Highlights of Results
Increased Accessibility and Use of HIV and Family Planning Services: Uganda
To address issues of maldistribution and retention undermining the government’s goals for halving unmet family planning (FP) need, reducing HIV incidence by 40%, and achieving 75% of eligible persons receiving antiretrovirals, CapacityPlus collaborated with the USAID/Uganda-funded Uganda Capacity Program to build the capacity of the Ministry of Health (MOH), Ministry of Public Service, and faith-based organizations (FBOs) in use of the Rapid Retention Survey Toolkit. National stakeholders conducted a rapid DCE with 158 health workers in the Western and Northern regions and 544 health professional students from three universities among priority cadres (doctors, nurses, pharmacists, and laboratory technicians). The resulting preferred financial and non-financial incentive packages were costed using iHRIS Retain to identify which combinations would be the most cost-effective and feasible.
Recruiting over 7,000 new health workers: The MOH, with technical assistance from the Uganda Capacity Program, used the results from application of the Rapid Retention Survey Toolkit and iHRIS Retain, along with data from the Uganda HRH Information System (developed by the MOH with Uganda Capacity Program and CapacityPlus mentoring using iHRIS Manage) to advocate with the Ministry of Finance to address workforce shortage and distribution issues. This resulted in allocation of an additional $20 million, or a 16% increase, for the health wage bill, allowing the MOH to recruit 7,211 new health workers in 2012–2013. The Ministry’s recruitment previously averaged about 500 health workers annually. The bill also doubled the pay of medical doctors working at the health center IV (HC IV) level to attract more doctors to work in the lower-level facilities and increase access to health services in rural areas.
The percentage of filled health worker positions by region increased from a mean of 55% in 2009 (range 39%-100%) to 66% in 2013 (range 57%-78%). Decision-makers can effectively use data to map where service burdens and workforce gaps intersect and better target recruitment, deployment, and retention efforts to the geographic areas and facilities with the highest HIV volume or unmet need for FP. For example, Central 1 region, where HIV prevalence is the highest in the country (10.6%), could be prioritized during health workforce recruitment. While Ugandan stakeholders did not necessarily use such data for deliberate planning, Central 1 witnessed a 41% increase in staffing (from 39.5% to 55.8% of positions filled). Other regions where HIV prevalence rose between the two survey years, such as West Nile, South Western, Mid Western, and Central 2, received a 35%-45% influx of new health workers. Notably, the urban area of Kampala (where HIV prevalence is slightly below the national average) experienced a decline in public-sector positions filled (from 100% to 78%), with more health workers recruited to work in rural areas to increase access for underserved communities.
Contributing to AIDS-Free Generation, Ending Preventable Child and Maternal Deaths, and FP2020
The increased accessibility and more equitable distribution of health workers in Uganda contributed to a significant rise in utilization of HIV, FP, and maternal, newborn, and child health (MNCH) services. The newly-recruited health workers were deployed to 1,030 health center IIIs (HC III; subcounty-level inpatient facilities serving 20,000 people) and HC IVs (HC IV; county-level mini-hospitals) across all 111 districts. An ecological analysis of service statistics from the District Health Information System (DHIS 2) between 2012 and 2014 at 962 matched facilities found that the mean number of persons tested for HIV and the number of persons living with HIV (PLHIV) started on cotrimoxazole prophylaxis increased significantly (t-test: p≤0.01). While this rise in service use may also be attributed to other concomitant factors, the large increase in access to health workers is likely to have been a key factor.
Similarly, the mean number of first visits for FP across 915 facilities witnessed a rise from 2012 to 2014 at a significance level of p≤0.01. The average total number of FP methods provided across all facilities as well as at the HC III level rose approximately 40% during the same period (p≤0.01). Individual FP methods, such as injectables, IUD, and male condoms also went up overall across the facility sample. The average number of first and fourth antenatal care (ANC) visits rose significantly across all selected facilities combined from 2012 to 2014 (p≤0.01), as well as at the HC III (n=808 facilities; p≤0.01) and HC IV levels (n=147 facilities; 1st visit: p≤0.05; 4th visit: p≤0.01). Institutional deliveries across all facilities combined, by facility type (HC III and HC IV), and by region also increased significantly during the same time period (p≤0.01).
Rural Retention Policy Increases Service Access: Lao People’s Democratic Republic
Although more than 70% of Lao People’s Democratic Republic (PDR)’s population lives in rural areas, the majority of health workers are located in urban areas. The inequitable distribution of health workers hinders the country’s goals to achieve a 55% contraceptive prevalence rate, 50% of births by skilled attendants, and 69% antenatal care coverage (Lao PDR MOH 2011). Following a governmental decree allowing for provision of financial incentives to civil servants working in rural areas, the MOH sought to develop a national rural recruitment and retention policy. To determine which incentives and interventions would be most effective to include in the policy, CapacityPlus, in partnership with the WHO, built the capacity of the MOH to apply the project’s retention tools. The MOH conducted a rapid DCE survey among 970 students from three provincial colleges and the University of Medical Sciences and 483 health workers in three provinces from the physician, nursing, and medical assistant cadres, and then used iHRIS Retain to cost the resulting preferred incentive packages to determine their financial feasibility.
Implementing an evidence-based national retention policy: The MOH used the evidence generated from application of the tools to develop and implement a national recruitment and retention policy. The policy stipulates that all graduates in medicine, nursing, midwifery, pharmacy, and dentistry, as well as postgraduates in family medicine, must complete three years of rural service to receive their licenses to practice. The policy provides incentives, based on the rapid DCE and costing results, to motivate health workers to provide high-quality services as well as encourage them to stay after their compulsory service has ended. Incentives include permanent civil service positions, transportation, and eligibility for continued education. The first phase of the policy, initiated in 2013, placed 360 newly qualified doctors, pharmacists, and dentists in 51 rural districts (of 142 total districts). The second phase, implemented in 2014, placed an additional 1,191 health workers across the country to provide essential health services.
Increased access to services: While the MOH did not necessarily stress FP coverage when determining where to deploy the new graduates, In many provinces, the increase in health workers occurred in areas with generally lower use of modern contraceptives by married women. Sekong, Xiengkhuang, and Champasack provinces, with modern contraceptive prevalence rates (25%, 32%, and 32%, respectively) well below the national average (42%), received 13%, 22%, and 12% more health workers, respectively. The new health workers provide a spectrum of primary care services, including FP, and thus contribute to improving women’s access to FP and other essential services. As a result of the increased recruitment and deployment of health workers in rural areas, CapacityPlus estimates that over two million people will gain access to a health worker.
Productivity Toolkit Informs Priority Interventions: Malawi
The Christian Health Association of Malawi (CHAM), which provides 37% of health services in the country, is contributing to the government’s implementation of an essential health package—addressing HIV/AIDS, maternal and neonatal outcomes, and other conditions contributing to high levels of morbidity and mortality—by increasing coverage and quality of service delivery through its network of 175 health facilities and over 9,000 health workers (CHAM 2015; Malawi MOH 2011). In response to CHAM’s request for technical support to strengthen the productivity of its workforce, CapacityPlus built its capacity to apply the Health Workforce Productivity Analysis and Improvement Toolkit through a pilot at nine health centers.
Comparing the aggregated health service outputs, which included MNCH and HIV service variables, to the total HRH costs (salaries and allowances paid to health center staff) revealed moderate to low levels of productivity in the majority of the assessed facilities, ranging from 29%-67% of the benchmark. Two-thirds of the health centers (six out of nine) were less than half as productive as the benchmark, or highest performing facility, in the sample. The qualitative portion of the assessment, which included community and health worker focus group discussions and health worker flow mapping, pointed to inefficiencies in service delivery, health worker absenteeism, and low patient demand as contributing to low productivity, and identified underlying causes and priority interventions.
Acting to improve productivity: In response, CHAM has progressed on many of the priority interventions. CHAM secured funding from DanChurchAid to pilot a community health insurance scheme at two facilities to reduce financial barriers. Health service price lists have been posted at most facilities to address lack of transparency. CHAM conducted a customer care orientation workshop for health facility in-charges to address issues of poor staff attitude and to institutionalize quality assurance methods to ensure that community expectations for quality care are met. CHAM also secured funding under a KfW Development Bank project to expand health center infrastructure, including construction of staff houses and maternity wards and installation of piped water, sewer, and solar systems; and to train health workers and procure equipment and supplies for basic emergency obstetric care. In the majority of facilities, in-charges acted immediately to correct individual issues affecting productivity and service quality such as adherence to clinical protocols and infection prevention standards, and adjusting staff rosters to reduce work overload while also providing day and night coverage.
 Estimates of health worker access are based on the assumption that the panel size for each health worker (regardless of cadre) is 1,400 patients annually.