Highlights of Results
Comprehensive HRM Strengthening to Improve HIV/AIDS Services: Dominican Republic
In the Dominican Republic, HIV testing among pregnant women remains low (47%) and rates of maternal-to-child transmission high (4.7%) (Pan American Health Organization 2014). CapacityPlus collaborated with USAID/Dominican Republic to support the Ministry of Health (MOH) to strengthen HRM to improve delivery of prevention of mother-to-child transmission (PMTCT) of HIV and other key services. The MOH drew on the HRM Assessment Approach to conduct a situation analysis of the health workforce in the country’s nine regions. The results guided the MOH to develop a national HRH strategic plan and design interventions to strengthen HRM systems at the national, regional, and facility levels. Supportive site supervision and other processes have been enhanced to improve health worker performance for PMTCT and other services in ten priority hospitals. Job descriptions were developed for health workers, which HR managers have noted are improving recruitment processes.
Savings from payroll cleaning used to improve services: The situation analysis identified the need for a payroll analysis, which revealed individuals receiving a salary but not working (“ghost workers”), along with workers who had been in the process of retirement for over three years. The MOH embarked on a process to clean its payroll and eliminated 3,913 ghost workers for an annual savings of $9.1 million, and also fully retired 2,241 staff, allowing their posts to be opened for new hires. The MOH has invested the savings to purchase medicines and supplies, repair health facilities, and increase access to health services at the primary level through hiring 2,511 doctors, nurses, and area coordinators. The Dominican Republic’s investment of savings from payroll cleaning, coupled with the elimination of user fees (a significant financial access barrier for the poor) and increased membership in national health insurance have led to improved coverage of primary health services in various regions of the country. For example, Region IV, a poor area bordering Haiti with a large immigrant population, witnessed a 500% increase over one year in the number of patient consultations (from 2,039 to 12,237) for HIV and syphilis prevention, family planning, and prenatal care.
Expanded role of HR managers in quality of care: Using CapacityPlus’s HRH Professional Development Program, the MOH also collaborated with the project to deliver a three-part program in leadership and management for 24 HR managers from the central and regional levels. To scale up and sustain HRM leadership development, regional managers were trained to build the capacity of hospital HR managers. To further professionalize the cadre of regional HR managers, the HRM leadership and management program has been formally established as a diploma course within the National Institute of Public Administration. Since its inception in 2014, 69 regional HR managers have graduated from this program, building a critical mass of Dominican leaders with specialized HRM skills.
The professional development program contributed to a shift in the role of HR managers from a purely administrative function to a more strategic role in improving the health workforce and quality of care through HR-related interventions. For example, coupled with newly standardized job descriptions, trained HR managers have improved recruitment processes resulting in hiring more qualified health professionals. Reorganization of services, extension of clinic hours, and redeployment of staff following better planning and supportive supervision interventions have resulted in improvements at the facility level. Overall, the percentage of infants tested for HIV within 12 months of birth at project-supported hospitals increased from 69% during October-December 2013 to 89% during April-June 2014.
“Everything changed after the training… it taught me to grow as a person and as a professional. I can defend my views and negotiate with my superiors. When something is not right, I have to point it out and be able to explain why.”
—Diana Santana, Dominican Republic Ministry of Health
After the HRM leadership and management training Diana Santana of the MOH refused to accept several unqualified candidates that a governor put forward for employment in her facilities. She and a colleague presented their reasons effectively, including the need to follow formal hiring procedures and to avoid a lawsuit from employees who would have been fired to make way for the unqualified candidates. “Our arguments were clear and precise and were accepted,” she noted. “This was possible because the training has enabled us to understand the role of human resources management in improving the quality of health services.”
Enhancing National Planning and Faith-Based Organization (FBO) HR Management: Ghana
A key finding of a situation analysis carried out in Ghana by CapacityPlus was the need for an active multi-sector, multi-organization HRH stakeholder leadership group. Such a group existed in the Ghana Health Workforce Observatory, but it was not fully functioning. At the request of the MOH, CapacityPlus provided support to re-energize and revitalize the Observatory, including addressing functionality challenges; strengthening strategic planning, monitoring, and evaluation capacity of members; and assisting the ministry to redesign the Observatory website as an effective mechanism to communicate and disseminate national health workforce information. These efforts contributed to the Observatory-led development (using a number of components from the HRM Assessment Approach) of a five-year national HRH policy and implementation plan, which aims to improve the development, distribution, and productivity of the health workforce and is guiding MOH activities.
“The HRH policy and plan are significant because we can’t run a sector without knowing where we are heading to. We need to have a vision and focus, and it should be documented so that anyone coming to assist you will know the [priorities] and your strengths and weaknesses. This policy provides the direction for HRH planning, management, and monitoring and evaluation” —Dr. Kwesi Asabir, Deputy Director, Human Resources for Health Development, Ghana Ministry of Health
Strengthening FBO HR management: The Christian Health Association of Ghana (CHAG) provides nearly one third of all health services in the country, making it the second largest provider of health care after the MOH. Like the Ministry, CHAG’s efforts in meeting critical health needs have been hampered by human resources challenges, including poor distribution of health workers, high attrition, and low morale (WHO/GHWA 2008). To address these issues, CHAG used the Human Resources Management Assessment Approach as a basis to develop its own HRM scorecard for member organizations to assess and strengthen their HRM processes. With CapacityPlus support, CHAG piloted the scorecard first in 27 facilities in Greater Accra and, once modified, in a second group of 30 facilities. CHAG then scaled up the scorecard application to all of its 183 facilities without further external support. Findings from the scorecard assessments have been used to prioritize interventions such as human resources information systems (HRIS) development, HRM policy implementation, and use of the WHO Workload Indicators of Staffing Need (WISN) tool to determine adequate staffing levels to meet service delivery needs at the facility level. The assessments also informed the development of a national HRM manual for CHAG managers and staff covering such topics as workforce planning, HR information management, and training. CHAG further incorporated the scorecard into an existing institutional assessment tool to ensure inclusion of health workforce components in its organization-wide performance assessments.
HRH Policy Intervention among Kenyan FBOs Shows Positive Workplace Improvements
CapacityPlus conducted an evaluation of Christian Health Association of Kenya (CHAK) facilities that participated in the nationwide adoption by CHAK and the Kenya Conference of Catholic Bishops of a comprehensive policy on HRH (supported by USAID through the Capacity Project and subsequently through CapacityPlus and the bilateral Capacity Kenya project). The policy is designed to address health worker discontent and exodus from the FBO workforce, which provides about 30% of health services in the country. Using a mixed-methods retrospective approach, the evaluation, conducted in early 2014, found large improvements in managers’ perceptions of professionalization of HR management (+67%); recruitment, promotion, and exit procedures (+84%); performance support mechanisms (+86%); and overall sense of pride and confidence (+84%). Health workers and workplace observations largely corroborated these and other positive changes. While inconsistencies in client data at facilities did not allow for analyses of trends in the services provided, the evaluation confirmed important changes in the FBOs’ institutional culture favoring HR management and workforce policies with potential implications for improved service delivery. FBOs in Ghana, Lesotho, and Malawi replicated the policy intervention.
State and National HRH Strategic Planning: Nigeria
Nigeria has one of the largest health workforces in Africa. However, acute shortages in rural locations, low morale, poor job satisfaction, and continuing professional migration hinder further progress in HIV prevention, care, and treatment in the country, which has the second largest population living with HIV/AIDS in the world (UNAIDS 2013).
To help address these workforce challenges, a national team adapted the Human Resources Management Assessment Approach, with support from CapacityPlus through USAID/Nigeria, to conduct a situational analysis of the health workforce in six states. The team used the tool with each of the state Ministry of Health-led HRH technical working groups to map and clarify stakeholders’ roles and responsibilities, and assess the stock, distribution, and characteristics of the health workforce. The results and findings provided each state MOH with a comprehensive overview of its HRH situation and highlighted state-specific challenges, including the availability, distribution, and productivity of the health workforce. Through participatory approaches each of the technical working groups then used the analyses to develop state-specific HRH strategic plans. The state ministries will use these strategic plans to strengthen the health workforce in each state. Drawing on these experiences at the state level, CapacityPlus supported national stakeholders to develop and validate a national HRH strategic plan to improve accessibility and quality of services to meet the nation’s health goals. The state assessments also informed production of a national HRH training manual that will be used by the Federal MOH to develop the capacity of HR managers and other staff working in HR departments and units across the country.
Strengthening District-Level Leadership and Management: Uganda
To scale up accessibility and use of health services, Uganda has embarked on a program to strengthen decentralized HRM and leadership at the district level in areas such as workforce planning, recruitment, deployment, performance, and retention. At the request of the MOH and the USAID-funded Uganda Capacity Program, CapacityPlus adapted its HRH Professional Development Program to the Ugandan context and the needs of identified learners. The project delivered a training-of-trainers course to participants from the MOH, Ministry of Public Service, Health Service Commission, Makerere University, and private health organizations. Uganda Capacity Program then supported these master trainers to conduct a training needs assessment, adapt the materials to the district health context, and train district-based HRH leaders and managers. By the end of 2014, 179 participants from 17 health districts had completed the course. An evaluation found that graduates in 75% of the intervention districts had advocated with their district leadership to support their HRH improvement plans. These interactions triggered a range of responses in these districts, including increased budgets, recruitment of new health workers, and improved staff welfare (such as construction of staff housing). A study comparing “trained versus untrained” districts found better performance in trained districts in terms of reduced absenteeism, improved motivation of health workers, development and implementation of worker safety guidelines, integration of HRH development plans into overall district health plans, more regular supervision visits, and use of up-to-date electronic data systems to inform recruitment planning.
“As a result of the course, there seems to be an improvement in time management, quality of services, and customer care following the interventions we put in place.”—Member of the Namutumba District team.
The interventions in Namutumba included forming a District Quality Improvement Team and a District Training Team, introducing arrival books at all health facilities, strengthening continuing medical education, and intensifying routine supervision.