Gilbert Kombe, MD, MPH Senior HIV/AIDS and Infectious Disease Technical Advisor

1. From Health Labor Market Analysis to Results-Based Financing: Insights from a Post-Conflict Country (Côte d'Ivoire) Gilbert Kombe, MD, MPH Senior HIV/AIDS and Infectious Disease Technical Advisor Health Systems 20/20 Project January 14, 2009

2. Discussion Outline • Country Context and HRH Background • Technical Approach • Key Findings • Use of Analytical Findings in Developing Key Interventions • Take Home Messages

3. Country Context • Population: 18,700,000 (2004) • GDP per Capita: $1,650 (2006) • HIV Prevalence Rate: 4.7% (2005) • Like many SS African countries, CI’s economy grew from 1960 -1990s • Between 1999-2002, military started demanding salary increases which were unmet • 2002, CI experienced the first coup d'état which brought General Robert Guei to power • 2002 witnessed mass exodus of all health workers due to civil unrest • In 2004, due to insecurity, health workers fled, relocated or were unable to go to work • Public health sector lost one-fifth of medical doctors and one quarter of nurses • WHO estimated that 70% of health facilities across the country were not functioning

4. Health Coverage per Inhabitant Doctor1/9,739, Nurse 1 /2,374, Midwife 1 / 2,081

5. HRH Situation: Per Cent Vacancy Rates By Cadre

6. HRH Expenditures in the Context of Total Health Budget

7. Why Health Systems 20/20 Project Focused on HRH? • Modeling exercise for PEPFAR indicated HRH shortage is a common problem in Sub-Saharan Africa • HRH was a reflection of social, political, and economic challenges • Little was being done to address this issue • With increased burden of HIV/AIDS, Malaria and TB, came projected increase in human resource need • HRH growth rate in many countries was very slow compared to population growth

8. Why USG cared about HRH in CI Investments in drugs and supplies will be wasted HW growing slower than population Are there staff to run facilities? Questions about reaching targets of major initiatives e.g. MDG & PEPFAR What was the impact of HIV/AIDS on HRH shortages?

9. Typical Dynamics of the Health Labor Market

10. Technical Approach • Three interrelated approaches were used. • Conducted a comprehensive desktop review of both published and unpublished documents. • Conducted key informant interviews with Ministry of Education, Ministry of Health and Population, development partners, and other key stakeholders. • Facility surveys of HRH in public and private health facilities (2 phases) • In 2005, collected data from 301 public facilities (primary, secondary, tertiary) out of 1,381 across the country (MOH, 2005). • In 2006, collected data from 279 facilities (polyclinics, clinics, medical centers/practices, nurse/midwife practices, social medical centers, village enterprises) out of 1,144 (MOH, 2005). Included training institutions.

11. Fundamental Analytical Questions • How big was the issue of HRH across the country? • How many doctors, nurses, laboratory technicians, social workers did the country have? • Were they available? • How were they distributed? • What proportion of HRH should go to HIV/AIDS, Malaria, TB? • How much would it cost to intervene and can the Ivorian government alone address the issue? • What were the health system wide effects of the HR crisis?

12. Assessment Limitations • Outdated national data from DHR. • Data registers did not reflect the existing situation of demand and supply. • Data on HRH in the private sector was scarce; no data since 1997. • Difficult to make comparisons between past and future HRH growth rates of private providers. • Data from training institutions did not indicate where graduates were going.

13. Findings

14. I. Supply of New Graduates • The Unite de Formation et de Recherche des Sciences Medicales de l’Université de Cocody • Doctors trained in 2004 (280) and in 2006 (203). Faculty-to student ratio ranged from 1:15 to 1:87. (2006) • Institute National de Formation des Agents de Santé (INFAS, laboratory technicians) • Nurses/Midwives 2004 (1,545), 2005 (1,818), 2006 (2,176). Instructors 2004 (66FT), 2005 (71), 2006 (71). • The Institute Nation de Formation des Agents de Santé • 117 (2004) to 160 (2005) and 218 (2006). Faculty-to-student ratio 2004, 2005, and 2006 are 1:117, 1:160, and 1:218, respectively.

15. II. Not All Graduates are Employed by the Public Sector

16. II. Very High Annual Attrition Rates Among Public Health Workers

17. III. Small HRH Growth Over Time

18. IV. Distribution of Public Health Workers Skewed Towards Abidjan • In 2002, the Lagunes region had 64% of doctors, 48% of nurses, 74% of pharmacists, 48% of lab technicians and 67% of social workers. • In 2004, the figures rose, especially among lab technicians (66%) and social workers (77%).

19. V. Private Sector Using a Combination of PT & FT Workers

20. VI. Growth Among Part- and Full-Time Private Physicians

21. VII. HRH Length of Service in Private Sector Facilities Interviewed 279 HW. • 33% of HCW worked for over 11 years • 27% spent between 6-10 years • 18% worked 3-5 years • Only 8% spent between 1-2 years

22. Using Health Labor Market Data for Policy Program Planning • Development of a 5-year National HRH Policy • Emergency hiring of nursing instructors • Development of pilot incentive scheme • Strengthening human resource information system • Strengthening of management of HRH

23. A. Development of a National HRH Policy

24. Key Components of the 5-Year Strategy

25. B. Emergency Hiring and Management Strengthening • Hired 35 clinical nursing instructors and mentors for 3 institutions • Reduced the faculty-to-student ratio from 1:39 (2007) to 1:28 (2008) • Trained 187 central, provincial and district managers in health services management • Developing HRIS at the central and provincial levels

26. C. Incentive Scheme Pilot in Ferke District

27. Population (2007): 330,048 HIV/AIDS Prevalence: 16.76% among those tested at facilities Infant Mortality Rate: 127 per 1000 Private Sector Health Facilities: 1 Hospital 2 Health Facilities 3 Dispensaries Public Sector Health Facilities: 1 District Department 2 General Hospitals 1 National Institute of Public Hygiene 4 Urban Health Facilities 6 Rural Health Facilities 8 Rural Dispensaries Facts About Ferke District

28. Elements of the Incentive Scheme

29. HRH Included in the Pilot Incentive Scheme • Participants: • District Department (6 facilities): 1 physician; 1 chemist; 1 assistant chemist; 3 nurses • 2 General Hospitals: 8 physicians; 2 chemists; 1 assistant chemist; 7 nurses; 3 nurse specialists; 5 midwives; 1 lab tech; 2 orderlies • 3 Urban Health Facilities: 3 physicians; 4 nurses; 3 midwives • 1 Rural Facility: 1 nurse; 1 midwife • Total Salary Top-Up: $24,172/month

30. Take Home Messages • HRH issue must be on the national and international agendas and action must be taken now • Implementing sustainable solutions requires time and resources to be successful • HRH interventions must not be more of the same... we need to implement comprehensive solutions in public and private health sectors • e.g. P4P,incentives, focus on increasing productivity • There are no “one-size-fits-all” solutions • Outcome-oriented, innovative, learning-oriented and system-linked • We must not walk away from HRH issues, we must walk into them • Long-term cost of not acting now is very high