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TRANSCRIPT
Global HealthWorkforce Alliance
Sharing Experiences
Meeting Report Lusaka, Zambia
4–5 April 2006
“The Global Health Workforce Alliance is hosted and administered by the World Health Organization.” The copyright should also be “© World Health Organization (acting as the host organization for, and secretariat of, the Global Health Workforce Alliance), 2006.”
© World Health Organization 2006
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This publication contains the collective views of an international group of experts and does not necessarily represent the deci-
sions or the stated policy of the World Health Organization.
Contents
Acknowledgements ...................................................................................................................... 5
Introduction ................................................................................................................................ 7
Background ................................................................................................................................ 7
Objectives ................................................................................................................................ 7
Opening session .......................................................................................................................... 8
Key-note addresses ...................................................................................................................... 8
Discussion ................................................................................................................................ 9
1. Information on the crisis .................................................................................................... 10
1.1 The World Health Report 2006 .......................................................................................... 10
1.2 Human resources for health: a vicious cycle ........................................................................ 11
1.3 Making the best use of existing resources ............................................................................ 12
1.4 The Zambian crisis ............................................................................................................. 12
1.5 The Zambian plan .............................................................................................................. 14
1.6 Summary of discussions ...................................................................................................... 15
2. Sharing experiences ............................................................................................................. 16
2.1 Workforce challenges .......................................................................................................... 16
2.2 Exploring incentives for Zambian nurses in the public-health sector ................................... 19
2.3 Session on HIV/AIDS and the workforce ........................................................................... 22
2.4 Summary of discussions ...................................................................................................... 24
3. Global actors and possible solutions to alleviating the crisis ................................................ 26
3.1 The Global Health Workforce Alliance ............................................................................... 26
3.2 The African Human Resources for Health Platform ............................................................ 28
3.3 Country perspectives, Zambia ............................................................................................ 29
3.4 The role of the private sector ............................................................................................... 30
4. Summary of discussions ...................................................................................................... 32
4.1 The Global Alliance versus the African Platform ................................................................. 32
4.2 Actions proposed for countries and the GHWA .................................................................. 32
4.3 Panel discussion .................................................................................................................. 33
5. Conclusions and recommendations .................................................................................... 34
Annex 1: Agenda ....................................................................................................................... 35
Annex 2: List of participants...................................................................................................... 38
Annex 3: Participants’ suggestions ............................................................................................. 42
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Acknowledgements
The Department of Human Resources for Health (HRH) of the World Health Organization thanks those listed below for their generous support and valuable contributions to the Consultation.
For funding: the Swedish International Development Cooperation Agency.
For their leadership in organizing the meeting: Dr Stella Anyagwe, WHO Representative, Zam-bia, Dr Simon Miti, Permanent Secretary, Ministry of Health, Zambia, Dr Diarra-Nama, Director, Division of Health Systems and Services Development, WHO Regional Office for Africa, Dr Akpa Gbary, Regional Adviser for Human Resources for Health, WHO Regional Office for Africa, Mrs Margaret Phiri, Regional Adviser for Nursing and Midwifery, WHO Regional Office for Africa, and Mr Pär Eriksson, Swedish International Development Agency.
For their support to the Swedish International Development Agency (SIDA) in organizing the meeting: Mrs Nora Mweemba, Dr Chipayeni C. Mtonga and Dr Kasonde Mwiinga from the WHO Country Office in Zambia.
For their participation: Mrs Sylvia Masebo, Honourable Minister of Health, Zambia; Dr Timothy Evans, Assistant Director-General, Evidence and Information for Policy (EIP); Dr Lincoln Chen, Special Adviser of the WHO Director-General on Human Resources for Health; Dr Diarra-Nama, Director, Division of Health Systems and Services Development; Dr Francis Omaswa, Executive Director, Global Health Workforce Alliance; Dr Tim Martineau, Liverpool School of Tropical Medicine, United Kingdom; and Mr Bjarne Garden, Senior Adviser, Norwegian Agency for Devel-opment Cooperation.
For the compilation and finalization of the report: Mrs Mwansa Nkowane with input from Dr Bocar Diallo and Mr Norbert Dreesch of the Department of Human Resources for Health, World Health Organization, Geneva.
For their contributions: participants from Ethiopia, Kenya, Malawi, Namibia, Uganda, the Unit-ed Republic of Tanzania and Zambia.
For their support: representatives of key partners, including the Canadian International Devel-opment Agency (CIDA), the United States Centers for Disease Control and Prevention (CDC), the United Kingdom’s Department for International Development (DFID, United Kingdom and Zambia offices), the Japanese International Cooperation Agency (JICA), the United Nations Chil-dren’s Fund (UNICEF) and the United States Agency for International Development (USAID).
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Introduction
Background
The consultation was convened jointly by the Global Health Workforce Alliance (GHWA), the World Health Organization (WHO) and the Swedish International Development Agency (SIDA) to discuss issues relating to the current crisis in human resources for health – a topic highlighted by the 2006 World Health Report and World Health Day. Participants were invited from the public and private sectors in Ethiopia, Kenya, Malawi, Namibia, Uganda, United Republic of Tanza-nia and Zambia to meet with technical experts from the World Health Organization and donor agencies, including the Norwegian Agency for Development Cooperation (NORAD), the United Kingdom’s Department for International Development (DFID) and the United States Agency for International Development (USAID) (for the List of participants, see Annex 2). This combination of individuals from ministries of health, training institutions and partners working in health, health planning, programme development and implementation assured a high-level participant profile.
Objectives
The objectives of the Consultation were:
1) to provide information on the global and regional crisis in human resources for health and propose activities based on the main recommendations of the World Health Report 2006;
2) to share experiences in human resources for health, including issues related to priority pro-grammes such as HIV/AIDS in the countries represented;
3) to present the African Human Resources for Health Platform and discuss possible solutions to the alleviation of the crisis in the African region.
Discussions focused on aspects of the Global Health Workforce Alliance and the African Human Resources for Health Platform, and the messages of the 2006 World Health Report on human resources for health. Other topics included skill-mix priorities, how to make the best use of exist-ing resources, training, migration, HIV/AIDS, and the development of a national plan on human resources for health in Zambia.
The expected outcome of the Consultation was that the participants would not only gain an un-derstanding of global and regional trends, the way forward for human resources for health, but also realise the possibilities of using evidence of current shortcomings as a basis in developing practical policies.
This report is not structured according to the sequence of the agenda, but by grouping topics within the three major objectives.
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Opening session
Key-note addresses
The first key-note address, by the Honourable Mrs Sylvia T. Masebo, Member of Parliament, Minister of Health, Republic of Zambia, stressed the points outlined below.
• The high-level representation of experts and stakeholders at the Consultation provided a strong basis for discussion and the opportunity to share lessons learnt in the area of human resources for health.
• The current crisis in human resources for health directly threatens global efforts to achieve the WHO’s Millennium Development Goals (MDGs).
• Zambia faces a serious crisis in human resources for health as a result of various factors, includ-ing high attrition rates, low morale in the health workforce, low productivity and the impact of HIV/AIDS on the workforce.
• This crisis has resulted in severe imbalances in terms of the number of staff, skill-mixes and the geographical distribution of the workforce, causing significant disparities in population-to-staff and urban-to-rural ratios.
The second key-note address – read by the WHO Representative from Zambia, Dr Stella An-yangwe, on behalf of Dr Luis Sambo, Regional Director of the WHO Regional Office for Africa – outlined the perspectives of the WHO Regional Office for Africa and highlighted the points below.
• Human resources are the pillars of the health system but have been neglected in Africa. The current human-resource shortages are a major impediment to the scaling-up of activities and the provision of skilled care. Drawing attention to this problem in regional and international consultative meetings has, however, generated a momentum and helped to put the issue on the political agenda.
• Despite successes in some countries, health systems in Africa are characterized by weak infra-structures, limited access to essential medicines, lack of adequate financial mechanisms, poor health-information systems and deteriorating health indicators.
• Any significant action should to be founded on core principles that include country-led action, regional and global responsibility, collective solidarity, learning from experience, going beyond the health sector in seeking solutions, seizing opportunities, attracting skilled persons from the diaspora, and training, retaining and sustaining health workers.
• Future action should be comprehensive and encompass:
– revitalization of national health systems and primary health care,
– integration of human resources for health development into macroeconomic and global health initiatives;
– prioritization of spending and making the best use of available resources, including health workers;
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– the harnessing of different stakeholders’ efforts;
– the strengthening of countries’ capacities to establish functional health-information sys-tems;
– development of a comprehensive and integrated approach to human resources for health issues at country level;
– evaluation and accreditation of training institutions for health sciences;
– alignment of training and skill development with health systems and staff needs;
– implementation of appropriate staff motivation and retention systems;
– the strengthening of countries’ capacities to manage their health workers efficiently and effectively.
• Human resources for health issues are complex and multifaceted so there are no shortcuts or quick-fix solutions. Integration, concerted action and sustained effort are required to respond to the crisis and enhance health services for the people of Africa.
Discussion
The discussion highlighted several points.
• To effectively respond to the crisis, it is best to start by understanding the problem.
• Regional meetings help by bringing countries together to learn from each others’s experiences on what works best.
• To make politicians aware of the facts of the crisis, real numbers and not percentages must be presented; this will help to give them a concrete understanding of the extent of the problem.
• Country-specific plans for human resources for health should be costed to facilitate budget projections and allocations.
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1. Information on the crisis
Objective 1: Provide information on the global and regional crisis in human resources for health and to propose activities based on the main messages of the World Health Report 2006.
1.1 The 2006 World Health Report
Presented by Mr Norbert Dreesch, WHO, Geneva
The 2006 World Health Report – Working together for health – and the activities leading up to the launching of World Health Day, 7 April 2006 in Lusaka, Zambia, highlighted the importance of the global crisis in human resources for health. While WHO is working on a Ten-Year Action Plan 2006–2016, the key messages in the 2006 World Health Report are outlined below.
a) Educated and well-trained health workers save lives. They are vital in providing access to disease prevention, treatment and care for all, including those living in poverty.
b) Support and protect health workers. Safe and supportive conditions must be ensured; sala-ries, resources and management structures must be improved.
c) Enhance the effectiveness of the health workforce through new strategies. Enormous op-portunities to achieve efficiency exist in many settings; strategies must focus on the existing workforce because of the time-lag in recruiting or training new health workers.
d) Tackle imbalances and inequities. There are widening imbalances and inequities in the avail-ability and migration of health workers that seriously undermine the provision of fair and universal health care.
e) Governments must take the lead. To make progress in all the above areas, governments must provide leadership in planning, formulating and implementing policies.
f ) Promote partnership and cooperation. To properly address the technical and political chal-lenges of health workforce development, alliances with stakeholders within countries need to be established and reinforced by global and regional backing.
g) Build trust among all stakeholders. Trust must be nurtured and maintained between govern-ments, employers, health professional and the communities they serve.
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1.2 Human resources for health: a vicious cycle
Presented by Mr Bjarne Garden, Senior Adviser, Norwegian Agency for Development Cooperation, Norway
Mr Garden’s presentation focused on the complexity of problems in human resources for health. He emphasized that setting up national priorities and guiding action depends on:
– making information available to national policy-makers as well as to those who implement activities and their patients;
– engaging in national-level dialogue on priorities;
– engaging in broad debate on whether progress is being made and, in effect, what leads to progress;
– using what is known at all levels;
– refining the questions as to “what we do know” and “what we do not know”.
Figure 1 illustrates the many facets in the cycle of human resources for health.
Figure 1: The complexity of the human resources for health problemFigure 1: The complexity of the human resources for health problem
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Fragmentingresponses tothe personnelcrisis by donorsand NGOs
Conflictingexpectationsand pressuresfrom donorsagencies andpartners;the macroeconomicstability issueand the drivesfor scale up andresults fromglobal initiatives
“Escape” of human resourcesfrom the vicious circle at all points- drain from public to non public- employment outside profession- rural to urban- national to international
Personnel Crisis: A Vicious Circle
Inefficientspending
Low salaries
Health workersalso themselvesaffected bythe economicrealitiesin communities
Poor workingenvironment
Freeze in publicrecruitment
Servicecollapse
Increasingpush to deliver
Reactiveallowances
Decreasingmotivation
Livehoodunder pressureIncreasing
public distrust
Disruptedservices
Weakenedcommunity
supportbase
Public distrustin health services
Increasinginequitiesin access
Private servicesto supplement
income
AIDS
PUBLIC HEALTHDISASTER
Health workerdissatisfaction
Increasing loadon health workers
Fix that backfires
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1.3 Making the best use of existing resources
PresentedbyDrTimMartineau,LiverpoolSchoolofTropicalMedicine,Liverpool, UnitedKingdom
In his presentation, Dr Martineau stressed that the aim of effective workforce management is to increase the number of appropriately skilled, motivated and equitably distributed health-service providers. He outlined a number of points to consider.
a) To reduce the losses in human resources it is critical to develop partnerships (with non-gov-ernmental organizations [NGOs] and other informal providers), change the skill-mix, increase entrants, and improve distribution and productivity.
b) Strategies and approaches targeted at enhancing the effectiveness of the health workforce need to be based on sound information, taking into account issues such as the characteristics of the workforce, leadership and human resource-management capacity, the diversity of context and the need to monitor changing contexts.
c) It is critical to determine the extent of poor staff distribution – both rural and urban – as well as reasons for poor productivity and poor performance.
d) In addressing the issue of incentives for human resources, flexibility should be exercised relative to policies for training opportunities, promotion of an appropriate working environment and living conditions for the workforce. In all these aspects, partnerships with both the private and public sectors, including civil society, should be considered.
e) The technical framework of human resources for health should highlight the benefits and core elements, including policy, leadership, partnership, education, human-resource management systems and finance. This will provide a starting point for an analysis of the analysis prior to planning and setting priorities, then monitoring and evaluation.
1.4 The Zambian crisis PresentedbyMrsMargaretKapiya,Director,HumanResources,MinistryofHealth, Zambia
In her presentation, Mrs Kapiya described characteristics of the crisis.
a) The human resource for health problem in Zambia has reached crisis point. The public health sector is operating at 50% capacity for reasons that are both exogenous and endogenous. Ex-ogenous factors include the austere fiscal measures (heavily indebted poor countries’ [HIPC] conditions) introduced by the International Monetary Fund and the World Bank and the growing global labour market for human resources for health. Endogenous factors relate to the poor conditions of service and the work environment, coupled with low training output.
b) In Zambia, resignations and death are the highest cause of attrition in all health cadres, es-pecially nurses. Records show that resignations in Zambia’s health sector can be explained by personnel being recruited by developed countries. Zambia loses more nurses to the United Kingdom and other countries than it trains. Between 2003 and 2004, the General Nursing Council processed 1222 applications for nurses and midwives to work abroad.
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c) Supervisory visits to district and provincial health services reveal a high workload, an absence of expert services (e.g. for surgery and obstetrics) and a lack of trained laboratory staff; some cadres are not even trained in simple diagnostic procedures. In one province it was found that eight health centres were staffed by untrained workers, with only three active midwives. A hospital clinical officer in one hospital may be the only provider of antiretroviral drugs (ARVs) in the district. He/she may also be filling other roles – working as district health information officer or district ophthalmologist while, at the same time, also a member of the district health management team.
d) Given the human resource crisis, Zambia cannot guarantee to provide the basic health care package so it fails to achieve the health-related MDGs.
Table 1: Health staff in Zambia – current versus recommended levels, 2004–2005Staff category Current staff levels Recommended es-
tablishmentShortfall
Doctor 646 2 300 1 654Nurse 6 096 16 732 10 636Midwife 2 273 5 600 3 327Clinical officer 1 161 4 000 2 839Pharmacist 24 42 18Pharmacy technician 84 120 36Laboratory scientist 25 50 25Laboratory technologist 100 210 110Laboratory technician 292 1 300 1 008Environmental health officer
53 120 67
Environmental health technologist
32 220 188
Environmental health technician
718 1 300 582
Dental surgeon 14 33 19Dental technologist 40 300 260Dental therapist 2 300 298Physiotherapist (with a degree)
0 50 50
Physiotherapist (with a diploma)
86 250 164
Radiologist 3 33 30Radiographer 139 200 61Paramedic 320 6 000 5 680Nutritionist 65 200 135Support staff 11 003 10 000 -1 003Total 23 176 49 360 26 184
Source: Ministry of Health MoHHRIS database 2004/2005.
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- Low training outputs- Restrictions on recruitment
to maintain the PE to GDP ratio- Establishment not consistent
with demand- Specialist versus management positions
Recruitment
Figure 2: Characteristics of the crisis in human resources for health in Zambia
- Death, mostlydue to HIV
- Resignations- Brain drain- Retirement age
Attribution
- Rural versus urban imbalances- Critical cadres versus support staff- Central versus service delivery- Public versus private
Distribution
1.5 The Zambian plan
Presented by Mrs Margaret Kapiya, Director, Human Resources, Ministry of Health, Zambia
The Ministry of Health has developed a comprehensive human-resource plan – the Zambian Na-tional Human Resources for Health Strategic Plan, 2006 – 2010 (see Figure 3). This plan provides a framework for the implementation of all efforts aimed at resolving the crisis and is designed to improve collaboration in the initiative. However, mobilization of adequate resources to implement the plan remains a major challenge.
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Figure 3: Conceptual framework of the Zambia National Human Resources for Health Strategic Plan
Skills mix
Reduce outflowlossesIncrease inflow
Improve distribution
Urban
TertiaryDistrict
Rural
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1.6 Summary of discussions
1.6.1 Zambia
a) The Zambian health budget is modest – US$ 18.00 as flexi per capital – of which 8% goes to cover the costs of tuberculosis and HIV activities. This is disproportionate to the need as 85% of the Zambian population is estimated to be HIV-negative. The imbalances caused by priority programmes need to be corrected.
b) Zambia needs to consider reappointing retired staff and working out flexible arrangements for their recruitment. It is plausible to imagine that staff who have retired at the age of 55 will have a life expectancy of up to 75 years and be in a position to extend their working life for a few years. The Government should establish agreements with agencies that recruit from the public-health sector to ensure that they pay something back to the health services for staff who have been trained at public-health expense.
c) Zambia will not succeed in transforming the performance of its health system as long as there are insufficient human resources for health. Most health workers choose to work in the private sector rather than the national public health services. Management of migration should be in-novative, with consideration given to outsourcing the recruitment and remuneration processes. Payment of workers' salaries could be decentralized to the district level where more health workers should be located.
d) There needs to be a culture of change in Zambia – the response to the problem of human re-sources for health should come from the Zambian Government and not from the donor com-munity.
e) The Ministry of Health in Zambia recognizes that social and economic issues may affect the implementation of the national plan so they will need to be flexible in implementing it – the plan cannot be considered to be “cast in concrete”. Costing the plan will help the Government to identify quick gains and to implement it in phases.
f ) The health boards created through health reforms in Zambia disrupted the entire health sector. However, in 2005 the Central Board of Health was replaced by the Ministry of Health; this change resulted in some flexibility and expanded the health budget from 8% to 12%.
g) The Government has reconsidered its policy of charging health fees. In view of the shortage of qualified health workers, many people receive health care from unqualified people but still pay fees.
h) The Ministry of Health in Zambia should view priority programmes as a window of opportu-nity through which to improve issues related to human resources for health.
1.6.2 General
Three options to mitigate the human resources crisis were proposed.
a) Establish international agreements for beneficiary countries to invest in increasing pre-service training output and to assure retention of health professionals in source countries.
b) Lift conditions imposed by multilateral organizations on the health sectors in developing coun-tries.
c) Encourage public–private sector partnerships in health-service delivery.
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2. Sharing experiences
2.1 Workforce challenges
Participants split into groups to discuss the following issues: a) making the best use of the existing workforce; b) skill-mix priorities; and c) training and migration. Each group provided a summary of its discussions, as summarized below. Case examples from Malawi, Namibia and Zambia were selected to illustrate these issues.
2.1.1 Making the best use of the existing force
The following challenges were identified:
• the workload grows as the disease-burden increases and health interventions are scaled up;
• the quality of work is compromised as workloads grow but the numbers of health workers stay the same;
• workers are sometimes required to do multiple tasks for which they are not trained – in many cases health workers are not equipped to deal with community requirements;
• employment conditions for staff are based on out-dated bureaucratic and administrative proce-dures;
• it is difficult to implement systems to attract and retain staff, especially in the face of competi-tion from organizations that offer better incentives;
• the work environment for health workers is generally poor;
• many cadres have ill-defined career prospects;
• it is difficult to measure quality of work against set standards.
In seeking solutions and responses to the workforce challenges it is essential to consider:
• increasing the capacity for institutional training of health workers;
• improving the conditions of service, including retention schemes;
• getting contingency workers to staff new programmes, instead of drawing on personnel already occupied with other activities.
• persuading governments to broaden the revenue base and to make health a priority.
Objective 2: Share experiences in human resources for health, including issues re-lated to priority programmes such as HIV/AIDS in countries represented.
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“Making best use” case examples
Malawi: The Ministry of Health developed a top-up salary scheme for health workers but are unsure of the success of this programme. They are therefore investigating other incentives such as transport privileges and amenities. It is difficult for staff working in rural and remote areas to keep up with new developments in health prac-tices and to attend training sessions.
Zambia: A rural retention scheme for physicians is in effect but, although 67% have been retained, it does not solve the problem of distribution imbalances or resolve practical issues such as access, good roads and amenities. There is a need to assess the success of programmes that target other workers. A package of incentives for staff is a key to success. A difficulty is that there are often too many stakeholders involved in the development of such schemes.
2.1.2 Skill-mix priorities
Each of the discussion groups observed that, in general, the right skill-mix at various levels of care is inadequate. This results in many health workers performing duties they are not trained for and the provision of appropriate care and supervision becomes a major challenge.
To respond effectively to this challenge, management needs to:
• endeavour to meet the prescribed complementary skill-mix at any given health facility;
• apply innovative ways to use other people, such as community health workers;
• provide training according to needs and make substantial improvements in the human re-sources information system.
Skill-mix case examples
Zambia: Community development agents are health workers who frequently per-form the functions of more skilled health providers when a gap or staff shortage ex-ists. They are trained to undertake tasks through “on-the-job” learning. This, however, poses a public safety risk. Skilled health workers are needed and yet there are health workers who are still unemployed.
Namibia: Volunteer community health workers were active in the provision of pri-mary health care in the 1990s. However, HIV/AIDS increased from 4% to 23% and, by 2000, volunteers had disappeared. Nurses were upgraded in 1996, but this left a gap in the health community as they moved from public to private practice. There is now a need for volunteers to become counsellors but, again, there are challenges in retaining them. The counsellors are currently funded by NGOs, but they should be integrated into the health system so that their services can be maintained after the donor funding runs out.
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2.1.3 Training
Challenges related to training are listed below.
• There is inadequate capacity to provide training due to poor infrastructure and lack of train-ers.
• Training does not respond to needs.
• Training models are fragmented and not sufficiently comprehensive.
• Bonding agreements are poorly managed – for example, experienced workers leave and some staff suffer from discrimination.
• Quick-fix training is given but it compromises the overall quality.
• Lecturers/tutors are poorly motivated.
In order to address these challenges, there is a need to:
• use innovative training methods to respond to the health needs;
• increase the capacity of training institutions; and
• encourage integrated training e.g. nurse/midwifery training to be given together.
2.1.4 Migration
Discussions on the migration issue raised the following points.
• The magnitude of the problem is not accurately known.
• Migration is a human rights issue; managing international arrangements on migration is not easy.
• Solutions to the problem would entail the creation and/or improvement of a human-resource data base, with the governments taking the lead in managing migration-related issues.
• Bonding arrangements after training should be established; this would ensure that health personnel work for a set period before being able to move to other organizations or migrate. (Participants recognized that this would not be easy).
• Programmes or proposals to restrict migration are not likely to stop the trend.
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Training and migration case examples
Namibia: Only nurses, radiographers and social workers are trained in Namibia. All other health personnel are trained in South Africa. There are limitations in the workforce generation and insufficient funds to fully support students’ studies. Na-mibia has established a code of conduct agreement with South Africa whereby no Namibian graduates will be employed in South Africa. There is, hence, a good return of graduates to the country after they complete their studies.
Malawi: Enrolment in training institutions has doubled and full support for students’ fees is offered. Training bonds exist but there are difficulties in enforcing them. In 2004, 17 medical school graduates enrolled in an internship programme, but only 2 remained after it. In 2005, there were 20 graduates and only 1 remained.
2.2 Exploring incentives for Zambian nurses in the public-health sector
Presented by Ms Naomi Toyoshi, London School of Hygiene and Tropical Medicine, London
A study was conducted at the Kitwe Central Hospital, one of the major hospitals in Zambia, with the objective of gaining a better understanding of how Zambian nurses perceive working in a public hospital and the attractions of migration. In-depth interviews with 36 Zambian nurses provided both qualitative and quantitative information. In addition to this, data from secondary sources were reviewed to provide a background to the analysis and interpretation of results. The preliminary results provided a basis on which to create an effective incentive strategy.
Table 2: Rates of turnover and resignation of nurses in the three major hospitals in Zambia, 2002–2004
Hospital Turnover rates
Resignation rates
Vacancy rates
Kitwe Central Hospital 32% 24% 43%
Ndola Central Hospital 23% 9% 50%
University Teaching Hospital, Lusaka
20% 12% 46%
Table 3: Rates of turnover of nurses and doctors, November 2002–October 2003
City Nurses Doctors
Lusaka District Health Management Team 6% 25%
Kasama District Health Management Team 3% 60%
University Teaching Hospital, Lusaka 14% 29%
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Information from the interviews highlighted some of the demotivating factors that trigger migra-tion.
a) Low remuneration and allowances. Nurses are unable to fulfil family demands despite long working hours. They do not have enough to eat, they lack funds for transport and their role is perceived to have a low status (relative to wage).
Quote on the low remuneration problem from an enrolled nurse in the Paediatrics Department:
“Lets talk of marketers – those people at the market – they have got more money than nurses. We are getting very little. Sometimes you approach a marketer; you want to borrow some money. What she will tell you, ‘Uh, no, you I can’t give. I can’t give my money to the nurses: one, they get very little, I have problem getting it back; and two, they are paid late.’”
b) The wage structure links to a pension system offering payments that are not only low but are usually paid late. There is a lack of incentive to stay within the public-health sector since wages are compressed and there is little recognition of additional qualifications (for registered mid-wives and registered theatre nurses).
2004200320022000199819971995199419931992
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Figure 4: The number of registered nurses requesting verifications from the General Nursing Councilfor top six countries (1991–2004)
450
400
350
300
250
200
150
100
50
0
UK South Africa Botswana New Zealand USA Australia
1991 1996
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c) As a result of inadequate levels of staff, working conditions are poor – there is a lack of access to equipment/drugs, supervisors have no empathy and do not recognise that staff are working hard, administration is poor, organizational practices are unfair, there is no opportunity for professional development opportunities and the working environment is hazardous.
Quote on pensions from a ward manager, High Cost Department:
“….It [pension payment] is a very, very slow process. Most people die even before they get their benefits…That’s why, even people who have gone away, they say ‘That pension, even if I don’t get it its OK. After all, I will get the whole total of what I should have got at 55 years within 2 months… eventually I will recover it all’.”
Quotes on staffing and working conditions
From a registered midwife, Obstetrics and Gynaecology Department:
“This girl came in with a breech presentation. The baby couldn’t come out. So I was there struggling with the baby – in the end it died. So there, when I am alone in the ward, what do you expect me to do?...I just said, ‘No one is going to question me on anything because I am not supposed to work alone…I couldn’t leave that patient! I had to finish!’ By the time I am finishing … it’s already too late...”
From a student nurse, School of Nursing:
“..she (a nurse) goes to work around 18:00 hours in the evening. Instead of knocking off in the morning, she will continue working up to 12:00 hours [midday] just to make money. That shift during the day is casual. Now what effective care can she give to the patient? She has no money at home, she needs to make some money…So she will rest only maybe for 4 hours in the afternoon. That’s what the nurses are doing.”
From a registered midwife, Gynaecology, Medical, Surgical High Cost Ward:
“She really needed to be on oxygen then unfortunately the oxygen finished and then she changed her breathing. I went, I wanted to get an ambuba. Unfortunately there was no oxygen in the hospital the patient had already collapsed. You know I felt like stopping, I really wanted to help her but there was no way. That is how she collapsed and that’s how she died. And then the relatives cried and said, ’This is negligence. How is it possible that this can happen in a high-cost ward?’ I felt so discouraged on that day, I felt like I just couldn’t go on…”
From a female clinical instructor, School of Nursing:
“You sometimes feel like leaving. Otherwise we just keep on hoping that maybe the government will change things, maybe this [new] government will change things. But when each government comes into power, it is almost the same. So maybe one day I might also go.”
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2.3 Session on HIV/AIDS and the workforce
The consultation took advantage of the presence of regional participants to share information and discuss human-resource issues relating to HIV and the workforce.
2.3.1 Overview of HIV/AIDS in Zambia
Presented by Dr B. Chirwa, Director General, National AIDS Council, Lusaka, Zambia
Dr Chirwa’s presentation showed that 16% of the adult population, aged 15–49 years, are HIV-positive; the infection rate in urban areas is 25% – compared to 11% in rural areas. HIV infection rates are higher among women (18%) than men (13%). The major challenges for Zambia include scaling up “best practices” for care, including ARV treatment, coordination of the multi-sectoral response, strengthening activities at the district level, and mobilizing community resources.
2.3.2 Joint ILO/WHO guidelines on health services HIV and AIDS
Presented by Mr Gerry Finnegan, ILO Representative for Malawi, Mozambique and Zambia
Mr Finnegan presented a summary of the guidelines on HIV/AIDS and the health workplace. Existing guidelines1 cover various issues including the legal framework, the policy framework and codes of conduct.
The presentation highlighted the fact that the health sector has a vital role to play in ensuring that health workers:
– are healthy and fit,
– work in a safe and healthy working environment,
– are well managed and highly motivated,
– operate efficiently, productively and effectively,
– are adequately remunerated, rewarded and appreciated,
– receive counselling and have their fears/anxieties acknowledged,
– are protected from avoidable injury,
– are treated and supported when injured or ill,
– receive public goodwill and support,
– are viewed as “champions” and are not stigmatized.
1 Examples of documents based on joint work include: a) HIV/AIDS and the world of work: An ILO code of practice (2001); b) Guidelines on addressing HIV/AIDS in the workplace through employment and labour law (2004); c) IOE/ICFTU joint statement: Fighting HIV/AIDS together (2003); d) WHO Global Health Sector Strategy for HIV/AIDS 2003–2007; and e) Scaling up HIV/AIDS care (2004).
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2.3.3 Challenges to access voluntary testing and counselling (VCT) in medical professions
Presented by Dr P. D. Njobvu, Zambia Medical Association.
Dr Njobvu focused on the results of an operational research project conducted among health work-ers in Ndola, Kitwe, Choma and Livingstone, Zambia. The objective of the project was to under-stand how health workers were coping with HIV/AIDS at home and at work. Key findings indi-cated that health workers were at substantial risk of HIV from risky sexual behaviour with multiple partners. Among 210 respondents reporting multiple sexual partners, 37% did not use condoms. There was also evidence of a high rate of exposure to needle-stick injury in the workplace. 53% of the respondents had had an average of 3.6 exposures in the past 12 months. Furthermore, only 25% knew about post-exposure prophylaxis (PEP). Overall, only 27.7% had ever been tested for HIV and only 20.8% knew the HIV status of their sexual partners. The main reasons for not being tested included indecision, fear of a positive test result, stigma, concerns about confidentiality, lack of psychosocial support, and real or unfounded beliefs about PEP.
2.3.4 Coping with the impact of HIV/AIDS among health workers in Zambia
Presented by Dr G. Biemba, Church Health Association of Zambia, Lusaka, Zambia
The summary of the results from a similar study conducted in two districts showed that: a) health workers reported an increase in their workload and changes in their tasks; b) 76% and 79% from the respective districts feared they could be infected in the workplace; c) there was little knowledge of PEP; d) there was a high risk of emotional exhaustion and stress; and e) there was fear of a stigma and discrimination against HIV-positive workers.
2.3.5 Caring for caregivers: responding to the needs of hospital workers in Zambia
Presented by Ms Chilufya Mwaba-Phiri, Population Council, Zambia
The importance of caring for carers has become more and more apparent in Zambia. In her pres-entation, Ms Mwaba-Phiri pointed out that mortality is the main reason they lose health workers. In Zambia as many as 40% of the health workers were found to be HIV-positive in the 1990s; mortality among nurses rose ten-fold between 1980 and 1991 – that is from 2.0 per 1000 to 26 per 1000. A survey of 1425 health workers from 4 hospitals showed that 72.3% did not know their HIV status, but all health workers in the clinical areas were concerned about getting infected with HIV in the workplace. However, while 90% of the doctors were aware of PEP, only 30% of the nurses knew about it.
2.3.6 Zambian Nurses Association/Norwegian Nurses Association/HIV and aids among nurses
Presented by Ms Olive Ng’andu, Project Director
In Zambia, health workers have been overlooked – there have not been enough programmes to raise awareness of exposure in the workplace despite the risks of infection through contaminated body fluids, needle pricks, “sharps” injuries, lack of protective clothing and limited knowledge of PEP. There is increasing evidence of psychosocial stress among health workers due to the heavy workloads that result from HIV/AIDS-related illnesses among staff. Most health workers have lost either a loved one or a relative from HIV/AIDS. They also suffer from the psychosocial stress of
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having to support not only their own families, but also patients’ families who are going through the psychological trauma of the impact of the illness. The majority of health workers do not know their HIV status because they fear being stigmatized should they test positive – this fear is a significant issue in the workplace. Furthermore most of the health workers do not practice safe sex and lack negotiation skills. Voluntary counseling and testing is a major part of this initiative.
2.4 Summary of discussions
There is a growing commitment to the need to respond to the human resources for health crisis. It is a complex issue but solutions can be sought – both immediate and long-term. There is a need to think outside the sphere of public-health services and mechanisms should be established for the public and private sectors to work together.
2.4.1 Training of human resources for health
a) Africa is short of training institutions for health workers. Training strategies should consider appropriate skill-mixes and the need to strengthen pre-service education.
b) According to the WHO Regional Office for Africa, an evaluation showed that significant finan-cial investments – in the amount US$ 10 million – would be required to scale-up training for health workers in formal training institutions. The evaluation also showed that current training has no system of follow-up or motivation.
c) Training should focus on all aspects of health, including prevention and promotion in order to reduce disease burden.
2.4.2 Quality training and retention schemes
a) Supply and demand have to be addressed jointly. Benin introduced a retention and motivation scheme to give more money to workers in rural areas but, within a year, workers had absconded from those areas because there were no further training opportunities and also they lacked ac-cess to information.
b) In most African countries soldiers and teachers are paid higher salaries than health workers. This situation must be reviewed.
c) Strategies to improve the quality of health educational institutions should consider the issue of attrition.
d) Issues of retention of human resources for health apply to both teachers, trainers and service providers. Basic needs such as accommodation and access to good childrens’ schools should be included in retention packages. In one country workers were encouraged to apply for post-graduate training and were provided with housing as part of an integrated retention package.
e) Scholarships should be provided on the basis of training needs and the national plan.
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2.4.3 Skill-mix
a) In Uganda, the introduction of comprehensive nursing and enrolled nurses has helped to retain staff.
b) It is difficult to evaluate people who take up negotiated jobs outside their training.
c) According to the Zambian experience, the best skill-mix at health-facility level is to have a nurse, a clinical officer and an environmental officer.
d) It is ethically wrong to have unskilled health workers doing laboratory work, operating X-ray equipment and performing tasks they are not trained for.
2.4.4 Migration
a) It is critical to track migration of human resources for health to get an overview of what is hap-pening. Internal migration can only be resolved by providing a wage package that includes ac-commodation and/or living expenses. There appears to be an emphasis on rural housing – this is a good initiative but it should be considered also for health workers in urban areas.
b) Management should develop appropriate policies for external migration. For example, in Ken-ya, the migration agreement indiscriminately allows human resources for health to go to Na-mibia. This compromises the health services provided to the local population.
c) There needs to be consistency – migration should also be on the agenda of countries that re-ceive migrants.
d) To manage migration, a workplan for the public sector needs to be drawn up and policies relat-ing to voluntary separation, based on a package, should be reviewed.
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3. Global actors and possible solutions to alleviating the crisis
Objective 3: Present the �lobal Health �or�force Alliance and the African Human�lobal Health �or�force Alliance and the African Human Health �or�force Alliance and the African Human Resources for Health Platform, and discuss possible solutions to the alleviation of the crisis in the African region.
3.1 The Global Health Workforce Alliance
Presented by Dr Omaswa, Executive Director, Global Health Workforce Alliance
The Global Health Workforce Alliance (GHWA) was established in response to recommendations made at a number of meetings that recognized the need to address the issue of strengthening health systems, including the human resources for health component. Various events and two World Health Assembly resolutions (listed in the table below) gave momentum to the establishment of the GHWA. Table 4: Events leading up to establishment of the GHWA, 2004–2006
African PartnershipAfrican Partnership
LondonLondon
WHA Resolution 58.30 **WHA Resolution 58.30 **
AfricaAfrica n Union Summit Abujan Union Summit Abuja
African Stakeholder Consultat ionAfrican Stakeholder Consultat ion
Brazzavi l leBrazzavi l le
African Regional Health MinistersAfrican Regional Health Ministers
MaputoMaputo
AU Minis ters of Health meetingAU Minis ters of Health meeting
GaboroneGaborone
Africa Commission ReportAfrica Commission Report
Transit ional WGTransit ional WG
Oslo Consultat ionOslo Consultat ion
HL Forum II AbujaHL Forum II Abuja
JLI ReportJLI Report
GG 8 Summit Gleneagles8 Summit Gleneagles
Asia Network BangkokAsia Network Bangkok
UNGA SummitUNGA Summit
PAHO Observatory TorontoPAHO Observatory Toronto
HL Forum III ParisHL Forum III Paris
World Health ReportWorld Health Report
World Health DayWorld Health Day
WHA; Launch of GHWAWHA; Launch of GHWA
WHA Resolution 57.19 *WHA Resolution 57.19 *
HL Forum I GenevaHL Forum I Geneva
JunJun
MayMay
AprApr
MarMar
FebFeb
DecDec
NovNov
OctOct
SepSep
AugAug
JulJul
JunJun
MayMay
AprApr
MarMar
FebFeb
DecDec
NovNov
OctOct
SepSep
AugAug
JulJul
JunJun
MayMay
AprApr
MarMar
FebFeb
JanJan
JanJan
JanJan
JunJun
MayMay
AprApr
MarMar
FebFeb
JanJan
20
06
20
06
DecDec
NovNov
OctOct
SepSep
AugAug
JulJul
JunJun
MayMay
AprApr
MarMar
FebFeb
JanJan
20
05
20
05
DecDec
NovNov
OctOct
SepSep
AugAug
JulJul
JunJun
MayMay
AprApr
MarMar
FebFeb
JanJan
20
04
20
04
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It is hoped that the GHWA will be the focal point to:
– bring multiple stakeholders to work together,
– serve as a powerful lever for joint action,
– build health systems,
– harmonize global initiatives – minimizing the waste of time and money, discouraging inef-fectual, fragmented, isolated and disruptive competition and promoting the sharing of best practices, lessons learned, standards, learning and monitoring; and
– mobilize the concept of “knowledge and learning”.
The current priority work areas of the GHWA are to:
a) accelerate work at country level – such as “quick wins”, retention schemes, skill-mix priorities and training;
b) harmonize actors for workforce alignment to strengthen priority programmes and health sys-tems;
c) build knowledge and promote learning as a “global public good” and disseminate information and communications to key audiences;
d) address specific global workforce challenges.
Figure 5: The structure of the Global Health Workforce Alliance
Vision and mission of the GHWA
Vision: to promote significant scale-up to ensure access to skilled, motivated and supported health workers by all people especially the poor and vulnerable.
Mission: to advocate, facilitate and create enabling environments to avail human re-sources for health for health-system MDGs, AIDS, and better health for all.
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Figure 5: The structure of the Global Health Workforce Alliance
Source: Global Health Worforce Alliance Strategic Plan
RegionalNetworks
TaskForces
Board
Secretariat
Alliance Members
Global Stakeholders
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Table 5: Summary of core functions and strategic guidelines of the GHWA
Core functions Strategic guidelines
• Mobilize “knowledge and learning”��
• Disseminate information and communica-tions�
• Harmonize actors for workforce alignment�
• Promote country-initiated and country-led actions�
• Ensure agile, responsive, and non-bureau-cratic movement: mission driven and time-limited�
• Establish inclusive membership, linking the national–regional–global levels�
• Endeavour to enhance the efficiency of existing funding flows (though the GHWA is not a funding mechanism)�
• Avoid duplication, build on existing work, and enhance capacity of members�
• View the workforce as the principal compo-nent for strengthening health systems and for tackling priority health problems�
3.2 The African Human Resources for Health Platform
Presented by Dr Akpa Gbary, Regional Adviser, Human Resources for Health, African Regional Office, WHO
The momentum for the establishment of the African Human Resources for Health Platform was generated by an incremental build-up at a number of events, including the Joint World Bank–WHO Conference, Addis Ababa, January 2002; the 53rd WHO Regional Committee, Sandton, September 2003; the High Level Forum II, Abuja, December 2004; the Abuja African Dialogue, January 2005, the Global Human Resources for Health Consultation, Oslo, March 2005; and the Human Resources for Health Consultative Meeting, Brazzaville, July 2006.
The Brazzaville Consultation discussed policy analysis and options, cross-cutting issues, the African human resources for health observatory, education and training, the workplace, migration and retention issues, human resources for health and priority health programmes, the link between hu-man resources and health systems, and research on human resources. The Consultation reiterated the consensus that, to be effective, the African Platform should:
a) be open and inclusive;
b) provide momentum;
c) build consensus on what needs to be done;
d) foster an enabling environment for technical work and the sharing of experiences and promis-ing practices;
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e) facilitate collaboration and harmonization for action;
f ) promote advocacy for human resources for health;
g) establish a human resources for health observatory as a technical arm;
h) neither own nor direct its members, but have the ability to drive the agenda;
i) not be a “doer” itself, though it may take some direct actions;
j) not be a conduit for funding, though it should mobilize some funds to support its own core actions; and
k) establish a steering committee – comprising country representatives, United Nations agencies, subregional organizations and civil society – to guide its actions.
Having an African Platform for human resources will ensure that the momentum is maintained, Africa will be speaking with one voice, there will be an increased chance of country ownership, complementarity and shared responsibility, and a strong link with the Transitional Working Group and the GHWA. Although challenges exist, there has been some progress and the following achieve-ments:
– a costed plan of action for the observatory has been finalized;
– two meetings of the Steering Committee were held – in Gaborone in October 2005 and in Nairobi in March 2006;
– the African Platform contributed to the Global Human Resources for Health Consultation II, Oslo, March 2006;
– the African Platform agenda was established;
– the Secretariat of the African Platform is in the process of being formalized.
3.3 Country perspectives, Zambia
A number of steps are being taken to address the problem, including those outlined below.
a) The government has increased the health sector budget – from 9% in 2004 to 12% in 2005.
b) A loan scheme for public health workers is being implemented.
c) Retention schemes at the district level include provision of staff transport, group performance incentive schemes, top-up salaries for staff in remote areas, renovation of accommodation and provision of electricity (using solar systems) in remote areas. In the Solwezi district for example, the District Health Management Team pays housing rentals for staff members.
Other initiatives are being implemented with the support of partners.
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3.4 The role of the private sector
Presented by Dr Godfrey Biemba, Executive Director, Church Health Association of Zambia
Dr Biemba’s presentation focused on the human resources for health strategy in the private sector. The Church Health Association of Zambia (CHAZ) works towards objectives which include:
a) strengthening partnerships – working together,
b) sharing best practices in retention schemes,
c) improving human resource management and financing,
d) sharing opportunities for training and practices,
e) advocacy, and
f ) knowledge-sharing.
The CHAZ provides 25–26% of the health care services and believes that its wealth lies in its work-ers. The distribution of facilities run by the CHAZ are mainly in rural areas (see Figure 6 below). Tables 6 and 7 show how church health institutions have been worst hit by the crisis in human resources for health.
Figure 6: Distribution of CHAZ facilities in Zambia
DipalataChavuma
Lukolac
Chinyingi
Chitokoloki
YutaLiumba
Sioma
Sitoti
Lwampa
Mangango
MonzeNisse
Sichili
Makunka
MwandiMasuku
Simalachella
Sinde Zimba Jembe
Sikilongo
Chaboboma
ChikuniChivuna
Chikankata
ChangaMtendere
Riverside
LusakaMulungushi
Katomdwe
Chipembe
MingaNyanje
Rural Health Centre
Hospital
Hospital with training School
Capital City
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St Francis
Msoro
Muzeyi
Kamoto Lumezi
Kanyanga
Chilonga
LwelaChilubi Chalabesa
MulangaLubwe
Kasaba Bondola
Manbilima
Chipili
Mulilasolo
MwenzoMungwiChilubiMbereshi
Chipempe
KayambiKashikishi
Manbwe
Mwami
St Francis St Dorothy’s
Fiwale Hill
Fiwale HillKafulafuta
Fiwale HillFiwilla
Chingombe
Mulungushi
Chibembi
MwembeshiKafue
Chilala
Macha
Mounde
KaparuNangoma
St MarysSt Joseph
St Antony’s
MukingeLoloma
St Kalemba
Fiwale Hill
Maheba
Kalene Hill
Lwalu
Sachibando
Churches Health Association of Zambia
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Table 6: Aggregated staffing levels in rural health centres, 2003–2004
Category Required Available Deficit % available National % available
Nursing officer 55 4 51 7.3 -
Nurse 242 96 146 39.7 52.0
Clinical officer 62 31 31 50.0 44.3
Laboratory technician
57 12 45 21.1 64.0*
Environmental health techni-cian/ technologist
56 18 38 32.1 -
Total 472 161 311 34.1 47.3
Table 7: Aggregated staffing levels in hospitals, 2003–2004
Category Required Available Deficit % available National % available
Doctor 30 15 15 50.0 51.0
Nurse 467 108 359 23.1 52.0
C/Officer 28 14 14 50.0 44.3
Laboratory technician
26 10 16 38.5 64.0
Pharmaceuti-cal technician
19 4 15 21.1 -
Total 570 151 419 26.5 52.6
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4. Summary of discussions
4.1 The Global Alliance versus the African Platform
Regarding the relationship of the African Platform to other regions, regional groups, WHO and the World Bank, it was considered that creating mechanisms and networks was not a major con-cerns since the Platform is a branch of the Global Health Workforce Alliance (GHWA). Other regional meetings of the GHWA will be held – there are plans for a conference in Asia, October 2006. WHO and the World Bank are members of the transitional Global Alliance Working Group and it was emphasized that the GHWA does not report to WHO but to the Board of the GHWA. However, since the GHWA is not a legal body, its operations can be implemented only through a legal entity such as WHO. The GHWA is part of an evolving and changing environment – so it will focus on issues that Member States are unable to handle.
4.2 Actions proposed for countries and the GHWA
The participants proposed priority activities for skill-mix and training (see Tables 8 and 9 below).
Table 8: Skill-mix priorities
Challenges and actions
For countries For the GHWA
• Identify the skill-mix requirements, based
on the needs of the country.
• Ensure effective distribution and use of
skills.
• Harness the full range of health workers
– including community workers, volunteers
and private-sector workers.
• Recruit and retain skilled health profes-
sionals.
• Sustain an appropriate budget and reduce
constraints, including knowledge gaps.
• Help countries to identify skill-mix priorities
matched to needs.
• Bring in donors to assist on human re-
sources for health.
• Create a taskforce on fiscal space.
• Provide and lead advocacy initiatives.
Table 9: Training
Challenges and actions
For countries For the GHWA
• Provide training to more health workers
to reduce the current capacity limita-
tions.
• Ensure that training matches the coun-
try’s health needs to prepare workers
adequately.
• Support the quality of education.
• Encourage curriculum reform and match
training and required competencies to needs.
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4.3 Panel discussion
The panel discussion, chaired by Dr Tim Evans, Assistant Director-General, Evidence and Informa-tion for Policy, WHO, Geneva, included the following participants:
– Mrs Sylvia Masebo, Honourable Minister of Health, Zambia
– Dr Simon Miti, Permanent Secretary, Ministry of Health, Zambia
– Dr Francis Omaswa, Executive Director, Global Health Workforce Alliance
– Dr Lincoln Chen, Special Adviser of the WHO Director-General on Human Resources for Health
– Dr Diarra-Nama, Director, Division of Health Systems and Services Development
– Dr Steward Tyson, Head of Health, DFID
The following key issues were discussed.
1) Solutions to the human resources crisis should be practical, simple and easy to implement.
2) The 2006 World Health Day launch in Zambia offered a great opportunity for global recogni-tion of the GHWA and the African Platform.
3) To assist countries come up with national plans it is essential to provide a technical framework for human resources for health.
4) For national work plans to be operational, financial commitments have to be met.
5) Harmonization and coordination between partners will help target financial support, even if donors move towards a general budget. In this way funding will go to countries under parlia-mentary control; this will help ensure equitable distribution of funds.
6) The Zambian plan has not made much reference to the church institutions even though they play a major role in the provision of health services. The Zambian plan should integrate ma-laria/HIV/tuberculosis and there should be comprehensive consultations with other sectors to ensure that they fully understand the implications and how to make the plan operational.
7) Since Zambia has a plan in place, consultation with the donor community may help donors identify specific areas to fund, such as retention schemes in training institutions or secondment of personnel.
8) Zambia should avoid the mistake of developing a plan but not implementing it, as some coun-tries have been known to do.
9) Community-based health staff in Zambia work without the support of skilled health workers and they are not motivated – these factors need to be taken into account.
10) A significant level of mismanagement occurs; this is an issue that should not be neglected. A system for responding to human resources for health needs to be implemented.
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5. Conclusions and recommendations1) No single solution responds to all the challenges. The human resource for health crisis is real; all
countries are affected. Practical policy changes are needed and collaborative efforts to spearhead the movement are critical.
2) It is recognized that human resources for health are important to meeting the MDGs. How-ever, other issues that also need to be considered jointly include drugs, effective country leader-ship, a technical framework, stakeholder partnerships and political leadership.
3) The awareness that the crisis in human resources for health has resulted in a major public health movement requires a broader “buy-in” (acceptance and participation) by various part-ners. There is a need to work with priority programmes to split resources between activities and human resources for health.
4) Allocation of WHO fellowship funds should aim to strengthen management of human re-sources for health.
5) Overall response efforts should encompass the four Rs: “Recruitment, Remuneration, Retire-ment and Re-entry”.
6) Countries should focus on “quick wins” related to recruitment and provide remuneration that includes a living package, retirement and re-entry. Where feasible, a new multi-purpose cadre should be established, especially at district level, and resource allocations to the overall health system should be optimized by working with priority health programmes.
7) The Global Health Workforce Alliance should:
– foster advocacy of human resources for health, complemented by evidence;
– support countries to ensure clarity on strategies;
– provide technical tools and frameworks;
– engage in harvesting the lessons learnt on human resources practices and undertake to share them; and
– provide support for the harmonization of national health development and human re-sources plans, while articulating cross-cutting policy issues such as fiscal space and interna-tional agreements to mitigate migration of health workers.
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Annex 1: Agenda
Global Health Workforce Alliance Sub-Conference on Human Resources for Health, Lusaka, Zambia 4 – 5 April 2006
Tuesday 4 April, 2006
09.00–10.00 Opening ceremony: Dr S� Miti, Permanent Secretary; Ministry of Health; Hon-ourable Mrs S� Masebo, Minister of Health, Zambia; Dr Lincoln Chen, Special Adviser of the WHO Director-General on Human Resources for Health
10.00–10.20 Key-note addresses on human resources for health: Dr Luis G. Sambo, Regional Director, AFRO; Honourable Mrs Sylvia T. Masebo, Minister of Health, Re-public of Zambia
10.20–10.40 The �orld Health Report 2006: Mr Norbert Dreesch, Technical Officer HRH, WHO, Ge-neva
10.40–11.00 Coffee and tea break
11.00–11.20 The �H�A – A global actor for support to countries in HRH: Dr Francis Omaswa, Executive Director, GHWA and Spe-cial Adviser, HRH, WHO, Geneva
11.20–11.40 The African HRH Platform: Dr Akpa R. Gbary, Secretary, Steering Committee African HRH Platform, Brazzaville, Congo
11.40–12.00 Introduction to topics: Dr Francis Omaswa
Making the best of existing workforce Skill-mix priorities Training Migration
13.00–14.00 Lunch
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14.00–16.00 Brea�out session: Coordinator: Dr Francis Omaswa
Challenges Response Implementation and lessons learnt
16.00–16.30 Coffee and tea break
16.30–19.00 Seminar on HIV and AIDS as a wor�place issue in the health sector (separate programme)
�ednesday 5 April, 2006
09.00–09.15 Recap from Day One and objectives for Day Two: Dr Francis Omaswa, Chair: P� Eriksson and M� Kapiya
09.15–10.30 The Zambia Case: Chair: P� Eriksson and M� Kapiya HR Challenge in Zambia: Naomi Toyoshi, LSHTM and Jere Mwila, MOH ZambiaThe Zambian HRH Strategic Plan: M. Kapiya, Director, Human Resources, MOH, Zambia
10.30–11.00 Coffee and tea break
11.00–11.30 The role of the private sector – The CHA HRH regional strategy: Dr Godfrey Biemba, CHAZ
11.30–12.00 Country leadership on HRH – �hat does it mean? Prof. Erich Buch, University of Pretoria, South Africa and Tim Martineau, LATH
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12.00–13.00 Panel discussion on global health initiatives and HR�Introduction by Dr Steward Tyson, Head of Health, DFIDPanellists:Barbara Hughes, USAID Marco Gerristen, RNE Francis Omaswa, WHO Mrs Sylvia Masebo, Honourable Minister of Health, Zambia Dr Lincoln Chen, Global Health Workforce Alliance Special Envoy to the WHO Director-General
13.00–14.00 Lunch
14.00–15.00 The way forward: panel discussionModerator, Dr Tim Evans, ADG, WHO, GenevaPanellists: Dr Simon Miti, MOH, Zambia Dr Francis Omaswa, GHWA, Geneva Prof. Lincoln Chen, Harvard, USA Dr Stella Anyangwe; WR, WHO, Zambia Dr Alimata Diarra-Nama, DSD, WHO, AFRO
15.00–15.30 Concluding remar�s: Dr Tim Evans
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Annex 2: List of participants
Global Health Workforce Alliance Sub-Conference on Human Resources for Health, Lusaka, Zambia 4 – 5 April 2006
AkpaGbary,Raphael WorldHealthOrganization CongoBrazzaville
Alisheke,L. MinistryofHealth Zambia
Anyangwe,Stella WorldHealthOrganization Zambia
Barnhart,ElizabethInternational Office on Migra�tion(IOM)
Zambia
Befecasu, Adeye SwedishEmbassy Ethiopia
Biemba,GodfreyChurch Health Association of Zambia(CHAZ)
Zambia
Bouwdyh, Ingrid Catholic Organization for De�velopmentandRelief)(COR�COR�DAID)
Netherlands
Bulterys, Marc Centers for Disease Control andPrevention
Zambia
Bwalya, Elicho MinistryofHealth Zambia
Caffrey,Margaret Liverpool Associates Malawi
Chiboleka,CatherineZambia Nurses Association (ZNA)
Zambia
Chilengwe,W. NdolaCentralHospital Zambia
Chipepo,BerthaE. General Nursing Council Zambia
Chishimba,G.C. MinistryofHealth Zambia
Chomba,BrightM. KonkolaCopperMines(KCM) Zambia
Cross,TanyaDepartment for International Development (DFID)
UnitedKingdom
Diallo, Bocar WorldHealthOrganization Switzerland
Diarra-Nama, Alimata WorldHealthOrganization CongoBrazzaville
Dreesch, Norbert WorldHealthOrganization Switzerland
Flynn, Fergal Lusaka District Health Man�agement Team (DHMT)
Zambia
Furlong, Mary ZAMUV Zambia
Garden,BjarneNorwegian Agency for Devel�opmentCooperation(Norad)
Norway
Gaston,CarolSwedish International Develop�ment Agency (SIDA)
Australia
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Gerritsen, Marco NetherlandsEmbassy Zambia
Holt, Louise Canadian International Devel�opment Agency (CIDA)
Canada
Hughes, Barbara United States Agency for International Development (USAID)
Zambia
Kangwa, Freddie BND Zambia
Kapampa,KangwaM. Africa Health Foundation Zambia
Kapihya,MargaretN.B. MinistryofHealth Zambia
Kata,StephenZambia National Broadcasting Cooperation
Zambia
Kilimboyi, Alice Zambia Electricity Supply Cor�poration(ZESCO)Limited
Zambia
Liambwa,George MansaGeneralHospital Zambia
Likwasi, PriscillaJapanInternationalCoopera�tion Agency (JICA)
Zambia
Lugina, Helen East, Central and Southern Africa (ECSA) Health Com�munity
Tanzania
Malawo, D. H. KabweGeneralHospital Zambia
Masebo,Hon.Sylvia MinistryofHealth Zambia
Meeus, Wilma Kabwe District Health Man�agement Team (DHMT)
Zambia
Miller,JaneDepartment for International Development (DFID)
Zambia
Milner, Sue Department for International Development (DFID)
Zambia
Minanu, Rachel K. L. Zambia Electricity Supply Cor�poration(ZESCO)Limited
Zambia
Miti,Simon MinistryofHealth Zambia
Moonga, Mutinta MinistryofHealth Zambia
Mphuka, Simon Church Health Association of Zambia(CHAZ)
Zambia
Mtonga,Chipayeni WorldHealthOrganization Zambia
Mukelasai, Mary MinistryofHealth(MOH) Zambia
Munjanja, Olive K. Independent consultant- Zambia
Munsaka, Jennifer M. Zambia Nurses Association Zambia
Musonda, Mutinta Lubinga Kabwe District Health Man�agement Team (DHMT)
Zambia
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Musowoya, Joseph MinistryofHealth Zambia
Mwale,Genevieve
“Reaching HIV/AIDS Affected People with Integrated Devel�opment and Support” (RAP�IDS)
Zambia
Mwale,HilaryHealth Sector Strategic Plan (HSSP)
Zambia
Mwanza, Nick Kalabo District Hospital Zambia
Mweemba,Nora WorldHealthOrganization Zambia
Mwewa, Dorica S. MinistryofHealth Zambia
Mwewa,John KitweCentralHospital Zambia
Mwiinga,Kasonde WorldHealthOrganization Zambia
Mwila,J.M. MinistryofHealth Zambia
Nabugwere, Alison Canadian International De�velopment Agency (CIDA) PrimarySamplingUnit(PSU)
Zambia
Ndapisha,Christine Community Health Promotion Zambia
Ngambi,ChandwaNdola District Health Manage�ment Team (DHMT)
Zambia
Ngandu, Olive Zambia Nurses Association (ZNA)
Zambia
Nkhoma,Lewis Deaf Christian Church Zambia
Nkowane,Mwansa WorldHealthOrganization Switzerland
Nsonda,Clive CNZ Zambia
Palale, Patricia WorldBank Zambia
Phiri,MargaretL WorldHealthOrganization CongoBrazzaville
Scholastika, Iipinge UniversityofNamibia Namibia
Shiferaw,TesfayeUnitedNationsInternationalChildren’s Fund (UNICEF)
Zambia
Sichinga, Karen Church Health Association of Zambia(CHAZ)
Zambia
Sichone, Tomoko JapanInternationalCoopera�tion Agency (JICA)
Zambia
Sunkutu, Rosemary WorldBank Zambia
Suya, Dickson MinistryofHealth Zambia
Teixeira,Hoana WorldHealthOrganization CongoBrazzaville
Toyoshi,NaomiLondon School of Hygiene and Tropical Medicine (LSHTM)
UnitedKingdom
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Tyson,StewartDepartment for International Development (DFID)
UnitedKingdom
Wochi, Edwin MinistryofHealth Malawi
Yungana, Thom D. Zambia Nurses Association Zambia
Zulu, Beatrice Zambia Nurses Association (ZNA)
Zambia
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Annex 3: Participants’ suggestions
Country level
Advocacy, political commitment
• Governments should fully demonstrate their political will, link up with stakeholders and at-tend to all the grievances including social, economic and scientific issues.
• Remove fiscal contaminants against the public sector.
• Increase hiring and expansion of the health workforce.
• Address environmental workplace issues for human resources for health (HRH) as a matter of urgency.
• Revitalize workplace settings such as clinics.
• Prioritize retention of health workers by paying particular attention to improving management of human resources for health – for example, respectful rewarding systems, career prospects, transparent promotion, good housing, transport and provision of electricity in rural areas. All health workers must be given a living package. Zambia should pay particular attention to remuneration of health workers vis-à-vis the remuneration in other developing countries and raise it to an appropriate level; it is sad to lose members of the Zambian health workforce not only to developed countries but also to other developing countries.
• Maintain and increase domestic investment in the health system and human resources for health as more resources are critical to global health and macro-economic initiatives.
• Advocacy for government to increase, by at least 15%, the proportion of money allocated to the health sector so as to permit the recruitment of more health workers and the improvement of their working conditions.
• Give attention to the health sector – it does not need lip service alone. To stop health workers from leaving the country they should be given a living wage so they can pay for basic foods and reasonable accommodation and can afford to take care of their children and their schooling, and are able to smile.
• Develop and strengthen alliances with, for example, the ministry of finance, cabinet office, ministry of labour, ministry of health and cooperating partners so that a common platform is established for joint commitments to allocate more resources to address HRH problems and to help resolve the inherent impediments in addressing issues such as limited HRH establish-ments and the ban on recruitment of health workers.
• There must be political will in order to help solve the HRH crisis and the government must listen to the health workers’ complaints.
• Make an outright improvement in remuneration of health workers.
• Develop policies, procedures and strategies for improving the health and safety of HRH.
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• Train multi-purpose health workers to meet the needs.
• Expand retention schemes in all categories of health facilities.
• When a receiving country poaches a health worker, it should have a plan to replace him/her.
• Establish a more sustained approach to improving conditions of service and health-care deliv-ery.
• A universal health cover will help supplement a health budget for Zambia.
Implementation
• Strengthen country-led coordination of interventions.
• Implement contract appointment for retired health workers.
• Establish a new cadre of health workers to respond to district-level needs.
• Reopen training facilities for nurses that have been closed; recruit health trainers on a contract basis from other countries – overseas or regionally – to fill the gap; set up an initial course to train trainers.
• Increase HRH training.
• Improve HRH management at facility level by strengthening management-capacity at district-hospital level.
• Define a living package as a basis on which salaries for HRH can be calculated.
• Strengthen coordination and collaboration.
• Strengthen HRH management.
• Zambia needs to look at the possibility of training a cadre to have multi-faceted skills – that is, a polyvalent well-remunerated health worker.
Monitoring and evaluation
• Comprehensive data analysis, plans, monitoring and evaluation need to be implemented.
• Every country should have a national strategic plan that can be implemented and evaluated; implementation of capacity should be increased at the health-service output level.
• Utilize available data bases to plan, implement, monitor and evaluate capital investments, in-cluding HRH.
• Ensure follow-up and reinforcement of monitoring; feedback from health workers should be linked to training and provision of other incentives (impact of HRH plan).
• Strengthen HRH record-keeping at central, provincial and district levels to enhance improved decision-making in the progress and management of HRH.
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• Ensure monitoring, implementation and improvement of plans.
• Countries need to be motivated to re-examine existing systems, structures and procedures re-lated to HRH. This should include the establishment of accurate information systems and a rigorous planning exercise to identify health needs, HRH needs, skill needs, etc. then to align them with solid and sustainable implementation strategies.
Suggestions for the global level
• Support country work.
• Create a strong alliance for coordination and management of international resource flows for HRH development.
• Most important HRH issues should be dealt with at global level.
• Catalyse resource mobilization.
• Establish international agreements on recruitment and retention.
• The World Bank and WHO should galvanize their activities to be more effective.
• The GHWA should foster advocacy for visibility and increased awareness of HRH.
• The GHWA should foster advocacy for visibility of and increased awareness of HRH.
• Countries that poach HRH from developing countries should be encouraged to invest in train-ing health workers in those countries.
• Share experiences and work together.
• Allow the donor fund to support the “HRH basket”.
• Strengthen links between the various players in HRH to allow “best practice” lessons be learnt by other countries.
• Ensure that trained medical health workers – doctors and nurses – are not be allowed to take up administrative positions with, for example, the central board of health, ministry of health and non-governmental organizations. They do this to gain what they perceive to be better-paying jobs – but, in doing so, they decrease the already-limited cadre of employees. This restriction should be included in the country’s strategic plan.
• Cooperating partners at the global level should provide funding for the GHWA.
• Donors and cooperating partners need to support remuneration packages in developing coun-tries to help use available resources rather than paying only for expatriate staff.
• Local health programmes require support that is confined to country facilities and initiatives.
• Help to strengthen finances.
• Coordinate meetings on HRH and convince donors to fund the “basket” of HRH scale-up.
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• International collaboration and support for HRH should be sympathetic to developing coun-tries and support payment of salaries.
• Look at international laws that govern migration to help determine measures to mitigate the loss of health workers to developed countries; that is, there should be compensatory measures for countries that lose their health workers.
• The Global Alliance should collectively mobilize resources in a central fund, similar to the HIV/AIDS Global Fund, to which countries can apply in order to address or help them imple-ment HRH plans.
• Work together to help solve each others' problems.
• Coordinate financial resources to assist in training.
• Align priority initiatives to invest in and align the workforce for sustainable health progress.
• All stakeholders should agree on HRH strategies that are health-based.
• Develop advocacy tools for developing countries to use in addressing the “pull factors” in inter-national migration.
• Advocate for country-level living packages.
• Advocate for HRH development and management to be included as a cross-cutting issue in every project/programme to be undertaken in a country.
• Advocate for greater integration of HIV/AIDS within other health initiatives – stop vertical programmes.
• Enter into and maintain discussions with key recipient countries of migrant workers to seek multilateral understanding and initiatives.
• Support training of HRH in less developed countries.
• A flexible HRH “funding basket” that will allow funding plans down to provincial and district levels is needed.
• An entry point for country support must be articulated.
• International community must put financial resources in place.
• Advocacy should promote support to countries that are losing staff; this could be in the form of training and supplementary salary top-ups to serving health workers.
• Advocacy for HRH funding, especially in Africa, should be promoted.
• Financial support to achieve improved conditions of service and health care is required.
• Recipient countries should explore the possibility of entering into agreements on HRH to regulate the movement of health staff.
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• Share attempts to solve HRH problems – good, bad and ugly – between HRH practitioners across the globe.
• Activate and plan stakeholders’ involvement and priorities in HRH functions.
