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Women account for more than 50 percent of the health workforce in Jordan; however, women are largely underrepresented at decision-making levels in the health sector. According to the USAID-funded HRH2030 program’s review of Ministry of Health statistics, women comprise 55 percent of the ministry’s staff, yet hold only 27 percent of management and leadership positions across all levels. A gender audit, also conducted by the ministry, further revealed that women hold fewer than ten percent of higher level administrative roles. Increasing women’s leadership builds on the Ministry of Health’s efforts to promote gender equity and is an important step to strengthen health system resilience and system responsiveness.

 

To address these disparities, HRH2030 recently launched a national study to explore the barriers and enablers of women’s career progression to management positions in Jordan’s health sector. The research results will inform national human resources for health (HRH) policy and the development of strategies to strengthen women’s leadership in Jordan’s health sector.

 

“To prepare for this research, we conducted a review of the existing literature on women’s roles in the Jordanian workforce. Reports from both USAID and the United Nations show that most women working in Jordan’s public sector face some degree of job discrimination. For example, female workers could be criticized for working late or be required to provide more detailed justification for leave than their male counterparts. Women who do rise to supervisory positions hesitate to assign tasks to their male employees,” explained Matthew Kuehl, deputy project director for the HRH2030 activity in Jordan.

 

“We need to gain a better understanding of the issues to ensure that everyone benefits from policies meant to protect workers’ rights and that women have an equal opportunity to lead within the health workforce,” Kuehl added.

 

The HRH2030 team will conduct the research nationally, targeting urban and rural areas covering Jordan’s north, middle, and south regions. The mixed-methods survey samples will include women and men working at the Ministry of Health, university hospitals, councils, and within the private sector to understand the differences and similarities in experiences across the health sector. Female and male health care providers, including physicians, registered nurses and midwives, pharmacists, and facility managers within the public and private sectors, will engage in interviews as part of the research.

 

HRH2030 will leverage the expertise of two local researchers, Professor Yousef Khader of the Jordan University of Science and Technology and Dr. Aida Essaid, director of the Information and Research Center at the King Hussein Foundation. A research advisory committee, chaired by former Senator and Minister of Higher Education and Scientific Research Dr. Rowaida Maaitah, will guide the research team. Other collaborating members on the committee include stakeholders from the Ministry of Health, Jordan Nursing Council, Women’s Study Center at the University of Jordan, and Faculty of Nursing at Jordan University of Science and Technology.

 

“This research gives us the opportunity to explore and identify the reasons why there is a gender gap in managerial positions in Jordan’s health sector,” said Dr. Essaid. HRH2030 will investigate the experiences and perceptions of female career progression in the health workforce and identify factors — including existing policies and practices — that support or impede women’s leadership in the sector.

 

Thoroughly researching barriers and enablers to women’s leadership in the Jordanian health sector “will provide timely information for decision-makers and legislators to inform their policies and legislation to enhance women’s advancement in management positions,” explained Professor Khader. HRH2030 will work with national stakeholders to develop practical recommendations to gender equity challenges and integrate those into the country’s national HRH strategy.

There is no question that a fit-for-purpose, fit-to-practice health workforce is a critical component in meeting global health goals. From volunteer community health workers in remote rural villages to doctors and health managers in urban hospitals, the health workforce is the primary link to the health system for individuals, families, and communities. If we are to meet the goals of ending preventable maternal and child deaths, Family Planning 2020, controlling the HIV/AIDS epidemic, and protecting communities from infectious diseases, we must ensure that people everywhere have access to a quality health workforce that meets their specific health needs.

On April 19, 2017 a multisectoral group of representatives from USAID, USAID implementing partners, the International Labour Organization (ILO), and the World Health Organization (WHO) gathered at Chemonics in Washington, D.C. to discuss the expansion and transformation of the health and social workforce. The recent recommendations of the High-Level Commission on Health Employment and Economic Growth served as the foundation. These recommendations propose actions to guide the creation of health and social sector jobs as a means for advancing inclusive economic growth.

Specifically, the goals of the meeting were to:

  1. Promote awareness of the commission’s recommendations
  2. Brainstorm ideas for greater focus on commission principles and identify areas for collaboration across existing cross-sector portfolios

 

Commission Recommendations to Enable Change

In her introductory remarks, Ariella Camera, Public Health Advisor for Human Resources for Health (HRH) at USAID, pointed to the agency’s commitment to addressing key HRH challenges through its work in health, education, and economic growth to foster innovation and partnerships.

Continuing with the theme of partnerships, ILO’s Stephen Pursey and WHO’s Tana Wuliji introduced the work of the commission, emphasizing the challenges and opportunities that investing in the global health and social workforce creates for sustainable development and the need to work across sectors to enact change.

Although improvements over the past decade in the health workforce in sub-Saharan Africa have been commensurate with population increases, Wuliji explained, “They haven’t fundamentally led to a new level of workforce capacity in many countries. We cannot keep going the way we have been,” she added, pointing to opportunities to work across sectors. “We need a shift in trajectory.”

The global economy will produce 40 million new health worker jobs by the year 2030, according to the World Bank. But, demand for those positions will come mainly from middle- and high-income countries. Experts project a shortfall of 18 million health workers, largely in low and lower-middle income countries, needed to achieve and sustain a basic level of health care by 2030.

“The shortfall [in low and lower-middle income countries] far outnumbers the demand … When we talk about demand, we’re not talking about population demand. We’re talking about it in the economic sense. So, the ability of the economy to create [health worker] jobs … That means that even if we invest in the supply of health workers in low-income countries — in particular, to train more health workers — the economies will not be able to create the jobs to employ them. Unless we can employ them in the work, we are not going to get the kind of impact in health and also in the broader economy that we would like to have,” Wuliji explained. Ultimately, efforts to advance global health are at threat unless the health and social workforce mismatch can be addressed.

The quality of the jobs needed is also critical. New jobs must be decent jobs, in better conditions of work, with improved occupational safety and health, and recognition of workers’ rights, said Pursey. In the absence of decent jobs, workers will migrate to areas where they can find work, and that can mean leaving their home country. Furthermore, some wealthier countries may not be able to sustain the health workforce they need, mainly as a result of a decline in the working age population. They may have to rely on foreign workers.

“But how do you do that without undermining others’ ability to provide health services,” Wuliji asked. Understanding the dynamics of the labor market is an opportunity for transformative strategies and investments. We can’t just count health workers. We have to study this interdependency. We need to understand the pipeline, where the inefficiencies are, and where labor market and public failures are, she explained. “[There is] no way that the health sector can do it alone.”

The opportunity to achieve multiple goals across the 2030 Agenda for Sustainable Development beyond health (SDG 3) is also critical to highlight. Pursey and Wuliji emphasized the potential impact of health and social workforce investments and action on quality education (SDG 4), gender equality (SDG 5) and decent work and inclusive growth (SDG 8). Women comprise 71 percent of the health and social workforce, yet half of women’s contribution to global wealth is in unpaid care roles. Investments in this workforce has the gender-transformative power to accelerate women’s economic empowerment and participation.

Resource mobilization to stimulate job creation in low- and lower-middle income countries, particularly, is a necessity. “You’ve got to move your fiscal space out at the same pace that you’re moving your health services,” said Pursey. For example, the International Monetary Fund emphasizes expansion of the tax base, which is low in many countries. We also need to take a new look at international investments. “A lot of the international investments in health workforce mainly concentrate on the existing supply — not so much in expanding the supply … We’ve got to look at that again.” In doing so, there is an opportunity to address the health workforce demand and supply mismatch to better position countries to achieve health goals and create decent jobs, particularly for youth and women.

Stakeholder Discussion

Following the presentations by Pursey and Wuliji, the group engaged in discussion, raising several questions and sharing current activities that further the work outlined by the commission.

Attendees agreed on the need for more accurate health data and analysis of that data. WHO led the development of the National Health Workforce Accounts (NHWAs), a system of standardized health labor market indicators applicable to all health and social workforce occupations. The health sector often overlooks labor force data/surveys, which could be useful for capturing private sector and unregulated occupations. Within the public sector, reliable data doesn’t exist, or it is kept in disparate systems that do not “talk” to one another. In Jordan, for example, the Civil Service Bureau (CSB) keeps health workforce data, but the CSB doesn’t necessarily communicate with the Ministry of Health. Another challenge is data harmonization and ensuring that stakeholders are working with the same health worker definitions. For example, does the description of “community health worker” in Mozambique mirror the definition in Indonesia?

Reliable data can shed light on many of the “mysteries” of HRH — informing policies and planning. In another example from Jordan, research carried out by HRH2030 showed that the country did not, in fact, have severe worker retention issues. Data collection and analysis dispelled this false perception. Data can also help to ensure that the right type of health workers are in the right places at the right times based upon the population’s health needs and epidemiological transitions. HRH2030 is also working in this area.

Labor market and fiscal space analyses have become increasingly important as countries strive to achieve the 90-90-90 targets. Greater shared responsibility for HRH requires greater evidence and analysis to make the business case for increased country HRH investment. HRH2030 is currently carrying out health labor market analyses in several countries in Southern Africa. In South Africa, for example, the program is focused on factors influencing migration of specific cadres between the public and private sectors.

Labor market analyses and implementation of NHWAs can aid in building the evidence base for HRH; however, stakeholders must be equipped to make sound economic arguments for HRH investments. Wuliji proposed development of a playbook that ministries of health could use to negotiate for resources with ministries of finance. Ministries of labor could be potential allies in this cause, Wuliji said, adding that they tend to be better positioned to have these discussions than ministries of health. In line with strengthening the economic argument for HRH, HRH2030 is developing a research methodology to assess potential health, social, and economic gains of HRH investments. The program welcomes contributions from others interested in this topic. HRH2030 recently conducted a literature review, which showed that while there is some evidence for the value of HRH investment, many studies were conducted in high-income countries and evidence for social cohesion, in particular, was scant.

The global health community must also recognize that HRH is not just a health or economic issue; it is also a political issue. In some cases, decision-makers may prefer to put their health investments into equipment, infrastructure, or medicines — something perceived to be more tangible with a more rapid return than HRH (e.g., a new hospital). One argument HRH advocates could use to appeal to leaders in elected positions is the benefit of gainfully employing constituents, particularly youth and women. They can leverage the demands of people wanting decent work.

Finally, when arguing for resources, HRH advocates have to demonstrate efficiency without sacrificing quality or value. As Wuliji pointed out, we need to “instill the sea change in service delivery reforms.” Others noted that stakeholders should explore ways to improve processes — look at how workers are spending their time and how they are distributed. They should also take into account the social workforce. These workers have been trained to work alongside health services. How can health systems better use them to realize system efficiencies and better outcomes?

The challenge for governments and societies going forward will be determining where to place their priorities. As HRH2030 partner Open Development’s Sarah Scheening summarized, “I think recognizing these political forces is important. Recognizing that there is this tremendous deficiency in funding is also really important, and I think being really rigorous in our ROI [is important] … We need to bring clarity to the conversation and not muddy the waters.”

Next Steps

In May 2017, the World Health Assembly adopted Working for Health: Five year action plan for health employment and inclusive economic growth. Through this program, ILO, the Organisation for Economic Co-operation and Development, and WHO are working jointly to catalyze and stimulate the expansion and transformation of the health and social workforce by supporting implementation of the high-level commission’s recommendations in line with the WHO Global Strategy on Human Resources for Health: Workforce 2030.

Organizations participating in the roundtable discussion are listed below. If you are interested in learning more or connecting with any of these groups, please email info@hrh2030program.org. HRH2030 looks forward to exploring opportunities for future collaboration among USAID implementing partners and other stakeholders in the health and social workforce.

Participating Organizations
  • Abt Associates
  • Chemonics
  • FHI 360
  • Global Social Service Workforce Alliance
  • International Labour Organization
  • IntraHealth
  • Open Development, LLC
  • Palladium
  • Pan American Health Organization
  • URC
  • USAID
  • World Health Organization

Eric Coulibaly serves as the HRH2030-supported technical advisor for capacity building at the National Malaria Control Program in Niger.

April 25 marks World Malaria Day, a time to rally support for eradicating the disease that claims the lives of more than 400,000 people each year. Countries have made tremendous progress in the fight to end malaria for good — a recent report estimates a 57 percent decrease in the rate of malaria deaths across sub-Saharan Africa during the past 15 years. Despite this achievement, the World Health Organization calls for accelerating the pace of progress in order to reach the goals laid out in its Global Technical Strategy for Malaria. Included among these are a 90 percent reduction in mortality rate (based upon 2015 data).

Health systems, which include human resources for health (HRH), play a critical role in the fight against malaria. Among its strategic approaches for 2015-2020, the President’s Malaria Initiative (PMI) focuses on building health system capacity. With support from PMI and USAID, HRH2030’s Capacity Building for Malaria activity works directly with Eric Coulibaly, a dedicated technical advisor to the National Malaria Control Program in Niger, to build the capabilities of program staff and optimize malaria control interventions.

How is HRH2030 helping Niger’s National Malaria Control Program staff make better supply chain decisions?

The malaria commodities supply chain in Niger suffers due to lack of reliable logistics data and weak staff capacity to use available data for decision-making. To improve the situation, the National Malaria Control Program (NMCP) recently recruited a pharmacist to manage its commodities supply chain. As HRH2030’s technical advisor to the NMCP, I am working with colleagues to develop new tools and improve existing tools for commodities management at the central level.

I’m currently coaching the NMCP pharmacist and other staff dedicated to supply chain to conduct quarterly inventory at the central medical store and analyze discrepancies. I’m also helping the team reconcile logistics data at the central level with morbidity data at the district level and analyze gaps to develop a better commodities distribution plan. For example, we can uncover discrepancies in the data by comparing the number of people receiving rapid diagnostic tests and the number of tests used with the stock on hand at the district level. Finding these discrepancies flags areas for the NMCP to conduct site visits and bolster supervision efforts.

Also, we are developing supply chain indicators, such as rate of facilities experiencing stock out, specifically for malaria commodities. These indicators will be incorporated into the global monitoring and evaluation plan of NMCP. Finally, we are supporting the country with the implementation of a logistics management and information system (LMIS), which will inform better decision making and result in improved availability of commodities for patients.

How are you using the activity’s maturity model to strengthen National Malaria Control Program capacity?

A year ago, the priorities for the NMCP in Niger focused on management of commodities and my interventions as technical advisor focused on supply chain. When my position officially transitioned to the HRH2030 program in January [from USAID SIAPS], we began viewing staff capacity as a key area for improvement.

We are in the process of conducting an assessment of the NMCP using the capability maturity model, which has been considered an important point of intervention. This framework, designed to identify capacity gaps across several dimensions — supply chain management, leadership and governance, strategic planning — allows for iterative improvements that are contextually appropriate given the country’s and the program’s available resources.

We’re currently focusing on monitoring and evaluation, using the capability maturity model to identify weaknesses and opportunities for improvement in the NMCP monitoring and evaluation (M&E) system. For example, we’ll look at how well staff integrate M&E into planning and implementation. After M&E, our assessment of the NMCP will continue by applying this model to management and leadership.

 

The Jordan Ministry of Health’s (MOH) Strategic Plan 2013-2017 lists both attracting new talent into the public health system and retaining staff as two of its biggest challenges. Because about 3.78 million people in Jordan — including refugees and marginalized populations — rely on services provided by the MOH, a full, committed staff is critical.

In response to the Strategic Plan’s findings, the HRH2030 performed a national level research study to identify factors influencing retention and job satisfaction and examine motivation among doctors, nurses, and midwives within MOH facilities. The study, which took place February to December 2016, provided evidence-based recommendations to support the ministry in formulating policies to improve staff recruitment and retention.

This poster was presented April 7, 2017 at the Annual Consortium of Universities for Global Health (CUGH) Global Health Conference.

Country: Jordan

Resource Type: Other

Topic: Performance & Productivity

 

Microphone

In many ways, a fully functioning health workforce drives the well-being of communities, regions, and entire countries. Policy-makers at the national level can use reliable data to make decisions about where and what type of health workers are needed based on population health needs. A facility with health workers trained to deliver a variety of services can seamlessly integrate maternal and child healthcare, family planning, and HIV services for its patients. A fully-staffed clinic in a remote village can serve as a critical line of defense against the spread of infectious disease.

In low- and middle-income countries weak health systems pose serious challenges for health workers and, by extension, the overall health of the population. Building strong health systems designed to support an optimized health workforce will move us closer to achievement of global health goals, such as ending preventable maternal and child deaths, FP2020, controlling the HIV/AIDS epidemic, and protecting communities from infectious diseases.

In honor of World Health Worker Week 2017, HRH2030 project directors explore some of the human resources for health (HRH) obstacles that impede access to quality health care and discuss solutions.

Jim GriffinJim Griffin, Project Director, HRH2030
Why Build a Fit-for-Purpose, Fit-for-Practice Health Workforce?
Jim Griffin highlights the crisis facing the health workforce as countries strive to reach global health goals.
(Running time 3:09)

Grace NamagandaDr. Grace Namaganda, Project Director, HRH2030 Malawi
Show Me the Numbers! Data for Decision-Making
Dr. Grace Namaganda discusses the importance of reliable HRH data and the challenges to collecting and analyzing it.
(Running time 7:21)

Edward ChappyEdward Chappy, Project Director, HRH2030 Jordan
Harmonizing Continuing Professional Education Systems for the Health Workforce
Edward Chappy describes obstacles caused by disparate continuing professional development systems and the need to work across sectors to harmonize them.
(Running time 3:59)

Isaiah NdongIsaiah Ndong, Project Director, HRH2030 Senegal
Drawing Health Workers to Remote Areas (and keeping them there)
Isaiah Ndong uses Senegal as an example of the problem that many countries encounter when trying to retain health workers in remote locations.
(Running time 5:39)

Country: Global, Malawi, Jordan, Senegal

Resource Type: Other

Topic: HRIS and health workforce data, Leadership and governance, Performance and productivity, Skill mix and competency

On International Women’s Day 2017, HRH2030 reflects on how to empower health workers to #BeBoldforChange by ensuring provision of gender equitable health services to women and girls.

When we think about gender and human resources for health (HRH), we typically think about the challenges women face to fully participate in the workforce. Are women able to enter pre-service education institutions — and complete their courses of study — at the same rate as their male counterparts? Is there a pay gap for men and women performing the same work? But, what about the challenges that women and girls face when seeking gender-equitable health services? On International Women’s Day 2017, we recognize the challenges that women and men in the health workforce face, but we also recognize the power that all health workers wield to be agents of change. With that, we pose the question:

How can we empower health workers themselves to #BeBoldforChange?

In large part, frontline health workers determine the experiences of clients coming to health facilities. A midwife could be critical of a pregnant teenager and treat her dismissively, or she could treat her patient respectfully as a soon-to-be mother coming to receive information during an antenatal care visit. A woman visiting a clinic to receive an HIV test might turn around when she sees she has to register and wait in front of two male nurses she knows from her community; or she might stay when offered a more private and comfortable place to wait for her HIV test from a provider of the same gender. A young woman visits a clinic to receive family planning information. Her counselor never asks about gender-based violence (GBV), so she never speaks up about the abuse she endures at home; or her counselor routinely asks her about GBV, so she has the opportunity to tell a trained professional.

Providers are not blank slates. Like any human being, they bring their biases and personal judgements to workplace interactions. Unfortunately, women’s ability to access a full range of care and information is affected by these biases. In some contexts, adult women are treated as minors who require permission or decisions by others in order to make health choices. Likewise, providers have a tendency to connect options with their personal judgment of women’s morality. For example, research in Rwanda found that health workers interpreted the recommendation to involve men in HIV-testing at the first antenatal care visit as a mandatory requirement, which ostracized single-mothers and actually seemed to dissuade women from completing all four recommended visits. If we can improve providers’ ability to distinguish gender bias and provide regular, evidence-based, and accurate information, we can increase women’s access to quality care.

Through increasing gender competence, health workers can #BeBoldforChange and achieve more positive health outcomes. As countries make progress in health workforce development, a critical missing piece is that health workers at all levels lack information about gender and how to appropriately incorporate gender- equitable approaches into the provision of care.

For example, in Nicaragua, the USAID-funded Applying Science to Strengthen and Improve Systems (ASSIST) Project identified a knowledge gap in teachers at pre-service education institutions. A baseline survey uncovered that teaching staff at universities for physicians and nurses did not clearly understand the concepts of sex and gender, or the magnitude of gender-based violence. There was total ignorance of the legal framework for gender equality and the prevention of GBV; moreover, teachers did not know how to discuss or address issues in the university community. In response, ASSIST designed a training on gender and GBV to improve the understanding of gender among newly trained nurses and physicians. On average, teachers’ knowledge and attitudes following the training improved 22 percent.

To further this work, the USAID-funded HRH2030 program is defining what it means to be a gender-competent health care provider. The program is doing this by comparing the definition of gender competence for inclusion with existing competencies. For example, do existing competencies require a provider to routinely ask about GBV and/or provide full information on a range of health options? Or, does a lack of defined gender competencies lead to providers making assumptions of clients’ needs based on gender? This comparison will show the difference between the ideal of a gender-competent health professional against the actual gender competence of providers. Using the resulting gaps, HRH2030 can inform improvement of curricula at the pre-service education level to strengthen gender competence as a health provider skill. Understanding what it means to be gender-competent and applying gender awareness to the provision of care will enable pre-service institutions to incorporate gender into competency-based education. It will also give supervisors a framework to actively coach and mentor providers in gender competency and will give professional associations the ability to integrate gender awareness into licensing and certification. Most importantly, it will empower health workers to #BeBoldforChange, forging a more inclusive and gender-equal world.

Joe Ichter is a health systems strengthening expert with over 20 years of experience. He currently works with the Palladium Group as senior technical advisor and leads several productivity and HRIS activities for HRH2030.

In many countries, health facility managers allocate service providers based upon the type of service site they manage or the size of the target population the facility serves. This approach often overlooks the actual health needs of the people in a facility’s service area. For example, an HIV clinic focused on getting patients onto antiretroviral therapy might miss an opportunity to counsel patients in need of family planning by not having providers who are trained to offer this service.

To best serve the health needs of communities, health facility managers should align the competencies of health providers with the health needs and demands of the people they serve. Through task analysis*, health system decision-makers can identify the core set of tasks that health workers must perform on a routine basis in order to meet their communities’ particular needs or address specific risks. HRH2030 is using a modified, “rapid” version of the task analysis approach in Cameroon, Haiti, and Madagascar.

HRH2030 is just gearing up to use task analysis in Haiti and Madagascar, but the approach has already been used by HRH2030 in Cameroon. Briefly, how was it used there? Were there takeaways from that experience that you will bring to the work in Haiti and Madagascar?

In Cameroon, an HRH2030 team led by our partner Amref Health Africa pulled together a team of local leaders to collectively identify an HRH issue impacting quality of care. The group chose family planning counseling as a weak spot for providers. At that point, HRH2030 selected six key family planning counseling tasks and interviewed providers from four clinics to explore their competencies in completing those tasks. We found that more than half of the providers interviewed had not received any form of training — including informal on-the-job training — on any of the tasks and do not perform them frequently. These findings influenced the design of provider training with the ultimate goal of increasing demand for family planning services.

The experience in Cameroon will inform the work that we are preparing to do in Haiti and Madagascar. Primarily, we realized that we need to revisit the structure of the task analysis questionnaire. Increasing the number of response options for self-perceived competence and adding a layer to some of the questions will give us more thoughtful, nuanced replies. We also identified a need to frame the questions more neutrally so that we weren’t encouraging providers to respond based upon what they perceived to be the “right” answer or fear of reprisal.

The World Health Organization’s Workload Indicators of Staffing Need (WISN) is designed to determine how many health workers of a particular type are needed to handle the workload of a given health facility. How does the task analysis approach differ?

The WISN is oriented towards measuring effort and staffing needs based on the time and intensity of particular health care provider job functions. It provides critical information for administrators and planners to properly staff health facilities based on the demand of the population. On the other hand, the adapted version of task analysis used by HRH2030 concentrates on assessing the competencies of providers to deliver the care their communities and patients need. Assessment of competency flows directly into the quality of care provided, assuring provider’s skills match the clinical needs of the population served. As management tools, the WISN and task analysis are complementary.

Is this a methodology that you envision ministry of health officials being able to carry forward on their own? What is HRH2030 doing to support that?

We see the adapted version of task analysis used by HRH2030 as a relatively simple methodology to inform in-service training activities, whether via MOH officials or by those in supervisory roles. Although the task analysis can be used as an overarching assessment of health providers’ skills as they relate to community needs, it can also be used in smaller “chunks”. For example, task analysis could be used to measure competencies related specifically to a service in the HIV continuum of care or a specific component of family planning that could be a priority for a district or region. Because task analysis has an easy-to-scale approach, it can be accomplished more regularly and without a great investment of time, using only a few questions to assess competency. The results can then inform targeted training activities.

HRH2030 intends to pilot this rapid methodology at a sample of service delivery points in select districts in both Haiti and Madagascar. We will debrief the district health management teams (DHMTs) on the results and demonstrate how they can be used to identify areas for improvement. We’ll then assist the district managers to review training, supervision, and performance support plans. Designated DHMT members will shadow the process throughout, learning how to use the tools, enter data, analyze the results, and make decisions according to the findings. Ultimately, if brought to scale, this replicable approach can help DHMTs better assess worker competencies to deliver the services their patients need, design training and supervision activities according to those needs, and move countries toward achievement of global health goals.

*HRH2030 has adapted the task analysis approach developed by Jhpiego.

On January 19, 2017 the HRH2030 activity in Jordan held an event at the Intercontinental Hotel in Amman to launch a new study examining factors in motivating and retaining health workers within the Jordan Ministry of Health. The launch event was attended by senior officials from the MOH, the High Health Council, and the directors of the fourteen health directorates in Jordan.

The results of the study revealed relatively strong retention and low turnover rates currently within the MOH. Many employees are satisfied with the value their work brings to society, positive interpersonal relationships, and a sense of teamwork in the workplace. Their greatest sources of dissatisfaction stems from a lack of financial incentives for better performance, supply and equipment shortages, poor infrastructure, and limited or unequal opportunities for professional and career development.

H.E. Acting Secretary General of the Ministry of Health, Dr. Ahmed Qteitat, opened the event stating, “The Jordanian Ministry of Health highly appreciates the United States Agency for International Development for supporting the health sector in Jordan. The Ministry of Health will provide support and cooperate with the recommendations of the study, which provides evidence to support the necessary reforms in the fourth axis of the ministry’s strategic plan 2013-2017 regarding human resources.”

Discussions are underway about how to best use these findings to improve the motivation and retention of the health workers at the MOH and to improve the quality of healthcare in Jordan.

This post originally appeared on Chemonics’ blog Connections.

During the internship year of my medical training, Peru was affected by a severe El Niño. At that time, millions of people living in the poor peri-urban belt of Lima lacked access to clean water and sanitation services. These factors were a recipe for a massive outbreak of diarrheal diseases in children. The pediatric services in the hospital emergency room where I worked received one child affected by mild to moderate dehydration every three minutes. That year, the Ministry of Health introduced oral rehydration therapy (ORT) in the country, and we learned to use it during the outbreak. Hospital doctors, however, feared that ORT could damage the children’s kidneys, so we had to use it with extreme caution. We measured electrolytes in children’s blood, and used a mathematical formula to determine the maximum amount of ORT we could give them every hour.

Twenty years later, I was working in Dhaka, Bangladesh. One day I was affected by diarrhea and had to go home early. Altaf, the driver, asked me if I was feeling well and I shared with him my condition. He stopped by a pharmacy and purchase a handful of oral rehydration solution (ORS) sachets and meticulously explained to me how to prepare and drink the solution. The explanation was clear, to the point, and technically impeccable. “Altaf, where did you learn this?” I asked. “At home, boss,” he told me. “My mother taught it to me when I was a kid.”

Curious about what Altaf told me, I researched who taught mothers about ORT. I found that it was an effort led in the ‘80s by the International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B) in collaboration with the Bangladesh Rural Advancement Committee (BRAC), which taught 12 million mothers to prepare and administer ORS at home.

I also remember my first visit to the Mulago Hospital in Kampala. I walked through a valley of death — a dark corridor where people infected with HIV and AIDS were waiting to see a doctor but were actually dying in front of me. That image still haunts me, and I feel tears in my eyes when I remember it. Yet, a couple of days later I was in the field, learning from a new type of health worker that was combating the AIDS epidemic. College graduates without a background in healthcare, who were trained, supervised, and supported by The AIDS Support Organisation (TASO), were in charge of following up with HIV patients at home. They developed the skills to assess the household environment, identify risk factors that could prevent clients from adhering to antiretroviral therapy, provide counseling to strengthen healthy behaviors, and also identify signs and symptoms of complications. Those tasks were previously in the realm of the very few doctors available at TASO. When the number of clients living with HIV increased significantly, TASO was forced to change the model of care and incorporate lay health workers.

From a complicated formula administered by hospital ER staff to a remedy administered by mothers at home, ORT is a dramatic example of the devolution of healthcare to non-professionals. It is likely that a significant factor in BRAC’s decision was the shortage of healthcare workers. In their absence, BRAC had no option but to assign that health care task directly to caregivers at home. Similarly, given the shortage of professional health workers, TASO opted for a similar strategy: re-assigning HIV treatment follow-up tasks to laypeople available in the community.

The point of sharing these anecdotes is that empowering mothers to provide ORS at home allowed Bangladesh to reduce under-five child mortality by 70 percent over a 30-year period without the recommended number of professional health workers. In a sense, BRAC added 12 million people to the health workforce, even if that was only for administering ORS.

I wonder whether we can do even better. So far, we have reacted to the lack of professional human resources for health to implement what is called “task shifting.” We have been forced to do it, and in those instances, we have succeeded. But, how long are we going to continue reacting?

The World Health Organization estimates that we need to add 39 million healthcare workers by the year 2030 in order to achieve the health-related sustainable development goals. But, if we switch to a people-centered health system approach, do we really need that number of health professionals?

Today, UNAIDS recognizes that about 70 percent of tasks for HIV prevention, care, and treatment can be delivered at the household and community levels by non-professional cadres. The evidence suggests that we can develop a proactive approach to redistribute healthcare tasks beyond professional health workers, not because we do not have enough health professionals, but because it is the right way of organizing the health system. The health system should not be limited to the provision of health services provided by professionals. If we continue thinking from a facility-based perspective, it is likely that we will have a hard time obtaining the resources to employ, train, and support all the health professionals we need according to estimates. Yet, through redistributing tasks among professionals, laypeople, and caregivers, we can achieve outstanding health outcomes without necessarily increasing the professional health workforce by 39 million.

Bruno Benavides is a director associated with Chemonics’ Global Health Division and an expert in human resources for health. 

PEPFAR Rapid Site-Level Assessment Lessons Learned Report ThumbnailWith funding from PEPFAR, HRH2030 supported application of the PEPFAR Site-Level HRH Assessment methodology developed by the interagency PEPFAR HRH Technical Working Group (TWG). The assessment is meant to help identify areas for further investigation and intervention to ensure adequate staffing to reach 90-90-90 goals, optimize efficient use of health workers, identify HRH barriers to quality HIV service delivery, and inform program planning. Applied in Zambia and Malawi across select facilities, information collected on health worker availability, task allocation, and in-service HIV training yielded better understanding of HRH issues and constraints to consider for scale-up of HIV service delivery.

This report presents a summary of lessons learned from conducting assessments in Zambia and Malawi and provides recommendations for other countries seeking to further utilize the PEPFAR instrument and conduct site-level HRH assessments. The detailed results from each country assessment are reported in separate documents (see associated content below).

Associated Content:

Process and Lessons Learned from Rapid Site-Level Human Resources for Health (HRH) Assessment Exercise in Three Districts in Malawi

Increasing Site-Level HRH Data Availability and Utilization for HIV Service Delivery: Process and Lessons Learned from Rapid Site-Level Human Resources for Health (HRH) Assessment Exercise in Four Provinces of Zambia

Country: Malawi, Zambia

Resource Type: Report

Topic: Performance & Productivity, HRIS and health workforce data, HIV/AIDS