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Monitoring, Analyzing & Evaluating HRH Policies in the Region of the Americas
Lima, PeruNovember 14‐16, 2012
Overview
• Background & Context• Caribbean Case Study• A Regional Collaborative Approach • The Process of HRH Analysis & Evaluation• Challenges & Lessons Learned• First Steps: A Regional Example• Moving Forward
Background & Context
• Second Regional Goals Measurement• Develop Regional HRH policy monitoring and evaluation models
• While progress has been made a number of HRH goals may not be reached by 2015
• Aging populations, aging workforces• Reduction in country resources and capacities• Out migration, rural distribution, slow growth
Regional HRH Forecast
Joint Learning
Laying the Foundation
Joint Learning Initiative (2004) Toronto Call to Action (2005)
WHO World Health Report (2006) Health Agenda for Americas (2007)
Global Health Alliance (2007) HRH Data Management Project (2007)
Twenty Regional Goals for Health (2007)
Kampala Declaration (2008) CARICOM CCH III (2008)
High Level Meeting, Caribbean HRH Road Map (2012)
Road Map Implementation, 2012‐17ROAD MAP IMPLEMENTATION, 2012‐17
RTRREGIONAL HRH POLICY
MONITORING & EVALUATION
Caribbean Case Study
• 20 HRH Goals Review• Roadmap for Strengthening the Caribbean Health Workforce
• Interview Survey and Inventory on HRH Governance
0
20
40
60
80
100
120
Challenge 1 Challenge 2 Challenge 3 Challenge 4 Challenge 51 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Caribbean 20 HRH Goals Summary
Percentage of Goals achieved by Region
High4 ‐ RNs to MDs9 ‐ Recruit PHC
1 – Supply3 – PHC teams12 ‐ Foreign cred.16 ‐ Labour negot.20 ‐ Accreditation
Low6 – Urban/rural gap11 ‐ Self‐sufficiency13 ‐ Secure posts
CARIBBEAN HRH REGIONAL GOALS
SUMMARY
Goal 2 ‐ Proportion of PHC physicians will exceed 40% of the total medical
workforce
Goal 3 ‐ Develop Primary Health Care teams with broad competencies
60%
88%
53%
Goal 4 ‐ Ratio of Nurses: Physicians is at least 1:1
Goal 5 ‐ Establish a HRH unit
100%
95%
Goal 1 – HRH density ratio of 25
per 10,000CHALLENGE ONE
The primary thrust of the Road Map is to strengthen HRH planning, management and provider skills in the region in order to create a more stable, efficient and effective health workforce that can meet the needs of an aging population with a growing incidence of chronic diseases by broadening regional access to PHC and public health services.
Caribbean HRH Roadmap
National Regional
HRH ROAD MAP
Caribbean HRH Road Map Context
Health Information ServiceFinancing Systems Delivery
Caribbean Health Workforce:Renewal Process
Retain Re-recruit
7 8Renew Re-invest
6 1
5 2Re-vitalize Re-educate
4 3
Re-deploy Re-employ
Strengthening the Foundation
CaribbeanHealthWorkForce
GOVERNANCE
EDUCATION& TRAINING
First Steps: Enhancing Workforce Capacity
HRH Capacity & Skills Development
EDU
GO
ERNANCE
HRH Planners‐ Legislation & regulation‐ Policies & programs‐ Data systems & monitoring‐ Communications & partnerships‐ Research & evaluation‐ Evidence‐based planning‐ Funding ‐H R H
Personnel Managers‐ Health, safety & security‐ Labour relations‐ Assessment & deployment‐ Professional development‐ Performance management‐ Succession planning‐ Incentives & compensation‐ Recruitment & retention
HealthCare Providers‐ Primary health care‐ Public health‐ Chronic care‐ Health promotion‐ Disease prevention‐ Community‐based‐ Integrated teams‐ Task‐shifting‐ Competency‐baseddeployment
EDUCATION
TRAINING
INFORMATIONSUPPORT
GOVERNANCE
MANAGEMENT
SERVICE PROVISION
ROAD MAP FOR STRENGTHENING THE CARIBBEAN HEALTH WORKFORCE, 2012‐2017
Context Components/Milestones Outcomes Impacts
L
2012 2013 ‐ 2017 2020+
POPULATION HEALTH ISSUES Epidemiology Aging Population Child Health Mental Health Education Poverty/Education Violence/Crime
GOVERNANCE
Develop & Implement HRH Plans HRH Policies Workplace Improvements HRH Inventories
EDUCATION & TRAINING
Managerial Skills HIS Training Policy Development Staff Management Provider Competence
STABILITY of Health Workforce EFFICIENCY of Service Delivery EFFECTIVENESS of Health Outcomes
ENABLERS
Legislation Programs Policies Management Funding Planning Partnerships Communications Evaluation/Monitoring
HRH Database
HRH
Observatory
Health Learning Network
HEALTH SYSTEM ISSUES
Inefficiency Costs & Capacity Poor Access Service Quality Leadership Management
WORKFORCEOptimal Competent Aligned with Needs Stable Distributed Flexible Accountable HEALTH SYSTEM Efficiency Quality Equity Access Administration Sustainability
POPULATION Improved Access Appropriate Access Better Quality Better Informed Better Health
HRH PLANSCommunity Based Integrated PHC Teams – Enhanced Skills ‐ Task Shifting – Competency Based
Deployment ‐ Needs Based Planning – Health Promotion – Disease Prevention – Chronic Care
HRH ISSUES HRH Shortages Rural Supply Growing Needs Attrition Emigration Health & Safety Training Productivity
Road Map – The Journey
HRH Road Map Final Destination
To achieve and maintain a stable and optimally trained, deployed and distributed health workforce with the capacity to provide responsive, timely, efficient and effective health care services to meet the identified health needs of the population in a way that is flexible and innovative as well as affordable and sustainable.
HRH Planning & Management Survey & Inventory
OBJECTIVESIn support of the Caribbean HRH Roadmap implementation process:
Short Term•To determine the role and scope of ‐ and capacity for ‐ HRH planning and management of Ministries of Health within the Caribbean region;•To identify legislative and regulatory mechanisms that govern HRH within the countries of the CARICOM;•To identify current gaps, challenges and areas requiring priority attention;Medium Term•To help identify HRH areas that would most benefit from additional skills and training;•To help identify areas were the country governance mechanisms might be developed or strengthened through regional collaboration; and,•To support the exploration of regional planning mechanisms to best support national HRH planning activities.
HRH Survey Results: “Single Biggest Challenges”
• HRH Database• HRH Unit• Redefine roles & skill mix• Capacity & resources• Inability to implement plans• Qualified staff• Program Evaluation
• Recruitment & retention schemes
• Identify training needs• Link HRH to Health plan• Salaries & Working Conditions• Inter‐Ministry HRH Management
• Rural distribution• Staff burnout• Chronic vacancies
A Regional Collaborative Approach
More effective HRH policies will achieve:•More stable, optimal workforce•Greater efficiency in health care delivery•Improve geographic, professional, intra‐professional and public‐private distribution•Enhance quality of care•Health supportive motivating work environment that maximize productivity
HRH Monitoring & Evaluation
HRH Governance
"GOVERNANCE is about the rulesthat distribute roles and responsibilities among government, providers and beneficiaries and that shape the interactions among them.
It encompasses authority, power, and decision‐making in the institutional arenas of civil society, politics, policy, and public administration."
DEFINITION
LEGISLATION
POLICIES
RULES & REGULATIONS
MANDATED ROLES & RESPONSIBILITIES
Role of Governance
HRH PLANNING & MANGEMENT
AUTHORITY ENGAGEMENT
DECISION‐ POWERMAKING
OVERSIGHT LEADERSHIP
Practices & Principles
Standards & Guidelines
HRH Policy
HRH Policy Support Framework
Legislation FinanceRegulations IncentivesPrograms Education
Strategic Plans LeadershipOperational Plans ManagementPartnerships VisionCommunications MandateKTE ResearchData Systems Evaluation
? ? ?
Program Commitments Shared/Mandated Responsibilities Competing Priorities
Fiscal Space Sustainability
Allocation of Resources Timing
Stakeholder Interests Long‐Term
Labour Negotiations Party Platform
Strategic Plan Issue Profile
Government Priorities Other Areas
Other Departments Deficit(s)
Data / Research / Information / KTE
HRH Decision‐Making Arena
HRH Policy Development & Implementation
• Lack of explicit HRH policies hinders progress• Need comprehensive policies & strategies• Need to be integrated, and pro‐active• Involve stakeholders in all components• Long‐term political support critical• Social & cultural environments representation• Assessment of financial implications of policies• Capacity of country to mobilize needed resources• 45 of 57 HRH crisis countries HRH poorly implemented
.
HRH Action Framework (GHWA)
Program Evaluation Framework
EVALUATION: check and verify
What do you want to know? How will you know it?
Logic Model in Evaluation Logic Model in Evaluation
Logic model and common types of evaluation
Needs/asset assessment: What are the characteristics, needs, priorities of target population?What are potential barriers/facilitators?What is most appropriate to do?
Process evaluation:How is program implemented? Are activities delivered as intended? Fidelity of implementation?Are participants being reached as intended? What are participant reactions?
Outcome evaluation: To what extent are desired changes occurring? Goals met?Who is benefiting/not benefiting? How? What seems to work? Not work?What are unintended outcomes?
Impact evaluation: To what extent can changes be attributed to the program? What are the net effects?What are final consequences? Is program worth resources it costs?
Outcome Mapping
• Defines outcomes as changes in partner’s behavior• Focuses on facilitating change, not causing it• Recognizes complexities of developmental contexts• Looks for logical links with outcomes, not attributed• Requires program staff and partners in all stagesLogic Models – less utility with unequal distribution of power, complexities of the design and terminologies and self‐contained nature that assume causal links between program components are not as viable.
Applied HRH Planning & Evaluation
• Human Resources for Health Action Framework• Handbook on Monitoring and Evaluation of HRH• Rapid Assessment of the Effectiveness of the Country Coordination & Facilitation Process
• Evidence‐Informed Policy Network
WHO/GHWA/CCF
Rapid Assessment Lessons Learned
• Review progress of stakeholder participation• Create Observatories, improve HRH information• Translate strategies into costed operational plans• Enhance professional and financialmanagement• Incentives & working conditions crucial to recruitment• Rural shortages require task shifting /innovative roles• Create a national migration inventory • Improve planning capacity of HRH committees • Scale‐up stakeholder and government commitment• Sustain collaboration through annual progress meetings
U K
Silcone Paint & PolishTire Pressure, Tread & SizeAir and Gas FiltersGas Octane LevelGearingAccelerationCity DrivingWarm‐Ups/Start & StopExhaust & Catalytic ConverterSpark PlugsEngine Valves & RadiatorSynthetic OilTop & Windows UpAir Conditioning & Power AssistsAltitude, Humidity & Termperature
$ $ $
HRH Regional Goal #6 – Reduce the gap in Urban‐Rural distribution in health personnel.
Linked Policy Areas –•Recruitment and Retention Schemes•Educational preparation•Return‐in‐Service commitments•Needs identification/Rural quotas•Rural salary and benefits incentives•Working conditions/health and safety•Immigration/Temporary Workers•Bursaries•Task Shifting / Teams
Educational Bursaries (1)CONTEXT INVEST ( INPUT) ACTIVITIES (OUTPUT)
Local HRH Priorities Budget Allocation Defined Targets20 Goals/Targets Staff Assigned Strategy/PrioritiesHealth Plan Accountabilities TrainingHRH Plan Equipment CommunicationsMoH Values Office Space Planning Groups Political Priorities Time Budget Plan/TargetsPlanning Committees Admin Support Incentives
Selection CriteriaRecruiting PlanTracking/Data Support
Educational Bursaries (2)OUTPUT (WHO) OUTCOMES (LEARN) OUTCOMES (ACTION)
#’sPartners Awareness UptakePlanning Groups Competencies Targeted/ApprovedUniversity Opinions Public/Private Mix Community Colleges Aspirations Responded/AcceptedMinistry of Health Acceptance Inter‐Professional MixMinistry of Education Interest Urban/Rural RatiosCivil Service Budget UtilizedFinance Student RetentionHealth Professions Geographic DistributionStudents Professional Mix
Educational Bursaries (3)
IMPACT•Dollars saved•Health Outcomes improved•Access to service enhanced•Improved rural supply•Improved workforce stability•Reduced dependence on Migrant Workers/Temporary Staff•Better working conditions•Improved teams and staff support
QUALITATIVE AND QUANTIATIVE INDICATORS
Key questions…Next StepsAre Regional HRH goals being met? If not, why not? How do we know?Is the rate at which goals are being achieved reasonable and adequate?Are current policies, practices, processes and partnerships adequate to support reaching the 20 Regional HRH goals?
What is the simplest and most affordable evaluation and monitoring mechanism that:• Can be implemented in a timely and credible fashion?•Produce credible and implementable results?•Be acceptable to and supported by key partners, stakeholders, donors and government decision‐makers?
To monitor progress…
…but with clearly defined goals
To encourage Innovation…
…but with Accountability
To adopt key partnerships…
…but with clear roles and authority
To seek out the best evidence…
…and then Act on it!
HRH Policy Evaluation Process
HRH POLICY EVALUATION : One Option…
HERE’S ANOTHER…
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