Dr. Freddie Ssengooba Makerere University, School of Public Health

1. Researching Health Workforce Dynamics in the Context of HIV Scale-up: Accumulating Evidence in Complex Health Systems Dr. Freddie Ssengooba Makerere University, School of Public Health International AIDS Society , Pre-Conference Cape Town, S. Africa 18th July 2009

2. Outline • Framework –perspectives and domains for health workforce management: • Strategic governance, • Labour market dynamics, • Workforce training and production, • Performance management, • The need for alternative methods for generating evidence for health system-level questions

3. Education Sector: Enrollment, carring capacity, curricula for market needs, faculty vacancies, leaning experiences Provider Organization: Attraction, Retention, skill mix, productivity, work tools & incentives mobility/stability Social political & Economic context GHIs for HIV GHIs for HIV 3 4 Performance Management GHIs for HIV GHIs for HIV 1 2 Health Sector: Workforce size, Equitable deployment, Wages, Job entry & vacancy ratios, Migration Source: Ssengooba, Kiwanuka et al 2009

4. Effects of HIV Programs on Workforce Governance Research question: 1. How and under what circumstances do HIV programs: • strengthen the governance and build consensus among stakeholders and • lead to coherent policy and implementation strategies across multiple agencies that may espouse conflicting objectives for HRH developments.

5. 1.1 Workforce Governance – Emerging issues • Unresolved conflicts among multiple stakeholder; • Inter-sectoral rivalries; • Health, Education, Public Service, Local Govts. • Dis-connected actions by actors; • Fragmented control systems for workforce; management; • Pervasive short-cuts to workforce developments; • Competition for scarce workforce;

6. 1.2 Governance and the workforce:Multiple-institutional bureaucracies • Finance, • Education, • Health • Public Service, • Local Govt. • District Councils • District Service Commission • Chief Executive Officer • District Health Office • Unit Mgt Commitees • Non State Sector managers • Donor projects on workforce • Ruling Party manifesto, • Public Service Commission • Professional Councils • Health SWAP donors, • HIV Global Initiatives • Worker Unions

7. Effects of HIV Programs on Health Sector Roles in Workforce Management Research questions 2.Under what conditions do HIV programs strengthen the capacity of the health sector to ensure effective workforce deployment, adequate workforce size, and optimal wage structures.

8. 2.1 System-level problem: - eg vacant posts in health facilities

9. 2.2 Inefficient recruitment processes? Source: Planning Division, Ministry of Health Uganda 2008/09

10. 2.3 Health sector workforce system: “Locked” or unattractive?

11. 2.4 Global Health Financing (GHF) and the Dynamics of Workforce Movement 73% changed job In last 3 years Source: Ssengooba et al 2009. Effects of Global Health Initiatives on the Workforce in Uganda

12. 2.5 Perceptions of Health Facility Managers:Extent of GHF for Organizational Capacity Developments( 126 HIV provider facilities in Uganda) Source: Ssengooba et al 2009. Effects of Global Health Initiatives on the Workforce in Uganda

13. 2.6 Salary Differentials: HIV and Non-HIV Health Facilities. Source: Ssengooba et al 2009. Effects of Global Health Initiatives on the Workforce in Uganda

14. HIV Funding mechanisms (HRH levers) Payment mechanisms Additional funds Organizational level Work teams National level Sub-national level Job markets Govt. NGO. networks Govt. NGO./CSO Govt. NGO. Govt. NGO. Capacity building Priority programs Intermediary Agencies for HIV Programs Context: Global, national & sub-national Health system Key Health system performance gaols Accessibility , Equity, Efficiency, Quality, Sustainability Direct GHI interraction Indirect GHI interraction

15. How do we accumulate evidence on health system impacts of HIV funds? 3. How do we demonstrate effectiveness of HIV investments on health workforce? • What are the linkages between HIV investments and the workforce? • What frameworks can assist to build the explanations of these linkages? • Which are the most critical analytical domains? • What methodologies should be employed? • Is there optimal research capability for this endeavor?

16. 3.1 Post-modern research methods are needed for health systems research “Systemography” ie the ethnography of the health systems is critical for policy relevance and actions: • System-level observation of events overtime, • Contextual dynamics and their explanations, • Comparative frameworks & perspectives for assessments, • Mixed methods and multi-desciplinary analyses, • Case-studies and their syntheses, • Real-time feedback loops between Reseach & Development, • Learning, adjusting and evolving for optimal fit in the contexts • Can we borrow methods from Complexity Sciences (Complex Adjusting Systems - CAS)?

17. Conclusions HIV programs need to build strategic governance capacity for workforce management; System-level evidence for effects of HIV programs on the workforce and health systems need to be synthsized from multiple perspectives; Methods need to be diversified to study workforce and health systems in general; Ethnography of health systems (systemography) is needed. Local & regional institutions should play “observatory” roles and build real-time links to policy.