The need for a broader look at human resources for health issues globally: 4th Global Human Resources for Health Conference, Dublin, Ireland

Mirwais Rahimzai

Regional Director for East Africa, USAID ASSIST/URC

Earlier this month, ASSIST's Regional Director for East Africa was in Dublin for the 4th Global Human Resources for Health (HRH) Conference. Below he shares key insights from the conference and gives five recommendations for addressing human resource problems to strengthen health systems.

It was raining and cold when I arrived in Dublin. After getting into the taxi, I asked the driver to take me to the hotel where I was staying for the 4th Global Human Resources for Health (HRH) Conference. As soon as the driver, Martin, learned that I was there to work with health systems in developing countries he started his long story of his frustrating interaction with the Irish health system.

A few years ago, his daughter got abdominal pain and was admitted to the public hospital. She went through a surgical procedure and received a lot of pain medicine. The pain never subsided and so he had to pay 15,000 Euros for his daughter to get another surgery in a private facility because doctors told him that the previous surgery was wrong. Martin complained about the lack of doctors, long waiting times and the price of medicine in his country. He said in nearby London medicine is 30% cheaper than Ireland. After Martin was quiet for some time, I picked up the newspaper in his car and was surprised to read that 15% of doctors already left Ireland and another 17% are planning to leave. I could not believe that this brain drain is as serious in Ireland as in many developing countries that I work with.

The 4th Global HRH Conference was opened by the Minister of Health of Ireland. Participants from 90 countries attended the conference. Panel discussions, participants questions and presentation from different parts of the world were enlightening.

(Simon Coveney, Foreign Minister of Ireland, speaks at the 4th Global Human Resources for Health (HRH) Conference [left]. The Youth Forum [right]. Photo credit: Mirwais Rahimzai, URC.)

I was particularly impressed by how the HRH world is dominated by women leaders who spoke from their experience and shared their excellent recommendations. In addition, it was the first time that a group of youth were invited for a plenary panel to share their thoughts on what they think should be done to achieve the HRH 2030 agenda. The sessions were a mix of theory and practical recommendations. The majority of sessions were designed around HRH issues, with limited focus on engaging the health system — which triggered me to write this blog.  

During the conference, I made a presentation on engaging local leaders in strengthening district health system and how it helped improve care. District level coordination – which perhaps like my taxi driver’s example – seems to be functional on the outside, but in reality, has many issues it has to grapple with. I will describe the scenario briefly below, after which I will provide my five recommendations for the need to have a broader look at the HRH issues globally.

Efficiency or numbers or both:

District Lucky (I avoid the actual name of the district) is located in East Africa. It has a population of about 250,000 people. HIV prevalence is around 4.5%. About 85% of the government sanctioned seats are filled by the health workers in this district. The biggest health facility in the district is a health center IV led by medical doctors and the smallest health center is health center II which is staffed by a nurse or midwife. Health center III is led by a clinical medical officer who has three-year medical training. The district is lucky because some other districts have less than 60% staff, have two times higher HIV prevalence and some of them are located three times farther from the capital.

Lucky district health system in the above picture shows the following:

  • The largest health facility in the district has only one anesthesia technician. It is the only operation theater (OT) in the district. The day a technician is not on duty the OT is nonfunctional and women in need of caesarian section has to travel a long way to get to the nearest OT. 
  • Health facilities in the same level are similarly staffed but their patient load is significantly different. The numbers on the top of the facilities (Figure 3) show monthly patient load in outpatient and inpatient departments. Some have higher outpatient loads and some have very high number of patients who were admitted and were treated in the health facility.
  • The two health center IIIs (#3), which are located near to each other, have different problems. One of them has the highest outpatient load in the district and the other one has the highest number of patients who were admitted to the facility. These two health facilities need different solutions.  
  • Some of the health center IIs are handling three times more patients than other health centers. However, there is little difference in their staffing pattern.
  • Data was collected on the staff absenteeism. Surprisingly, more than 20% of the staff were absent from their post on the day of the assessment. Absenteeism is a huge problem and some districts experience up to 40% staff absenteeism at a time.
  • Health facilities either didn’t have basic equipment or the equipment were not in the right place or it was not clean. Highly qualified staff without basic equipment can’t provide quality care.    

A sustainble solution to these problems is impossible without the engagement of local leaders. No matter how many times a staff is trained or how many staff are assigned, lack of basic equipment will lead to poor performance. In August 2015, a team of senior leaders from Lucky and 5 other districts were invited for a meeting. Elected members, district administrative leaders and district health officials attended the meeting and after a long discussion they decided to focus on their priorities step by step and take immediate action. They agreed on three major priorities to focus on in the first step: 1) reducing absenteeism, 2) improving availability of medicine, and 3) enhancing coordination within the district.

“That further shore is reachable from here.”  
- Seamus Heaney

It was the first time for elected and administrative leaders of the district to see their health structure, staffing and patient load on one slide in front of them. At the beginning of the meeting, many blamed the health workers for not doing their job. However, as the meeting progressed everyone agreed that it is the system that is weak and decided not to blame individuals. In the course of 6 months, these leaders implemented a number of initiatives that helped reduce absenteeism from more than 25% to less than 7%. Lucky district leaders successfully introduced the following changes to reduce staff absenteeism in their district. The most effective changes have been monthly review of staff attendance data, clarifying rules on long-term leave, and filling vacant positions through redistribution or new recruitment. Directives were followed by spot checks and feedback mechanisms to ensure better staff attendance.

My 5 recommendations:

  1. HRH issues can’t be solved in isolation. We must engage the health system to solve problems in and around human resources for health.  

  2. Training should not be the blanket solution. We need innovative ways of engaging health workers and building their knowledge and skills on need based.

  3. Producing more health workers is important. However, it is equally important to improve efficiency of currently available human resources.

  4. Every health facility has its unique set of problems. The health system should be flexible enough to respond to the local needs.

  5. Effective engagement of local leaders to solve human resources issues is crucial, needed for sustainability and promotes ownership.

At the end of the conference, we stood up for the Dublin declaration on human resources for health. I hope copies of the final declaration will soon be available online for everyone to access it. The declaration confirms stakeholders’ commitment in achieving HRH 2030 agenda.

I truly appreciate the World Health Organization and partners, as well as the city of Dublin, for organizing such an important conference.

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