March Prepared by: The Britain Nepal Medical Trust (BNMT), Lazimpat, Kathmandu, Nepal along with its National Partner NGOs BPMHF, FPAN and WHR.

Transcription

1 THE BRITAIN NEPAL MEDICAL TRUST Serving the People of Nepal Since 1967 European Union A Desk Review Report: Key Issues, Challenges and Gaps of Human Resources for Health in Nepal and Recommendations to MoHP and Development Partners for Action March 2014 Prepared by: The Britain Nepal Medical Trust (BNMT), Lazimpat, Kathmandu, Nepal along with its National Partner NGOs BPMHF, FPAN and WHR.

2 Table of Content Executive Summary... 3 Background... 6 Study Methodology... 6 Socio-demographic Context of Nepal... 6 Nepal s Health Context... 6 Health workforce in Global Context... 7 Health workforce in SAARC... 8 Health Workforce situations... 9 District HRH Context Finance for HRH Intervention Discussion: Health Workforce Provision in policies, strategies and plans Public private and CSOs partnership to address the HRH issues Issues1: Recruitment, Retention and Reduction of Absenteeism of Health Workforce Issues 2: Professional and personal qualities and competencies (Capacity) Health workforce Issue 3: Week Leadership and Centralized Authority hindering necessary HRH provision Issue 4: Week Health Service Governance to foster HRH provision at local level Issue5. Less competitive benefit packages provided to health workforce Issue 6: Poor enabling environment for health work force CONCLUSION REFERENCE Table Table: 1 Acronyms... 1 Table: 2 Ratio of doctors and nursing/midwifery staff to population of SAARC Countries... 8 Table: 3 Human Resource for Health under MoHP in Nepal ; Table: 4 Distribution of public health workers by facility type Table: 5 Government spending on Health Table: 6 Salary scales of government health workers effective from 2068/04/01 (15 June 2011) (NRs)

3 Acronyms AUS AID AHW BNMT BPMHF BPKIHS CTEVT DFID DPHO DoHS DDC EHCS EU EPI FPAN FCHV GIZ HRD HRH HuRIS HFMC HMIS HFOMC JICA JAR MoF MoHP MDG MoE MDGP NHSP NHTC NAMS PHCC PBF PAHS SAARC SOLID SLTHP SLGA SWAP SC TWGs USAID Australian Agency for International Development Auxiliary Health Worker Britain Nepal Medical Trust B.P. Memorial Health Foundation B.P. Koirala Institute of Health Science Council of Technical Education and Vocational Training Department for International Development District Public Health Office D of Department Health Service District Development Committee Essential Health Care Service European Union Expanded Programme on Immunization Family Planning Association Nepal Female Community Health Volunteer German Society for International Cooperation Human Resource Department Human Resource for Health Human Resource Information System Health Facility Management Committee Health Management Information System Health Facility Operations and Management Committee Japan International Cooperation Association Joint Annual Review Ministry of Finance Ministry of Health and Population Millennium Development Goal Ministry of Education MD in General Practices Nepal Health Sector Program Nepal Health Training Centre Nepal Academy of Medical Science Primary Health Care Centre Performance Based Finance Patan Academy of Health Science South Asian Association for Regional Cooperation Society for Local Integrated Development (SOLID Nepal) Second Long Term Health Plan Self-local Governance Act Sector Wide Approach Save the Children Technical Working Groups U.S. Agency for International Development 2

4 Executive Summary The report is prepared on the basis of desk review of relevant acts (Nepal Civil Service Act 1993 and Nepal Health Service Act 1997), National Health Policy 1991, Second Long Term Health Plan , Ninth Five Years Plan , Tenth Plan and Health Strategies, HRH Strategic Plan , The HRH Strategic Plan Besides these documents, the HRH review report of NHSP II was also reviewed. After thorough review, the issues, challenges and gaps were extracted from HRH project reports and research report produced by Merlin/SOLID, SC and BNMT. Fortunately this report has also captured the ideas and aspiration expressed by representatives of health professional associations (Medical, Nursing, Health Professional and Ayurbeda) organized by BNMT on 19 March 2013 and national HRH Conference of 4 April 2013 jointly organized by MOHP, BNMT, SC and Merlin/SOLID. Also some information was extracted from the HRH profile review study conducted by BNMT/RDN. From this study, the issues, challenges and gaps of effective, efficient management of HRH recruitment, deployment, retention, advancement and monitoring and evaluation are listed as following: 1. Nepal has adequate capacity of producing enough of health workers of different categories and specialties with few exceptions, but recruitment, deployment distribution and retention is unsatisfactory by contradiction between Nepal Health Service Act and Civil Service Act as noticed by the Supreme Court in 2008; 2. Nepal has low utilization of HRH and the human resources are concentrated in urban areas and outside the government sector, away from the places where their need is acutely felt; 3. As provision done in various health policies, strategies, plan and programmes, health system has not yet been able to ensure HRH availability for the services to the people living in the rural, difficult terrain, without low socio-economic conditions; 4. HRH Policies, strategies and plans have sufficiently addressed the issues of HRH development and utilization but the gap in implementation is still challenge; 5. There is mismanagement in selecting appropriate candidates for in-service training because of the lack of updated records on staff who had received training which resulted in repetition and oversight. As a result many employees were working but did not receive required training or repletion of the same training; 6. Strategy for deployment and retention for HRH in remote areas is not mate; 7. The existing skill mix revealed that only 5% of total health care providers are doctors, 12% nurses excluding ANMs, 47% paramedics, public health officers, and 3.1% traditional health care providers (HuRIC 2008). There is currently high number of unskilled support staff (28% of the total workforce); 8. Dissatisfaction of health workers on their transfer that based on political influence rather than based on policy. This caused demonization due to the fear of being transferred from one place to another, regardless of the policies in place; 9. There is an unsystematic health worker record at the personal Administrative Section of the DoHS; 10. In addition, lack of coordination with civil society, due to an unclear definition of role of civil society. The NHSP IP II has recognized the role of civil society organization. However, in practice, there is 3

5 the need to initiate an open policy progress where stakeholders' views are valued and CSOs are involved in health planning and policy progresses; 11. Low morale and low productivity to yield quality the service; 12. uncertain prospects for career development; 13. The week reward and punishment systems; 14. Frequent change in civil service rules and regulations along with changes in institutional structure; 15. Pervasive corruption at all echelons of administration; 16. Replacement and dignified retirement of ageing health workforce 17. Health workers need to be kept motivated in an enabling environment 18. Performance assessment and quality of care are afforded insufficient priority 19. Country capacity to establish future human resources for health needs and design longer-term policies varies. 20. Human resource information data and systems to meet the needs of decision-makers require strengthening and investment. 21. Frequent interruption in HRH related decision making from political instability and week commitment; 22. Week enabling environment due to scarce resources, limited staffs housing, poor personal security, power failure, poor access to rad and communication, difficulties in child rearing/education, lack of network problems, 23. Decreasing social harmonization between service providers and users due to communication and information barriers 24. Poor career choices and prospects, limited staffs housing, rare opportunities for continues education personal security are other major issues to retention of health workforce; 25. Low number of sectioned post in proportion with the increase of population 26. Undeveloped physical infrastructure, week public sectors management and lack of inter organizational coordination for public private partnership 27. Limited HRH financing and unexplored scope of matching resources locally 28. No individual job descriptions and induction system; 29. Mainstreaming multi-sectoral HR alliances at district and national level To address above issues, challenges and gaps following are the key recommendations to MOHP and other related stakeholders: 1. Increase the current number and revise the type of sanctioned positions to address the issues of skill mix, disease burden and population growth; and to provide quality health care services and health messages based on local needs; 2. Form a high level monitoring mechanism in coordination with MoHP to monitor the quality and distribution of both private and public medical and allied health science academic institutions, and their equitable distribution; 4

6 3. Train and empower the existing health workforce to tackle the shifting disease pattern and to revise the curricula of different health sciences courses; 4. Update HuRIS for all types of HRH working in the country and to develop a clear-cut career path for every health worker who joins the government health services so that the health workers are informed of their future professional development opportunities; 5. Create a separate desk within PSC to accelerate the HRH recruitment process and to provide additional incentives and career opportunities for the rural staff; 6. Establish the norms that government is responsible to provide security for health workers and to provide conducive working environment at their workplace whereas people have the right to get health services and health information; 7. Create enabling environment for civil societies as they play vital roles in increasing access to health care services and to fulfill their health needs; 8. Make a plan for replacement and dignified retirement for the health workforce, who are ageing; 9. Improve skill mix balances of physician, surgeons, midwives, nurses, and ancillary staff anesthesia, radio, lab etc.; 10. Do legal reformation for effective and efficient HRH management; 11. Create enabling environment to improve satisfaction level HRH; 12. Performance assessment and quality of care are afforded insufficient priority; 13. Enhance country capacity to establish future human resources for health needs and design longerterm policies vary; 14. Human resource information data and systems to meet the needs of decision-makers require strengthening and investment; and, 15. Increased reeducation of political and opinion leaders to improve political commitment to doing. In nutshell we can say that the effective, efficient and competent health workforces are necessary for production and delivery of quality promotive, preventive, curative and rehabilitative health service. The MoHP and concern stakeholder should give due attention on effective improvements in management of health workforce for the country. This report is proposing issues, challenges and gap and respective interventions in the forms of recommendation to MOHP and their concerned counter parts as per the needs of health in the days to come. 5

7 Background This is planned activity (EA 38) of HRH project. The aim of this desk review report is finding out the key HRH issues and make recommendations to MOHP and development partners to take action to address these identified issues on the basis available reports and documents produced from the WHO, MOHP, BNMT, Merlin/SOLOID, Save the Children at micro, meso and micro level. This task was performed during March 15 to April 30, Study Methodology The report is prepared on the basis of desk review of relevant various documents namely, acts (Nepal Civil Service Act 1993 and Nepal Health Service Act 1997), National Health Policy 1991, Second Long Term Health Plan , Ninth Five Years Plan , Tenth Plan and Health Strategies, HRH Strategic Plan , The HRH Strategic Plan Besides these documents, the HRH review report of NHSP II was also reviewed. After thorough review, the issues, challenges and gaps were extracted from HRH project reports and research report produced by Merlin/SOLID, SC and BNMT. Fortunately this report has also captured the ideas and aspiration expressed by representatives of health professional associations (Medical, Nursing, Health Professional and Ayurbeda) organized by BNMT on 19 March 2013 and national HRH Conference of 4 April 2013 jointly organized by MOHP, BNMT, SC and Merlin/SOLID. Also some information was extracted from the HRH profile review study conducted by BNMT. Socio-demographic Context of Nepal Nepal lies in the central Himalaya, wedged between India and China. The flat Terai plains in the south, the central hills and the high Himalayas in the north define the country's three geographical areas. The population of Nepal according to census 2011 is 26,620,809, with an annual average growth of 1.4% which is improved then the 2001's population growth rate The census 2011 had reported that, 12,927,431 (48.56 per cent) males and 13,693,378 (51.44 per cent) females. The sex ratio is (males per hundred females) compared to 99.8 of census The population composition by ecological belt shows that Terai has half of the country s population with per cent of people living in that region, with an increase of 1.8 per cent compared to last census. The population in the hill and mountain regions has slightly decreased though, with the hill region constituting 43.1 per cent and mountain 6.75 per cent. Population density of the country is 181 per square km compared to 157 in Millions of people are at risk of infection and thousands die every year due to communicable disease, malnutrition other health related events like lack of human resources and coordination between other sector which particularly affect the poor living in rural areas. Nepal s Health Context Nepal has is primary health Care based health system. Nepal has 95 public hospitals; 209 Primary Health Care Centers (PHCCs); 676 Health Posts (HPs); and 3,129 Sub Health Posts (SHPs). It also includes service coverage of 12,790 Primary Health Care/Outreach Clinics (PHC/ORC); 16,579 EPI Clinics and 48,680 Female Community Health Volunteers (FCHVs. Nepal has also on track of all MDG except MDG1 (hunger index) and MDG7 (access to sanitation and safe drinking water). Significant progress has been made by 6

8 the Nepal national family planning program. The total fertility rate (TFR) decreased from 6.3 in 1976 (NFS) to 2.6 in 2011 (NDHS). Maternal mortality ratio (MMR) declined from 850 in 1990 to 170 in 2013 and much of this decline was attributed to increased use of family planning. Despite these achievements, several challenges especially related to sustainability and disparity amongst different ethnicity and wealth quintiles are apparent in the proposed project catchments. Though the CPR has increased from 2.9% in 1976 to 48% in 2006, it has remained stagnant with only 2% increase in 6 years (50% in 2011). Moreover, the CPR of modern methods is only 43.2% in Unmet need for FP is still a major challenge. In total, 27% of currently married women have reported unmet need for FP services in 2011, with 10% having an unmet need for spacing and 17% having unmet need for limiting. Nepal s current MDG targets include an increase in CPR (modern methods) to 67% and a decline in unmet need for FP to 15% by In addition, unwanted birth amongst adolescents is higher (24.8%) than among women aged years (19.3%). Unsafe migration is another glaring issue in Nepal. With 1.92 million migrant populations, there is high risk of transmission of HIV and STIs, especially amongst spouses of the migrants. The discontinuation of contraceptive use is very high amongst wives of migrants with CPR of modern methods at only 22.5% in this group (NHDS, 2011) with a total of 52% reporting unmet need for FP. As per the National Centre for AIDS and STD Control, 26% of 50,200 people estimated to be living with HIV in Nepal. Health workforce in Global Context Without the people who provide cares - health workforce - there can be no health improvement for individual, families and communities, is the fundamental issues and are discussed globally. 1 All total 57 nations of the UN member nations mostly from Africa and Asia faces a sever health workforce crisis. 2 Later in 2010 the number of workforce shortage nations becomes 59 from all UN nations. The WHO in 2009 has estimated that over 2 million health service provider and 1.8 million management support workers are needed to fill the gap. Therefore, health workforce is center attaining, sustaining an accelerating progress on universal health coverage and WHO questions to decision makers; what health workforce is required ensure effective coverage the agreed package of health care benefits? What health workforce is required to progressively expand coverage over time? And how does a country produce, deploy and sustain health workforce that is both fit for purpose and fit to practice in support of universal health coverage? About 46.6% of WHO Member States report to have less than 1 physician per 10,000 populations. Europe and North America together have only 21% of the world population, 45% of the world s allopathic doctors, and 61% of nurses work there. South East Asia region with 26% of world population only has 20.2% of total allopathic doctors and 7.9% of nurses. Sub-Saharan Africa faces the greatest challenges of deficit of HRH. The region has 11% of the world's population and carries 25% of the global disease burden, but has the most acute shortage of human resources which can be termed as work force crisis. The shortages of human resources in rural areas are a universal problem and affect both developing countries and developed countries equally although their impacts on the developing and poorer countries are more devastating. At the country level, imbalances are even more prominent. There are also some countries like Mali and Democratic Republic of Congo, where despite the overproduction of health workers, with medical HRH in Nepal unemployment in urban areas, chronically suffer with shortages in rural areas; a situation similar to Nepal.1, 10, 11 1 No health without a workforce by global health workforce Alliance and WHO 2 The World Health Report,

9 According to above HRH information of WHO, South East Asia is the home of approximately 25% world population with almost 30% of the global diseases burned and has only 10% of global health workforce. Within 57 countries by WHO, Nepal is also one which has a critical shortage of health workforce. The Global Health Observatory Report by WHO on workforce data for 186 countries, but 53% of these countries have fewer than 7 annual data points on midwives; nurse and physicians across the past 20 years. Further of the 57 countries identified in 2006 with low human resources for health density and low service coverage, 17 countries have no data point in the past five years. As the report had compared three density thresholds of skilled health professionals (midwives 22.8, nurses 34.5 and physicians 59.4) per populations were purposively selected availability. The report makes clear that the thresholds are not developed to promote targets that a country should or must achieve but are used to illustrate the pattern of availability globally. Therefore, the following human resources for health themes may/are common to most countries 3 : There are shortages of some categories of health workers, and more are forecast; The health workforce is ageing and replacement is a challenge; Although skill mix imbalances persist advance practitioners, midwives, nurses, and auxiliaries are still insufficiently used in many settings; Availability and accessibility continue to very widely within countries because of difficulty in attracting and retaining workers; Adapting education strategies and the content of pre-service education is a major Challenge; Health workers need to be kept motivated in an enabling environment Performance assessment and quality of care are afforded insufficient priority Country capacity to establish future human resources for health needs and design longer-term policies varies. Human resource information data and systems to meet the needs of decision-makers require strengthening and investment. Countries that have shown progress in improving the essential availability, accessibility, acceptability and quality dimensions have in common that political commitment to doing so has been strong, that they have strived to improve human resource for health workforce development initiatives and also with boarder action to strengthen health systems, and that continuity in implementing their preferred strategies has been maintained Health Workforce in SAARC HRH ratio to population in selected SAARC countries shows differences. The existing skill mix revealed that only 5% of total health care providers are doctors. Ratio of selected staff to population ratios Nepal was found to have 0.68 doctors and nurses per 1,000/population, which is significantly less than the WHO recommendation of 2.3 doctors, nurses and midwives per 1,000/population. The table 2 compares the ration of selected HRH and population between some SAARC countries as available in WHO 2013 and MoHP 2012 HRH database. Table: 1 Ratio of doctors and nursing/midwifery staff to population of SAARC Countries Country Doctor Date Nursing & midwifery Date Bhutan Bangladesh A Report on "A universal truth: no health without a workforce" by WHO and Global Health Workforce Alliance 8

10 Nepal India Nepal s Health Workforce Situations The World Health Organization puts Nepal among 59 and countries with a critical shortage of human resource in health 4. Nepal has been identified with critical shortage of HR with only seven health workers (doctors, nurses and midwives) per 10,000 populations, a lot less than the minimum requirement of 23 set by WHO 5 to achieve health related millennium development goals (MDGs). The situation is even bleak if we consider just the public health system, which is the single largest provider of preventive, promotive as well as curative services. This is evident given the fact that Nepal s health system is guided by the Health Policy brought into effect in Since then the population of Nepal has increased by one-fourth (25%) between 1991 and 2008 but the number of health workers has increased only by 3.4 percent in the public sector 6. In 2011, MoHP has 27,316 employees, of whom 20,179 are technical and 7,137 are administrative and supporting staff working in health sector. 7 In addition there are also approximately 48,680 FCHVs who support the delivery of health services in Nepal. And even the number of workforce shows shortages because of the new emerging issues and growth of population. To this total number, the doctors made up 5% of the public health workforce. It was also highlighted in 2008 WHO report that the shortage of qualified doctors and midwives and indicated that a third of PHCCs had no doctors because of their preference to migrate and lives in urban areas. The existing skill mix revealed that only 5% of total health care providers are doctors. Ratio of selected staff to population ratios Nepal was found to have 0.68 doctors and nurses per 1,000/population, which is significantly less than the WHO recommendation of 2.3 doctors, nurses and midwives per 1,000/population. The health sector is a major employer in all countries. The International Labor Organization supposes that 35 million persons are currently employed in the health sector worldwide. HRH is defined as "people primarily engaged in action with the intent of enhancing health". They includes in various categories of health professionals varies from doctors, nurses, health professionals of different specialty of health science, public health professionals and researchers. HRH is therefore important building blocks of the health care systems. Therefore, effective human resource which equals to better management strategies are greatly needed to achieve better HRH production, deployment, management, retention, health outcomes, and better access to health care and Nepal has limited number of HRH specific plan, policies and strategies to Millennium Development Goals (MDG). The population of Nepal has approximately increased 35% while the number of health worker has increased only by 3.4% in public sector. Even though the existing HRH situations of Nepal present a mixed scenario of over production with underutilization, and in some cases, insufficient production that falls far short of actual need being met. Similarly, the unequal distribution of available health workforce, inappropriate skill mix manpower, training, motivation, and deployment, wages and incentives are 4 The WHO Report WHO Global Atlas of the Health Workforce Nepal Health Sector Implementation Plan II (NHSP IP 2) , MoHP, GoN, HMIS Report, 13 June 2013, DoHS, Government of Nepal, Teku, Kathmandu, Nepal 9

11 among the major concern in human resource management of Nepalese health system. The newly emerged issue for retention of HRH is "performance base appraisal". The NHSP's Human Resource for Health Nepal Country Profile 2013 had reported, 54,177 health workforces are working in public and private health sector. Doctors made up 12% of the private health sector workforce, 5% of the public health workforce and 8% of the total. From the recent data obtained from HRH Assessment 2012 (HuRIS), posts are sanctioned in public health service including main staff categories doctor, nurses, paramedics, administrative and support staffs and Ayurveda and traditional medicine comparatively good then the number sanctioned last fiscal year 2010/2011has a total of 24,477 sanctioned posts of the health workforce in health sectors. Among them 88% of positions are filled and only 12% are vacant. The shortage across the different cadres indicates that there were shortages across the board but these were most acute for doctors. It was also reported in the 2008 WHO report that the shortage of qualified doctors and midwives and indicated that a third of PHCCs had no doctors because of their preference to migrate and lives in urban areas Table: 2 Health Workforces in Health System of Nepal 8 Baseline 2011 Review 2014 % of filled positio n % of filled positio n Sanctione Vacan Sanctione Vacan Category of HW d Filled t d Filled t Medical Doctor Nursing staff Paramedics/Professio n Allied to Medicine Ayurveda &Traditional Medicines/Public Health Total To address the shortage of HRH in Nepal, public and private academic institutions are producing different categories of HRH. The public health institutions in Nepal are under Tribhuwan University and Ministry of Health and Population and private sectors institutions should license by Council for Technical and Vocational Training (CTEVT) or one or another University. Under the MoHP Nepal produced different categories of health workers by BP Koirala Institute of Health Sciences (BPKIHS), National Academy of Medical Sciences (NAMS) and Patan Academy of Medical Sciences (PAHS). Likewise, under the Ministry of Education, produced HRH from different universities like; Tribhuwan University, Pokhara University and Purbanchal University. In addition to these, Sanskrit University produces HRH in Traditional Systems. Nepal, then produces about 3,600 basic level health workers, 4,250 mid-level health workers and about 3,600 high level health workers (including 390 MD/MS/Medical Doctor 8 HRH in Nepal-Situational Analysis, http// 10

12 General Practitioner, 1,255 MBBS) annually, there is a huge gap in the distribution of HRH. Among the total health workers, only 10.2 per cent are engaged at public institutions and 3.9 percent are working in rural areas. 9 Nepal has more other considerable challenges in HRH management, which is characterized by top-down decision-making despite the fact that amendments to policy have emphasized the empowerment of local government to regulate and monitor local development agencies. Furthermore, the implementation of the Human Resource Information System (HuRIS), which was established to facilitate HR planning and management at all levels, is used primarily for administration rather than proactive management. This research report therefore examines the main gaps in the current HR planning and management system in Nepal, and recommends viable mechanisms to strengthen the system; Scattered information on HRH should be consolidated and streamlined; Fragmented initiatives do not work well; Active involvement of the relevant stakeholders is essential; Bringing all stakeholders to one table generates strong ownership, maintains transparency, and builds synergistic relationships. District HRH Context Nepal is in five regional development region and 75 districts. Within 75 districts there have 95 public hospitals; 209 Primary Health Care Centers (PHCCs); 676 Health Posts (HPs); and 3,129 Sub Health Posts (SHPs). The community also includes service coverage of 12,790 Primary Health Care/Outreach Clinics (PHC/ORC); 16,579 EPI Clinics. The rural health service is mainly functions from 48,680 Female Community Health Volunteers (FCHVs). As a complex HRH recruitment system in Nepal, needs multiple authorization, a lengthy legal selection process and administrative delays lead to posts being vacant for a long time in districts, and results in numerous positions being filled on a temporary or daily wage basis at the local level. Furthermore, there are contradictions between the Health and Civil Service Acts which has resulted in the cancellation of advertisements for specific jobs. Table 4: Distribution of Public Health Workers by Facility Type 10 Com SHPs Health muni posts ty. PHCCs DHOs / DPH Zonal hospit als Central hospita ls Regio n, sub- Teachi AyurvDistrict ng eda. Ayurve hospit clinic da. Centr Total al no. jail Health occupational Generalist medical ,123 3% Specialist medical % Nursing , ,371 10% Nursing associate 2 2, ,876 15% Total % 9 Source: Situation Analysis of Human Resource for Health in Public and Private Secretors in Nepal 2011 (BNMT) and HRH in Nepal-Situational Analysis 10 HRH Assessment

13 Paramedical practitioners 2 4,316 2, ,679 26% Ayurveda medicine practitioners % Dentists % Pharmacists % Environmental and % Laboratory % Health management 2 1,395 1, , , ,797 33% Other health % Unclassified k ,118 3% Total no. 7 8,261 4,623 1,999 4,382 1,958 7, , ,809 Total % 0% 25% 14% 6% 13% 6% 23% 3% 7% 2% 1% 0% Note: Unclassified health workers are health workers for whom no occupation was specified and/or documented by the HRH Assessment. However, the skill mix HRH at local level seems shortage even after there has authority to local recruitment from the Health Act along with other Local Self Governance Act (LSGA) Doctors and nurse appeared least employed but other likes; ANM, AHW, VHW and administrative staffs appeared high locally. Though the local employment is also apparently in practice sometime now, but frequent and adequate use of such provision appears to be in recent days only. It is immediate to increase the current number and revise the type of sanctioned positions to address the issues of skill mix, disease burden and population growth; and to provide quality health care services and health messages based on local needs. The MoHP recently published advertisement for the fulfillment of sanctions positions but has held in reserve to increase the number of HRH sanction to meet the population target. Health Financing for HRH Intervention The MoHP accounts for about two thirds (70%) total government spending on health. Of the total public financing for health, the share of the government has shown an increasing trend at every year. The salary and benefits paid by MoHP to its staffs are not similar. Health service is categories into different groups i.e. anesthetic, lab and administrative group where incentives and career path rules are not the same. 12

14 Table 5: Government Spending on Health 11 Description 2066/ / / / /71 Total Budget of Nepal (In Crore) Total Health Budget of Nepal Total Health Sector Expenditure GDP Compare to Health Budget in % GDP Compare to Health Expenditure in % Total Budget Compare to Health Budget % Total Budget Compare to Health Expenditure % From the total budget of the country, Health Sector spends 16-19% and even there has bios between HRH and lack to address parallel. However, health service is classified in different groups and paid salary and incentives are different. Salaries for health workers are given under Section 9 of the Health Service Act, with basic salaries indicated in Table below paid on a monthly basis, including during periods of leave. Salaries range from NRs 11,290 to NRs 31,680 across the 11 active classes. Each class is then divided into a specific number of salary grades (between 5 and 20 depending on the class) on the basis of the duration of service. In addition, government health workers are provided with a range of allowances, including an annual dress allowance of NRs 7,500, allowances for those in remote postings and travel, daily and lodging allowances when traveling within Nepal (SOLID, 2012). Table: 3 Salary scales of government health workers effective from 2068/04/01 (15 June 2011) (NRs) Class Beginning Salary No of Grade Rate of Grade Total grade Total No of Grade Addition on beginning salary Final Salary 3 rd th th Source: Fictitious data, for illustration purposes only It has not mechanism to collect financial information. The data from MoHP budget analysis shows that of the total HR budget (which is 16-19% of total MoHP budget), 85-90% are allocated to salary and allowance. The budget in HR related items has sharp increase from previous years. There is no explanation on sharp increase in training related cost. Despite the fact that, most of technical and programmatic training are budgeted under respective program budget. Discussion on Health Workforce Provision in Policies, Strategies and Plans of Government of Nepal The Interim Constitution of Nepal, 2007 has identified Health as the fundamental right of every citizen to get basic health service free of cost from the State as provided in the law12. The Government of Nepal with its limited resources trying to provide free health service to all citizens without any discrimination. Government also set up health institutions to provide its service at the door through subhealth post at village level and Central hospital for tertiary care in township. However, the services provided by those institutions are not up to the standard because of several reasons. Apart from others 11 Source: Government of Nepal, MoHP, HRH Strategic Plan Prepared & Presented by KB Adhikari a Joint Secretary from MoHP on 21 March Interim Constitution of Nepal 2063 (2007) 13

15 Human resource gap is a major challenge. Specifically, Human Resources (HR) are one of three principle health system inputs, with the other two major inputs being physical capital and consumables13. Nepal Civil Service Act 1993 and Nepal Health Service Act 1997 are the major legal instrument to support management of the of health sector staff. For health sector, the Health Service Act is more "tailor made" then the umbrella Civil Service Act. Clearly, MOHP has not a single act to govern their staff and roles of them. As much as the progresses are increased in the health sector, there is still much more work to be done to improve the quantity, number and overall management HRH. The Local Self Governance Act 1999 also provided enlarged scope to DDCs, VDCs and Municipalities for HRH management. Some problem associated with workforce were shown by one study are 14: Low morale and productivity, Measurement of productivity, Uncertain prospects for career development, the weak reward and punishment system; frequent changes in civil service rules and regulations along with changes in institutional structure; and, pervasive corruption at all echelons of administration. After establishment of multiparty system, Government has formulated Nepal National Health Policy was in The primary objective of the National Health Policy was to extend the primary health care system to the rural population so that they benefit from modern medical facilities and the services from trained health care providers. This policy has given emphasis on technically competent human resources in all health facilities. Nepal has formulated a National HRH Master Plan in 1993 which has proposed numbers, types and distribution of health workforce needed for health service delivery. It has adopted the policy to collaborate and coordinated with universities, private and Non-Governmental Organizations (NGO) in production and deployment of HRH. The HURDIS was also initiated by this master plan. In 1997, a 20-year Second Long-Term Health Plan (SLTHP) for FY ( ) is developed. It has attempted to address the issues of gender equity and disparities on access to and utilization of health services. The SLTHP provided a guiding framework to develop technically competent and socially responsible health personnel in appropriate numbers for quality healthcare throughout the country, particularly in under-served areas. In the area of human resource development, together with other programmes, the main thrust of the SLTHP was to ensure co-ordination among public, private and NGO sectors and development partners. The SLTHP opened the door wide to the private sector for training Human Resource for Health. The 10th five year plan has reinforced the directive of SLTHP to privatize health profession education and producing Human Resource for Health. It also outlined the importance of retention of trained staff in rural areas for services. Nepal Health Sector Programme ( ) has made human resource development as one output among three program outputs and eight sector outputs envisioned in the document. NHSP has emphasized reformation of HRD unit to get better co-ordination and systematize training. It also facilitate for better ordination among MOHP, MOE, planning commission and CTEVT. Three Years Interim Plan (2007/ /2010) has also indicated the need to ensure that the human, financial and physical resources provided by the government, private sector and NGOs would be managed effectively for improving the quality of health care services. The HRH Strategic Plan ( ) has pointed out chronic shortage in HRH in most cadres, especially doctors, nurses, and midwives (the density is 7 per 10,000 populations) 15. It also highlighted on 13 World Health Organization, World Health Report 2000: Health Systems: Improving Performance. 2000, Geneva: WHO. 14 Administration and Management Review Volume 21, No.2, August, Mo General administration 15 WHO Global Atlas of the Health Workforce,

16 challenges: poor staff performance in terms of productivity, quality, availability, and competency, fragmented approach to HRH planning, management, and development, imbalance between supply and demand, and narrow skill mix, limited HRH financing and low attraction / retention in public service, and brain drain largely due to the migration of health workers. The MoHP Strategic Plan for Human Resources for Health ( ) called for expansion of the pool of health care workers by nearly 50,000 over this period, especially in the case of midlevel workers. The HRH Strategic Plan ( ) highlighted on perceived need of appropriate supply of health workers, equitable distribution, health workers performance, effective and coordinated HR planning, management and development across the health sectors. So, this is the evidence based plan prepared through the participation of HRH stakeholder through the Country Coordination and Facilitation (CCF) mechanism. It has prioritized major five areas to address; shortage of HRH as a result of imbalance between supply and demand, mal distribution, poor performance including productivity, quality and availability, fragmented approaches and funding to HRH etc. Although HRH Strategic Plan ( ) is well developed, unbiased and is a right steps toward the right direction, there are many provisions in place on HRH policies, plans and intentions to improve the health sector, implantation is still a applicable challenge. Public private and CSOs partnership to address the HRH issues There are External development partners (EDPS) namely, the World Bank, DFID, USAID, GTZ, KFW, the Asian Development Bank, JICA, AUS Aid and SDCs. There are 137 international NGOs and thousands of NGOs working in health. Globally, HRH is deficit in development countries. It is due to mobility of health workforce from one to another countries and Nepal is also one in those development countries who is losing it HRH regularly. At the movement HRH is very relevant topic to advocacy between concern stakeholders in Nepal. In the meantime, European Union (EU) has implemented three years project to assist Ministry of Health and Population (MoHP) through partner organizations like; Britain Nepal Medical trust (BNMT) with BPMHF, FPAN & WHR, Save the Children and Marlin with SOLID-Nepal. These organizations as EU partners for HRH have made important contribution by generated knowledge through research, piloting testing and sensitization and evidenced based advocacy for adequate, effective, efficient health workforce as per need of Nepal. Knowledge Generated on HRH through Researches ( ) BNMT has conducted following four studies: 1. Research: Situation analysis of HRH in Public and Private Health Sector in Nepal 2011; 2. Research: HRH in Nepal Analysis of Policy and Practices 2011; 3. Baseline Report Knowledge, Practices and Coverage Survey on ASRH Services Key finding: This study has explored issues poor distribution of doctors and specialist. The reasons behind are poor career prospect, limited or no staffs housing, few opportunities for continue education, lack of network problems, low participation of marginalized population in the health work force at both policy and service delivery level, poor physical infrastructures and personal security are major issue to retention of health work force. 17 Save the Children has conducted on study: 1. Tackling human resources for health: Crisis in Nepal through informed policy decisions and action. 16 Human Resource for Health Mainstreamed in Health Systems, through Strengthened Advocacy Capacity of CSO s 17 HRH in Nepal Analysis of Policy and Practices

17 Key finding: Challenges mainly in Human Resource Management (HRM) include mal-distribution, retention, irregularities in promotions, capacity building and transfers of health workers and maintaining the right kind of skill-mix of health workers in Nepal health sector. 18 Merlin and with SOLID Nepal has conducted six studies: 1. Research: Distribution and Skill Mix of Human resources for Health in Nepal; 2. Research: Training, Recruitment, Placement and Retention of Health Professionals; 3. Research: Health Workforce Performance and Accountability; 4. Research: Human Resources for health Management from Central to District Level in Nepal; 5. Research: Working Condition of the Health Workforce in Nepal and 6. Research: Role of Civil Society in Human Resources for Health. All the six study report focused for: increase the current number and revise the type of sanctioned positions, to provide quality health care services and health messages based on local needs, form a high level monitoring mechanism, train and empower the existing health workforce, update HuRIS, to create separate desk in PSC, establish norms to provide security and suggest to create environment for CSOs for vital role on HR management. HRH Issues, Challenges and Gaps Based on all the findings from desk review, HRH workshops, its National Conference and expressions of the section provides a summary of the key human resource issues coming from the MoHP, NPC, MOF, MOFALD and Private sectors is explain below: Nepal has adequate capacity of producing enough of health workers of different categories and specialties with few exceptions, but recruitment, deployment distribution and retention is unsatisfactory by contradiction between Nepal Health Service Act and Civil Service Act as noticed by the Supreme Court in 2008; Nepal has low utilization of HRH and the human resources are concentrated in urban areas and outside the government sector, away from the places where their need is acutely felt; As provision done in various health policies, strategies, plan and programmes, health system has not yet been able to ensure HRH availability for the services to the people living in the rural, difficult terrain, without low socio-economic conditions; HRH Policies, strategies and plans have sufficiently addressed the issues of HRH development and utilization but the gap in implementation is still challenge; There is mismanagement in selecting appropriate candidates for in-service training because of the lack of updated records on staff who had received training which resulted in repetition and oversight. As a result many employees were working but did not receive required training or repletion of the same training; Strategy for deployment and retention for HRH in remote areas is not mate; The existing skill mix revealed that only 5% of total health care providers are doctors, 12% nurses excluding ANMs, 47% paramedics, public health officers, and 3.1% traditional health care providers (HuRIC 2008). There is currently high number of unskilled support staff (28% of the total workforce); Dissatisfaction of health workers on their transfer that based on political influence rather than based on policy. This caused demonization due to the fear of being transferred from one place to another, regardless of the policies in place; 18 "Tackling HRH Crisis in Nepal through Informed Policy and Decisions and Action (2012)" 16

18 There is an unsystematic health worker record at the personal Administrative Section of the DoHS; In addition, lack of coordination with civil society, due to an unclear definition of role of civil society. The NHSP IP II has recognized the role of civil society organization. However, in practice, there is the need to initiate an open policy progress where stakeholders' views are valued and CSOs are involved in health planning and policy progresses; Low morale and low productivity to yield quality the service; uncertain prospects for career development; The week reward and punishment systems; Frequent change in civil service rules and regulations along with changes in institutional structure; Pervasive corruption at all echelons of administration; Replacement and dignified retirement of ageing health workforce Health workers need to be kept motivated in an enabling environment Performance assessment and quality of care are afforded insufficient priority Country capacity to establish future human resources for health needs and design longer-term policies varies. Human resource information data and systems to meet the needs of decision-makers require strengthening and investment. Frequent interruption in HRH related decision making from political instability and week commitment; Week enabling environment due to scarce resources, limited staffs housing, poor personal security, power failure, poor access to rad and communication, difficulties in child rearing/education, lack of network problems, Decreasing social harmonization between service providers and users due to communication and information barriers Poor career choices and prospects, limited staffs housing, rare opportunities for continues education personal security are other major issues to retention of health workforce; Low number of sectioned post in proportion with the increase of population Undeveloped physical infrastructure, week public sectors management and lack of inter organizational coordination for public private partnership Limited HRH financing and unexplored scope of matching resources locally No individual job descriptions and induction system; and, Mainstreaming multi-sectoral HR alliances at district and national level. Key Recommendations Recommendations to Ministry of Health and Population (MOHP) and Development Partners to respond to key issues, Challenges and Gaps of Human Resources for Health under following key clusters: Increase the current number and revise the type of sanctioned positions to address the issues of skill mix, disease burden and population growth; and to provide quality health care services and health messages based on local needs; 17