Transcript DRAFT HR FOR CHILD SURVIVAL

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
• 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 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
”HARDWARE”

Facilities e.g. Hospitals, Health Centres

Technology / Equipment / Drugs

Transport

Communications

Finance
“SOFTWARE”
Human Resources
*Human Resources for
Health
*Communities
*Other Sectors’ Personnel
Processes – policies, service provision, legislation/regulation, advocacy
Human resources are centrally important
Health system functions
Financing
Stewardship
HUMAN
RESOURCES
account for 60-70% of
health expenditures
Resource generation
Service delivery
HUMAN RESOURCES
convert other resources
into outputs that
contribute to better health
outcomes
HEALTH
OUTCOMES
Neglect of human resources
planning, production,
retention, and motivation
will continue to cause other
resources to be wasted
Source: Adapted from JLI
A case study of management of malnutrition
Mortality in Children 0-5 Years Old
in Southern Africa
Others
Perinatal
complications
Diarrhoeal
Diseases
Malnutrition
Acute
Respiratory
Infections
Malaria
Measles
WHO’98
‘Globalisation’ results in unequal growth of wealth
..and growth of poverty
Poverty in Southern Africa
Population living below Population living below
poverty line 1996
poverty line 2001
Lesotho
49%
49%
Malawi
60%
65%
Mozambique
69%
69%
Swaziland
48%
66%
Zambia
69%
86%
Zimbabwe
61%
75%
(Source: Cited in UNOCHA, July 2002)
Would it be better to born a Japanese cow
than an African citizen?
0
500
1000
1500
2000
2500
3000
U S dollars
J apan annual dai ry s ubs i dy , per c ow
E U annual dai ry s ubs i dy , per c ow
P er c api t a annual i nc om e, s ub-S aharan A f ri c a
P er c api t a c os t of pac k age of es s ent i al heal t h i nt erv ent i ons
P er c api t a annual heal t h ex pendi t ure, 63 l ow i nc om e c ount ri es
AN EXAMPLE FROM SOUTH AFRICA:
MT. FRERE HEALTH DISTRICT
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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
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
Policy
Advocacy
Evaluation
Teambuilding
Implementation
and Management
Capacity Development
Situational
Assessment
Planning
Analysis
CASE FATALITY IN RURAL HOSPITALS
PRE-INTERVENTION CFRs –calculated from ward
registers
Mary Teresa 46%
Holy Cross 45%
St. Elizabeth’s 36%
Mt. Ayliff 34%
St. Patrick’s 30%
Bambisana 28%
Sipetu 25%
St Margaret’s 24%
Taylor Bequest 21%
Greenville 15%
Rietvlei 10%
Implementation Cycle
Policy
Advocacy
Evaluation
Teambuilding
Implementation
and Management
Capacity Development
Situational
Assessment
Planning
Analysis
WHO 10-STEPS PROTOCOL – Nutrition component of
hospital level IMCI
Step 1 Treat/prevent hypoglycaemia
Step 2: Treat/prevent hypothermia
Step 3: Treat/prevent dehydration
Step 4: Correct electrolyte imbalance
Step 5. Treat/prevent infection
Step 6. Correct micronutrient deficiencies
Step 7. Cautious feeding
Step 8. Catch-up growth
Step 9. Stimulation, play and loving care
Step 10. Preparations for discharge
Comparison of recommended and actual practices
SITUATIONAL ANALYSIS
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
Children were left
waiting in the queue
in the outpatient
department and
during admission
procedures.
Lack of knowledge
about risks of
hypoglycaemia
Training to explain why
malnourished children
are at increased risk
Lack of knowledge
about how to prevent it
Training on how to
prevent and treat
hypoglycaemia
In the wards, they
were not fed for at
least 11 hours at
night
Shortage of staff
especially during the
night
Malnourish
ed children
fed
straightawa
y and 3
hourly
during day
and night.
Feed every 2
hours during the
day and night.
Start straight
away.
No supplies for testing
for hypoglycaemia
Hypoglycaemia not
diagnosed
Motivated for more
night staff in paediatric
wards
Motivated the
Department of Health to
provide resources (10%
glucose and
Dextrostix.)
The
number of
night staff
was
increased
Dextrostix
and 10%
glucose
obtained
WHO 10-STEPS TRAINING – Mt. Frere District,
Eastern Cape
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Developed as part of a DistrictLevel INP
Training & Implementation from
March 98 to Aug 99
Two formal training workshops
for Paeds staff
On-site facilitation by nursetrainer
Adaptation of protocols –
Now have Eastern Cape
Provincial Guidelines
Evaluation of Implementation

Major improvements:

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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:

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Intermittent supply problems for vitamins and micronutrients
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
38
Case Fatality Rate (%)
40
35
30
25
25
20
20
18
15
10
5
0
PRE-INTV
TRAINED
TRAINED-STUDY
UN-TRAINED
DIFFERENCES IN TREATMENT
Treatment
Trained
Un-Trained P-Value
KCl
Broad Spectrum
Antbx
IV Hydration
Vitamin A
78%
13%
p=0.0000
47%
5%
92%
15%
6%
76%
p=0.0001
p=0.774
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
“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
50
45
40
35
1998-1999
30
2000-2001
25
2002
20
2003
15
10
5
0
Holy-cross
St. Patricks
Mt. Ayliff
St. Elizabeth
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


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


76% remembered key messages about food
fortification
71% of caregivers unable to implement
acquired knowledge of feeding practices
STAPLE FOOD INVENTORY LIST
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Samp / Maize
Beans
Maize Meal
Flour
Rice
Sugar
Soup
Tea / Coffee
Milk
Oil
Peanut Butter
Eggs
No. of food items in HH % of
Cupboard
HH
0-4
47
5-8
30
9 - 11
23
HOUSEHOLD SOURCE OF INCOME
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
PENSION GRANT
MIGRANT LABOURERS
NO INCOME FAMILIES
DOMESTIC WORKERS
CHILD SUPPORT GRANT (CSG)
40 %
25 %
20 %
15 %
0%
CSG – Children aged 0-9 years in families earning less than
R800 per month eligible
CSG - currently R160 ($26)
Implementation Cycle
Policy
Advocacy
Evaluation
Teambuilding
Implementation
and Management
Capacity Development
Situational
Assessment
Planning
Analysis
Sunday, September 22 2002
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
EMPTY STOMACHS: Year-old Samkelo is one
of nine children that his jobless grandmother,
Nofuduka Mbulawe, has to feed
Picture: Richard Shorey
Advocacy Component
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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
% Change in CSG Beneficiaries Per Province
from Dec 2001 to Oct 2002
70
61.1
56.3
Percent Change
60
44.8
50
40
38.5
36.3
31.4
30
36
40.2
31
21.8
20
10
0
EC
L
KZN
NW
MP
FS
NC
GT
WC
S.A
Province
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
IMCI pneumonia case management
(Tanzania)
% children receiving intervention
Coverage: child actually receives the intervention
e
Br
100
90
tfe
as
80
70
60
50
40
30
20
10
0
in
ed
-1
g6
o
m
1
Me
le
as
ine
c
ac
v
s
ta
Vi
n
mi
A
i ll e
k
S
tt
a
h
d
t
bi r
e
a
nd
nt
ta
Te
Source: Jones et al, Lancet 2003, 362: 65-71
s
nu
to
id
xo
tib
n
A
i
for
s
c
oti
e
pn
u
ni a
o
m
T
R
O
N
bo
w
e
r
u
es
r
n
ti
ita
c
s
on
IMCI pneumonia case management (Tanzania)
Towards
population
impact
Coverage
under actual
programme
conditions
Population
effectiveness
9%
Pneumonia mortality
averted ==
The HR
Intervention
efficacy x
factor
Intervention efficacy
65%
Health workers
are trained x
80%
Intervention
availability
Diagnostic
accuracy
Health
workers assess
child xcorrectly 63%
Provider
compliance
x
Health workers
treat
child correctly
65%
CoveragePatient
(mothercompliance
recognised x 40%
illness, sought care and complied
Coverage
with treatment:
child receives the intervention)
Tugwell framework applied to multi-country evaluation data
Source: Tugwell, J Chron Dis, 1985; 38(4):339-51
IMCI pneumonia case management (Tanzania)
Towards
population
impact
Coverage
under improved
programme
conditions
Population
effectiveness
19%
Pneumonia mortality
averted ==
The HR
Intervention
efficacy x
factor
Intervention efficacy
65%
Health workers
are trained x
90%
Intervention
availability
Diagnostic
accuracy
Health
workers assess
child xcorrectly 90%
Provider
compliance
x
Health workers
treat
child correctly
90%
CoveragePatient
(mothercompliance
recognised x 40%
illness, sought care and complied
Coverage
with treatment:
child receives the intervention)
Source: Tugwell, J Chron Dis, 1985; 38(4):339-51
HR Issues Raised by Case Studies
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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!
9
Mortality (per 1,000, log)
8
7
Maternal
6
5
Infant
4
3
Under-5
2
1
0
0
1
2
3
4
5
Density (workers per 1,000, log)
Anand & Barnighausen, 2004
Coverage (%)
Nurse density and vaccination
100
90
80
70
60
50
40
30
20
10
0
MEASLES
DTP
POLIO
1
10
100
Density (per 100,000)
1,000
Anand & Barnighausen (forthcoming)
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
Human resource cycle
Management
Production
Policies
Planning
Based on: Hall and Mejia, 1978
Align and link HR and
CS programme
policies (based on
population health
needs and
programme
interventions &
targets)
Define tasks and
skills required per
level.
Estimate time
requirements.
Define distribution
and skills mix.
Estimate total HW
numbers required
(FTE) per level
Planning for HRH needs
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….
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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 Ethiopia
were 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…
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
HRH and Africa…
Burden of disease
Share of population
Share of health workers
Our Common Interest 2005:184
HRH Density by Regions
0.8
Sub-Saharan A frica
2.3
A sia
2.6
S&C entral A merica
4.2
Glo bal
6.9
M iddle East
8.7
Western P acific
9.9
N o rth A merica
10.3
Euro pe
0
2
4
6
8
10
12
Workers (physicians, nurses and midwives) per 1,000 population
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
• 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 :Increase during a period when a “ban”
on active international recruitment had just come into effect
Buchan et al 2003
Migration ‘Carousel’
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 crossborder movement (GATS Mode 4).
International migration - losers
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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
Source countries
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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
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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
Health outcomes
Outputs (quality)
Design
retention
strategies,
Institutionalise
supportive
supervision
Management
Policies
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.
Production
Planning
Based on: Hall and Mejia, 1978
Basic and Pre-registration training
• 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 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
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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
• 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
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
•
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