Ed Wood, Clinton Health Access Initiative Human Resources for Health October 13, 2011 Ira Magaziner
Overview of CHAI How we work in partnership with Governments as a change-agent on catalytic projects that result in massive and lasting change VISION Entrepreneurial approach to help create a world where everyone has equitable access to high quality health care APPROACH 1) Act as close and trusted strategic governments advisors; ensure governments have ownership and receive credit for successes 2) Focus on key systemic bottlenecks to allow governments to offer sustainable public health services nationwide 3) Apply a business-minded skill set and knowledge base FOCUS AREAS HUMAN RESOURCES FOR HEALTH; HIV/AIDS; Effectiveness/Efficiency of Global Health Spending; Malaria; Vaccines; Maternal, Newborn and Child Health 2
Principles of how CHAI works and achieves impact on its programmatic focus areas CHAI s GUIDING PRINCIPLES DEGREE of impact - Break previous common understanding of what is possible in terms of speed, scale, efficiency, quality SCALE of impact - National and/or global BREADTH of impact Reshape the way governments and partners approach an issue SUSTAINABILITY of impact - Phase out activities without any erosion of the impact achieved CHAI s CORE COMPETENCIES Strong relationships of trust with partner governments accelerates the pace at which change can occur within government systems Identify and address market inefficiencies demand, supply, utilization Focus on strong management and organization of ambitious and complex processes to accelerate roll-out Unique staffing model mix - people with experience in business and traditional public health and clinical skills Respond quickly to opportunities - flexible decision-making, staffing model, entrepreneurial culture 3
CHAI s approach to HRH 1 Partner with the government to understand root of the local HRH crisis 2 Comprehensive approach - strengthens each component of the health worker pipeline: training, hiring and deployment, productivity, and attrition Rooted in analytical understanding of country s supply, demand and utilization of health workers All projects must address key government priorities Interventions are targeted and government financial resources more effectively prioritized Creates a portfolio of interventions that delivers both immediate positive effects and medium- to long-term results Helps governments utilize funds more efficiently by avoiding interventions that silo parts of the pipeline All projects must strengthen national HR systems 3 Prioritize practical interventions that governments and partners can implement under existing systems with limited additional resources Focus on high-leverage activities that prove a concept, serve as an enabling element to jumpstart scalable interventions and processes, accelerate implementation of other critical interventions Optimize use of resources across partners Avoid doing what others are already doing well 4
CHAI s approach to HRH is anchored on program goals that are based on system root causes of the HRH crisis System Root Causes CHAI s HRH Program Goals Inadequate supply of health workers - constrained by limited output from training institutions, high attrition Insufficient demand for health workers - suboptimal civil service hiring processes and limited financing for civil service posts INCREASE the NUMBER of qualified new healthcare workers OPTIMIZE the DISTRIBUTION of healthcare workers to reflect the distribution of clinical need Time to see measured impact is longerterm Inefficient utilization of health workers in the system MAXIMIZE the PRODUCTIVITY and UTILITY of existing healthcare workers Shorterterm Enable more patients to receive appropriate care from a qualified healthcare worker at a national scale 5
Impact of CHAI s comprehensive approach to HRH: Zambia example Train, graduate, and deploy almost 4,000 healthcare workers Helped the Zambian MoH double the growth rate of its workforce (from 4% to 8%) Mobilize more than $16 million for national HRH priorities Contribute almost 60% of the MOH workforce increase since 2008 6
Impact of comprehensive approach: Example interventions and Zambia case study Program Goal Example Interventions Impact in Zambia INCREASE the NUMBER of qualified new healthcare workers (pre-service training) OPTIMIZE the DISTRIBUTION of healthcare workers to reflect the distribution of clinical need MAXIMIZE the PRODUCTIVITY and UTILITY of existing healthcare workers Develop school-specific operational and costing plans to double training targets Identify novel approaches to accelerate training time of highpriority cadres Highlight new strategies to train more workers given existing financial or physical resources Job fair to accelerate the speed and equity with which new graduates are hired and deployed (based on unique Excel demand-based optimization model) Create National Community Health Worker Strategy (CHW) and design implementation roll-out Strengthen management skills of hospital administrators Student enrollment increased by 150% New training program that cuts training time in half: 160 midwives (24% of all midwifery graduates in 2009 and 2010, increased national midwifery growth rate from 1% to 10% annually); 17 tutors who can train 250+ nurses/midwives Malawi, Lesotho: Leveraged operational planning methodology for nurses/midwives 2,800+ health workers recruited / deployed half to underserved, rural areas Malawi, Liberia: Leveraged unique datadriven approach to determine optimal distribution of health workers needed to provide greatest coverage of health services Recruit, train and deploy 330 CHWs - serves 165 unmanned health posts; access for 577,000 Zambians who live in rural areas with no access to a trained clinician Goal: produce 5,000 CHWs, 33% increase in 7 the overall health workforce
CHAI s Approach in Practice: Develop policies in planning to reshape government HRH priorities 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 What is the magnitude of the HRH crisis in-country? Root Cause Drivers Analysis 14,748 180 Total HCWsTotal Hired in 2009 from Abroad Inflow 19,035 1,284 Total Intakes (from Tis) Total Did not graduate 3,630 Total Graduated but not entering workforce Outflow 725 3,826 2,677 Current efforts focused on voluntary attrition, but preservice and not entering workforce are greatest preventable drivers Total Total Total Retiring InvoluntaryVoluntary attrition attrition 3,321 Total Back to School 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 --- 2009 2011 2013 2015 2017 2019 2021 2023 2025 2027 2029 2031 2033 2035 2037 2039 2041 2043 2045 18,499 Total in 2018 20,861 39,360 Remaining gap Target Pipeline Analysis Even at fantasy output (0% attrition, other variables constant), targets would only be reached in 2045 No Interventions No Interventions and 0% Voluntary Attrition Target At current output MoH targets will never be reached CHAI will focus on the most challenging root cause drivers that are not being fully addressed in the current response 8
Example: National training operational plans set bold training targets, mobilize financial resources for scale-up and identify practical steps to achieve targets (Zambia, Malawi, Lesotho) School-specific Example: operational plans National for all Training Operational Plan training institutions nationwide - costs all resources required to reach training targets Aggregate data to national level Harmonized national training operational plan from which MoH and all partners can implement training scale-up and mobilize resources 9
Example: Workforce optimization analyses used to deploy graduates and re-entry health workers in national job fairs to the underserved areas (Zambia, Malawi, Liberia) Excel demand-based model to determine optimal distribution of health workers needed to provide greatest coverage of health services National policy with deployment prioritization by district, health facility and type of health worker Example: National Training Operational Plan Targeted recruitment and deployment of new graduates 2009 2011 10 10
Example: Ethiopia Health Management Initiative Train hospital CEOs (through Masters of Hospital Administration Program in partnership with Yale University) on how to effectively and efficiently manage hospitals to deliver quality health services 81 CEOs enrolled or graduated Includes HR management training on recruitment, motivation, retention and performance monitoring to increase productivity of health workforce Launched by Federal Ministry of Health Developed with 62 different partners (health and other government sectors, NGOs, etc) Guidelines focus on 13 key hospital management areas (patient flow; leadership and governance; management of HR, medical records, facilities, finances, quality, reporting, medical equipment; services in nursing care, pharmacy, laboratory, infection prevention) 11
Collaborations in-country among multiple partners is required to execute successful HRH interventions Nursing/midwifery schools Schools of Medicine Universities Biomedical colleges Paramedical schools Training Institutions Regulatory bodies Medical council/boards Nursing council Professional associations Union bodies DFID CIDA SIDA WHO USAID EU World Bank Bilateral donors, implementing partners Government partners Ministry of Health Ministry of Education Ministry of Finance Cabinet Ministry of Works and Supply Ministry of Science Technology and Vocational Training 12
Where CHAI is putting its HRH expertise to work Zambia: intensive 3-year programmatic work Malawi, Lesotho, Liberia, Haiti: technical program support Ethiopia, Rwanda: Targeted HRH program Government priorities and local situation determine which program goals we focus on 13
Our vision to move the HRH agenda Global shortage of 3.5M health workers Africa has 11% of the world s population, 24% of its disease burden, but just 3% of its health workers Opportunity Collaborate with multilaterals WHO GHWA GFATM Expand core countries Emphasize focused themes Expand support for comprehensive programming Apply lessons learned from successful interventions to additional countries where there is an urgent need to concretely solve the HRH shortage and meet MDGs 4, 5 and 6 targets Midwives - Reduce maternal mortality by scaling-up production and rationalized distribution Community health workers Integration into the 14 formal health workforce and national scale-up
Thank you 15