Oped»
Step by step
APR 10 -
Health services are at the heart of the universal development agenda, with four of the eight millennium development goals focused on the topic. WHO’s 62nd session meeting elevated the member states’ concerns on the health workforce in South East Asia, and has highlighted some areas of focus — the shortage of personnel in the health workforce; the existing constraints on the health workforce due to an unbalanced skill mix, improper distribution and paucity of appropriate competency levels; lack of effective and efficient human resource management capacity; acute shortage of trained health human resources professionals; inadequate training and investment, poor planning, and an unfavourable demand-supply ratio of trained workers and the effects of brain-drain.
Similar scenarios can be seen in Nepal, too. We have been fighting the same obstacles for a long time. For example, insufficient competencies in providing services, narrow skill mix of the workforce, uneven distribution of trained human resources, and improper HR management.
Commonly observed problem areas in HR management in the public sector in Nepal are recruitment, legislation, discipline, development, training, rewards, and promotions. These underlying issues have incited decreased motivation on the job, low retention rate, and low productivity in health services. As a result, the outcomes of health service indicators are highly affected.
Although the production of doctors and nurses in the country is satisfactory, these resources have not been fully utilised. Evidence points to a chronic shortage in public health services in positions like physicians, cardiologists, pediatricians, nursing staff, gynecologists, anesthesiologists, radiologists, hospital administrators, nutritionists, epidemiologists and microbiologists. Specialists prefer to join private institutions in urban settings or migrate to developed countries, and newcomers generally choose air-linked, remote districts to be quickly eligible medical doctors.
Health Sector institutions
In Nepal, there are about 4,750 public health institutions in operation. The breakdown of this number is as follows: 11 central level hospitals, centres, and laboratories; 31 regional/zonal hospitals and centres; 130 district level hospitals and public health offices; 4,283 below the district — health facilities like primary health care centres, health posts, and sub-health posts; 293 ayurvedic dispensaries; and two homeopathic and unani dispensaries.
Inadequate mobilisation of the available human resources has been identified as a primary weakness in the health sector. It is estimated that the health care workforce is about 37,000 strong. According to the MoHP, the sanctioned posts in health institutions throughout the country are distributed as: 19,293 in the health sector, 1,009 in ayurveda, 6,151 in administrative services, 663 in a reserve pool, and about 10,000 (estimated) in academic and hospital boards.
Various factors have been contributing to greater HRH (human resources for health) mobilisation: population growth has raised the demand to address basic health problems in the community leading individuals to seek primitive, preventive, curative and rehabilitative services accordingly; increased health awareness leading people to seek health services; free essential health care — a new agenda; preparedness for disaster mitigation and rescue; new challenging diseases (diarrhea, cholera, H1N1, H5N1, HIV/AIDS, etc.); and growing concerns about access and coverage of health services.
How to deal with HRH management
To address the above concerns there is an immediate need to review the health service legislation, deployment policy, transfer guidelines, and strategic plan for HRH and to strengthen the human resource planning and management capacity at each level, including the ministry. WHO has also recommended improving training, education, and research capacity to revitalise the community-based health workforce; trying to curb the international migration of health personnel; conducting a comparative study on the best practices for the management of community based health workers; strengthening the health workforce through the PHC approach; and standardising the preventive and social medicine curriculum in medical schools. To these ends, the following measures can be taken as an action points:
Projection
Projection of HRH and a handy information system with reliable databases would increase effective functioning. Identifying the category and numbers of HRH available as well as and numbers of sanctioned posts, filled posts, and wo/men in the workplace to update records has yet to be addressed. For this a careful projection of HRH can be recommended at least in line with Nepal Health Sector Support Programme Implementation Plan II. The Ministry of Health and Population (MoHP) and the Department of Civil Personnel Record, a department within the Ministry of General Administration, have taken joint initiatives to update a database of civil servants, linking the databases of the Personal Information System (PIS) and Human Resource Information System (HuRIS) under the MOHP.
Employment
Most of the sanctioned posts at the 11th grade, ninth grade and staff nurse level are still vacant. There are two possible ways to solve this deficiency. First, recruit these posts permanently. Second, hire human resources for these posts on a contract basis. However, current legal provisions are a barrier to find a resolution as to which arrangement would be best. Amendments in the existing health rules and regulations and preparation of guidelines are vital to remove these barriers.
Skill mix in workforce
The skill mix refers to the combination of employees and skills available during a specific time at a given health institution; alternatively, it may refer to the combination of activities that comprise each worker’s role, rather than the combination of different job titles at each level of services.
Sufficient health service delivery is only possible if the skill mix is comprehensive. An absence in any category may negatively affect health services. In this regard, finding a balance of general practitioners, specialists, and nurses in district and zonal hospitals may be fruitful. Analysing and cataloging HR resources will be useful to address this problem. In some cases, the required resources are not available. Therefore, there is a need to inspire and encourage further research on the skill mix in both the context of the organisation and the system.
Managing migration & retention
The increasing trend of health workforce migration from rural to urban centres, urban centres to the capital, national to international, as well as migration from public health care to the private and NGO sector or UN system is very common in Nepal. These have affected the regional distribution, especially in hardship areas of the nation. To address these challenges, both monetary and non-monetary incentives are needed.
A sustainable strategy also needs to be developed to retain the trained workforce in remote districts. MoHP has been proposing incentive packages to address this issue through a pilot program since the beginning of fiscal year 2009/10.
Pre and in service training
Nineteen academic institutions — 4 public and 15 private — and six public training institutes are involved in supplying pre- and in-service health training courses at various levels. The production of trained health care professionals in comparison to needed HRH is sufficient, but still there is gap in adjusting for attrition, the career path of paramedics and certain other categories.
For this purpose, analysis of supply side institutions and additional unused capacity, annual HRH production and potential, and the total number of HRH needed have to be planned accordingly.
Funding
In the end, it always comes down to funding. These initiatives must be affordable and sustainable. There are inevitable gaps in financial resources from the government, development agencies and institutional revenue after accounting for employment and training costs. There should be clear provisions to fill these resource holes.
To sum up, there may be various methods to improve health management, but these six action-points may widely contribute to the betterment of service delivery and reform. The lack of access, coverage and quality services can only be solved once the commitment and retention of the health workforce has been improved and the skills have been properly utilised.
(Acharya is Joint Secretary, Human and Financial Resource Management Division, Ministry of Health and Population)
Posted on: 2010-04-11 10:21
Headlines
Advertisements
