Making Health Systems Work for Child Survival: Developing and

Monitoring Critical Human Resources

David SandersAndy Haines

Robert Scherpbier

Outline of Presentation

• A definition of health systems and the place of human resources

• Two case studies of ‘child survival’ interventions illustrating key human resource issues

• Africa’s HRH crisis and out-migration• The HR development cycle and key interventions

needed - in policies and planning - in production and management - in monitoring progress• Conclusions

The Health System and its Human Resources The WHO definition of health systems includes “all the

activities whose primary purpose is to promote, restore, or maintain health”:

Interventions in the household and community and the outreach

(health information and education, etc.) that supports them;

Facility-based system and broader public health interventions, such as food fortification or anti-smoking campaigns.

All categories of providers: public and private, formal and

informal, for-profit and not-for-profit, allopathic and indigenous

Mechanisms, such as insurance, by which the system is financed

Regulatory authorities and professional bodies who are meant to be the “stewards” of the system.

Components of Health Systems ”HARDWARE” Facilities e.g. Hospitals, Health Centres

Technology / Equipment / Drugs

Transport

Communications

Finance

“SOFTWARE” *Human Resources for

Human Resources Health

*Communities

*Other Sectors’ Personnel

Processes – policies, service provision, legislation/regulation,

advocacy

Human resources are centrally important

Stewardship Financing

Service delivery

HUMAN RESOURCES convert other resources

into outputs that contribute to better health

outcomes

Neglect of human resources planning, production,

retention, and motivation will continue to cause other

resources to be wasted

HUMAN RESOURCES

account for 60-70% of health expenditures

Resource generation

HEALTH OUTCOMES

Source: Adapted from JLI

Health system functions

A case study of management of malnutrition

Mortality in Children 0-5 Years Oldin Southern Africa

MalnutritionMalnutrition

Diarrhoeal Diseases

AcuteRespiratoryInfections

MeaslesMalaria

Perinatal complications

Others

WHO’98

Political, cultural,religious,economic, andsocial systems,including women’sstatus, limit theutilization ofpotential resources

Inadequateand/or

inappropriateknowledge anddiscriminatoryattitudes limit

household accessto actual resources

Poor water/sanitation and inadequate health services

Child malnutrition, death and disability

Inadequate maternal and

childcare practises

Insufficient access to food

Potential resources: environment,

technology, people

Causes of Child MalnutritionCauses of Child Malnutrition

Inadequateefficacious nutrient

supply

Disease

Basiccauses atsocietallevel

Outcomes

Immediatecauses

Underlyingcauses athousehold /family level

Quantity and quality of actual resources - human,economic, and organisational - and the way they

are controlled

UNICEF Conceptual Framework

‘Globalisation’ results in unequal growth of wealth

..and growth of poverty

Poverty in Southern Africa

Population living below poverty line 1996

Population living below poverty line 2001

Lesotho 49% 49%

Malawi 60% 65%

Mozambique 69% 69%

Swaziland 48% 66%

Zambia 69% 86%

Zimbabwe 61% 75%

(Source: Cited in UNOCHA, July 2002)

0 500 1000 1500 2000 2500 3000

US dollars

J apan annual dairy subsidy, per cow

EU annual dairy subsidy, per cow

Per capita annual income, sub-Saharan Africa

Per capita cost of package of essential health interventions

Per capita annual health expenditure, 63 low income countries

Would it be better to born a Japanese cow Would it be better to born a Japanese cow than an African citizen?than an African citizen?

AN EXAMPLE FROM SOUTH AFRICA: MT. FRERE HEALTH DISTRICT

Eastern Cape Province, South Africa

Former apartheid-era homeland

Estimated Population: 280,000

Infant Mortality Rate: 99/1000

Under 5 Mortality Rate: 108/1000

STUDY SETTING:PAEDIATRIC WARDS IN RURAL HOSPITALS

Nurses have the main responsibility for malnourished children

Per Ward: 2-3 nurses and 1-2 nursing

assistants on day duty, and 2 nurses on night duty 10-15 general paediatric

beds and 5-6 malnutrition beds

Implementation Cycle

Capacity Development

Advocacy

Teambuilding

Analysis

Situational Assessment

Planning

Implementationand Management

EvaluationPolicy

CASE FATALITY IN RURAL HOSPITALS

PRE-INTERVENTION CFRs –calculated from ward registers

Mary Teresa 46% Sipetu 25%Holy Cross 45% St Margaret’s 24%St. Elizabeth’s 36% Taylor Bequest 21%Mt. Ayliff 34% Greenville 15%St. Patrick’s 30% Rietvlei 10%Bambisana 28%

Implementation Cycle

Capacity Development

Advocacy

Teambuilding

Analysis

Situational Assessment

Planning

Implementationand Management

EvaluationPolicy

WHO 10-STEPS PROTOCOL – Nutrition component of hospital level IMCI

Step 1 Treat/prevent hypoglycaemia

Step 2: Treat/prevent hypothermia

Step 3: Treat/prevent dehydration

Step 4: Correct electrolyte imbalance

Step 5. Treat/prevent infection

Step 6. Correct micronutrient deficiencies

Step 7. Cautious feeding

Step 8. Catch-up growth

Step 9. Stimulation, play and loving care

Step 10. Preparations for discharge

Comparison of recommended and actual practicesSITUATIONAL ANALYSIS IMPLEMENTATION

Recommended practice  

Practice prior to intervention

Perceived barriers to quality care

Programme intervention

Changes reported at follow up visits

Step 1: Treat/prevent hypoglycaemia  Feed every 2 hours during the day and night. Start straight away.

Children were left waiting in the queue in the outpatient department and during admission procedures. In the wards, they were not fed for at least 11 hours at night   Hypoglycaemia not diagnosed

Lack of knowledge about risks of hypoglycaemia  Lack of knowledge about how to prevent it Shortage of staff especially during the night No supplies for testing for hypoglycaemia

Training to explain why malnourished children are at increased risk  Training on how to prevent and treat hypoglycaemia Motivated for more night staff in paediatric wards Motivated the Department of Health to provide resources (10% glucose and Dextrostix.)

Malnourished childrenfed straightaway and 3 hourly during day and night.  The number of night staff was increased Dextrostix and 10% glucose obtained

WHO 10-STEPS TRAINING – Mt. Frere District, Eastern Cape

Developed as part of a District-Level INP

Training & Implementation from March 98 to Aug 99

Two formal training workshops for Paeds staff

On-site facilitation by nurse-trainer

Adaptation of protocols – Now have Eastern Cape Provincial Guidelines

Evaluation of Implementation

Major improvements: Separate HEATED wards 3 hourly feedings with appropriate special formulas

and modified hospital meals Increased administration of vitamins, micronutrients

and broad spectrum antibiotics Improved management of diarrhea & dehydration

with decreased use of IV hydration Health education & empowerment of mothers

Problems still existed: Intermittent supply problems for vitamins and

micro-nutrients Power cuts – no heat Poor discharge follow-up Staff shortage, of both doctors and nurses, and

resultant low moraleAshworth et al, Lancet 2004; 363:1110-1115

SIPETU CASE FATALITY RATES BY TRAINED/UNTRAINED PERIODS

25

2018

38

0

5

10

15

20

25

30

35

40

Cas

e F

ata

lity

Rate

(%

)

PRE-INTV TRAINED TRAINED-STUDY UN-TRAINED

DIFFERENCES IN TREATMENT

Treatment Trained Un-Trained P-ValueKCl 78% 13% p=0.0000Broad SpectrumAntbx 47% 15% p=0.0001IV Hydration 5% 6% p=0.774Vitamin A 92% 76% p=0.0115

*No change in diagnoses, severity, co-morbidity or nursing care related to 10-steps across the two time periods.

“There wasn't enough emphasis on patient management in a lower level institution, our training was mostly theoretical…most patients are filtered out at this lower level therefore the students don't see them...

…it's not so much WHAT as WHERE the training takes place…

...the Sister is teaching me a lot, I'm learning more than I ever learnt in my whole training!”

Quotes from a Community Service Doctor

CHANGES IN CFRs IN RURAL HOSPITALS

0

5

10

15

20

25

30

35

40

45

50

Holy-cross St. Patricks Mt. Ayliff St. Elizabeth

1998-1999

2000-2001

2002

2003

Ongoing research indicates leadership and management at all levels are the keyreasons for the differences between well and poorly performing hospitals

EVALUATION OF STEP 10

To determine Household Food Security(HHFS), caregiver knowledge & factors associated with malnutrition

To look at the rate of recovery & health status at 1 month & 6 months post discharge

POST DISCHARGE HOME VISITS(HV)

At 1 month (n) = 30 At 6 month (n) = 24

76% remembered key messages about food fortification

71% of caregivers unable to implement acquired knowledge of feeding practices

CAREGIVER KNOWLEDGE OF NUTRITION

STAPLE FOOD INVENTORY LIST Samp / Maize Beans Maize Meal Flour Rice Sugar Soup Tea / Coffee Milk Oil Peanut Butter Eggs

No. of food items in HH Cupboard

% of HH

0 - 4 47

5 - 8 30

9 - 11 23

HOUSEHOLD SOURCE OF INCOME

PENSION GRANT 40 % MIGRANT LABOURERS 25 % NO INCOME FAMILIES 20 % DOMESTIC WORKERS 15 % CHILD SUPPORT GRANT (CSG) 0 %

CSG – Children aged 0-9 years in families earning less than R800 per month eligibleCSG - currently R160 ($26)

Implementation Cycle

Capacity Development

Advocacy

Teambuilding

Analysis

Situational Assessment

Planning

Implementationand Management

EvaluationPolicy

EMPTY STOMACHS: Year-old Samkelo is one of nine children that his jobless grandmother, Nofuduka Mbulawe, has to feed

Picture: Richard Shorey

Sunday, September 22 2002

Starving to death on arable land Poverty is killing children in the Eastern Cape. But breaking out of its grip is no easy task, write Thabo Mkhize and Heather Robertson

A nutrition study by the University of Western Cape showed that Samkelo is one of the more fortunate - 166 babies at 11 hospitals in the northeastern district have died of malnutrition

ONE-year-old Samkelo Mbulawe has only a tattered blanket to cover his distended stomach and flaking skin. He has just returned home after two months in the Mount Ayliff Hospital where he was treated for kwashiorkor, a form of malnutrition.

Advocacy Component

Presentation of data to Government Commission on Social Welfare

Partnership with ACESS resulted in TV documentary – ‘Special Assignment’ – elicited unexpected response from both public and government

Minister of Social Development visited Mt Frere and ordered mobile team in to process CSGs

Questions in Parliament re child welfare

Massive Child Support Grant Campaign in E. Cape, October 2002

% Change in CSG Beneficiaries Per Province from Dec 2001 to Oct 2002

31.4

61.1

38.5

21.8

36.3 3631

44.8

56.3

40.2

0

10

20

30

40

50

60

70

EC L KZN NW MP FS NC GT WC S.A

Province

Pe

rce

nt

Ch

an

ge

Source of data: SOCPEN daily records: 19/12/2001 and 3/10/02 in T. Guthrie, UCT & ACESS, Feb. 2003

A Case Study of Management of Pneumonia

IMCI pneumonia case management (Tanzania)

Coverage: child actually receives the intervention

0

10

20

30

40

50

60

70

80

90

100

Breastfe

eding

6-11

mo

Measle

s vacc

ine

Vitamin

A

Skilled

birth

atten

dant

Tetanu

s toxo

id

Antibiot

ics for

pneu

monia

ORT

Newbo

rn res

uscita

tion

% ch

ildre

n re

ceivi

ng in

terv

entio

n

Source: Jones et al, Lancet 2003, 362: 65-71

Towards population impact

Population effectiveness =

Intervention efficacy x

Intervention availability x

Diagnostic accuracy x

Provider compliance x

Patient compliance x

Coverage

Tugwell framework applied to multi-country evaluation data

IMCI pneumonia case management (Tanzania)

Intervention efficacy 65%

Health workers are trained 80%

Health workers assess child correctly63%

Health workers treat child correctly 65%

Coverage (mother recognised illness, sought care and complied with treatment: child receives the intervention)

40%

Pneumonia mortality averted =

9%

Source: Tugwell, J Chron Dis, 1985; 38(4):339-51

The HR factor

Coverage under actual programme conditions

Towards population impact

Population effectiveness =

Intervention efficacy x

Intervention availability x

Diagnostic accuracy x

Provider compliance x

Patient compliance x

Coverage

IMCI pneumonia case management (Tanzania)

Intervention efficacy 65%

Health workers are trained 90%

Health workers assess child correctly90%

Health workers treat child correctly 90%Coverage (mother recognised illness, sought care and complied with treatment: child receives the intervention)

40%

Pneumonia mortality averted =

19%

Source: Tugwell, J Chron Dis, 1985; 38(4):339-51

The HR factor

Coverage under improved programme conditions

HR Issues Raised by Case Studies

Low doctor/nurse : patient ratio due to inadequate production, distribution and retention

Inappropriate training Poor health worker performance – assessment,

treatment, care, communication, advocacy Inadequate monitoring and support/supervision,

management, leadership incl senior policymakers

Erratic ordering of supplies Poor community coverage and follow-up Poor performance of health-related sectors

Health Workers Save Lives!

0

1

2

3

4

5

6

7

8

9

0 1 2 3 4 5

Density (workers per 1,000, log)

Mo

rtal

ity

(per

1,0

00,

log

)

Maternal

Infant

Under-5

Anand & Barnighausen, 2004

Nurse density and vaccination

0102030405060708090

100

1 10 100 1,000Density (per 100,000)

Co

vera

ge

(%)

MEASLES

DTP

POLIO

Anand & Barnighausen (forthcoming)

Accumulating Evidence of Effectiveness of Community Health

Workers • Experiences of improved coverage and health

outcomes in large-scale NGO programmes in Bangladesh (BRAC, GK), India (Jamkhed) (1970s/80s.

• Experiences of Good Health at Low Cost countries – Sri Lanka, Kerala, China (1960s-80s

• Experiences of Thailand, Ceara Brazil (1990s)• Recent studies in India (Bang), Nepal

(Manandhar), Pakistan (Bhutta)

Coverage increased in all through community participation and CBHWs

HR Policies and Planning for child survival programmes

Policies

Production

Management

Planning

Human resource cycle

Based on: Hall and Mejia, 1978

Align and link HR and CS programme

policies (based on population health

needs and programme

interventions & targets)

Define tasks and skills required per

level.Estimate time requirements.

Define distribution and skills mix.

Estimate total HW numbers required

(FTE) per level

Planning for HRH needs

Assessment of numbers, skills and distribution of HRH is complex. Service-target planning requires knowledge of

• Needs• Targets• Tasks and skills• Time • Productivity Dreesch et al, Health Policy and Planning,

2005

For instance, Ethiopia spends 22% of its national budget on health and education, but this amounts to only US$1.50 per capita on health. Even if Ethiopia were to spend its entire budget on healthcare, it would still not meet the WHO target of US$30–40 per capita (Save the Children 2003).

““Countries just don’t have enough Countries just don’t have enough money.”money.”

Rt. Hon. Hilary Benn, April 2004, Rt. Hon. Hilary Benn, April 2004, WFPHA/UKPHA, BrightonWFPHA/UKPHA, Brighton

But….

In 2000, Tanzania was preparing 2,400 quarterly reports on separate aid-funded projects and hosted 1,000 donor visit meetings a year.

AIDS and Aid may both disrupt health systems…

Labonte, 2005, presentation to Nuffield Trust

HRH and Africa…

Burden of diseaseBurden of disease

Share of populationShare of population

Share of health workersShare of health workers

Our Common Interest 2005:184 Our Common Interest 2005:184

HRH Density by Regions

2.3

2.6

4.2

6.9

8.7

9.9

10.3

0.8

0 2 4 6 8 10 12

Europe

North America

Western Pacific

Middle East

Global

S&Central America

Asia

Sub-Saharan Africa

Workers (physicians, nurses and midwives) per 1,000 population

Source: JLI, 2004

Workforce data are aggregates that mask unequal distribution between rich and poor

African countries and between rural and urban areas

Health professional migration from Africa

• Between 1985 and 1995, 60% of Ghana’s medical graduates left

• During the 1990s Zimbabwe lost 840 of 1,200 medical graduates

• In 1999, 78% of doctors in South Africa’s rural areas were non-South Africans

• 2,114 South African nurses left for the UK during 2001

NURSE REGISTRATION IN UK :Increase during a period when a “ban” on active international recruitment had just come into effect

Buchan et al 2003

Migration ‘Carousel’ From rich to poor sectors/nations within and between

countries/continents Push and pull factors In search not just of better economic conditions but also.. Promotion prospects New techniques and knowledge Better working conditions- (hours , burn-out, support, less

disease risk ) Some positive effects (e.g. remittances, improved skills of

returnees etc)

The GATS (General Agreement on Trade in Services) is likely to aggravate “trade” in health professionals by increasing the size of the private sector North and South (GATS Mode 3) and easing cross-border movement (GATS Mode 4).

International migration - losers UN Conference on Trade and Development

(UNCTAD):for each professional aged between 25 and 35 years, US$ $184,000 is saved in training costs by rich countries

The loss of approximately 20,000 skilled workers per annum results in an annual loss of US$ 4 billion to Africa

Africa spends an estimated 35% of ODA annually, approx. US$ 4 billion, on salaries of 100,000 foreign experts (all sectors, not only health) to replace lost capacity, to ‘build capacity’ and/or provide technical assistance

Pang et al, 2002; UNECA, 2000; IRIN, 30 April 2002

Potential policy options to address migration

Source countries Pay and non pay incentives ( hardship allowances, better support,

promotion, training access, child education , housing etc) Train more mid level cadres ( clinical assistants, nursing aides etc)

Address HIV/AIDS and gender issues Structured return programmesReceiving countries Increase own production ‘Ethical recruitment’ Bilateral agreements Compensation inc. educational initiatives

But little evidence of what works

HR “Production” and Management for child survival programmes

Policies

Production

Management

Planning

Health outcomes

Based on: Hall and Mejia, 1978

Design retention

strategies,Institutionalise

supportive supervision

Harmonise HW estimates and skills

needs with ‘production’ plans and curricula (of medical schools,

‘auxiliary’ schools, nursing colleges).

More in-service and CE. Train CHWs.

Outputs (quality)

Basic and Pre-registration training

• Review alignment of under- and post-graduate training (and texts) of doctors and nurses towards major child health problems

• Increase amount and importance of practice-based learning in low-resource settings

Waterston and Sanders, Medical Education, 21, 1987

• Accelerate production of mid-level workers such as medical assistants and nurse aides (Overcome resistance of professional registering bodies)

• Revisit evidence for effectiveness of CHWs and accelerate their production

Lewin SA et al, Cochrane Database 2005, Issue 1.

Capacity development

Capacity development is required at all levels of the health sector: – central management, who need skills

in change management and stewardship;

– local managers and service providers (doctors, nurses, mid-level workers) who need different combinations of clinical and public health skills;

– Southern institutions, including universities, training schools and units

Improving performance of existing health workers is a priority Rowe A et

al, Lancet 2005

Audit and feedback – more focus on problem-solving through health systems research

Supportive supervision Educational outreach Guideline implementation strategies Performance – related allowances ? Harries A,

Salaniponi F, Lancet 2005

“ ..If training and guidelines are to have an impact they must be provided within a context that provides reminders, supportive supervision, feedback and, perhaps, more formal quality assurance…”

English M, Arch Dis Child 2005

Monitoring

• Policies– Targets (# HW trained and distribution)– Quality of care (standards for competencies)

• Planning– Estimates (# HW trained and distribution)

• "Production"– Balance inflow/outflow– New trainees and old trainees upgraded

• Management– Supervision and support– Implementation of retention strategies– Quality of care (measurements though special

surveys and tools)

Possible Indicators

Several sources of data e.g. censuses, labour force surveys, enrolment and completion figures (N.B forthcoming World Health Report)

Criteria – policy relevance, reliability, validity, simplicity, ability to (dis)aggregate

• Density per 1000 population• Skill mix• Participation, employment opportunities ,

retention• Distribution – geographical ( equity), private vs

public, disease specific programmes etc• Production - training, attrition rates etc • Performance

Conclusions• Prioritise and plan Human Resources

• Reinstitute mid-level and community health work

• Education should be problem-oriented and practice-based - especially in low-resource environments.

• Reorientate and upgrade skills of teaching staff through continuing education.

• Improve problem-solving, audit, support and supervision

• Invest in leadership development

• Develop regulations and incentives to improve staff retention

• Develop mechanisms, including compensation of poor countries, to mitigate migration of health professionals to rich countries.

• Advocate for increased investment in enhancing capacity of and reorientating Southern institutions (incl. equitable collaboration/partnerships with Northern institutions)

• ADDRESS UNFAIR GLOBAL MACROECONOMIC REGIME