how to promote a resilient health workforce in conflict affected settings - insights from four...

How to promote a resilient heath

workforce in conflict affected areas:

insights from four countries

Chair: Sophie WitterHSG, 18 November 2016

Research for stronger health systems post conflict

Overview• Background on ReBUILD & health worker incentive

research• Health workers’ motivation to join the profession (Justine

Namakula)• Health workers’ experience of crisis and conflict & how

they coped (Haja Wurie)• Health worker’s experiences of incentives and incentive

policies post conflict and crisis (Sophie Witter & Yotamu Chirwa)

• How health staff manage complex remuneration in fragile and post-conflict settings (Maria Bertone)

• Wrap up and overview of resources • Discussion


Background on ReBUILDDecisions made early post-conflict can steer the long term development of the health system


Post conflict is a

neglected area of health system

research

Opportunity to set health

systems in a pro-poor direction

Useful to think about what policy space there

is in the immediate

post-conflict period

Choice of focal

countries enable

distance and close up view

of post conflict

ReBUILD research and partnerships

Health financing

Gender &equity

Health workforce

Aid effectiveness

Contractingmodels

Health systems and resilience


Consortium partners• College of Medicine and Allied

Health Sciences (CoMAHS), Sierra Leone

• Biomedical Training and Research Institute (BRTI), Zimbabwe

• Makerere University School of Public Health (MaKSPH), Uganda

• Cambodia Development Research Institute (CDRI)

• Institute for International Health and Development (IIHD), Queen Margaret University, UK

• Liverpool School of Tropical Medicine (UK)

Consortium affiliates working in additional countries: Cote d'Ivoire, Nigeria and South Africa; Sri Lanka, Gaza and Liberia

Background on ReBUILD research on health worker incentives

Research tools Cambodia

Sierra Leone Uganda

Zimbabwe

1. Stakeholder mapping

√ √

2. Document review √ √ √ √3. Key informant

interviews√ 33 √ 23 + 18 + 19 √ 25 √ 28

4. Life histories with HWs

√ 24 √ 23 + 39 +25 √ 26 √ 34

5. Quantitative analysis of routine HR data √ √ √

6. Survey of health workers

√ 310+266 (+logbooks) √ 227

Witter, S., Chirwa, Y., Namakula, J., Samai, M., Sok, S. (2012) Understanding health worker incentives in post-conflict settings: study protocol. ReBuild consortium. http://www.rebuildconsortium.com/media/1209/rebuild-research-protocol-summary-health-worker-incentives.pdf


Objective: to understand the evolution of incentives for health workers post-conflict and their effects on HRH and the health sector

http://www.rebuildconsortium.com/media/1209/rebuild-research-protocol-summary-health-worker-incentives.pdf



Scope and sample sitesCambodia Sierra Leone Uganda Zimbabwe

Site selection

6 provinces (covering all 4 ecological regions)

4 districts (covering all main regions)

3 districts in most conflict-affected area

2 provinces – one well served and one under-served

Sectors included

Public sector only Public sector only

65% public; 35% PNFP (private not-for-profit - largely mission sector)

Mixture ranging from the government sector; the municipality; the Rural District Councils, the mission sector and the private sector

Time-frame

1999 onwards (post-conflict)

2000 onwards (last phase of conflict; post-conflict since 2002)

2000 onwards (six years during; six years after)

1997 onward (economic crisis, and post- since 2009)

Motivation to join health workforce: learning from four

settingsJustine Namakula


Focus

• Factors influencing motivation to join• Patterns in expressed motivation to join

the profession across different settings and cadres

• Linkage between motivation and retention

• Implications for HRH policies in the health systems studied

Factors influencing motivation to join

Personal calling• Desire to serve communities • Innate caring personality

“Reason for choosing this career because I love it and can help people

in my community” (Cambodia)

“…. it was a calling and feeling of wanting to serve people, so I thought that if I am trained I can also come and save the life of my people” (Uganda)

Family influence • Instruction and advice• Role models• Relatives with health problems

“I became a nurse because […] I was also encouraged by my grandfather who

was employed at Mashoko Mission Hospital to join the nursing field “

(Zimbabwe)

‘[…] My Mother too wanted me to do nursing […]She made all the arrangements that I

should do nursing because she had wanted to do it but she did not do it.. […]that’s what

made me to do it[…] (Sierra Leone)

Factors influencing motivation to join

Factors influencing motivation to joinStatus and esteem of health professionals “I learnt that doctor had good income and respect from people

in the community. I can also help people” (Cambodia)

‘From the way I saw how the nurses were all well-dressed at that time, the doctors were working efficiently…….. ‘(Sierra

Leone)

‘’[...] I could see the nurses fully dressed and very smart. So that is one thing that inspired me mostly. I therefore decided that I should be a nurse and be smart like them’’ (Uganda)

‘ I used to adore nurses in their white uniforms since I was young so I came to train as a nurse in 1995 up to May 1999”

(Zimbabwe)

Factors influencing motivation to joinEconomic factors• Perceived better pay than other professions• Incentives (Uganda)• Means of survival for family (all)• Short training time= money more quickly (Cam)• Scholarships for medical training (SL)

Educational background• Science subjects• Flexibility in level of education background• Failure to get medicine [some cadres]

Proximity to facilities• For those who joined through volunteering

Policy implications for resilienceRecruitment strategies for retention in hard to serve areas should focus on staff with strong intrinsic motivation• key for conflict and crisis (erratic pay, difficult working conditions, non-functional formal

promotion structures) [e.g. Ug.]

Training policies should focus on offering good access for less advantaged local students • May contribute to strong retention and loyalty to sector

Volunteering • should not be ‘abused’ [ e.g. SL]. • also need to ensure quality

Consider themes of professional status in policy circles• Uniforms ( SL, Zim, Ug]• Maintain respect [ Ug]• Revive trust in epidemiological crisis [ SL]• Maintain brand image?[ may be costly but also very beneficial]

Effect of conflict & crisis on health

workers and coping

mechanismsDr Haja Wurie


Conflict – Northern Uganda, Cambodia, Sierra Leone• Cambodia

• 1969-1978 conflict - Khmer Rouge regime• Devastating effects on social and economic infrastructures and severe HRH

implications• 1979: Regime partially overthrown in 1979, but continued conflict in some

areas• 1999: reconstruction initiated but challenges for the health system still exist

• Northern Uganda • Conflict lasted 20 years (1986-2006) • Negative impact for the broader health system including health workers who

stayed• Peace Recovery and Development Plan informed the post conflict recovery phase to improve the general health service delivery

• Sierra Leone• Civil war that spanned 11 years ending in 2002 Health care system devastated and its effect still evident a decade after the war

Economic crisis - Zimbabwe

• Resulted in the decline of Zimbabwe’s Gross Domestic Product leading to inadequacies to finance government services.

• Negative impact on the economy between 2000 and 2008

• Mid-2008, hyper-inflation led to the demonetisation of the Zimbabwe dollar and the adoption of multiple currencies as official tender in 2009

• Decline in living standards and increase in poverty occurred during this crisis period, alongside dramatic decline in health indicators

Decade long socio-economic and political crisis between 1997 and 2009

Ebola – Sierra Leone (2014-15)

• All efforts made in the post conflict phase suffered a major setback

• Outbreak and the response further exposed the gaps in the health sector

• Second rebuilding phase underway

Effect of conflict on health workersPersonal

• Abduction ‘…. I was abducted by rebels in 1993. I was

with the rebels up to 1995, and when I gained my freedom..’ (Sierra Leone)

‘…and so the rebels went with the clinical officer to go and tell them which drug works

for which infection[...] but he came back after some months…’ (Northern Uganda)

• Death and injury ‘My family had 6 members, after Khmer Rouge, only 3 were left. My father was

taken for education and never returned. My sister and brother died of malaria’

(Cambodia)• Insecurity and fear

“…soldiers coming to hospital for service and when we could not provide them

service or medicine as fast as what they wanted, sometime they shot to the air or

they threatened us” (Cambodia)“Then you could hear gunshots, someone shooting just very near at times you feel

like you are going to be short at that time, that fear was there” (Northern Uganda)

Professional• Overload“Also in the PHU the work load was too much,

the staff capacity was very low […] initially we were only 3, myself, the CHO, one SECHN and one MCH aide, so we were subjected to work right round the clock… (Sierra Leone)

• Challenging working conditions“At the beginning it was terrible. The hospital

at Prek Pnov had only one or two beds and there were a lot of patients who got malaria,

diarrhoea, and so on. The road was often very bad. It was not really safe, some of the

sounding area, Khmer Rouge pass by very often” (Cambodia)

• Non-receipt of salary‘…we lived by magic […] you don’t know

when you will get your salary and what you have at home you don’t want it to get

finished because there are children […] So we had to manage the finances […] the little we had […] People who had the stuff will hide it

because they don’t want it to get finished and what you wanted you are searching all over the place. Even one of our church members lost his life just going out to look for rice and

he was shot’ (Sierra Leone)

Effect of economic crisis on health workers

• Increased shortages of staff“…there are challenges of shortage of human resources and other materials. We

are short staffed; six nurses short, there is need to increase the number of nurses” (Zimbabwe)

• Devaluation of pay• Resource shortages at work“There is a shortage of drugs and there are no doctors, it is very difficult to work

in those conditions. There is also a shortage of equipment and drugs to use during labour, people endure pain for a long time and at times there will be no driver for

the ambulance to transfer the patients to a referral hospital” (Zimbabwe)• Living conditions“Staff accommodation is also a problem - some nurses are staying in boys hostels and there are no cooking facilities and some building have deteriorated but they

cannot be renovated because of lack of funds” (Zimbabwe)

• Loss of quality and discipline“There is no transparency in the recruitment of students and workers. You will see

a husband, wife and children working at the same place. You cannot control behaviour of people with power, they corrupt the situation and they are difficult to

manage and supervise” (Zimbabwe)

Effect of Ebola on health workersPersonal

• Fear of death• Fear of patients• Changed family dynamics“I left home and since then I’ve not been back because I didn’t want to

work with patients and go home and if I should fall sick, if its Ebola then

my family will have to be in quarantine for 21 days […] this is

one sacrifice I have had to make to get separated from my family”

• Community stigma“(They were) saying your husband is working there, please don’t get from

our (water) well […]So my wife is really stressed by them. I always told her ‘please just be calm, we know we are doing the right thing, let us pray”

Professional• Lack of supplies and

equipment“You need to have the necessary

equipment to fight. What has been the problem is that even when

there is this readiness of facing this battle we have not been given the

proper equipment to fight.” • Increased stress and

workload• Economic difficulties

“Many health workers, their basic earning power decreased as a result

of Ebola. So it has this economic impact….”

• Worsened relationships with colleagues

“… colleagues in the general ward they were really intimidating us. If I walked through this corridor, they

will just move and just give a space for me to pass.”

Similarities and differences

Physical safety(conflict and epidemics)

Psycho-social(conflict and epidemics)

Working conditions and remuneration(all shocks)

Impact of shock on health workers

• Death and injury

• Infection• Fear for

self, family and colleagues

• Loss of trust in community, in colleagues, in patients

• Disrupted family lives

• Stress

• Overload• Lack of resources

for working and living

• Blockages or loss of pay and remuneration

• Loss of quality and discipline in the workplace

Coping strategies Physical

safety(conflict and epidemics)

Psycho-social(conflict and epidemics)

Working conditions and remuneration(all shocks)

Coping by health workers

• Self-protection

• Internal values and resources, including religion, patriotism etc.

• Personal strategies for distraction, comfort and sedation

• Peer support, including through social media

• Family support

• Additional earning options • Dual practice (mainly in

economic crisis)• Borrowing money• Working longer hours• Task shifting and taking on

new roles; improvisation to cover material shortages

• Informal movements of staff

• Using own resources for patients or passing on costs to patients

External support

• Protective materials provided

• Managerial support (local and international)

• Workshops and training

• Rebuilding relationships with communities

• Donor support• Expatriate staff support • Additional allowances (e.g.

risk allowance)

Policy implications

Working conditions and remuneration

• Plans in place for rapid response – e.g. providing back-up drug supplies

• More flexible payment systems for staff• Greater freedom for local responses• Redeployment where needed

Physical safety

• Enforcement of protective laws for health workers during conflict

Psycho-social

• More proactive communication• Support for health staff and communities in

all crises

HRH incentive policies post-

conflict and crisisSophie Witter & Yotamu Chirwa


Analysing policy evolution across contexts

• HRH challenges widely shared across the four cases in the post-conflict period but that the policy trajectories were different – driven by the nature of the conflicts but also the wider context

• Problems are well understood in all four cases but core issues – such as adequate pay, effective distribution and HRH management – are to a greater or lesser degree unresolved

• These problems are not confined to post-conflict settings, but underlying challenges to addressing them – including fiscal space, political consensus, willingness to pursue public objectives over private, and personal and institutional capacity to manage technical solutions – are liable to be even more acute in these settings.

• The role of the MoH emerged as weaker than expected, while the shift from donor dependence was clearly not linear and can take a considerable time

• Financial and technical dependence can change at different paces

• Windows of opportunity for change and reform can occur but are by no means guaranteed by a crisis – rather they depend on a constellation of leadership, financing, and capacity

• Recognition of urgency is certainly a facilitator but not sufficient alone• Evidence of path dependency in decisions made post-conflict

• Post-conflict environments face particularly severe challenges to evidence-based policy making and policy implementation, which also constrain their ability to effectively use the windows which are presented

Incentive packagesIncentives – need to ensure a balanced package over time, once the intensity of the conflict experience recedes, which prioritises those who serve in hard-to-reach areas but also ensures equity across conflict lines.

• Consultation of staff is key in developing these policies; good communication within facilities and within the sector is a ‘low hanging fruit’

• Also reinforcing supervision and improving working conditions• Aspects which require more organisational change can receive less priority than

financial incentives, which donors find easier to finance In PC settings, similar motivations for staff and changing aspiration over the career cycle to more stable settings but even greater tendency to fragmentation of incentive structures• Linked to multiple actors?

• Incentive policies tend to be piecemeal, poorly funded and implemented • No feedback loops• Policies often crafted with external inputs but limited traction • Some areas of reform particularly hard to address, like management reforms• Some countries experience increased patronage/interference with postings and

promotionsPhases: fragmentation initially may be adaptive, but when to harmonise (e.g. Timor Leste – on to payroll quite quickly). Also opportunities to learn and innovate - e.g post-Ebola SL; able now to capitalise on interest; use evidence from past.

Mind the (sectoral) gapThe conflict/post-conflict dynamics can affect the balance of attraction and retention across sub-sectors within health, distorting the provision of care. • e.g. in northern Uganda, during the conflict, the PNFP sector

remained more functional, including in terms of supporting staff with pay.

• The public sector was boosted in the post conflict phase due to increased investments under the PRDP, consolidation of allowances and introduction of hard to reach allowances. The salaries also became more regular while pension continued to be provided.

• Our findings suggest that retention within the PNFP sector has had to rely on more personal factors, such as loyalty and family ties, while many still working in the PNFP sector express the intention to leave, if circumstances permit.

• In Zimbabwe, the public sector has been unable to offer the same terms and conditions for staff, given the crisis; the municipalities have independent income source and so employ more senior staff to do less demanding roles in urban clinics, adding to shortages in other areas

Rural retentionRural health workers face particular challenges, some of which stem from the difficult terrain, which add to common disadvantages of rural living (poor social amenities etc.).

• Poor working conditions, emotional and financial costs of separation from families, limited access to training, longer working hours (due to staff shortages) and the inability to earn from other sources make working in rural areas less attractive.

• Moreover, rules on rotation which should protect staff from being left too long in rural areas are not reported to be respected.

• Incentives for rural areas limited political focus – especially ineffectual? • Insecurity

By contrast, poor management had more resonance in urban areas, with reports of poor delegation, favouritism, and a lack of autonomy for staff. Tensions within the team over unclear roles and absenteeism are also significant demotivating factors in general. Local staff & mid-level cadres more likely to work in remote areasDuring economic crisis, rural areas can have advantages (e.g. Zim – lower costs, able to subsist etc.)To work in remote areas workers need:

• recognition of role and achievements in challenging circumstances• practical measures to improve their security• provision of decent housing, working conditions, training and pay• trust, communication and teamwork

The gendered health workforce

• Lack of balance: in all contexts women predominate in nursing and midwifery cadres; are under-represented in management positions and tend to be more clustered in lower paying positions

• Gender roles, shaped by caring responsibilities at the household level, also affect attitudes to rural deployment and women in all contexts faced particular challenges in accessing both pre- and in-service training as compared to their male counterparts

• Conflict and coping strategies within conflict emerged as a key theme, with gendered strategies and experiences also shaped by poverty and household structure

• Most HRH regulatory frameworks did not use the PC moment to address gender. Key priority areas for addressing gender equity in the health workforce in FCAS include (1) ensuring gender is integrated into policy and (2) fostering dialogue and action to support change for gender equity within institutions and households.


Overview of incentive evolution in Zimbabwe

• Inability to remunerate health staff effectively since start of crisis• Emergency response from international partners, who contributed to

the retention allowances and later critical post allowances, was crucial after the crisis in 2009

• Contributed to a reduction of internal movement of health workers as a result of an improvement in incentives in the post- crisis period (harmonized retention, HTF and RBF)

• Dollarisation in the immediate emergence from crisis also contributed to the relative stabilisation of the health workforce

• RAA is the only incentive specific to rural areas, but has not been effective because it is universal, low and not related to hardship posts

• Senior and experienced health personnel concentrated in PHC facilities (in municipalities)

• Insecurity of allowances and debates over who receives them continue… with renewed threat of brain-drain

Salary differentials• Higher salaries in the municipality compared to public and

mission subsector (main providers of health care in rural areas)• Nurses and midwives willing to take up positions in the

municipal subsector even if they were more senior and qualified because of the higher salaries

32

Cadre Government

Municipality Mission

Cadre Maximum salary (USD)

Maximum salary (USD)

Maximum salary (USD)

EHP 420 2,700 550MWs 485 2,200 350Nurses 434 2,203 400

Comparison of hourly rates of remuneration by sector (2013)

Other benefits, by sector

Gov

t

Mun

icip

ality

Mis

sion

Gov

t

Mun

icip

ality

Mis

sion

Gov

t

Mun

icip

ality

Mis

sion

Housing Food Health Care

0%

20%

40%

60%

Percentange of cadres who received non- finan-

cial benefits by sub-sector

Transport

Housing

Retention

Uniform

0

20

40

60

80

100

120

140

160

180

Incentives paid by sub-sector in $

GovernmentMunicipalMission

Amou

nt in

$

Health workers experiences of different sectors in ZimbabweMunicipal health workersafter qualifying I worked at [FBO]at City Health since 1988… I applied …was …interviewed and I passed the interview. …I’m staying here till retirement… I’m getting a very good salary, housing allowance, professional allowance, midwifery allowance, water allowance, transport allowance (IDI 015 female Nurse

I applied to the municipality for a job, was interviewed and got the job in 1990 and ever since I have been a nurse in the municipality and I will retire from here in a year’s time (IDI 003Nurse

‘

Public sectorI am not happy, am not satisfied because of the salary and the conditions of service. A person in my post must have incentives e.g. car loan, i.e. incentives that make you comfortable (IDI 011 female matron Public sector District 1)

Salaries in the public sector were unrealistically low especially during the difficult times…there is some improvement, health workers continue with private work and the question of whether this is sanctioned or not does not arise because the salaries are very low. (KII 22 female Doctor Public sector)

‘I am managing’: complex remuneration and income use strategies of primary health

workers in Sierra LeoneMaria Bertone


www.fondation-aedes.org

FONDATION

Background

• Limited evidence on health workers’ actual earnings in post-conflict settings

• Formal allowances, but also informal incomes

• Is the incentive package is effective in addressing HRH challenges?

• How much do primary health workers earn? • What are health workers’ perspectives and views on

their incomes?• How do health workers use their incomes?

Methods

Methods (1)

• Survey of 266 primary health workers in 198 randomly selected health centres in Bo, Kenema and Moyamba

• Different cadres of nurses and nursing aides (CHOs, CHAs & nurses MCH Aides)

• Daily logbook completed by health workers over 8 weeks detailing incomes earned and activities performed• 39 in-depth interview with a sub-sample of health workers

Methods (2)

Cross-sectional survey

Share of user fees

Salary

Remote Allowance

PBF (individual bonus)

Salary supplementations / top-ups

Per diemsNon-health income-generating activities

Longitudinal logbook

Gifts and payments from patientsSale of drugs and items w/in facilityPrivate practice

Implementation of HRH reforms

“They [MoHS at central level] don’t even communicate with us. We are dealing with the staff here, we know the staff movement. [...] But they say that they have the data there. But sometimes they pay staff that are not even in remote areas” (KII – DHMT)

“I mean, [PBF] is good in theory, but when it comes nine months later, I think it defeats the whole purpose” (KII – DHTM).

“I heard many, many health workers, PHU staff, and DMOs talk about performance-based financing. I've never heard anyone mention this remote area allowance”(KII – NGO).

“The real key issue is that with all of these policies and all of these strategies, none of them have been properly operationalised and none of them have stayed around. Like, in 2002, there was a free health care policy announced [...] and then it just didn’t happen. So free health care is announced again in 2010, and it’s like, OK, it’s happening, but is that going to slowly start to fall apart? If PBF is announced, it’s like, oh it comes and then it stops, you know.” (KII – NGO).

Remote allowance: 5%-8% of income of all HWs (Dec. 2012) delayed and then stopped from Jan. 2013Performance Based Financing: 11% of income of HWs (Sept. 2013) payments received more than one year later than services are performed

Health workers’ incomes

Health workers’ incomes

Health workers’ views of their incomes

Health workers’ views of incomes (1)• Somewhat incongruous accounts on incomes

• Importance of non-financial features of incomes:• Entitlement vs. windfall• Ease of access (cash vs. bank)• Fairness and transparency • Delays in payment • Transparency in sharing practices

• Income fragmentation as an issue

PBF “helps”, “good money”, “really enough” (HWs in all districts).

Salary is “not enough”, “is small for the job”, is “not satisfying” (HWs in all districts).

Health workers’ views of incomes (2)• Health workers said that they “manage”

“Well, if I gather everything together at the same time it helps [i.e. my income is enough], but the money does not come together, it comes in little bits. So what I have at the moment, I manage with it. I have no other way to do it” (CHA/nurse in Kenema).

“I have to manage my life with it [my income]” (MCH Aide in Moyamba) “Well, it is not

easy. You have to manage yourself” (CHA/nurse in Moyamba)

Health workers’ use of incomes

• Health workers take advantage of the different financial and non-financial features of their incomes spend different incomes differently

• Salary• High and regular (“earmarked”) expenditures• Received through bank account and not readily available• Subject to family pressures

• Per diems, non-health activities, in-kind gifts from patients and communities

• Personal subsistence while in post+ emergency expenditures• Readily available • Unknown to family (“hidden”)

• PBF bonus • Substantial amount which can be re-invested in non-health activities (e.g.

business such as buying palm oil, etc.)

Background

Policy implications

Policy implications (1)

• How generalizable are these findings to other settings?

• Formal revenues are the most important income for health workers and essential for their motivation

improve management of official payments• Salary payroll• Remote allowance to improve retention/motivation in rural areas• PBF bonuses

• Strengthen routine information system• Decentralize HRH management• Streamline and clarify allowances• Improve transparency and regularity of payments

Policy implications (2)

• Non-governmental incomes are also key in the income utilization strategies of health workers

Improve incentive packages for health workers• Gather information on the entire remuneration of health

workers, including informal incomes, and include them in harmonization efforts (e.g. per diems)

• Reflect on the health workers’ perspectives and use of their incomes

• Incomes are not fully ‘fungible’

Think of post-conflict/crisis legacies• Income fragmentation due to presence of NGOs (per diems and

salary supplementations)? Where? For how long?

Thanks to the whole team and all research participants

Cambodia: Sovannarith So, Sothea SokSierra Leone: Haja Wurie, Mohamed SamaiUganda: Justine Namakula, Freddie SsengoobaUK: Sophie Witter, Maria Bertone, Alvaro Alonso-GarbayoZimbabwe: Yotamu Chirwa, Pamela Chandiwana, Wilson Mashange, Mildred Pepukai, Shungu Munyati

Thank youAll resources can be

found on the ReBUILD website:

www.rebuildconsortium.com

Contact:[email protected]

@ReBUILDRPC

https://rebuildconsortium.com/media/1410/hrh-resources-from-rebuild-october-2016.pdf

http://www.rebuildconsortium.com/

http://www.rebuildconsortium.com/

mailto:[email protected]




how to promote a resilient health workforce in conflict affected settings - insights from four...

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