A Synthesis and Systematic Review of Policies on Training and Deployment of Human Resources for Health in Rural Africa

A collaboration between the WHO/PAHO Collaborating Centre on Health Workforce Planning & Research and The University of Zambia School of Medicine

OverviewI. Background and context

II. Research questions

III. Project approach

IV. Methods: Scoping review and in-depth analysis

V. Results: Scoping review and in-depth analysis

VI. Discussion

VII. Limitations and key messages

VIII. Conclusion

IX. The way forward

X. Research team and acknowledgements

Full report, as well as French and Portuguese executive summaries, available at www.whocentre.dal.ca

Background and Context con’t

The health and well-being of women and children is at the forefront of global policy and planning discussions, as illustrated by the Millennium Development Goals (MDG) specific to maternal and child health, MDGs 4 and 5, and the post-2015 agenda.

Many progress reports and post-2015 agendas comment on the importance of, and challenges in, meeting these goals. MDG 4 – reduce the under-five mortality rate by two thirds, by 2015. MDG 5 – reduce maternal mortality by 75%, and achieve universal

coverage of skilled birth attendance by 2015.

The current state of maternal, newborn and child health in Africa reveals a need for increased access to primary health care, emergency services, reproductive health and family planning (WHO,

2005).

Essential in achieving such enhanced access is the availability and appropriate deployment of sufficient numbers of adequately trained HRH to deliver those services (WHO, 2005).

Background and Context

The vast majority of African countries are enduring a long-standing, and previously unseen human resources for health (HRH) crisis, lacking sufficient personnel to deliver the necessary MNCH services, especially in remote and rural areas (Joint Learning Initiative, 2004).

Estimates suggest that approximately 1 million additional health personnel are required in Africa to achieve minimum recommended density of 2.3 doctors, nurses and midwives per 1,000 population (WHO Regional Office for Africa, 2012).

The dire HRH situation demands effective policies for the planning and management of the limited, existing workforce. However, limited resources constrain the ability for country-level policy makers to review and synthesize available policy information from different countries, limiting capacity to create evidence-based policies.

Research Questions

Key Question: What is known about policies to support training and deployment of nurses, midwives and doctors for maternal-child health care in rural Africa?

Additional Questions: What is currently known about. . .

the research, theories, frameworks or other factors that have guided the development of these policies?

the implementation of these policies? the effectiveness/impact of these policies on system,

provider and health outcomes?

Project Approach

Two-stage review: Scoping review of peer- and non-peer reviewed literature for all

African countries with English, French, or Portuguese as official languages

In-depth policy analysis of country sub-set – Ethiopia, Ghana, Mali, Mozambique, Niger, Uganda, Tanzania, and Zambia - informed by Hercot et. al (2011) policy analysis framework: content, context, process, actors, impacts.

Capacity building activities: Training sessions on systematic review design and application

methodology for students/faculty of Dalhousie University and University of Zambia

Repeated group meetings for students/faculty to review policy mapping and analysis.

Engagement and consultations with International, African-centred Advisory Committee throughout: Refining research objectives, questions, and parameters Provision of hard-to-access policy documents Validation of findings and dissemination of final report

Methods: Scoping Review

Two phases: Peer-reviewed literature:

14 electronic databases were scoped with search strategy developed by an information scientist and Advisory Group.

Inclusion criteria was applied and articles appraised by no less than three research team members; publication and policy data extracted.

Non-peer-reviewed literature: Ministry of Health websites were scoped for policy

documents meeting inclusion criteria for all African countries in the three linguistic groups.

Websites of reputable international organizations and agencies were scoped for relevant policy documents for designated country sub-set.

Methods: In-depth Review

Country sub-set of Ethiopia, Ghana, Mali, Mozambique, Niger, Tanzania, Uganda and Zambia was selected in consultation with Advisory Group to represent all African regions and identified linguistic groups.

Relevant literature obtained from scoping activities and directed searches was reviewed and mapped using data extraction templates for both research and non-research literature.

Application of Hercot et al. (2011) framework delineated the respective contributions of the policy content, context, actors, process and impacts.

Aspect Criteria

Language of publication English, French, or Portuguese

Years published 1990 – 2013

Type of policy initiative Applied (i.e. not theoretical, but some evidence that the policy has been/continues to be implemented)

Country or countries of focus

Any African country whose official languages include English, French, and/or Portuguese

Policy focus Training and/or deployment of providers as it pertains to rural health

Type(s) of providers Doctors, nurses, and/or midwives

Specific clinical focus Maternal-child health: reproductive health, pregnancy, birth, newborns, childhood disease, and adolescents

Jurisdictional focus International or national (e.g. not provincial or district-specific)

Types of data sources Policy documents, policy evaluations, professional protocols/clinical guidelines, literature reviews, peer-reviewed research related to policy implementation and/or evaluation

Methods: Inclusion Criteria

Results: Scoping Review

Peer-reviewed literature: 513 articles identified for appraisal: 426 unique articles from

database search and 87 articles identified by Zambian research team and Advisory Group

37 articles met inclusion criteria: Published in 22 different peer-reviewed journals. 13 countries represented in final body of papers, covering

each region of Africa and linguistic group. The vast majority (89%) published in or after 2003,

suggesting building momentum around maternal and child health after the release of the MDGs in 2000.

Fairly equitable representation of doctors, nurses and midwives in literature, with many articles including these providers implicitly due to the high-level nature of some policies.

Policies focused exclusively on training and/or deployment were scarce; often embedded in broader HRH of health system policies.

Results: Scoping Review

Non-peer reviewed literature: Ministry of Health websites varied from limited to

comprehensive in terms of functionality, accessibility, and available policy documents.

Organizational websites held no government policy documents, but a wide variety of pertinent literature to inform policy context for in-depth policy analysis:

Professional guidelines and protocols Independent policy evaluations Conference proceedings Additional peer-reviewed literature

Many of the official government policy documents, located via directed Google searches, were hosted on websites administrated by international organizations, such as United Nations Population Fund and the World Health Organization.

Results: Identified National Policy Initiatives by Country

Country Policy Year Implemented

Ethiopia Mandatory public service after graduation  

Differentiated terms and conditions for pay & benefits  New Medical Education Initiative 2011

Nurse anaesthetist program 2010

Accelerated training & increased staffing for midwives 2009

Ghana Decentralized medical resident training 2000

Deprived Area Incentive Scheme Allowance (DAIA) 2004

Health Staff Vehicle Hire Purchase Scheme 1997

Community-based Health Planning and Services program (CHPS) 1999

Mali Medicalization of rural areas  

Mozambique

No available information on applied policies meeting criteria  

Niger Scholarships for rural students 2011

Mobile health teams 2011

District-level surgery training 2005

Tanzania No available information on applied policies meeting criteria  

Uganda Incentives scheme for human resource in hard-to-reach areas  

Integrated Management of Childhood Illness (IMCI) 1995

Community-based education and services (COBES)  

Specialist outreach  

Building and staffing operating theaters at the level of the ‘‘health subdistrict’’ or health center type IV

 

Zambia One-year rural attachment for trainees 1991

Zambia Health Worker Retention Scheme 2003Rural and Remote Hardship Allowances  

Housing Allowance  

Results: Information Availability by Policy

Country Policy Development

Implementation

Impacts1

Ethiopia Mandatory public service after graduation      

Differentiated terms and conditions for pay & benefits      

New Medical Education Initiative (NMEI)    

Accelerated midwifery & increased staffing for midwives  

Nurse anaesthetist program  

Ghana Decentralized medical resident training    

Deprived Area Incentive Scheme Allowance (DAIA)    

Health Staff Vehicle Hire Purchase Scheme    

Community-based Health Planning and Services program (CHPS)  

Mali Medicalization of rural areas    

Niger Scholarships for rural students    

Mobile health teams    

District-level surgery training

Uganda Incentives scheme for human resource in hard-to-reach areas      

Integrated Management of Childhood Illness (IMCI)

Community-based education and services (COBES)      

Specialist outreach      

Building and staffing operating theaters at the level of the ‘‘health subdistrict’’ or health center type IV

     

Zambia One-year rural attachment for trainees      

Zambia Health Worker Retention Scheme  

Rural and Remote Hardship Allowances      Housing Allowance      

1As per the methods of this review, only information published in peer-reviewed scientific journals was considered as evidence of policy impact.

Discussion: Policies

Relatively few training and deployment policies for doctors, nurses and midwives for maternal and child health were identified not only in country sub-set, but in Africa as a whole, despite a multi-faceted search strategy. However, this should not be interpreted as a lack of prioritization of these issues: Several important programs are being implemented by many countries

to address these issues, but were excluded from the review as they did not meet the exact inclusion criteria.

Policies and programs may be in place within these countries that do meet our inclusion criteria but information is not publicly accessible.

Several promising policies and programs aimed at improving maternal and child health in these countries did not meet one or more of our inclusion criteria, but had significant information available. As examples, these included: Mozambique’s Agentes Polivalentes Elementares program Uganda’s Village Health Teams program Ethiopia’s Health Extension Program Tanzania Essential Health Intervention Project

Discussion: Country Context

Where the review yielded little information on specific policies within its scope, it revealed a large body of relevant contextual information about the selected countries: Ethiopia, Ghana, Mali, Mozambique, Niger, Tanzania, Uganda, and Zambia.

Contextual information is essential to understanding the identified policies, as guided by the Hercot et al. policy analysis framework.

Country-specific contexts are explored at length in the full report; key quantitative data pertaining directly to the research question for each of the selected countries is provided on the next slide.

Discussion: Country ContextCountry Populati

on (%rural)

GDP per capita1

Health funding (% of GDP)

HRH density2 (% rural)

% of HRH posts filled

Annual HRH training output3

Public sector HRH absorption4

Maternal mortality5

Under 5 mortality6

Ethiopia 91,729,000 (83%)

$1,110 4.7% 2.8 (54% doctors/83% nurses /82% midwives)

      350 72

Ghana 25,666,000 (48%)

$1,810 10.7% 2.3(30%/30%/60%) 40%     350 78

Mali 15,840,000(65%)

$1,040 6.8% 0.3 (23% / 46% /59%) 72%   32% 540 176

Mozambique

23,930,000(69%)

$970 6.6% 3.7 (3% / 60% / 3%)       490 103

Niger 16,069,000(82%)

$720 5.3% 1.6 (14% / 28% / 24%)     25% 590 125

Tanzania 46,218,000(63%)

$1,500 7.3% 2.5 (24% / 50% / 88%) 35% 3% 16% 460 68

Uganda 34,509,000 (84%)

$1,310 9.5% 14.3 (30%/ 60% /60%) 63% 12%   310 90

Zambia 14,075,000 (61%)

$1,490 6.1% 2.1 (46%) 41% 4% 80% 440 831Purchasing Power Parity (PPP) international dollars2Doctors, nurses, midwives (headcount) per 1,000 population3From HRH training programs, as % of # of established posts4Proportion of graduates from health training programs who enter employment with government health services5Per 100,000 live births6Per 1,000 live births

Discussion: Cross-cutting Issues Recurring issues, outside the scope of analysis but directly

related to the subject of HRH training and deployment, were described across documents reviewed from multiple countries: Fiscal considerations: cash-flow and under-funding Resource management: people, supplies, services Monitoring and Evaluation: low capacity and resulting ability for policy

planning and addressing corruption Competing Priorities Political Stability Decentralization Importance of partnerships: within and across governments, training

institutions, international funding agencies and other non-governmental organizations.

Transparency and access to information

These issues are thought to contribute in part to the observed disparity between what appears to be implemented and the true breadth and depth of health strategies proposed in these countries.

Limitations and Key Messages

Main limitations of this study: Lack of country-specific searches in scoping.

Search criteria might have missed potentially eligible citations and documents since a wide range of terminology is used to describe policy options for HRH.

In this particular field of study, document analysis and synthesis is not necessarily sufficient to create context-driven conclusions or recommendations, as suggested by the presence of method triagulation in the peer-reviewed literature.

Despite limitations, clear and reiterated key messages emerged, underpinning the policy process and the way forward:

1. Planning-implementation gap 2. Underfunding

3. Policy visibility 4. Unavailability of evidence

5. Research bias 6. Innovation

7. Aligning services and competencies 8. Alignment of donor funds

9. Management, monitoring and evaluation

Conclusion

Overall, it is clear the Ministries of Health in the countries studied have attempted, and continue to explore, a broad spectrum of HRH policy options aimed at improving maternal and child health among their respective populations.

Implementation of existing and identified policies seem to be acutely restricted by economic, political, social, geographic and technological factors beyond the Ministries’ influence.

Of note is how little information on what health policies currently exist in these countries is readily available, or even obtainable through dedicated searching.

Most policies were analyzed based solely on secondary information, as copies of actual relevant policies were not accessible; this lack of transparency makes an objective assessment of these policies – necessary for any meaningful improvement on them – virtually impossible.

The way forward

Dissemination of findings and key messages to increase accessibility through open access downloads and publications, conference presentations, social media, and translation into French and Portuguese.

Expansion of this research to further assist in informing the evidence-based policy process in Africa through a triangulation of methods: extension of search strategy and scope, and interviews with key stakeholders, opinion leaders and policy makers.

Continued engagement and development of relationships formed throughout the project to strengthen communication, collaboration, and alignment around HRH policy.

Increased emphasis on, and application of, capacity building activities to foster African-owned HRH research and policy capabilities.

Full report, as well as French and Portuguese executive summaries, available at www.whocentre.dal.ca

Team and Acknowledgements

Research Team: Dr. Gail Tomblin Murphy, Dr. Fastone Goma, Dr. Sheri Price, Dr. Selestine Nzala, Adrian MacKenzie, Stephanie Bradish, Annette Elliot Rose, Janet Rigby, Nellisiwe Chizuni, Chilweza Muzongwe, Amanda Carey, Derrick Hamyhwa,

The research team would like to thank our Advisory Group – Dr. Maina Boucar, Dr. Paulo Ferrinho, Ms. Allison Annette Foster, Mr. Solomon Kagulura, Dr. Vic Neufeld, Ms. Jennifer Nyoni, Dr. Francis Omaswa, Dr. Judith Shamian, and Dr. Mohsin Sidat – for their important contributions and support of this work. We would also like to thank the GHRI for providing the funding to support the work described in this report.

This work was carried out with the support from the Global Health Research Initiative.

Citation: Tomblin Murphy G, Goma FM, MacKenzie A, Bradish S, Price S, Nzala SH et al. (2014). A Synthesis and Systematic Review of Policies on Training and Deployment of Human Resources for Health in Rural Africa. Report to the Global Health Research Initiative. Ottawa: International Development Research Centre (IDRC).

References

Joint Learning Initiative (JLI). Human Resources for Health: Overcoming the Crisis. Cambridge, MA: Harvard University Press; 2004. Available at: http://www.who.int/hrh/documents/JLi_hrh_report. pdf.

Hercot, D., Meessen, B., Ridde, V. & Gilson, L. (2011). Removing user fees for health services in low-income countries: a multi-country review framework for assessing theprocess of policy change. Health Policy and Planning, 26, ii5-ii15.

World Health Organization (2005). Make every Mother and Child Count. Geneva: World Health Organization. Available at: http://www.who.int/whr/2005/whr2005_en.pdf

World Health Organization Regional Office for Africa (2012). Road Map for Scaling Up the Human Resources for Health for Improved Health Service Delivery in the African Region 2012–2025. Luanda: WHO.