Making Health Systems Work for Child Survival: Developing and Monitoring Critical Human Resources

1. Making Health Systems Work for Child Survival: Developing andMonitoring Critical Human Resources David Sanders Andy Haines Robert Scherpbier

2. 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

3. 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.

4. 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

5. HUMAN RESOURCES account for 60-70% of health expenditures Human resources are centrally important Health system functions HUMAN RESOURCES convert other resources into outputs that contribute to better health outcomes Financing Stewardship HEALTH OUTCOMES Neglect of human resources planning, production, retention, and motivation will continue to cause other resources to be wasted Resource generation Service delivery Source: Adapted from JLI

6. A case study of management of malnutrition

7. Mortality in Children 0-5 Years Oldin Southern Africa Others Diarrhoeal Diseases Malnutrition Perinatal complications Acute Respiratory Infections Malaria Measles WHO’98

9. ‘Globalisation’ results in unequal growth of wealth

10. ..and growth of povertyPoverty in Southern Africa (Source: Cited in UNOCHA, July 2002)

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

12. 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

13. 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

14. Implementation Cycle Policy Advocacy Evaluation Capacity Development Teambuilding Implementation and Management Situational Assessment Planning Analysis

15. 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%

16. Implementation Cycle Policy Advocacy Evaluation Capacity Development Teambuilding Implementation and Management Situational Assessment Planning Analysis

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

18. SITUATIONAL 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 children fed straightaway and 3 hourly during day and night. The number of night staff was increased Dextrostix and 10% glucose obtained Comparison of recommended and actual practices

19. 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

20. 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 morale Ashworth et al, Lancet 2004; 363:1110-1115

21. SIPETU CASE FATALITY RATES BY TRAINED/UNTRAINED PERIODS

22. DIFFERENCES IN TREATMENT TreatmentTrainedUn-TrainedP-Value KCl 78% 13% p=0.0000 Broad Spectrum Antbx 47% 15% p=0.0001 IV Hydration 5% 6% p=0.774 Vitamin 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.

23. Quotes from a Community Service Doctor “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!”

24. CHANGES IN CFRs IN RURAL HOSPITALS Ongoing research indicates leadership and management at all levels are the key reasons for the differences between well and poorly performing hospitals

25. 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

26. CAREGIVER KNOWLEDGE OF NUTRITION • 76% remembered key messages about food fortification • 71% of caregivers unable to implement acquired knowledge of feeding practices

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

28. 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 eligible CSG - currently R160 ($26)

29. Implementation Cycle Policy Advocacy Evaluation Capacity Development Teambuilding Implementation and Management Situational Assessment Planning Analysis

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

31. 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

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

33. A Case Study of Management of Pneumonia

34. IMCI pneumonia case management (Tanzania)Coverage: child actually receives the intervention Source: Jones et al, Lancet 2003, 362: 65-71

35. 9% Pneumonia mortality averted = Intervention efficacy 65% Health workers are trained 80% Health workers assess child correctly 63% Health workers treat child correctly 65% Coverage (mother recognised illness, sought care and complied with treatment: child receives the intervention) 40% IMCI pneumonia case management (Tanzania) Towards population impact Coverage under actual programme conditions Population effectiveness = Intervention efficacy x Intervention availability x Diagnostic accuracy x Provider compliance x Patient compliance x Coverage The HR factor Tugwell framework applied to multi-country evaluation data Source: Tugwell, J Chron Dis, 1985; 38(4):339-51

36. Intervention efficacy 65% Coverage (mother recognised illness, sought care and complied with treatment: child receives the intervention) 40% IMCI pneumonia case management (Tanzania) Towards population impact Coverage under improved programme conditions Population effectiveness = Intervention efficacy x Intervention availability x Diagnostic accuracy x Provider compliance x Patient compliance x Coverage 19% Pneumonia mortality averted = The HR factor Health workers are trained 90% Health workers assess child correctly 90% Health workers treat child correctly 90% Source: Tugwell, J Chron Dis, 1985; 38(4):339-51

37. 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

38. Health Workers Save Lives! Anand & Barnighausen, 2004

39. Nurse density and vaccination Anand & Barnighausen (forthcoming)

40. 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

41. HR Policies and Planning for child survival programmes Align and link HR and CS programme policies (based on population health needs and programme interventions & targets) Human resource cycle Define tasks and skills required per level. Estimate time requirements. Define distribution and skills mix. Estimate total HW numbers required (FTE) per level Based on: Hall and Mejia, 1978

42. 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

43. But…. • 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 Ethiopiawere 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 money.” Rt. Hon. Hilary Benn, April 2004, WFPHA/UKPHA, Brighton

44. AIDS and Aid may both disrupt health systems… In 2000, Tanzania was preparing 2,400 quarterly reports on separate aid-funded projects and hosted 1,000 donor visit meetings a year. Labonte, 2005, presentation to Nuffield Trust

45. HRH and Africa…

46. Burden of disease Share of population Share of health workers Our Common Interest 2005:184

47. HRH Density by Regions Workforce data are aggregates that mask unequal distribution between rich and poor African countries and between rural and urban areas Source: JLI, 2004

48. 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

49. NURSE REGISTRATION IN UK :Increase during a period when a “ban” on active international recruitment had just come into effect Buchan et al 2003

50. 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).