Review of HRH-Related Bank Activities in Africa

1. Review of HRH-Related Bank Activities in Africa Oscar F. Picazo, AFTH1 Marko Vujicic, HDNHE October 28, 2004

2. HRH in World Bank Projects • Part I: HNP Projects (O. Picazo) • Past projects (ICRs): review by E.Elmendorf, et al • Current projects (PADs): AIDS, other specific disease interventions, health sector • Part II: Macro Programs (M. Vujicic) • HIPC and PRSP documents • PRSCs (PADs): current and recently closed

3. Part I: A. Past HNP Projects(n= 63 ICRs from 1974-2002) • Wide range of activities, but highly concentrated on training • Construction and equipping of training facilities • Pre- and in-service training; ToT; distance ed; curriculum dev’t • Some HR planning & management • HR activities represent only about 10.3 percent of aggregated project cost of US$902 million

4. B. Current HNP Projects(n=17 PADs) • HIV/AIDS projects (MAPs) • 9 out of 30 projects • Specific disease interventions • 3 out of 9 projects • Health sector projects • 5 out of 17 projects

5. 1. HRH in HIV/AIDS Projects • Administrative structures & processes • Multisectoral coordination and partnerships • NACs and new institutional arrangements • Subgranting to NGOs and CBOs • Capacity building • At communities (CHWs) and subnational levels (‘focal points’ and local AIDS committees) • In specific fields (epidemiologic surveillance; behavior change; blood screening/testing; treatment, care and support)

6. 2. HRH in Specific Health Interventions • Eritrea Early Childhood Development • Cross-sectoral linkages and coordination • Capacity building for program management and zonal implementation • Nigeria Polio Eradication • No major institutional support • Focuses only on providing financing gap for vaccines • Senegal Nutrition Enhancement • Capacity building for M&E and program management

7. 3. HRH in Health Sector Projects • Analysis and planning • Production • Deployment and retention • Performance management and support • Administration and HRD systems • Regulation and quality assurance • Elements of “new public administration”

8. 3a. HRH Analysis & Planning • Chad: Recognizes HR problem as “catastrophe,” but sets modest HR goals • Ethiopia: Recognizes gaps in staffing and supervision; links facility expansion to staff availability and deployment • Ghana: Recognizes medical brain drain, unequal distribution of staff, and declining number of practicing nurses • Nigeria: Recognizes personnel shortage and fragmentation of responsibilities of various tiers of government as cause of suboptimal provision of services • Tanzania: Recognizes shortage (numbers, skills) and “aging” of district health staff due to freeze in public employment, under-investment in tertiary education, HIV/AIDS and migration; proposes long-term manpower planning

9. 3b. HRH Production • Chad: Targets graduation of 700 new paramedical personnel by June 2005; proposes reform and decentralization of paramedical training system • Ethiopia: Plans for development of a large number of few new cadres of frontline workers and mid-level health service providers • Ghana: No specific strategy • Nigeria: Aims to improve quality of training in State nursing, midwifery, and health technology schools; training of trainors • Tanzania: “More strategic use of zonal training centers”

10. 3c. HRH Deployment & Retention • Chad: Paid particular attention to recruitment of women; no strategy on retention as such • Ethiopia: Gov’t issuance at project inception of new guidelines on career structure and appropriate incentives • Ghana: Intension to restructure health sector’s personnel size, distribution and skill mix • Ghana, Nigeria and Tanzania: All expressed intention to use decentralization as mechanism for staff retention, but provided no details on how to go about it

11. 3d. HRH Performance Management & Support • Chad and Nigeria: Not clear or specific • Ethiopia: Project management component addresses personnel management and supervision • Ghana: Identifies need for continuous professional staff development and staff performance management system, but wanting in specifics • Tanzania: Spells out roles of central and regional levels in HRH, but not local authorities

12. 3e. HRH Administration and Systems • Occupational safety • Unclear whether “universal precaution” for HIV/AIDS is practiced • No mention of ARVs for health workers • In Tanzania PAD, the risk of AIDS on hospital staff is recognized, but proposed solution is unclear (“mitigated through HR strategies”) • Industrial relations • No discussions on the role of professional societies, councils, or unions • Unclear whether these were involved in project design or policy formulation • HR systems • Little, if any, discussion, since much of these systems are outside the purview of MOHs (ie., with civil service or DHRMD)

13. 3f. HRH Regulation & Quality Assurance • HRH training standards • Marketability of locally-trained doctors and nurses imply ‘acceptable’ standards • But available evaluations underscore rote learning, lack of practical training, Western orientation, and low rate of passing • HRH norms and standards of care • Workloads and provider/patient ratios have not been updated in a long time to take account of AIDS and resurgent epidemics • Accountability being enhanced by increasing community involvement in managing and financing local health facilities, and introduction of user satisfaction surveys • Regulation • Relationship between MOH as major employer and professional councils as regulator of HRH not underscored in Bank projects • Increasing HRH needs of NGOs/private sector not taken into account

14. 3g. Elements of New Public Management • Implicit contracts with mission facilities well-established in Ghana, Tanzania • Increasing size of private sector/NGOs well recognized, but contracting is ‘grudgingly’ endorsed and slowly implemented in sample countries • Autonomous management of central hospitals proposed, but actions and timelines not specified • Decentralization of health services has been slow • No ‘innovative’ HRH recruitment/deployment measures identified

15. Observations • Number of health sector projects declining; narrowly-focused HIV/AIDS and broadly-pitched PRSCs increasing. Implications of this trend on HRH? • Governments promise higher budgetary allocations to cover for additional recurrent costs of Bank projects, but mostly for ORT, not personal emoluments (PE). Not clear whether increase in PE consistent with WB/IMF macroeconomists’ position • PADs clearly recognize HR as problem but offer little lasting solution for increased deployment and retention. Use of Bank funds for personal emoluments strictly prohibited.

16. Observations • Capacity building revolves around immediate project requirements. Large-scale capacity building inhibited by lack of resolution on key sector issues (decentralization, autonomy of tertiary hospitals, public/private partnerships). • Capacity building heavily focused on general institutional requirements (planning, procurement, financial management), and less so on specific HNP technical areas. Unstated assumption that “other donors” provide technical management skills not always true.

17. Observations • Training focused on frontline and sometimes mid-level workers; little attention on technical managers • There is a focus on numbers: little attention on HR management, incentive schemes, productivity, leadership, performance management • Overly focused on short- or medium-term results related to specific initiatives; little cognizance of long-term strategic needs of the health sector

18. Part II: HRH in PRSP, PRSC and HIPC Initiatives in Africa Key Questions: • To what extent are HRH issues acknowledged in PRSP and HIPC documents? • To what extent do PRSP and HIPC documents describe country strategies to address HRH issues? • Are the cross-sectoral linkages relevant to HRH taken into account?

19. Findings • PRSPs and HIPC documents reviewed for 28 countries in SSA by WorldBank and in 6 countries in DfID study • In most countries HRH is mentioned as a constraint to improved health system performance (17/26 documents) • However, strategies to address the HRH constraints are described in very few of the PRSPs and HIPC documents (3/26)

20. Findings • While disease-specific strategies and objectives are identified frequently, implications for HRH associated with initiatives are rarely discussed

21. HIPC Initiative • HIPC funds provide donor support for education and health sectors • Some countries are using HIPC funds to directly address HRH constraints • 15% of HIPC funds going to the health sector in Benin were used for recruiting staff to fill vacancies in primary health care facilities • 8% of salary payments in Burkina Faso are from HIPC sources

22. PRSCs • Are there specific objectives or targets within PRSCs that relate to HRH? • In Ghana, decentralization of PE and incentives for recruitment and retention are mentioned as health sector objectives in PRSC3 • In Burkina Faso PRSC4 specifies decentralizing HRH functions to Regions and implementing incentive schemes consistent with budgetary allocations in MTEF

23. PRSCs • Tanzania and Uganda PRSCs do not have HRH-specific objectives outlined • Key finding: Specific, measurable targets or triggers related to HRH are not present in PRSCs

24. Cross-Sectoral Linkages • There is almost no linkage between HRH and reforms outside of the health sector that influence HRH policy • This is a key shortcoming since broad reforms such as decentralization, public sector downsizing, privatization initiatives, pay reform have an important impact on HRH policy • Civil service reforms were prominent in 50% of the countries examined yet the impact on the health sector was ignored

25. Cross-Sectoral Linkages • E.g. in Tanzania, PRSP noted strengthening salaries in the public sector as part of civil service reform but in health section it was explicit that salary budget would not increase • E.g. Mauritania was only example where civil service reforms incorporated the needs of the health sector • World Bank operations not harnessing cross-sectoral linkages related to HRH

26. Recent Global Initiatives in HRH in Africa • Joint Learning Initiative • High Level Forum on MDGs • World Bank and WHO collaboration • Country briefs on HRH in 9 SSA countries • Overview report • Bank’s Role Moving Forward • Joint partnership between WHO, WorldBank and JLI successor moving agenda forward after High Level Forum in December

27. Conclusion • Past HNP projects provided little support to HR; mostly in-service training and small piece-meal interventions • Current HNP and MAP projects do not focus on HR, but ESW/AAA and CSRs are providing early analysis of the problem

28. Conclusion • HRH issues and recognition of HRH problems have a presence in PRSP and HIPC initiative • However, information on policies to address the HRH problems is largely absent • Countries are not ‘making the case for HRH’ • There is an opportunity to increase the role of HRH policy in World Bank operations • World Bank policy on lending for recurrent costs • Suitability of each instrument for HRH issues