CHA 2009 C0NFERENCE HELD IN KAMPALA UGANADA

1. CHA 2009 C0NFERENCE HELD IN KAMPALA UGANADA CHAG HRH STAUDY REPORT PRESENTED BY PHILIBERT KANKYE BERNARD C. BOTWE

2. TITLE OF STUDY • An Assessment of the Impact of Government Human Resources for Health (HRH) Policies on Network Members of the Christian Health Association of Ghana • February 2008 • Philibert Kankye, CHAG • Peter Yeboah, CHAG • Bernard C. Botwe, CHAG

3. OUTLINE OF PRESENTATION • INTRODUCTION • BACKGROUND OF STUDY • PROBLEM STATEMENT • STUDY OBJECTIVES • METHODOLOGY • POLICY OBJECTIVES • POLICIES AND STRATEGIES • POLICY IMPLEMENTATION • FINDINGS • CONCLUSIONS • RECOMMENDATIONS • LESSONS • NEXT STEPS

4. INTRODUCTION • The Ministry of Health (MOH) and Christian Health Association of Ghana (CHAG) have maintained operational relationships since the establishment of CHAG in 1967 • In 1975 the government commissioned Adibo Committee to study the role of mission health facilities in Ghana. • The Committee recommended that Government should sun-vent CHAG Facilities to enable them to pay salaries. • This recommendation led to a strengthened relationship between the government and CHAG.

5. INTRODUCTION CONT. • This relationship was further evidenced in the signing of a Memorandum of Understanding (MOU) and Administrative Instructions (AI) in 2003. The objectives of which are: • To provide a framework to formalize the working arrangement between the parties • To ensure accountability and transparency in the working relationship.

6. INTRODUCTION CONT. • In the MOU, • CHAG agreed to adopt the HRH policies outlined by the MOH and to submit its human resource needs to the MOH for support. • For its part, • the MOH agreed to facilitate the equitable distribution of health professionals among its agencies including CHAG.

7. INTRODUCTION CONT. • Health professionals from training institutions shall be proportionately allocated to CHAG institutions through negotiation or based on needs. • Staff placement and deployment in CHAG institutions shall be in accordance with MOH guidelines and norms. • CHAG training institutions shall receive support from the MOH like all MOH training institutions.

8. INTRODUCTION CONT. • The MOH shall provide fellowships to CHAG in line with the approved Human Resource plans and budgets

9. BACKGROUND OF STUDY • In 2002, the MOH launched an HRH policy intended to facilitate the development and retention of a highly trained and motivated workforce with skills appropriate to implement the health sector’s Program of Work (POW).

10. BACKGROUND OF STUDY CONT. • Christian Health Association of Ghana (CHAG), in the broader scheme of things, subscribed to both the HRH policy and the five-year POW as covenant in the Memorandum of Understanding (MOU) and Administrative Instructions (AI). • The implementation of the policy reached its final year in 2006.

11. BACKGROUND OF STUDY CONT. • As a major stakeholder in the health sector, CHAG conducted this study to assess the extent to which the policy impacted the health service delivery of its network members. • The outcome of the study will be used to guide the development of future HR policy options and to strengthen CHAG’s capacity to remain a key partner in the health service delivery throughout the country.

12. PROBLEM STATEMENT • The health sector reform initiatives in Ghana recognized HRH as the most crucial aspect of the delivery of efficient and cost effective health care • The reforms also addressed the issue of increased participation of private providers in health care delivery from 35% to 50% by 2010,

13. PROBLEM STATEMENT • The operations of CHAG network members continue to be affected by the HRH policy direction of the MOH and its implementing agency, Ghana Health Service (GHS). • HR inequities still exist between GHS and CHAG member institutions at all levels. This phenomenon is further compounded by a number of factors. Internal brain drain: • CHAG staff continue to resign their post to join GHS. Uneven staff distribution: Newly qualified and existing skilled professionals are also distributed to the disadvantage of the CHAG member institutions

14. PROBLEM STATEMENT Career development: • the exclusion of CHAG network members where opportunities do exist. Policy implementation gaps: • CHAG in its policy document, CHAG continues to be adversely affected by implementation structures and processes. Latent competition: Underlying the above developments is the seemingly hostile attitude of public health professionals toward those in private sector, especially CHAG. There are serious challenges and inequality gaps in HRH that work against CHAG.

15. STUDY OBJECTIVES • To assess MOH HRH policy/program implementation and impact on CHAG’s HR capacity. • To provide HR policy options to strengthen CHAG’s capacity to engage the MOH, stakeholders and other partners in HR development and maintenance.

16. METHODOLOGY • Document Reviews - from published and unpublished sources. • Primary data was collected with the use of questionnaires, interviews and focus group discussions with key informants.

17. GOVERNMENT HRH POLICY OBJECTIVES The objectives of the HRH policy are: • To provide a strategic basis for human resource development, deployment and compensation • To ensure coherence between national/MOH policies and HR policies and strategies • To ensure improved performance of the health sector workforce • To depict the extent and impact of the brain drain on the health sector and the country as a whole, and strategies to mitigate these effects.

18. HRH POLICIES AND STRATEGIES • Policy 1: The MOH will ensure high quality training for all categories of staff. Strategies include: • Continuing to train increasing numbers of high quality professionals • Restructuring training programs • Coordinating in-service training programs • Coordinating fellowships to ensure that awards are based on national needs, and to ensure equity in the distribution of awards.

19. Policy 2: The MOH will ensure equitable distribution of health professionals to benefit deprived areas. Strategies: • Paying rural allowance (30% and 50% of basic salary to doctors and other staff respectively) to rural area health staff • Providing staff with viable housing ownership schemes • Encouraging mission/NGO hospitals to run more satellite clinics in the rural areas where they operate.

20. Policy 3: The MOH will ensure retention of trained staff. Strategies: • Providing career development avenues by increasing opportunities for further training, attendance of conferences and updates; providing access to fellowships for eligible staff of all categories at all levels; and encouraging, supporting and recognizing essential non-clinical programs. • Reviewing salaries of all health staff by consolidating basic salaries and ADHA [Additional Duty Hours Allowance] with an appropriate top-up • Providing non-salary incentives by providing saloon cars/year for health staff; and providing housing units/year to health sector workers.

21. Policy 4: The MOH will ensure efficiency in human resource management. • Developing and implementing a continuous performance management system to replace the current appraisal system • Decentralizing HR management to teaching hospitals, regional and district directorate levels with clear lines of responsibility and authority • Promoting interview at agency level except for very senior staff • Training and employing a new cadre of staff as health care assistants to take care of non-technical duties • Training and employing nurse prescribers and dispensary technologists.

22. Policy 5: The MOH will foster close partnerships with other MDAs, private and nongovernmental providers to improve access to health care. Strategies • Encouraging and supporting legitimate institutions to train health professionals • Providing human resources • Providing interest-free vehicles for institutional use.

23. POLICY IMPLEMENTATION • The MOH developed the policy to run concurrently with the second five-year POW, spanning 2002-2006. • There was, however, no action plan • No system of monitoring and evaluation to guide the implementation. • Nevertheless, the policy was implemented somehow

24. ACHIEVEMNTS • There were minimal achievements in the implementation of the HR policy. • These include the following: • Training of health professionals: • There has been significant expansion of all existing health training institutions to accommodate increase intake of students. • Twenty-eight new training institutions were set up • 21 of these by the MOH, six by the private sector and one by CHAG. • These new training institutions include the Ghana College of Physicians and Surgeons

25. ACHIEVEMENTS CONT. • New programs for direct entry into midwifery, health assistants (clinical) and a diploma in community health nursing were introduced. This period of expansion resulted in an increase of 50% in admissions into the Health Training Institutions and a 20% increase in intake into all the universities.

26. ACHIEVEMENTS CONT. • HR retention measures. A number of schemes were simultaneously implemented with the ultimate objective of curbing the brain drain. These include: • Vehicle Hire Purchase scheme (VHPS): This scheme was instituted to provide affordable private ownership of vehicles for Health Staff by monthly deductions over a longer period of time. Thus, the scheme led to the procurement and distribution of 1,082 saloon cars for health workers at all levels and for categories of staff.

27. ACHIEVEMENTS CONT. • Additional Duty Hours Allowance (ADHA): Subsequent to Health Workers agitations for better remuneration packages, the MOH instituted the ADHA policy in 1999 with 3 objectives: • To recognize and remunerate health workers for any hours performed over and above the normal 8 hour per day or 40 hours per week respectively. • To ensure a 24-hour cover by all health delivery points in the country. • To motivate health workers for higher performance. This was expected to restore and sustain public confidence in the health sector’s capacity for quality health service delivery.The massive enhancement of salaries of health workers with the consolidation of ADHA into the basic salary with a top-up

28. ACHIEVEMENTS CONT. • Deprived Area Incentives Allowance (DAIA): • The DAIAwas intended to target critical health staff (Doctors, Nurses/Midwives, Pharmacists) working in disadvantaged and underprivileged areas of the country. The designation of deprived area status was the exclusive responsibility of the Ministry of Local Government that had the added duty of administering the DAIA to eligible health staff. • Deployment strategy: • A ministerial committee for posting of health professionals was formed to ensure the equitable distribution of staff among providers including CHAG. Also, a number of policy guidelines were developed to guide the management of the existing stock of staff at all levels.

29. FINDINGS • POSITIVE IMPACT • High staff retention rates • Increased workforce productivity in-spite of low staff numbers • Increased motivation as a result of enhanced salaries • Increased professional and technical skills for service delivery

30. FINDINGS CONT. • POSITIVE IMPACT • Increased infrastructural investment in nursing training schools • Increased production of nurses to fill the vacancies • and increase in the ratio of professional to nonprofessional nursing staff in hospitals.

31. FINDINGS CONT. • ADVERSE IMPACT • Perverse incentives to overstay at workplace due to pecuniary gains other than service delivery to patients. • Low morale of some staff due to inequitable allocation of the HR incentive packages • enabled its staff to receive more money.

32. FINDINGS CONT. • ADVERSE IMPACT • Apathy in the case of some staff who felt marginalized. • Internal migration of CHAG staff to GHS due its relaxed implementation of the ADHA, which

33. CONCLUSIONS • QUOTES FROM RESPONDENTS • “It tended to lower morale because of the inequities in quantum size between what CHAG staff got and staff in Ghana Health Service.” • “It bred mistrust, enmity as a result of its inbuilt exclusionist principle at the facility level initially.”

34. CONCLUSIONS CONT. • “The policy came to kill the spirit of sacrifice in the mission institutions and we are now struggling to resuscitate it.” • came “to disturb the peace in the mission hospital environment.”

35. RECOMMENDATIONS • CHAG should develop a common HRH strategy for adoption by all members. • CHAG should adopt an HR transfer policy that will institutionalize or facilitate staff transfers and deployment amongst CMIs and across denominational lines. This would ensure equitable allocation and rational utilization of scarce human resources within the CHAG fraternity. • CHAG should develop a separate incentive package for its network members that will be equitable and linked to performance.

36. RECOMMENDATIONS CONT. • CHAG Staff that return from further training and who do not fit well in their old places of work should be deployed within the CHAG instead of losing them to either Ghana Health Service or other organizations. • CHAs should analyze the impact of government HR policies on thier staff, evolve own HR strategies and implementation plans, and gather and use evidence for engagement with their Ministries of Health.

37. LESSIONS FOR CHAG • CHAG was unable to maximize the opportunities created by the MOH’s HRH policy for lack of effective participation. • CHAG’s commitment to the MOU in relation to HR made it possible for CHAG network members to benefit from the policy, especially with regards • the equitable distribution of the newly trained health professionals • incentive packages to motivate and the ability to retain health staff • the infrastructural expansion of their nurses’ training colleges

38. LESSIONS FOR CHAG CONT. • Improved relationship between CHAG and the MOH in the area of HR production • CHAG needs to develop its own HR policy and strategy document that would feed into the national policy and strategic document in future

39. LESSIONS FOR CHAs • The experience of CHAG indicates that • Government HR policies directly affect Christian Health Associations in Africa (CHAs). • There is perennial problem of inequitable allocation of resources to the disfavour of CHAs. • Staff working with CHAs often feel marginalized when their counterparts in government receive preferential treatments, incentives and advantages that are not readily available at CHAs facilities.

40. LESSIONS FOR CHAs • Given the insightful preliminary findings of this study, CHAs are highly encouraged to conduct a similar study into the impact of government policies on their network members. It would enable them to identify key issues around which they engage their respective Ministries of Health in a constructive dialogue to find pragmatic solutions to HR challenges in their countries and throughout Africa.

41. ACKNOWLEDGEMENT • CHAG is very grateful to the following: • Charles Franzen, and • Craig Hafner, of IMA World Health, for failitaing the funding of the research; • Capacity Project and • USAID for financing the study • The heads of CHAG Institutions for participating in the rearch • The staff of CHAG Secretariat for assisting in the retrieval of relevant documents

42. ACKNOWLEDGEMENT • BIG THANKS TO MIKE OF THE CHA PLATFORM FOR HELPING ME OUT LAST NIGHT. • THIS PRESENTATION WOULD NOT HAVE BEEN POSSIBLE WITHOUT HIM • THE END!!!

43. THANKS • YE DA MO ASE • BARKA YAGA • ASANTE SANA • MERCI