ability and support to conduct
supervision: This means that supervisors need to be trained to provide
supportive supervision (many may have been trained in traditional forms of
supervision or not trained at all); that supervision is an explicit part of their
work load, rather than something they do by default and when they have
time; and that the outcomes of supervision are used for performance
improvement and planning.
d) Making staff motivation an integral part of supervision.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
96
Self study
TASK 31 (Self-study): STUDY PRINCIPLES AND EXAMPLES OF
SUPPORTIVE SUPERVSION.
1. Study pages 1 – 9 of the PATH document and make notes of what strikes
you as particularly important, unusual, useful for your on context and
practice.
2. Then read the four case studies on supervision in Tanzania, Kenya and
Guinea, Honduras and India.
3. Via e-mail or the google group, or in one of your meetings with mentors,
discuss what the lessons from this document for your own country practice
might be and how you can think about introducing some of the ideas in the
document.
4
Session summary
This session explored one of the key elements of good HR management, the
supportive supervision of staff. Although acknowledged as important by most
managers, supervision all too often falls by the wayside under the pressures
of day-to-day management. However, all evidence agrees that careful
supervision can contribute dramatically to personnel satisfaction and
productivity.
5
FURTHER READINGS & REFERENCES
The PATH document has a number of annexes which contain tools for
different aspects of supervision. I have not included them here, because they
make the document too bulky. If you want to make use of or adapt some of
them for your own purposes, please you to the website:
http://www.path.org/vaccineresources/files/Guidelines_for_Supportive_Superv
ision.pdf
Master of Public Health: Introduction to Health Workforce Development – Unit 3
97
Master of Public Health: Introduction to Health Workforce Development – Unit 3
98
Unit 3 - Session 3
Skills session – Learning to
write a policy brief
INTRODUCTION
We undertake many forms of writing every day: reports, proposals, academic
papers, and so forth. In this course you inevitably will do a lot of academic
writing, as a Masters is primarily an academic qualification. In the course of
this module you have already engaged in different forms of writing: doing a
mind map, answering questions, written reflections. In this session I want to
introduce you to a form of writing which policy makers and planners use quite
a lot, but which is rarely specifically taught – how to write the POLICY BRIEF.
Policy briefs are frequently used to introduce one or several policy choices (or
strategic choices) to address a problem. They are written for people who are
influential, busy, and have little time to read – ministers, parliamentarians,
permanent secretaries, etc. So a policy brief has to be, as the names says –
BRIEF; some will argue, not more than two pages, others will say anything up
to about eight pages. This may vary with audience and complexity of the
policy suggested. Very importantly, the quality of a policy brief is determined
by the clarity of argument, structure and sense of audience. The writer has
very limited space to explain the background to the “problem” to be solved,
context and rationale, and to motivate one or several policy options to address
the problem. So, brevity and clarity are essential.
1
LEARNING OUTCOMES OF THIS SESSION
By the end of this session you should be able to:
 write a policy brief,
Master of Public Health: Introduction to Health Workforce Development – Unit 3
99
2
READINGS
You will be referred to the following readings in the course of this session.
Details
IDRC (not dated). The Two-pager. Writing a Policy Brief. Available on URL
http://www.idrc.ca/uploads/userS/1226604937112265958681Chapter_8%5B1%5D.pdf [21 Feb. 2010]
Young, E. and Quinn, L. (not dated). The Policy Brief. Available on URL
www.policy.hu_PolicyBrief-described. [21 Feb. 2010]
Prof. Tsai. Guidelines for Writing a Policy Brief. Available on URL:
http://www.rhsupplies.org/fileadmin/user_upload/toolkit/B_Advocacy_for_RH
S/Guidelines_for_Writing_a_Policy_Brief.pdf. [24 March 2010].
3
WRITING A POLICY BRIEF
Several organisations have developed well-written guidelines for constructing
policy briefs. I have decided to share three of these with you here, so that you
can get a sense of the similarities and differences of how policy briefs are
constructed. Two of them are very short (two and three pages respectively).
One, developed by the “Research Matters” project of the Canadian
International Development Research Centre (IDRC), is a bit longer, because it
provides a detailed case example of the development of a policy brief.
Self study
TASK 32 (Self-study): UNDERSTANDING HOW TO WRITE A POLICY BRIEF
This task will prepare you for the next assignment (in the task immediately following
this one), in which you will be asked to write a policy brief.
1. Study all three guidelines on how to write a policy brief. You will find that all three
of them have similarities regarding the purpose of a policy brief, but they suggest
slightly different structures as there is not only one way to write such a brief.
2. Make notes on those elements that all three guidelines agree on and what the
main differences are.
3. Find an example of a policy brief on the internet or maybe one written for your
MoH, and compare this example with the suggestions of the guidelines.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
100
Assessment
Task
TASK 33 (Assessment): WRITE A POLICY BRIEF
This is your biggest assessment task and will make up 30% of your overall mark.
Instructions:
Write a policy brief to the Minister of Health and Permanent Secretary in your
country, arguing the case for improved supervision structures and practices
for community health workers.
This should be a “real-life” policy brief. In other words, it should be based on the
actual situation in your country (or region or district). It assumes that there are CHW
programmes in your countries, either large national ones, like the Health Extension
Worker programme in Ethiopia, or smaller ones. And it assumes that while there
may be supervision practices in places, there is substantial room for improvement.
To write this policy brief, you need to draw on other sessions of this module, in
particular the session on task-shifting in unit 2 and the session on supervision in unit
3, but the content of other sessions should also inform your argument. You
furthermore need to do the necessary research for your own country to present the
problem and make policy suggestions.
You can use any one, or even a mix, of the three guidelines to structure your brief.
I would also suggest that .you discuss your assignment with the other students and
with the mentors.
The criteria for marking the assignment will be:
 the statement of the problem is clear and succinct;

you have provided enough background and information to understand the
importance of the problem;

the policy options are clearly explained (including pros and cons and resource
requirements);

your recommendations are well motivated;

a list of sources consulted and recommended is included;

the policy brief is clearly structured and easy to read.
Your policy brief should not be longer than 2,000 words at most, but
preferably between 1,000 and 1,500 words.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
101
4
SESSION SUMMARY
This skills session introduced guidelines for writing a policy brief – and
required that you undertook the challenge of writing one.
Policy briefs are a crucially important tool for managers, policy makers and
advocates to make a brief and very focussed argument for a particular
strategy or course of action. You may find it useful in many aspects of your
professional practice.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
102
Unit 3 - Session 4
Managing health workforce
attrition
INTRODUCTION
Health workers leave their posts for a number of reasons:
 the may be moving to better paid or higher ranking posts;

they may move from the public to the private sector (rarely the other way
around);

they may move from rural areas to the city (for better paid posts, because
of better schooling opportunities for their children; because of better
opportunities for continuing education and career development, to name
just a few reasons);

they may leave their profession altogether to pursue other work;

they may leave the country to work overseas;

they may die; or

they may retire.
All departures, regardless of their reason, comprise attrition and mean that an
urgently needed and precious health worker is no longer available to render
services. Planning for, and the management of, attrition happens at two
levels:
a) providing new health workers through training, introduction of new cadres,
etc. This is what we discussed in Unit 2. Some people call this “feeding the
pipeline”;
b) reducing the “leaks” in the system by addressing the reasons why people
leave the health services prematurely (improving working conditions; making
work safer, increasing salaries, etc.)
In this session we will look at some of the strategies which have been
employed to address premature attrition.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
103
1
LEARNING OUTCOMES OF THIS SESSION
By the end of this session you should be able to:

Demonstrate an understanding of the key reasons for workforce attrition;
and

Understand and discuss some of the strategies used to address and
remedy workforce attrition.
2
RESOURCES
You will work with the following resources in this session.
Details
WHO. (2006). Working Together for Health. World Health Report 2006.
Geneva: WHO. Chapter 5.
The BBC documentary Doctors and Nurses, which you received as a DVD
3
CAUSES OF THE BRAIN DRAIN AND STRATGIES
OF ADDRESSING IT
In any discussion about the HRH crisis in Africa, the “brain drain” will be listed
as THE, or one of the, most important causes. Huge numbers of health
professionals are working in high-income countries. Among health
professionals working in their home countries, most work in urban areas, and,
in some countries, in the private sector. The result is that public health
services, and in particular health services in remote areas in most African
countries, are dramatically and chronically under-staffed. The reasons why
health workers are moving, are many: discontent with existing working and
living conditions as well as better living conditions and better work or career
opportunities elsewhere.
(If you want to read a detailed analysis if the so-called “push” and “pull” factor
of the brain drain, find the study on “Migration of Health Professionals in Six
Countries”, written by M Awases et al., on the internet. The URL is:
http://www.afro.who.int/hrh-observatory/hwinformation/migration_en.pdf.)
In recent years countries and organisation have developed numerous
strategies to diminish the negative repercussions of the brain drain. Some of
these are discussed in chapter 5 of the World Health Report.
The BBC documentary “Doctors and Nurses” discusses strategies to address
retention in two countries. It briefly presents the very successful Lady Health
Worker programme in Pakistan, and then discusses the causes, impacts and
strategies to address the brain drain of doctors in Malawi.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
104
Assessment
Task
TASK 34 (Assessment) (Assignment 8):
DISCUSSING THE BRAIN DRAIN IN MALAWI
Please watch the BBC documentary “Doctors and Nurses” and make
notes of what you found important, relevant and interesting, relating to
the brain drain and efforts to address it.
Please post your comments on the video on the google discussion
group, focussing in the following:
 What did you find particularly important and/or interesting in this
video with respect to the brain drain and efforts to address it?

Which of the strategies employed by Malawi resonate with your own
experiences? Do you have similar or different experiences?
As with previous discussion groups, I would like some discussion of all
your comments on the Google group.
The assignment will be marked out of 8 marks.
4
Session summary
In this session we discussed one of the very complex issues in health
workforce management - understanding and managing workforce attrition.
The discussion here has been by no means complete or even comprehensive.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
105
5
FURTHER READINGS & REFERENCES
There is a very substantial literature on this topic alone by now. If you want to
explore it further, I encourage you to visit the website of WHO and their
documents on migration (http://www.who.int/hrh/en/), as well as our own
Electronic Resource Centre (http://hrhforafrica.org.za/).
(If you want to read two academic papers dealing with the reasons for attrition
and strategies to address it, find the following on the internet:
 Willis-Shattuck M et al. (2008). Motivation and retention of health workers
in developing countries: a systematic review. BMC Health Services
Research, 8:247. URL: http://www.biomedcentral.com/content/pdf/1472-6963-8247.pdf

Lehmann U, Dieleman M, Martineau T. (2008) Staffing remote rural areas
in middle- and low-income countries: A literature review of attraction and
retention. BMC Health Serv Res 8: 19. URL:
http://www.biomedcentral.com/content/pdf/1472-6963-8-19.pdf )
Master of Public Health: Introduction to Health Workforce Development – Unit 3
106
Unit 3 - Session 5
Introduction to monitoring
and evaluation in HRD
INTRODUCTION
This is the last session of this module, and it aims to give you a first overview
of the rationale and scope of monitoring and evaluating the health workforce,
and to introduce you to a recently published key resource in this area (see
below). One of the modules you will take in this course will be entirely
dedicated to Human Resource Information Systems and Monitoring and
Evaluation.
1
LEARNING OUTCOMES OF THIS SESSION
By the end of this session you should be able to:
 Demonstrate an insight into the rationale and scope of monitoring and
evaluation of HRH

Develop some M&E questions in the context of your organization.
2
RESOURCES
You will work with the following resource in this session.
Details
M dal Poz et al. (2009). Handbook on Monitoring and Evaluation of Human
Resources for Health. Geneva: WHO. (You received this as a separate
book).
3
The role of M&E in health workforce development
The aim of monitoring and evaluation in health workforce development is
three-fold:
 To work out where the existing gaps in HRH are.

To make informed planning decisions.

To keep track of the outcomes and impacts of HR interventions.
M&E makes use of quantitative and qualitative methods to collect data, some
of the through routine information systems, some of them through audits and
Master of Public Health: Introduction to Health Workforce Development – Unit 3
107
surveys, and some through research projects. What methods you employ will
depend on what it is that you want to find out or monitor routinely.
Self study
TASK 35 (Self-study): GETTING AND OVERVIEW OF M&E IN HEALTH
WORKFORCE DEVELOPMENT
 Please read the first three chapters in the Handbook on Monitoring
and Evaluation of Human Resources for Health which you received
with your module pack.
4

Reflect on the scope and the available evidence base for monitoring
and evaluation in your country and in your own organisation.

Draw up and prioritise some preliminary M&E questions you think
would be important to address in your organisational context.
Session summary
That’s all for this session. It’s aim was only to introduce you to some of the
ideas being developed around M&E and to start to get you thinking about
M&E issues in your context. We will spend substantially more time on this
topic in the next while.
5
MODULE SUMMARY
You have come to the end of your introductory HRD module. It has introduced
the range of issues dealt with in this field. There are other issues we could not
cover here, and many themes were discussed fairly superficially. As
mentioned, there will be a number of modules, dealing with specific areas in
more details: Human Resource Policy and Planning; Managing Human
Resources in the Health Sector; and Monitoring and Evaluation in HRH.
I hope you enjoyed this first module, and I am looking forward to collaboration
on the coming ones.
Master of Public Health: Introduction to Health Workforce Development – Unit 3
108