3.1 HRH coordination mechanisms
This section reports on the coordination mechanisms, their main functions and selected attributes (particularly the wider coordination mechanisms) including leadership and accountability; participation, inclusivity and consensus building; sustainability; and finally, performance.
3.1.1 Coordination mechanisms
Multiple coordination mechanisms were identified in all three study countries (see Table 7). Malawi’s HRH TWG and Sudan’s National Stakeholder Forum have broad stakeholder reach and appeared to be long standing and embedded in the MoH systems. Nepal does not have a fully institutionalised health workforce stakeholder coordination mechanism. However, it has general coordination mechanisms that include health workforce and has ad hoc task-focused mechanisms such as the HRH roadmap working group.
Table 7: Summary of coordination mechanisms and functions in study countries.
Country
|
Type of Mechanism
|
Summary of functions
|
Malawi
|
Health Sector Working Group, MoH
|
· Oversees all MoH Technical Working Groups (TWGs), including HRH TWG
· The ultimate governance body for the health sector; the highest level governance body that can tackle HR issues when necessary (MWI 003)
· Comprisesthe Secretary for Health, donors, civil society, the private sector, other government departments, but attendance of other Ministries, this also is something that's not really very strong (MWI 003)
|
HRH TWG, under the Health Sector Working Group, MoH
|
· Multisectoral and multi-partner mechanism, established in the early 2000s; comprises approx. 30 members (covering multiple central government departments, local government, regulatory bodies, training institutions, the faith-based organisations, development partners and donors, some of whom provide technical and financial support to HRH functions)
· Provides technical advice and generates evidence for MoH Senior Management TeamHRH decision making; reviews and endorses national HR policies and plans [19, p23]
· Monitors and reviews implementation of HRH Strategic Plan against annual targets and planned activities [19, p17]
· Advocates for adequate funding [19, p23]
· Functions according to TOR, led by the MoH HR Director (Chair), with a development partner as rotational co-Chair, withMoH Directorate of Human Resource Management and Development (DHRMD) providing the Secretariat
· Meets quarterly
· Athink tank that considers issues government cannot make a decision about (MW 001)
|
Task Forces, under the HRH TWG, MoH
|
· Constituted by the HRH TWG to work on specific HRH issues and tasks as per agreed ToR e.g. the development of the HRH strategy, recruitment
· Comprises volunteer TWG members and consultant hired when required
· Mechanism through which the TWGs deliver (MWI 001)
|
Parliamentary Committee for Health
|
· Advocates for health including health workforce issues
|
Permanent Secretaries (PS) Committee
|
· Multi sectoral committee addressing health sector issues, includes Permanent Secretary for Health and for DHRMD in the Office of the President and Cabinet. among others
· Health sector coordination and policy decision making, and potential to influence HRH decision making
|
MoH Senior Management Team
|
· Main decision-making body in the MoH, considers evidence presented by all TWGs, including HRH TWG for HRH decision making and allocating resources
|
|
Human Resources for Health (HRH)Coalition
|
· Umbrella body for professional associations and unions including medical and nurses and midwives’ associations
· Petitions government on various HRH issues on behalf of its members
|
Sudan
|
National Human Resources for Health Observatory (NHRHO)
|
· Established 2007
· Produces evidence and documents for review
· Develops meeting agendas, follows up actions identified by the Stakeholders Forum
|
National HRH Committeeheld the NationalHRH Stakeholder Forum reporting to the National Council for Healthcare Coordination (NCHC)
|
· Multisectoral body
· Headed by the Undersecretary for Health with links to the President and has “the strength and the power and the authorization even to push HRH issues and agenda” (SDN 004)
· Serves as the Board for the NHRHO
· Coordination and decision-making role e.g. salary increases, distribution, production and migration, “when the decision is taken in this committee, so it is likely to be done” (SDN 002)
· Meets quarterly
|
Nepal
|
Health Coordination Division,MoHP
|
· General health coordination role across the three tiers of government, including for HRH
· Coordination with multisector including development partners
|
Ad hoc TWGs/committees, MoHP (set up for specific tasks)
|
· CCF process todevelop 2011 HRH plan which included task-specific working groups
· Development of the HRH Strategic Plan/Roadmap (2017-2020) co-led by MoHP and WHO
· Committee for planning for the (re) deployment of staff - the Employee Adjustment process - under federalisation
· Groups may comprise MoH officials and development partners
|
Interdivisional meetings, MoHP
|
· Weekly meetings to discuss policy issues, including HRH, but "lack of clear agenda, preparation and participation"(NPL 004).
|
3.1.2 Attributes
The important attributes of the coordination mechanismscover leadership and accountability; participation, inclusivity and consensus building; and sustainability.
3.1.2.1 Leadership and accountability
The TWG in Malawi is led by the MoH and is accountable to the broader Health Sector Working Group and the MoH Senior Management Team, “who decides whether to allocate funds to execute” (MWI 001). The National HRH Committee in Sudan is also led by the Under-secretary for Health and accountable to the President, which gives it power.The interdivisional coordination mechanisms in the MoHP in Nepal report to the Secretary in the MOHP, and the HRHRoadmap TWG was led by the joint-secretary and reported to the Secretary MoHP.
The coordination mechanisms in Sudan had clear Terms of Reference(TOR)and guidance documents which describe the roles and responsibilities of the members, the reporting system, and schedule of meetings, with the HR observatory acting as the secretariat. In Malawi, the HRH TWG and the task forces reportedly had clear TORs. There are clear procedures for MoHP interdivisional meetings in Nepal. These instruments, along with the leadership capabilities of senior management (GLO 001), enhance the legitimacy of the mechanisms.
Leadership capacity was impacted by high staff turnover in Malawi and Sudan (partly through migration). HRH coordination mechanisms should address national rather than donor-driven priorities (GLO 003), but because of frequent changes in leadership in the MoHP (NPL 002, NPL 003 and NPL 005) the TWG in Nepal was driven by a development partner. A participant in Malawi referring to the development of the HRH Strategy described how development partners ‘jumped in’, ‘took the heavy lift’, and how a “team of experts really pushed with the HRH Directorate, and then it came to reality’(MWI 006).
3.1.2.2 Participation, inclusivity and consensus building
The Malawi TWG had wide participation (see Table 7). In Sudan, the Stakeholder Forum had a similarly wide reach of stakeholders with additional attendance by police and military HRH representatives. Respondents highlighted thechallenge of leadingand maintainingsuch large and diverse groupsengaged; this required effective communication and trust building efforts. In Nepal and Malawi, the composition of the working groups depends on the task, but donors and development partners will usually participate if they are contributing funds. In Malawi, participation by some MoH Directorates can be sporadic. At one point Sudan had dedicated staff and budgets to promote stakeholder engagement.In all three cases,some allowances were needed to support participation.
In Sudan, development partners, including UN agencies, have their own forum for general coordination which is represented in the NHC. In Malawi, development partners are members of the TWG, and one is always the co-chair. In Nepal the composition of the working groups depends on the function, but development partners contributing funds usually participate.
Though there is rapid expansion of private health worker training in Nepal and Sudan. The for-profit private (health) sector, which lack representative bodies, was absent from the HRHcoordination mechanisms. Moreover, in Sudan, the private (health) sectorremains unconvinced of the value in sharing data or the benefits of participation. Civil society was also missing from HRH coordination in thestudy countries.
Tensions and conflicts between stakeholders were reported due to the politicisation of health and healthcare funding and the presence of many powerful actors who believe they have a legitimate HRH governance and gatekeeping remit (GLO 002; GLO 006). These tensions were often intersectoral, such as education and defence (e.g. reluctance of security forces to share information in Sudan) or as a result of political transitions and resultant changes in institutional roles and responsibilities(GLO 001 and GLO 008). However,consensus-building,collective agenda setting,sharing objectives, use of workshops and informal communication helped to foster collective insight and views on the HRH topic, which eased tensions. Several global respondents observed that this process also improved HRH literacy amongst stakeholders and in Sudan ‘…the structures for coordination and the meetings, the culture of frequent meetings, has done a lot to mediate this relationship and to address conflicts.” (SDN001).
3.1.2.3 Sustainability
Many respondents emphasised the need for a sustained forum for developing and overseeing the long-term strategy for the health workforce. The longevity of the HRH TWG in Malawi, despite high turnover of government staff, was attributed in part to its embeddedness within existing MoH governance structures and the perception by stakeholders that it was “a competent structure”and essential to the coordination of new initiatives: “a donor wouldn’t really commit into a serious undertaking before being convinced that the TWG has reviewed and is happy with the direction”(MWI 005).
In contrast, the functioning of the high-profile Stakeholder Forum in Sudan was affected by the recent political transition in the country. One respondent claimed that “it [Stakeholder Forum] was functioning, though the country was unstable politically and the issues around the revolution make it a bit difficult to have the regular meetings as it is scheduled in the plan.” (SDN 004).
Holding regular face-to-face meetings can be expensive if held in hotels and travel costs are required, though for smaller meetings one respondent (NPL 005) said that paying for a “few cups of tea” was a good investment if it helped bring people together. In Sudan, the Stakeholder Forum had dedicated government funding and commitment, with the majority provided through external partners and donors, though“sometimes [per diems] it’s equal[…]maybe to their[…] monthly salary. So this is one of the things that really motivate people to attend” (SDN 009). During the pandemic in Malawi, the opportunity to hold virtual meetings meant more people were available, meetings were more frequent and cheaper.
3.1.2.4 Performance
The coordinating mechanisms in Sudan and Malawi and the Road map working group in Nepal had all supported the development of HRH strategic plans to support the long-term health workforce strategy. The coordinating mechanisms in Sudan and Malawi appeared to meet regularly, though this became difficult in Sudan after the 2019revolution in Sudan. Effective HRH coordination mechanisms were reported in Indonesia under the UHC umbrella which shared information and planning processes (GLO 006); and in Mozambiquewhere a strong champion created the coordination mechanism which was supported by an HRH observatory. They gained the interest of stakeholders by demonstrating at the health system annual reviews that “even if the issue is not a workforce issue, if you bring it their attention, and workforce component will be looked at” (GLO 003). Two global respondents compared the challenge of coordinating multiple stakeholders in larger – especially federated – countries with smaller countries where all stakeholders could be “in one room” (GLO 002).
3.2 HRH Units
This section reports on findings about the structures ofHRH Units, their functions and attributes (leadership/accountability, capacity, support to decentralised HRH units), and performance.
3.2.1 Types and functions of HRH units
Table 8 shows that whereas Malawi and Sudan have clear HRH units to oversee health workforce functions, in Nepal there was no single structure to provide this oversight.
Table 8: Summary of HRH units
Country
|
Type of HRH Unit
|
Description/Function
|
Malawi
|
Directorate of Human Resource Management and Development (DHRMD), Ministry of Health (MoH)
|
· Provides strategic direction on the rational use of HRH [19, pp23-4]
· Headed by a Director who reports to the Principal Secretary for Health
· Provides the secretariat for the HRH TWG
· Leads the implementation of the HRH Strategic Plan (2018-2022)
· Relies on external technical assistance to perform core functions such as workforce planning
· Comprises health workforce planning; management; and development sections
· The health workforce management section is responsible for a broad range of HRM functions, including the “interpretation of the Malawi Public Service Regulations (MPSR) for central hospitals” [19]
· Works with the Health Services Commission, Local Government Service Commission, and District Councils which have responsibility for some HR functions
|
Sudan
|
Directorate General of HRH,Federal Ministry of Health (FMoH)
|
· Evolved from personnel management unit in 2003 to a Directorate General of HRH Development, reporting directly to the Undersecretary for Health
· Responsible for “strategic health workforce development including the development of several policies for the health workforce and expanding its role in coordination and facilitation of the health workforce issues”(SDN001)
· Includes 8 directorates and institutes to carry out functions with 150 staff: Policy and Planning, National HRH Observatory, Internship Affairs, Fellowships Affairs, Continuous Professional Development (CPD), Academy of Health Science (AHS), Public Health Institute (PHI) (now under the direct management of the Undersecretary of Health), Blue Nile National Institute for Communicable Diseases (BNNICD) managed collaboratively with the University of Gezira
|
Nepal
|
Personnel Administration Section, Division of Administration, Ministry of Health and Population (MoHP)
|
· Covers all functions related with personnel administration,HRH information, communication and management
· 2012 Mid-Term Review of Nepal Health Sector Strategic Plan NHSP-2recommended for “a single human resources division and that all human resources activities are assigned to this division” [24, p15]but not acted on.
|
|
Curative Service, Education, and Research Section, under Policy, Planning and Monitoring Division, MoHP
|
· Responsible for coordination with health academia, education institutions, hospitals, and technical schools
|
|
Health Coordination Division, MoHP
|
· Responsible for: the Employee Adjustment process; formulation of HRH policies and plans; workforce planning and projection; HR information systems; training needs assessment, training plans and career development; and HRH research [41]
· Includes Provincial and Local Health Coordination Section
[41]
|
|
AdministrationSection, Department of Health Services (DoHS)
|
· Personnel administration for staff employed by DoHS, including attendance and staff leave.
|
|
National Health Training Centre, Department of Health Services (DoHS)
|
· Responsible for: HRH training strategy and plan; coordination for training and other capacity development initiatives for HRH; development and use of training materials for HRH
|
|
Nursing Capacity Development Section, under the Nursing and Social Security Division, DoHS
|
· Coordination of planning, capacity development and management of nursing and midwifery work force
|
All 11 countries in the Southeast Asia region reported in 2019 that they have some form of health workforce unit, compared with eight in 2018[23], though in Timor-Leste “it was just a one-person show.” (GLO 001). In the African region, 15 out of 16 countries surveyed: “had a responsible HR unit … but in practice, what had happened was that it was not really functional, many of them were just passing papers in practice” (GLO 003). Below we have listed selected findings relating to the functions of the HRH units (or equivalent).
3.2.1.1 HRH strategy: development and implementation
HRH functions need to be coordinated within the MoH (GLO 008). A HRH strategic plan is need for both stakeholders and within the MoHto guide, coordinate, and align HRH initiatives to longer-term health plans. Nevertheless, thefindings showed that Malawi was the only study country with a plan (2018-22)currently being implemented.The development of an HRH plan appeared to be very time consuming, often getting stuck at the approval stage with Nepal’s 2020-2030 plan only recently signed off. As a pathfinder country for GHWA, there was some externalfundingfor developing Sudan’s 2012-16 HRH strategy, but the process was apparently owned by the MoH and national stakeholders. In contrast, according to some respondents, the development of strategic HRH strategyin Malawi and Nepalwasstrongly influencedby development partners.Implementation may be hampered without alignment to the budget process. Although Nepal’s 2011 HRH strategywas officially approved and aligned to the budget “the implementation of activities in the strategic plan which require financial resources [was] therefore frozen.”[24, p41].Dissatisfaction with thefinancing andimplementation of Malawi’s current strategy was expressed:“you need to have a proper budget, you need to have a proper plan, indicators, whether you meet those things or not, so, there should be that kind of platform” (MWI 006).
One global respondent remarked that in many countries HRH departments do not operate at a strategic level and are mainly focused on routine recruitment and deployment (GLO 001).Sometimes major HRH changes may be taken on by a different department. The ‘employee adjustment process’ to support federalisation in Nepal was not managed by HRH officials, but a focal person of the rank of Chief Specialist was appointed to manage this process (NPL 002).
3.2.1.2 Workforce planning and HR information
Though workforce planning is often a “self-contained exercise within the health sector carried out in relative isolation from other development processes”[25, p359], in Malawi the staffing projections were part of the wider strategic HRH plan. The intelligent usage of HRH data[26]is needed for workforce planning and other workforce management processes. WHO has supported Health workforce observatories to generate such data. In 2015, 34 member states in the AFRO region had these observatories – including Sudan [27], yet most countries struggle to get accurate, comprehensive and current data on the workforce and only nine are currently active in the African region [28]. Despite years of donor support, the dedicated HRH information system in Nepal had failed and reliance of the personnel information system (PIS) for civil servants – including health workers -is only of“some limited use for the training and other planning purposes” (NPL002). Sudan’s donor support to HRH information systems was curtailed by political sanctions.In Malawi, several information systems were in place,but the outputs could not be combined to produce useful information. In Indonesia the HRH data sharing between ministries was spelled out in a memorandum of understanding“being very clear what data is going to be shared, when, by whom, and which platforms and everything … they were very systematic on that”(GLO 006).
3.2.1.3 Lessons from COVID-19 about existing functions
A report from the South East Asian regionsuggested that lessons from COVID-19on surge management and protection of health workers should be integrated into updated national HRH strategies [29]. In Malawi, in response to the COVID-19 pandemic, recruitment processes that normally take six months were completed “within two weeks or even less than that, and that is without compromising any quality” (MWI 006).
3.2.1.4 Missing HRH functions
In Sudan the HR manual identifies the need for anemployee relations unit, and this has been recommended in Nepal[30]. However, in spite of the risk of industrial action generally [28]and in all study countries some of which was related to COVID-19, there was no evidence of the practice of ‘employee relations’ within MoH structures.
3.2.2 Attributes
Three important attributes of the HRH Unitsemerged from the findings: leadership and accountability; capacity of HR unit staff; and support to decentralised units.
3.2.2.1 Leadership and Accountability
The success of Sudan’s HRH Directorate was attributed to the leadership’s clear vision and ability to think “outside the box and how to conduct thingsnot like … routine” (SDN 009).Elsewhere, HRH units may be hampered by unclear mandates and weak coordinating powers[8] or be low in the organisational hierarchy excluding them from strategic decisions-making[31].Leadership at levels above the HRH unit was also cited as being important to the creation and functioning of such a unit. Strong support was demonstrated in Sudan, but despitenumerous callsfor its establishment the Personnel Administration Section In Nepal has not been replaced by dedicated HRH Division – “this is the leadership matter”(NPL 002).Weak leadership at both levels will affect accountability. Lack of ownership where initiatives were driven externally, such as the development of strategic HRH plans, was also found to be associated with lack of accountability.
3.2.2.2 Capacity of HR Unit staff
The Global HRH strategy [3] promotes the need for a professionalised body of HRH scientists, planners and policymakers to support HRH at a strategic level. Some respondentsreported HRH expertise in selected high-income countries, but a recent study in the South-East Asia region found that only 14% of staff in the HRH units were professionals(eg with Master’s Degree in Public Health)[23] and in the African region only7% of staff were described as ‘technical’[28]. In Malawi and Nepalthe HRH functions are staffed by people from “common services” ministries with knowledge of routine personneladministration, but who may be unfamiliar with the complexities of developing and managing a health workforce. “The perception is just managing, veterinarian managing, agriculture managing[….]or managing other things, the same with the public health and the public or the physicians or nurses. They look [at] everything as … general.” (NPL 006). Arespondent from Malawi observedthat generally “people who are thrown to the HR department are those who are incapable, or who has a disciplinary issue or who want to have some calm time, so that they will do their own things. So, that is the debacle and because of those things always you see capacity issues”(MWI 006).
Becoming ‘literate’ about the health workforce takes time. One respondent at a senior level in Sudan had been working for many years inHRH. However, just when the officer can develop effective and appropriate strategies, they may be transferred: “when they start to pick up things, they also move to the other institution. So that's really quite a big handicap for an institution as specialized as health.”(MWI 003). A review from Nepal in 2013 showed very high turnover of staff working on HR functions, especially those in leadership roles [30]. High turnover of senior managers has continued in Nepal, some of which is associated with political instability. In Sudan, training in health workforce developmentcontributed to improved capacity of the HRH directorates at State and National levels.In the absence of a stable body of HRH professionals, some countries have relied on the use of international consultants with the risk that no expertise remains when the contracts finish [8]. “In Burkina[Faso]they have received support from I think Belgium cooperation to have again an expert to strengthen the HRH unit. And they have done a good job to strengthen HRH information system at the national level. And then when the expat left, nobody was able to manage the system. Then the system died.” (GL 004)
3.2.2.3 Support to decentralised Units
Many countries either have or are moving towards decentralised health systems and management of the health workforce, as in the three study countries. This requires provision of support, including capacity strengthening,to the decentralised HRH units[3, 32].Support strategieswere included in Sudan strategic HRH plan for 2012-16 [33]and implemented. One respondent reported that all 18 state-level HRH units (staffed with one or more focal persons)are functioning. Strategies to support decentralised HRH units in the federal, provincial, municipal structures were included in Nepal’s HRH Roadmap. Similar support to Malawi’s devolution was anticipated in its HRH strategic plan - the “devolution of the HR function led to a delineation of roles and responsibilities between the line Ministry (MoHP) and the Councils”[19, p16], but at the time of this study, institutional HRH roles and responsibilities e.g. of the health service commission and the local government service commissionat central and subnational levels had not been fully delineated.
3.2.3 Factors impacting on performance
A range of factors were found to impact on the performance of HRH Units, including: their legitimacy and power linked to positioning within the MoH structure and hierarchy(GLO 001) [10]; their political capital and engagement of stakeholders at the highest level, “that gives you the power in order to bring different departments on the table” (GLO 001); and “funding power” (GLO002). To maintaintechnical autonomy and financial and programmatic independence, availability and use of monitoring and evaluation instruments and HR data are needed to monitor, report on and be accountable for results. This requires the availability and retention of HR literate professionals [11].