The John Kevany Lecture Human Resources & Inclusive Health

1. The John Kevany LectureHuman Resources & Inclusive Health Mac MacLachlan Professor of Psychology Associate Director, Centre for Global Health Trinity College Dublin malcolm.maclachlan@tcd.ie

2. 1. What is Inclusive Health? • 2. How are inclusion and HRH linked? • 3. From an HR point of view is aid divisive or inclusive? • 4. What about human resources for health in Ireland - from an inclusive global health perspective?

3. We specialise in multi-countrycomparative interdisciplinary research seeking to strengthen health systems & ensure equitable access, for all.http://global-health.tcd.ie CENTRE FOR GLOBAL HEALTH

4. Centre for Global Health addressing two basic Issues • 1. Who provides health care? • Coverage + Performance • 2. Who receives health care? • Access + Equity • Both related to inclusion

5. 1. What is Inclusive Health?

6. Inclusion is about how as well as whoMacLachlan, Khasnabis & Mannan (2012) Inclusive Health. Tropical Medicine & International Health, 17,139–141 • Health for All (Alma-Ata Declaration, 1978) ….Inclusive Education has been more successful. • ‘there is nothing more unequal, than the equal treatment of unequal people’.

7. Inclusive health is about health for all humankind, • BUT • it is important to recognise that human differences – disability, ethnicity, gender - influence people’s experience of healthcare.

8. We have a plethora of ‘culturally sensitive’, ‘gender appropriate’, ‘disability aware’, ‘child friendly’ • etc., policies and practices, BUT we lack a broader recognition that what marginalises many vulnerable groups is often not the intrinsic features that are used to characterise those groups, but instead their position in, and positioning by, larger society • Burke and Eichler (2007) BIAS-FREE

9. Hierarchy • Placement determines access to all types of resources • Ignoring hierarchies reinforces them.

10. Equity is the process of being fair to all people , respectful of differences, and free from discrimination. • Equality is the outcome reached through equity and reflects the goal of fostering equitable conditions of all people, rather than treating them the same.

11. Inclusive health recognises that for every group that is marginalised and ⁄ or vulnerable, there may need to be strategies to address their particular needs in such a way to overcome their particular barriers to health. • Inclusive is a verb!

12. Inclusive health delivery means • allowing for a range of health practitioner cadres to be involved in providing an acceptable quality of care in the most efficient and cost-effective manner. • Alternative cadre, task shifting, supervision, motivation, performance, efficacy

13. Inclusive health is about … • Who gets healthcare • And • Who provides healthcare

14. 2. How are inclusion and HRH linked? The Example of Community Based Rehabilitation

17. Disability

18. Who is disabled?The World Report on Disability 2011 • 1 billion people • 15% of the population • 80% living in low-income countries

20. CBR Guidelines 150global experts

24. The World Report on Disability (2011)

25. Alternative cadre?

26. Staff skills not staff types for community-based rehabilitationMacLachlan, Mannan & McAuliffe (2011) Lancet, 377, 1998-99

27. Job Design • What needs to be done • Job Analysis • Job Specification • Training • All should be done as scientifically as possible

28. Switching from ‘them’ to ‘us’ • Are ‘we’ being divisive?

29. 3. From an HR point of view is aid divisive or inclusive? • The dual salary system - a taboo

30. In aid there are often huge pay discrepancies • Which replicate the very inequities they are meant to eliminate!

31. How would anyone feel if a work ‘partner’ was earning 20X more, or less, than oneself?

32. Double DemotivationFrom: Psychology of Aid,Carr, Mc Auliffe & MacLachlan (1998). London: Routledge

33. Field survey from Malaŵi • ____________________________________________________________________ • Expatriates Malaŵians • ____________________________________________________________________ • Items about foreign expatriates • Some expatriates on large salaries feel guilty • because they earn much more than local workers 3.4 2.0 • Expatriates are better employees than their 2.7 1.6 • local counterparts • ------------------------------------------------------------------------------------------------------- • Items about local instructors • Expatriates who work abroad should work under • the same terms and conditions as local people 2.2 4.1 • Most companies are unfair to their local employees 3.3 4.6 • Local people are de-motivated by the large salaries 2.9 4.2 • that some expatriates earn • ____________________________________________________________________ • Scale ranged from 1 – 5, with higher ratings indicating stronger agreement.

34. And in the lab….

35. Effects of Unreasonable Pay Discrepancies for Under- and Overpayment on Double Demotivation.Carr, McLoughlin, Hodgson & MacLachlan (1996) GS&G Psychology Monographs, 122, 475-494.

37. Methodology – Sample Design • Professional workers = 1290 • Local workers = 992; expatriate = 298 • Organisations = 202 • Sectors: Aid (60), Govt (40), education (27), business (75) • Countries: • Landlocked: Malaŵi; Uganda • Island Nations: Solomon Islands; PNG • Emerging economies: India, China

38. Methodology • Self-reported pay and benefits (compared using the World Bank’s “Purchasing Power Parity”) • Variables (with checks for common method variance): • Self-assessed ability, pay comparison, feelings of pay (in)justice, pay (de)motivation, thinking about turnover, thinking about international mobility, job satisfaction, work engagement • Covariates: cultural values, culture shock, age, gender, experience, highest qualification, social desirability () • Recommendations from in-country workshops

39. Findings (b) Consequences for Work? Irrespective of pay group, significant predictors of de-motivation were: Feelings of pay Injustice (.50) Remuneration Comparison (.11) De-motivation predicted thinking about Turnover (.18) De-motivation predicted thinking about international mobility (.13) (brain drain of locals and, to a lesser extent, early return of expatriates)

40. Impact? • DFID/UK Aid??? • CAFOD • UPNG • The other side of research utiliszation?

41. www.theaidtriangle.com

42. 4. What about human resources for health in Ireland from an inclusive global health perspective?

43. Irish Times Opinion piece. • What are the HRH challenges for Ireland in a global health context.

44. Access: Unknown cutting of HSE staff. • Comparative data? • IFGH ? • HRH?

45. Migrant labour: Dependency of the Irish Health service on foreign doctors and nurses. • Comparative data? • IFGH ? • HRH?

46. Inequity: Discrepancy in training and practising in the Public Health Speciality in Ireland • Comparative Data? • IFGH • HRH??

47. Resource allocation: • Huge salaries of some clinicians in the Irish public health service. • Comparative data? • IFGH? • HRH?

48. Right to Practice: • Without fear of imprisonment. • Comparative data? • IFGH? • HRH?

49. Institutional obligations • Training of health workers. • Comparative data? • IFGH? – obligations too! • HRH?

50. As the IFGH our credibility/integrity is dependant on how we respond to HRH issues ‘abroad’ • but also • on whether what we would comment on abroad, we also comment on at home – using our unique comparative perspective. • Inclusion is about giving and receiving health • If, failing to address ‘some topics’ reflects hierarchies of dominance and agendas of exclusion – then we need to address them.