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Making Health Systems Work for Child Survival: Developing and Monitoring Critical Human Resources. David Sanders Andy Haines Robert Scherpbier. Outline of Presentation. A definition of health systems and the place of human resources

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Making health systems work for child survival developing and monitoring critical human resources

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

David Sanders

Andy Haines

Robert Scherpbier


Outline of presentation
Outline of Presentation and

  • 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


The health system and its human resources
The Health System and its Human Resources and

  • 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.


Components of health systems
Components of Health Systems and

”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


Human resources are centrally important

HUMAN RESOURCES and

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



Mortality in children 0 5 years old in southern africa
Mortality in Children 0-5 Years Old andin Southern Africa

Others

Diarrhoeal

Diseases

Malnutrition

Perinatal

complications

Acute

Respiratory

Infections

Malaria

Measles

WHO’98



And growth of poverty poverty in southern africa
..and growth of poverty andPoverty in Southern Africa

(Source: Cited in UNOCHA, July 2002)


Would it be better to born a Japanese cow and

than an African citizen?


An example from south africa mt frere health district
AN EXAMPLE FROM SOUTH AFRICA: andMT. 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


Study setting paediatric wards in rural hospitals
STUDY SETTING: andPAEDIATRIC 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


Implementation cycle
Implementation Cycle and

Policy

Advocacy

Evaluation

Capacity Development

Teambuilding

Implementation

and Management

Situational

Assessment

Planning

Analysis


Case fatality in rural hospitals
CASE FATALITY IN RURAL HOSPITALS and

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%


Implementation cycle1
Implementation Cycle and

Policy

Advocacy

Evaluation

Capacity Development

Teambuilding

Implementation

and Management

Situational

Assessment

Planning

Analysis



SITUATIONAL ANALYSIS level IMCI

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


Who 10 steps training mt frere district eastern cape
WHO 10-STEPS TRAINING level IMCI – 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


Evaluation of implementation
Evaluation of Implementation level IMCI

  • 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


Sipetu case fatality rates by trained untrained periods
SIPETU CASE FATALITY RATES BY level IMCITRAINED/UNTRAINED PERIODS


Differences in treatment
DIFFERENCES IN TREATMENT level IMCI

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.


Quotes from a community service doctor
Quotes from a Community Service Doctor level IMCI

“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!”


Changes in cfrs in rural hospitals
CHANGES IN CFRs IN RURAL HOSPITALS level IMCI

Ongoing research indicates leadership and management at all levels are the key

reasons for the differences between well and poorly performing hospitals


Evaluation of step 10
EVALUATION OF STEP 10 level IMCI

  • 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


CAREGIVER KNOWLEDGE OF NUTRITION level IMCI

  • 76% remembered key messages about food fortification

  • 71% of caregivers unable to implement acquired knowledge of feeding practices


STAPLE FOOD INVENTORY LIST level IMCI

Samp / Maize

Beans

Maize Meal

Flour

Rice

Sugar

Soup

Tea / Coffee

Milk

Oil

Peanut Butter

Eggs


HOUSEHOLD SOURCE OF INCOME level IMCI

  • 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)


Implementation cycle2
Implementation Cycle level IMCI

Policy

Advocacy

Evaluation

Capacity Development

Teambuilding

Implementation

and Management

Situational

Assessment

Planning

Analysis


Sunday, September 22 2002 level IMCI

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


Advocacy component
Advocacy Component level IMCI

  • 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


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


A Case Study of Management of Pneumonia 3/10/02 in T. Guthrie, UCT & ACESS, Feb. 2003


Imci pneumonia case management tanzania coverage child actually receives the intervention
IMCI pneumonia case management (Tanzania) 3/10/02 in T. Guthrie, UCT & ACESS, Feb. 2003Coverage: child actually receives the intervention

Source: Jones et al, Lancet 2003, 362: 65-71


Towards population impact

9% 3/10/02 in T. Guthrie, UCT & ACESS, Feb. 2003

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


Towards population impact1

Intervention efficacy 3/10/02 in T. Guthrie, UCT & ACESS, Feb. 2003

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


Hr issues raised by case studies
HR Issues Raised by Case Studies 3/10/02 in T. Guthrie, UCT & ACESS, Feb. 2003

  • 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


Health workers save lives
Health Workers Save Lives! 3/10/02 in T. Guthrie, UCT & ACESS, Feb. 2003

Anand & Barnighausen, 2004


Nurse density and vaccination
Nurse density and vaccination 3/10/02 in T. Guthrie, UCT & ACESS, Feb. 2003

Anand & Barnighausen (forthcoming)


Accumulating evidence of effectiveness of community health workers
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


Hr policies and planning for child survival programmes
HR Policies and Planning for child survival Workersprogrammes

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


Planning for hrh needs
Planning for HRH needs Workers

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


But…. Workers

  • 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


AIDS and Aid may both disrupt health systems… Workers

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



Burden of disease Workers

Share of population

Share of health workers

Our Common Interest 2005:184


Hrh density by regions
HRH Density by Regions Workers

Workforce data are aggregates that mask unequal distribution between rich and poor African countries and between rural and urban areas

Source: JLI, 2004


Health professional migration from africa
Health professional migration from Africa Workers

  • 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


NURSE REGISTRATION IN UK Workers :Increase during a period when a “ban” on active international recruitment had just come into effect

Buchan et al 2003


Migration carousel
Migration ‘Carousel’ Workers

  • 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).


International migration losers
International migration - losers Workers

  • UN Conference on Trade and Development (UNCTAD):for each professional aged between 25 and 35 years, US$ $184,000 is saved in training costs by rich countries

  • The loss of approximately 20,000 skilled workers per annum results in an annual loss of US$ 4 billion to Africa

  • Africa spends an estimated 35% of ODA annually, approx. US$ 4 billion, on salaries of 100,000 foreign experts (all sectors, not only health) to replace lost capacity, to ‘build capacity’ and/or provide technical assistance

    Pang et al, 2002; UNECA, 2000; IRIN, 30 April 2002


Potential policy options to address migration
Potential policy options to address migration Workers

Source countries

  • Pay and non pay incentives( hardship allowances, better support, promotion, training access, child education , housing etc)

  • Train more mid level cadres( clinical assistants, nursing aides etc)

  • Address HIV/AIDS and gender issues

  • Structured return programmes

    Receiving countries

  • Increase own production

  • ‘Ethical recruitment’

  • Bilateral agreements

  • Compensation inc. educational initiatives

    But little evidence of what works


Hr production and management for child survival programmes
HR “Production” and Management Workersfor child survival programmes

Health outcomes

Outputs (quality)

Design retention strategies,

Institutionalise supportive supervision

Harmonise HW estimates and skills needs with ‘production’ plans and curricula (of medical schools, ‘auxiliary’ schools, nursing colleges). More in-service and CE. Train CHWs.

Based on: Hall and Mejia, 1978


Basic and pre registration training
Basic and Pre-registration training Workers

  • Review alignment of under- and post-graduate training (and texts) of doctors and nurses towards major child health problems

  • Increase amount and importance of practice-based learning in low-resource settings

    Waterston and Sanders, Medical Education, 21, 1987

  • Accelerate production of mid-level workers such as medical assistants and nurse aides (Overcome resistance of professional registering bodies)

  • Revisit evidence for effectiveness of CHWs and accelerate their production

    Lewin SA et al, Cochrane Database 2005, Issue 1.


Capacity development
Capacity development Workers

Capacity development is required at all levels of the health sector:

  • central management, who need skills in change management and stewardship;

  • local managers and service providers (doctors, nurses, mid-level workers) who need different combinations of clinical and public health skills;

  • Southern institutions, including universities, training schools and units


Improving performance of existing health workers is a priority rowe a et al lancet 2005
Improving performance of existing health workers is a priorityRowe A et al, Lancet 2005

  • Audit and feedback – more focus on problem-solving through health systems research

  • Supportive supervision

  • Educational outreach

  • Guideline implementation strategies

  • Performance – related allowances ? Harries A, Salaniponi F, Lancet 2005

    “ ..If training and guidelines are to have an impact they must be provided within a context that provides reminders, supportive supervision, feedback and, perhaps, more formal quality assurance…”

English M, Arch Dis Child 2005


Monitoring
Monitoring priority

  • Policies

    • Targets (# HW trained and distribution)

    • Quality of care (standards for competencies)

  • Planning

    • Estimates (# HW trained and distribution)

  • "Production"

    • Balance inflow/outflow

    • New trainees and old trainees upgraded

  • Management

    • Supervision and support

    • Implementation of retention strategies

    • Quality of care (measurements though special surveys and tools)


Possible indicators
Possible Indicators priority

Several sources of data e.g. censuses, labour force surveys, enrolment and completion figures (N.B forthcoming World Health Report)

Criteria – policy relevance, reliability, validity, simplicity, ability to (dis)aggregate

  • Density per 1000 population

  • Skill mix

  • Participation, employment opportunities , retention

  • Distribution – geographical ( equity), private vs public, disease specific programmes etc

  • Production - training, attrition rates etc

  • Performance


Conclusions
Conclusions priority

  • Prioritise and plan Human Resources

  • Reinstitute mid-level and community health work

  • Education should be problem-oriented and practice-based - especially in low-resource environments.

  • Reorientate and upgrade skills of teaching staff through continuing education.

  • Improve problem-solving, audit, support and supervision

  • Invest in leadership development

  • Develop regulations and incentives to improve staff retention

  • Develop mechanisms, including compensation of poor countries, to mitigate migration of health professionals to rich countries.

  • Advocate for increased investment in enhancing capacity of and reorientating Southern institutions (incl. equitable collaboration/partnerships with Northern institutions)

  • ADDRESS UNFAIR GLOBAL MACROECONOMIC REGIME


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