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  • 1. i Report on assessment of the health workforce retention initiatives in Ethiopia A Collaborative Work 2011 December, 2011
  • 2. i Consultant: Fikru Tessema (DSc, BSc. MSc) Public Health Professional M&E Specialist
  • 3. ii Acknowledgments This study was done with the support and contributions of the various experts of the HR directorate of FMoH, experts from the HR regional health bureaus, respective health facility HR managers. We are grateful for sharing their ideas; discuss their own views and experiences. We thank the World Health Organization, Ethiopia, country Office for having supported this initiative as part of its biennium activity, both technically and financially. Mr Fikru Tessema, consultant, also provided a technical expertise in data collection and analysis for report writing of this document. Lastly, we would like to state that while every attempt has been made to ensure that the information provided is accurate, some of the facts and figures may not be updated.
  • 4. iii Acronyms AA : Addis Ababa BoH : Bureau of Health CEOs : Chief Executive Officers ETB : Ethiopian Birr FMoH : Federal Ministry of Health GPs : General Practitioners HCHs : Health Centre Heads HR : Human Resources HRH : Human Resources for Health HSDP : Health Sector Development Programme HRD : Human Resources Department MDs : Medical Directors MoCS : Ministry of Civil Servant MoE : Ministry of Education MoFED : Ministry of Finance and Economic Development SNNPR : Southern Nations and Nationalities Peoples Region
  • 5. iv Contents Page Acknowledgments ..................................................................................................................................i Acronyms .............................................................................................................................................. iii 1. Introduction....................................................................................................................................1 2. Methodology..................................................................................................................................3 3. Findings ..........................................................................................................................................4 3.1 Study sites and participants....................................................................................................4 3.2 Presence and implementation of policies and regulations on retention by level of the health care systems.......................................................................................................................................4 3.3 Presence and implementation of plans for retention by level of the health care systems.....4 3.4 Typology of Motivation and retention schemes for employees .............................................5 3.4.1 Financial incentives .............................................................................................................5 3.4.2 Non-financial incentives ......................................................................................................9 4. Discussion and Conclusion............................................................................................................10 5. Recommendations .......................................................................................................................11 References ...........................................................................................................................................12 Annexes................................................................................................................................................13
  • 6. 1 1. Introduction An effective Employee Retention Program is a systematic effort to create and foster an environment that encourages employees to remain employed by having policies and practices in place that address their diverse needs. “Retention” is defined as an increase of numbers of health workers staying in rural and urban areas as a consequence of specific policy interventions [1, 2] . In the Health Sector Development Programme Four (HSDP IV), improving human capital and leadership is one of the strategic objectives that entail human resource planning, development and management including recruitment, retention and performance management. The expected outcome of this strategic objective is adequate, availability of skilled and motivated health staff and committed to work and stay in a well managed sector [3] . HSDP-IV will use a mix of strategies to achieve these outcomes, including:  Ensuring demand driven production of human resources;  Maximizing use of available resources in producing key categories of health workers for which there is scarce supply;  Improving inter-sectoral collaboration in HRD;  Enhancing private sector involvement in HRH development;  Enhancing quality assurance in the training of health professionals;  Using appropriate ICT to enhance quality & efficiency of medical education;  Improving geographic distribution of HRH;  Strengthening the regulatory system;&  Enhancing cost-effectiveness in staff retention & motivation schemes. The way staff retention & motivation schemes were in the past: National and sub-national state jobs in the health sector were considered desirable and sufficient candidates could be found to fill most critical jobs. Moreover, once employed, workers would often spend their entire careers in public service. In areas where there was turnover, new employees could be recruited easily [4] .
  • 7. 2 The way staff retention & motivation scheme is today: there is a high demand in the public and private health sectors for workers in critical areas such as clinical services and high level professionals in public health. The supply of qualified health workers is limited and good workforce planning requires an aggressive recruitment and innovative retention strategies. Retention policies need to focus on elimination of unwanted turnover [5, 6] . Unwanted turnover is expensive: Costs to the employer can include separation benefits, lost productivity, recruitment costs and training costs. When a valuable employee leaves it costs the employer money and diminished services as new employees get up to speed [5, 6] . Ethiopia works to achieve health equity and to meet the health needs of its populations, especially vulnerable and disadvantaged groups. The key challenge however has been ensuring people living in rural and remote locations have access to trained health workers. Skilled and motivated health workers in sufficient numbers at the right place and at the right time are keys to attain the Millennium Development Goals. More than 85% of the Ethiopian population currently lives in rural and remote areas. The problem is that most health workers live and work in cities. This imbalance is caused by the overall shortage and high level of attrition of the health workforce from the public sector. This therefore poses a major challenge to the nationwide provision of health services [7] . Cognizance to the health workforce crisis, the Ethiopian government has been working across all dimensions of the health workforce development that include scaling up of production while addressing mal-distribution across the various population with focus to the key workers and in line with its health sector policy and strategy, strengthening health systems and aiming for universal coverage in the context of primary health care [7] . To this end the Federal Ministry of Health in collaboration with the regional states has developed and endorsed initiatives on health workforce attraction and retention schemes as part of the comprehensive sector-wide reform implementation. This has been to improve workforce distribution and enhance health services across the country. The belief has been that doing so will address a long-standing problem, contribute to more equitable access to health care, and boost prospects for
  • 8. 3 improving maternal and child health and combating diseases such as AIDS, tuberculosis and malaria [7] . This study explored the existing national and sub national level policies and strategies to increase the availability of health workers through improved motivation and retention schemes, but recognizing the fact that what may work in one setting may not work in another. This review aimed to detail the various retention and motivation schemes nationally and in six selected regional states and one city administration. The review encompasses all HR departments/units that handle HRH matters (e.g. policy, planning, management, training, payroll, human resource information systems etc.) at national level, and a sample of departments at regional and health facility levels to describe to what extent the contextual conditions of employee retention schemes, which would be needed to implement the programme, are present and to provide essential information for strengthening stewardship and leadership of HRH in the MoH in order to improve strategic function of employee retention schemes; 2. Methodology Desk Review: this involved collection of existing data and information to describe the current contextual conditions (policies, strategies, guides, distributions of these materials by level, status of actions) [8] . Interviews: Two targets. First, with key stakeholders who would have an important role as future providers of administrative and operational support to the programme (e.g. heads at federal level, RHBs and facility managers); second, health workers of various categories (medical doctors, midwives, nurses, anesthetists, lab and pharmacy) [8] . Geographical coverage: This study took place in six regions including AA and the FMOH: these included, the FMOH/HRD and seven regional states (AA, Oromiya, Amhara, Southern nations, Tigray, BG and Somale) and respective hospital and health center that have been selected for the study).
  • 9. 4 3. Findings 3.1 Study sites and participants National: Federal Ministry of Health and one federal hospital were included in this study. Of the total respondents who participated in the study were Human resource (HR) director, CEO, Medical director, and senior HR staff (see annex 1). Sub-national: A total of six regions including Addis Ababa were included in this study. Of the total respondents, about 16.2% were managers and senior staff from regions and 81.3% was from health facilities (42.5% from hospitals and 38.8% from health centers). About 59% of the participants were male and 41% were also female respondents to the study (see annex 1). 3.2 Presence and implementation of policies and regulations on retention by level of the health care systems National: The Human resource (HR) director, CEO, Medical director, and senior HR staff responding to this study reported that there exists a policy or equivalent (guideline) that addresses employee retention schemes in human resources for health (HRH) system (see annex 2). Sub-national: About 48% health facility health workers and managers responding to this study reported that there exists a policy or equivalent (guideline) for human resources for health (HRH). More than half (54%) of the health facility health workers and managers also acknowledged the presence of HRH regulation that addresses the issue of employee retention schemes (see annex 2). Oromiya and Addis Ababa City Bureau of Health have developed their own regulation for employee retention schemes in addition to the regulation of Ministry of Civil Servant. Tigray and Somale Bureau of Health are on the process of drafting a regulation for employee retention schemes. The federal hospitals and the remaining regions use the guideline of the federal government. All health workers and managers responding to this study also mentioned that the legal instruments for employee retention schemes are not regularly updated to fit to current living conditions (see annex 2). 3.3 Presence and implementation of plans for retention by level of the health care systems National: The managers and senior HR staff responding to this study reported that there exists a strategic plan that addresses employee retention schemes in human resources for
  • 10. 5 health (HRH) development schemes (see annex 3). The health sector has also a strategy/plan for HRH as part of Health Sector Development Programme, i.e., HSDP-IV. Sub-national: Fifty percent of the total health workers and managers responding to this study also reported that there is a strategy or plan for HRH. The regional health bureaus visited during this study period mentioned that they do have HRH plan as part of regional HSDP-IV for five years (see annex 3). Health facilities have HRH plans cascaded from the regional bureau of health on annual bases. 3.4 Typology of Motivation and retention schemes for employees National: The managers and senior HR staff responding to this study reported presence of different forms of employee motivation and retention schemes at National and Federal hospitals level (see annex 5). Sub-national: The majority (96%) of the health workers and managers responding to this study knew the presence of any form of employee motivation and retention schemes at regional and health facilities level (see annex 5). The employee incentive packages included financial and nonfinancial incentives in different forms. The incentive packages vary from region to region and health facilities to health facilities in the same region at the same level. 3.4.1 Financial incentives 3.4.1.1 Professional allowance National: Eligible for professional allowance at federal MoH hospitals level are anesthetist, midwifery and psychiatrist with the rate of ETB 125, 50 and 75 per month respectively (see annex 6). Sub-national: In Oromiya, anesthetists are eligible and paid at the rate ranging from ETB 300- 625 per month. The rate for midwifery and psychiatrist is the same as the federal hospitals. Beside these professions, only specialists and general practitioners (GPs) also are eligible for professional allowance with the rate of ranging ETB 1000-1200 and 500-700 per month respectively. Still it varies from facilities to facilities in Oromiya Region for specialists. In health centre, only professional allowance for midwifery is in practice (see annex 6). Health workers and managers responding to this study from Addis Ababa Bureau of Health and HFs reported that specialists, general practitioners and midwifery are eligible for professional allowance and paid at the rate ranging from ETB 1000-1200, ETB 800 and ETB 50 per month respectively, which is also the same only for GPs and midwifery working at health
  • 11. 6 centre level. Still there is variation from facilities to facilities in Addis Ababa City for specialists (see annex 6). Health workers and managers responding to this study from SNNPR Bureau of Health and HFs reported that only midwifery are eligible for professional allowance at the rate of ETB 50 per month for both hospitals and health centers. This is also true for Somale Region; even professional allowance for midwifery is not in practice (see annex 6). Participants in the study from Amhara Bureau of Health and HFs reported that only specialists, general practitioners, anesthetist and midwifery are eligible for professional allowance with the rate ETB 1000 with 800 top-up, ETB 800 with 600 top-up, ETB 75 and ETB 50 per month respectively, which is also the same only for midwifery working at health centre level (see annex 6). Health workers and managers responding to this study from Tigray Bureau of Health and HFs reported eligible professions for professional allowance, such as specialists who paid at a rate of ETB 1078 per month, general practitioners ETB 875, anesthetist ETB 125, midwifery ETB 50, psychiatrist ETB 75, emergency surgeon ETB 875and field surgeon ETB 356 (see annex 6). Participants in the study from Benshangul Gumz Bureau of Health and HFs reported that only specialists at the rate of ETB 3500 plus ETB 4200 top up, general practitioners ETB 1700, anesthetist ETB 1000 and midwifery ETB 50 have professional allowance per month, which is also the same only for midwifery working at health centre level. The specialists working at hospitals are also eligible for additional allowance, ETB 4200 per month in the form of top up (see annex 6). 3.4.1.2 Positional allowance National: Positional allowance is not in practice at federal level for Ministry of Health and its referral Hospitals (see annex u7). Sub-national: In Oromiya region only chief executive officers (CEO), medical directors (MDs), health center heads (HCHs), process owners and matrons working at HFs level are eligible for positional allowance and paid at a rate of ETB 500, ETB 300, ETB 150-200, ETB 150 and ETB 250 per month respective. For HCHs, it ranges from ETB 150-200 per month in HFs at the same level, fore stance, Dukem and Hmbisso Health Centers. The process owners are heads of work processes at health facility level. But process owners at Health Bureau level have no positional allowances (see annex 7). Positional allowance is in practice in Addis Ababa City HFs only for CEO who paid at rate of ETB 400, for MDs ETB 450, for HCHs ETB 400 and for Case team leaders ETB 100 per month.
  • 12. 7 The case team leaders are coordinators of work processes at health facility level. The positional allowance in practice in SNNPR is only for CEOs at a rate of ETB 350 per month. But in Smale Region only both CEOs and MDs have positional allowance with the same rate of ETB 400 per month. In Amhara region only MDs, HCHs and process owners have positional allowance with ETB 200, ETB150 and ETB 90 per month respectively. The process owners are heads of work processes at Health Bureau level (see annex 7). Both medical directors and case team leaders/unit heads of Tigray Region are the only eligible for positional allowances and paid at the rate of ETB 420 and ETB 182 per month. But in Benshangul Gumz Region, MDs and HMIS Committees have positional allowance at a rate of ETB 100 and ETB 70 per month (see annex 7). 3.4.1.3 Transport allowance National: Transport allowance is not in practice at National level. At Sub national level, it is in practice only in Addis Ababa City HFs. Only CEO, MDs, HCHs, Process owners and GPs are eligible for transport allowances with the rate of ETB 200, ETB 200, ETB 100, ETB 243 and ETB 100 per month respectively (see annex 8). 3.4.1.4 Telephone allowance National: Telephone allowance is also one of the incentive packages at national level. Only Director Generals, Directors, CEOs, MDs and Unit heads at federal level are eligible for telephone allowance with the rate of ETB 200, ETB 125, ETB 200, ETB 100 and ETB 100 per month respectively (see annex 9). Sub national: Addis Ababa City is one of the city administrations that also practicing telephone allowance at HFs level, in which only CEOs, MDs and GPs are eligible with the rate of ETB 200, ETB 150 and ETB 100 per month respectively. Amhara region is also one of the regions that practicing telephone allowance with the rate ranging from ETB 200-500 for CEOs and ETB 300 for MDs. In Benshangul Gumz, CEOs and HCHs are eligible for telephone allowance with the rate ETB 150 and ETB 100 respectively per month. The rest four regions participated in the study like Oromiya, SNNPR, Somale and Tigray were not practicing telephone allowance (see annex 9). 3.4.1.5 Duty allowance National and Sub national practice: Duty allowance varies across the level from federal to region, region to region and health facility to health facility, even within a region. Federal hospitals (FH) have a rate of ETB 27 per duty for health assistance; ETB 62 per duty for BSc professionals (see annex 10).
  • 13. 8 Hospitals in Addis Ababa (AA) City also have a rate of ETB 41 per duty for health assistance. For health workers with advance diploma, federal hospitals have ETB 53 per duty and hospitals in AA City have ETB 80 per duty. The rest health facilities (HFs) of other regions participated in the study have no health assistance and health workers with advance diploma. The SNNPR and Beneshangu Gumz (BG) HFs have the same rate ETB 62 per duty for BSc professionals. Oromiya HFs has a rate of ETB 50 per duty, AA City HFs ETB 98 per duty, Somale and Tigray HFs ETB 81 per duty, and Amhara HFs ETB 45 per duty, which is the least rate for duty for BSc professionals (Nurses, Lab, Pharma, etc). The federal HFs and AA City, Somale, and Amhara HFs have no duty allowances for midwifery but compensate with duty off. Oromiya HFs have a rate of ETB 50 per duty. SNNPR and Beneshangul Gumz HFs paid ETB 62 and Tigray ETB 81 per duty for midwifery. The federal HFs and Oromiya, Somale, Amhara and Beneshangul Gumz HFs have also no duty allowance for anesthetists but they will be on duty off. Addis Ababa City HFs have a rate of ETB 114, SNNPR HFs ETB 62 and Tgray HFs ETB 67 per duty. Duty allowance for health officers (HOs) is in practice at all level. Federal HFs have a rate of ETB 62 per duty and Regional HFs of Bureaus of Health, Oromiya ETB 50, AA City ETB 126, SNNPR and Beneshangul Gumz have the same rate to Federal ETB 62, Smale and Tigray ETB 81, and Amhara ETB 45 per duty. Duty allowance rate for GPs at federal HFs level is ETB 86 per duty. It is also ETB 100 in Oromiya HFs, ETB 185 in AA City HFs, SNNPR have the same rate to Federal ETB 86, Somale and Amhara HFs have also the same rate ETB 120, and Tigray HFs ETB 118 per duty. The duty allowance rate for all type of specialists at federal HFs level is ETB 114 per duty. ETB 150 in Oromiya and Amhara HFs, ETB 248 in AA City HFs, SNNPR HFs have the same rate with federal HFs ETB 114. Somale HFs have different schemes by type of professionals, ETB 240 for Surgeon and Gynecologists, and ETB 150 for Internist and Pediatrician, ETB 171 in Tigray HFs and ETB 240 in Beneshangul Gumz HFs. Operation Room (OR) Nurses have no duty allowance at federal HFs level. But they do have duty off. AA City HFs and Regions HFs (SNPPR, Somale and Beneshangul Gumz) reported that they have no special rate for OR Nurses. But Oromiya, Amhara and Tigray HFs have a rate of ETB 50, ETB 45 and RTB 67 per duty respectively. For cleaners, cashiers and card registrar of HFs of Somale and Amhara have ETB 35 and ETB 15 per duty. In the rest regions including the federal HFs, there is no duty allowance but they do have duty off per duty.
  • 14. 9 3.4.1.6 House allowance National: House allowance is also one of the incentive packages for employees in the health sector. Federal MoH and hospitals have no such incentive packages (see annex 11). Sub national: In some regions only MDs, CEOs and HCHs are eligible for house allowance. SNNPR arranged only for MDs (referral hospital) at the rate of ETB 500 per month. Amhara HFs only for CEOs and paid at the rate of ETB 300 and Beneshangul Gumz HFs only for CEOs and HCHs with the rate of ETB 200 and ETB 100 per month respectively. Addis Ababa City has special arrangements for Specialists, GPs, Health officers, Medical directors and CEOs of HFs. They will arrange condominium houses with ETB 350 subsidy per month (see annex 11). 3.4.1.7 Staff working part-time in the private wing Health professionals and support staff were also working in private wing in their hospital. Rate of income share from par-time for staff working part-time in the private wing is 70% for Professionals, 15% for Support staff and 15% for Organization (HFs). 3.4.2 Non-financial incentives 3.4.2.1 Residential House National: Non financial incentives are also included in the employees’ incentive packages at federal, regional and health facilities level. At federal level general directors, directors and CEOs of hospitals are eligible for the provision of residential houses (see annex 12). Sub national: Addis Ababa City also has an arrangement for condominium house only for specialists, GPs and health officers. Beneshangul Gumz also have the same experiences with federal level and provides houses only for specialists, GPs, medical directors, health officers, unit heads and senior staffs, which may not uniformly practiced in the region. The rest regions did not have a practice of providing a house for employees (see annex 12). 3.4.2.2 Car for Transport National: Federal MoH and its Hospitals are the one who provided car for general directors, directors and CEOs (see annex 13). Sub national: Addis Ababa City Hospitals also provide car only for CEOs and medical directors. The rest regions have no provision of individual level cars (see annex 13). 3.4.2.3 Continuous education About 43% of the health workers and managers responding to the study mentioned that there exists a strategy/plan for continuous education. Nearly 33% of health workers and
  • 15. 10 managers also reported that continuous education programmes match human resource for health needs and staff in the main human resource for health categories benefit from continuous education (see annex 20). 4. Discussion and Conclusion There exists a policy (guidelines of Ministers’ of Council) and regulation (civil servant regulation of MoCS) that addresses employee retention schemes at national and sub national level. Regions, Oromiya and Addis Ababa City Bureau of Health in placed their own regulation; and the remaining regions did not have their own tools but use the guideline of the federal government. Regularly updating the guidelines and regulation was missing at all level to fit to current living conditions. There exists a plan/strategy that addresses employee retention schemes as part of Health Sector Development Programme, i.e., HSDP-IV. Health facilities have also HRH plans cascaded from the regional bureau of health on annual bases. About 15% respondents are also mentioned that a planned continuous education has to be provided for employees’ educational career. About 25% also reported transport services have to be accessible for employees. The policies and regulations for employees’ incentive packages in place are guidelines of the Councils of Ministers and regulation of Ministry of Civil Servant at National level. Oromiya and Addis Ababa City have Regional regulations. Both national and regional tools lack regular updating. The existence of different forms of employee motivation and retention schemes is reported by the majority (96%) of the health workers and managers responding to this study. The most commonly practiced financial incentives are professional, positional, duty and telephone allowances at all level. Non-financial incentives mainly included provision house, car, short and long term trainings and certificate of recognition at all level [9] . Lack of comprehensiveness of retention schemes in including main HRH professionals and variation for the same level HFs from region to region and from facility to facility is observed for both financial and non-financial incentive schemes.
  • 16. 11 Income sharing for staff working at part-time in the private wing was reported with 70% of the total income goes to professionals; 15% for support staff and 15% for the hospital income supplementations. Continuous education programmes are low (33%) in matching human resource for health needs and benefiting staff in the main human resource for health categories. 5. Recommendations The existence of policies, regulations and plans/strategies at all level is a good practice, but they have to regularly update and especially the FMoH has to have lead role and take initiative in updating the tools. A comprehensiveness incentive packages have to be in placed to benefit all staff and minimize the gap of the rate especially in professional, positional and duty allowances at all level, and the federal MoH has to take the lead role and initiative. Motivational and retention schemes for nurses and physicians need further study to identify what satisfy them at all level, and the federal MoH has to take the lead role and initiatives. Private wing for part time work of staff at facility level has to be encouraged in all hospitals at regions level and regional bureaus of health have to take a lead role in encouraging practicing private wing in all hospitals. Continuous education programmes have to match the needs of HRH and benefit staff in the main HRH categories.
  • 17. 12 References 1. Peru med exp. Addressing the HRH crisis in countries: How far have we gone? What can we expect to achieve by 2015?, Salud Publica, 2011 2. World Health Organization. International migration of health personnel: a challenge for health systems in developing countries. Resolution WHA57.19. Geneva, Switzerland: WHO; 2004. 3. FMoH. A five year health sector development programme, HSDP-IV (2010/11- 2014/15), 2011 4. World Health Organization. Global Code of Practice on the International Recruitment of Health Personnel. Resolution WHA63.16. Geneva, Switzerland: WHO; 2010. 5. Harvard University. Human Resources for health: overcoming the crisis. Joint Learning Initiative. Cambridge, Massachusetts: Press Global Equity Initiative; 2004. 6. Prince Mahidol Award Conference. Proceedings of Second Global HRH Forum. January 27-29, 2011. Bangkok, Thailand; PMAC/GHWA/WHO/JICA; 2011. 7. FMoH. Human resource development redesign study report, 2008 8. Salary.com. Employee Job Satisfaction & Retention Survey 2007/2008 9. World Health Organization. Rapid scaling up of health workforce production. WHA59.23. Geneva, Switzerland: WHO; 2006. 10. George C. Sinnott, George H. Madison, etal. EMPLOYEE RETENTION: Report of the Employee Retention Workgroup, September 2002
  • 18. 13 Annexes Annex 1: No of participants responding to this study, 2011 Level Frequency Percent Male Female Federal (MoH) 2 2.5% 2 0 Regional 13 16.2% 10 3 Hospital (Federal + Regional) 34 42.5% 21 13 Health center 31 38.8% 14 17 Total 80 100.0% 47 33 Total 59% 41%
  • 19. 14 Annex 2: Financial and non-financial incentives Level Policy Regulation Type of Incentive packages Incentive packages by type and level Eligible Health office Health facility by level and eligibility criteria* Health workers satisfaction level - MoH/RHB (ETB/ m) A (ETB/m) B (ETB/m) C (ETB/m) Good Poor Federal MoH/Hospital Guideline of Councils of Ministers Regulation of the MoCS Professional allowance Anesthetist NA** 125 NA NA 40% 60% Psychiatrist No 75 NA NA Midwifery No 50 NA NA Telephone allowance General directors 200 NA NA NA Directors 125 NA NA NA CEO NA 200 MD NA 100 Duty allowance HA NA 27 NA NA Diploma NA 41 NA NA Diploma (Advance) NA 53 NA NA BSc Professionals No 62 NA NA MW No Duty off NA NA Anesthetist NA Duty off NA Na Health Officer No 62 NA NA GP No 86 NA NA Specialist No 114 NA NA OR nurse NA Duty of f NA NA Cleaners/ Cashier/ Card Registrar No Duty of f NA NA Residential house General directors - Provided- NA NA Directors Provided NA NA CEO Provided NA NA Car for transport General directors - Provided- NA NA Directors - Provided- NA NA CEO - - Provided NA NA MD - - Provided NA NA
  • 20. 15 Level Policy Regulation Type of Incentive packages Incentive packages by type and level Eligible Health office Health facility by level and eligibility criteria* Health workers satisfaction level - MoH/RHB (ETB/ m) A (ETB/m) B (ETB/m) C (ETB/m) Good Poor Oromiya BoH No regional Regional Regulation Professional allowance Specialist No 1000-1200 2000 3000 54% 46% GP No 500-700 1000 2000 Anesthetist NA 300 625 1000 Psychiatrist No 75 75 75 Midwifery No 50 50 50 Positional allowance Process owners - No 150 150 150 CEO NA 500 500 500 Medical director NA 300 300 300 Health center head NA NA NA 150-200 Matron NA 250 250 250 Duty allowance Diploma NA 41 41 41 BSc Professionals NA 50 50 50 MW NA 50 50 50 Anesthetist NA Duty of Duty of Duty of Health Officer NA 50 50 50 GP NA 100 100 100 Specialist NA 150 150 150 OR nurse NA 50 50 50 Cleaners/ Cashier/ Card Registrar NA Duty of Duty of Duty of Addis Ababa City BoH No regional Regional Regulation Professional allowance Specialist No 1000- 1200 NA NA 100% 0% GP No 800 NA NA Anesthetist NA 125 NA NA Midwifery No 50 NA NA Positional allowance Process owners - No 243 NA NA CEO NA 400 NA NA
  • 21. 16 Level Policy Regulation Type of Incentive packages Incentive packages by type and level Eligible Health office Health facility by level and eligibility criteria* Health workers satisfaction level - MoH/RHB (ETB/ m) A (ETB/m) B (ETB/m) C (ETB/m) Good Poor Medical director NA 450 NA NA Health center head NA NA NA Transport allowance CEO NA 200 NA NA Medical director NA 200 NA NA Health center head NA 100 NA Process Owner No 243 NA NA GP No 200 NA 200 Team leaders No 200 NA NA Telephone allowance CEO No 200 NA NA Medical director No 150 NA NA GP No 100 NA NA Health center head No NA NA NA CEO No 200 NA NA Duty allowance HA NA 41 NA NA Diploma NA 62 NA NA Diploma (Advance) NA 8 NA NA BSc Professionals NA 98 NA NA MW NA Duty of NA NA Anesthetist NA 114 NA NA Health Officer NA 126 NA NA GP NA 185 NA NA Specialist NA 248 NA NA Cleaners/ Cashier/ Card Registrar NA 41 NA NA House allowance Specialist No 350 NA NA GP No 350 NA NA Health officer No 350 NA NA Medical director NA 350 NA NA
  • 22. 17 Level Policy Regulation Type of Incentive packages Incentive packages by type and level Eligible Health office Health facility by level and eligibility criteria* Health workers satisfaction level - MoH/RHB (ETB/ m) A (ETB/m) B (ETB/m) C (ETB/m) Good Poor Specialist No 350 NA NA Residential house Specialist N0 Provided N0 N0 GP N0 Provided N0 N0 Health officer N0 Provided N0 N0 General directors - Provided NA NA NA Directors - Provided NA NA NA CEO - - Provided NA NA Car for transport CEO NA NA - Provided NA Medical director NA NA - Provided NA SNNPR BoH MoH Guidelines Regulation of the MoCS Professional allowance Anesthetist NA 125 No 0% 100% Midwifery No 50 50 Positional allowance Medical director No 350 No Duty allowance Diploma NA 41 41 41 BSc Professionals NA 62 62 62 MW NA 62 62 62 Anesthetist NA 62 62 62 Health Officer NA 62 62 62 GP NA 8 8 8 Specialist NA 114 114 114 Cleaners/ Cashier/ Card Registrar NA Duty of Duty of Duty of House allowance Medical director No 500 No No Somale BoH MoH Guidelines Regulation of the MoCS Positional allowance CEO NA NA 400 400 0% 100% Medical director NA - NA 400 400
  • 23. 18 Level Policy Regulation Type of Incentive packages Incentive packages by type and level Eligible Health office Health facility by level and eligibility criteria* Health workers satisfaction level - MoH/RHB (ETB/ m) A (ETB/m) B (ETB/m) C (ETB/m) Good Poor Duty allowance Diploma NA 62 62 62 BSc Professionals NA 81 81 81 MW NA Duty of Duty of Duty of Anesthetist NA Duty of Duty of Duty of Health Officer NA 81 81 81 GP NA 120 120 120 Specialist NA NA NA NA Surgeon & Gynecologist NA 240 240 240 Internist& Pediatrician NA 150 150 150 Cleaners/ Cashier/ Card Registrar NA 35 35 35 Amhara BoH Regional Guidelines Regulation of the MoCS Professional allowance Specialist No 1000 1200 1500 0% 100% GP No 800 1000 1200 Anesthetist NA 75 75 75 Midwifery No 50 50 50 Positional allowance Process owners 90 No No No Medical director NA 200 200 200 Health center head NA 150 150 150 Duty allowance CEO 500 200 200 Medical director 300 300 300 Diploma NA 35 35 35 BSc Professionals NA 45 45 45 MW NA Duty of Duty of Duty of Anesthetist NA Duty of Duty of Duty of Health Officer NA 45 45 45 GP NA 120 120 120
  • 24. 19 Level Policy Regulation Type of Incentive packages Incentive packages by type and level Eligible Health office Health facility by level and eligibility criteria* Health workers satisfaction level - MoH/RHB (ETB/ m) A (ETB/m) B (ETB/m) C (ETB/m) Good Poor Specialist NA 150 150 150 OR nurse NA 45 45 45 Cleaners/ Cashier/ Card Registrar NA 15 15 15 House allowance CEO NA 300 No No Tigray BoH Regional Guidelines Regulation of the MoCS Professional allowance Specialist No 1078 1078 1078 8% 92% GP No 875 875 875 Anesthetist NA 125 125 125 Midwifery No 50 50 50 Psychiatrist No 75 75 75 Emergency Surgeon 875 875 875 Field Surgeon 356 356 356 Positional allowance Medical director NA MoE 420 420 Case Team Leaders - No - MoE 182 182 Duty allowance Diploma NA Duty of Duty of Duty of BSc Professionals NA 81 81 81 MW NA 81 81 81 Anesthetist NA 67 67 67 Health Officer NA 81 81 81 GP NA 118 118 118 Specialist NA 171 171 171 OR nurse NA 67 67 67 Cleaners/ Cashier/ Card Registrar NA Duty of Duty of Duty of Benshangul Gumz Regional Guidelines Regulation of the MoCS Professional allowance Specialist No No 3500 3500 38% 62%GP No No 1700 1700 Anesthetist NA No 1000 1000
  • 25. 20 Level Policy Regulation Type of Incentive packages Incentive packages by type and level Eligible Health office Health facility by level and eligibility criteria* Health workers satisfaction level - MoH/RHB (ETB/ m) A (ETB/m) B (ETB/m) C (ETB/m) Good Poor Midwifery No No 50 50 Positional allowance Medical director NA No 100 100 HMIS Committee NA No No No Duty allowance Medical director No No 150 150 Health center head NA NA NA NA Diploma NA 41 41 41 BSc Professionals NA 62 62 62 MW NA 62 62 62 Anesthetist NA Duty of Duty of Duty of Health Officer NA 62 62 62 GP NA 100 100 100 Specialist NA 240 240 240 Cleaners/ Cashier/ Card Registrar NA Duty of Duty of Duty of House allowance CEO NA NA 200 No Health center head NA NA NA 100 Residential house Specialist NA No Provided No GP No No Provided No Health officer No No Provided No Unit head/ Senior staff No No Provided No Medical director NA No Provided No CEO NA No Provided No * Eligibility criteria: health facilities located in areas classified as A, B and C based on the availability of infrastructure. ** NA: Not Applicable *** ETB/m: Ethiopian Birr per month
  • 26. 21 Annex 3: No of respondents acknowledge the existence of HRH policy, regulation and plan for employee retention by region, 2011 Annex 4: Expenditure rate for HRH in the total recurrent expenditure of health by level, 2011 National/Sub- national Have HRH policy (or equivalent) Have HRH regulation (or equivalent) Have strategy or plan for HRH Y N % Y N % Y N % MoH 5 0 100% 5 0 5 0 Oromiya 7 0 7 7 0 11 0 Addis Ababa City 9 0 5 7 0 9 2 SNNPR 6 0 5 6 0 2 9 Somale 3 3 6 6 0 3 3 Amhara 1 6 4 5 2 5 2 Tigray 4 0 4 4 0 3 0 Benishangu Gumz 3 1 1 3 1 2 1 Total 38 10 32 43 3 40 17 Total 48% 13% 40% 54% 4% 50% 21% National/Sub- national Rate of expenditure for HRH in the total health expenditure Have <70% of recurrent budget for HR Salary Have >70% of recurrent budget for HR salary I do not know MoH 1 3 1 Oromiya 1 5 8 Addis Ababa City 3 3 8 SNNPR 0 5 6 Somale 2 4 6 Amhara 0 3 8 Tigray 0 4 4 Benishangu Gumz 0 3 2 Total 7 30 43 % 9% 37% 54%
  • 27. 22 Annex 5: Number of health workers and managers approved the existence of HRH policy, regulation and plan for motivation and retention schemes for employees, 2011 By Level Y N MoH Federal hospital s RBoH RBoH Hospital s WoHO HCs Federal 5 0 2 3 Oromiya 14 0 3 3 8 Addis Ababa City 11 3 3 3 5 Amhara 11 0 3 3 5 Tigray 12 0 3 3 6 SNNPR 11 0 2 4 5 Benshangul G 8 0 2 2 4 Somale 5 0 2 1 2 Total 77 3 2 3 18 19 35 Percent approved 96% 4% 100% 100% 100% 95.0% 94.6% Annex 6: Professional allowance for Health Facilities, 2011 National/Sub- national Professional allowance in Birr per month For Specialist For GP For Anesthetist For Midwifery For Psychiatrist For Emergency Surgeon For Field Surgeon MoH - Hospital No No 125 50 75 No No - Health center NA NA NA NA NA NA NA Oromiya - Hospital 1000-1200 500-700 300-625 50 75 No No - Health center NA No NA 50 No NA NA Addis Ababa City - Hospital 1000-1200 800 No 50 No No No - Health center NA 800 NA 50 No NA NA SNNPR - Hospital No No No 50 No No No - Health center NA No NA 50 No NA NA Somale - Hospital No No No No No No No
  • 28. 23 Note: NA (Not Applicable) Annex 7: Positional allowance, 2011 - Health center NA No NA No No NA NA Amhara - Hospital 1000 800 75 50 No No No - Health center None No NA 50 No NA NA Tigray - Hospital 1078 875 125 50 75 875 356 - Health center NA No NA 50 No NA NA Benishangu Gumz - Hospital 3500 1700 1000 50 No No No - Health center NA No NA 50 No NA NA National/Sub- national Positional allowance in Birr per month For Process Owner For CEO For Medical director For Health center head For HMIS Committee For Matron For Case Team Leaders MoH No No No NA No No No Oromiya 150 500 300 150-200 No 250 No Addis Ababa City 243 400 450 400 No No No SNNPR No No 350 No No No No Somale No 400 400 No No No No Amhara 90 No 200 150 No No No Tigray No No 420 No No No 182 Benishangu Gumz No No 100 No 70 No No
  • 29. 24 Annex 8: Transport allowance, 2011 Annex 9: Telephone allowance, 2011 National/Sub- national Transport allowance in Birr per month For CEO For Medical director For Health center head For Process Owner For GP MoH No No No No No Oromiya No No No No No Addis Ababa City 200 200 100 243 200 SNNPR No No No No No Somale No No No No No Amhara No No No No No Tigray No No No No No Benishangu Gumz No No No No No Region Telephone allowance in Birr per month For D/General For Director For CEO For Medical director For Health center head For Unit heads For GP MoH 200 125 200 100 NA No No Oromiya NA NA No No No No No Addis Ababa City NA NA 200 150 100 No 100 SNNPR NA NA No No No No No Somale NA NA No No No No No Amhara NA NA 200-500 300 No No No Tigray NA NA No No No No No Benishangu Gumz NA NA 150 No 100 No No
  • 30. 25 Annex 10: Duty allowance, 2011 Region Duty allowance in Birr per duty For HA For Diploma For Diploma (Advance) For BSc Profe. For MW For Anesthetist For Health Officer For GP For Specialist For Surgeon & Gyn For Internist & Pedia For OR nurse For Cleaners/ Cashier/ Card Registn MoH 27 41 53 62 Duty of Duty of 62 86 114 NA NA Duty of Duty of Oromiya NA 41 NA 50 50 Duty of 50 100 150 NA NA 50 Duty of Addis Ababa City 41 62 80 98 Duty of 114 126 185 248 NA NA NA Duty of SNNPR NA 41 NA 62 62 62 62 86 114 NA NA NA Duty of Somale NA 62 NA 81 Duty of Duty of 81 120 NA 240 150 NA 35 Amhara NA 35 NA 45 Duty of Duty of 45 120 150 NA NA 45 15 Tigray NA Duty of NA 81 81 67 81 118 171 NA NA 67 Duty of Benishangu Gumz NA 41 NA 62 62 Duty of 62 100 240 NA NA NA Duty of Note: NA=+ Not Applicable
  • 31. 26 Annex 11: House allowance, 2011 Annex 12: Organizations providing residential house by type of position and profession, 2011 National/Sub- national House allowance For D/General/ Director/ Process Owners For Specialist For GP For Health officer For unit head/ Senior staff For Medical director For CEO For HC head MoH No No No No No No No No Oromiya No No No No No No No No Addis Ababa City No 350 350 350 No 350 350 No SNNPR No No No No No 500 No No Somale No No No No No No No No Amhara No No No No No No 300 No Tigray No No No No No No No No Benishangu Gumz No No No No No No 200 100 National/Sub- national Residential For D/General/ Director/ Process Owners For Specialist For GP For Health officer For unit head/ Senior staff For Medical director For CEO MoH Yes No No No No No Yes Oromiya No No No No No No No Addis Ababa City No Yes Yes Yes No No No SNNPR No No No No No No No Somale No No No No No No No Amhara No No No No No No No Tigray No No No No No No No Benishangu Gumz No Yes Yes Yes Yes Yes Yes
  • 32. 27 Annex 13: Organizations providing car for transport by type of position and profession, 2011 Annex 14: Number of organization awarding certificate of recognition for best performers and providing shot and long term trainings, 2011 National/Sub- national Car For D/General/ Director/ Process Owners For CEO For Medical director For Health center head MoH Yes Yes No No Oromiya No No No No Addis Ababa City No Yes Yes No SNNPR No No No No Somale No No No No Amhara No No No No Tigray No No No No Benishangu Gumz No No No No National/Sub-national Certificate of recognition for best performer Short and long term trainings Yes No Yes No Federal 2 3 5 0 Oromiya 4 10 8 6 Addis Ababa City 2 12 8 6 Amhara 0 11 5 6 Tigray 4 8 7 5 SNNPR 2 9 9 2 Benshangul G 0 8 8 0 Somale 0 5 2 2 Total 14 66 52 27 % 18% 65%
  • 33. 28 Annex 15: Health facilities employees’ motivation and satisfaction level grossly by region, 2011 Annex 16: No and category of staff leaving for the private health or non-health sector in the last one year and organizations with <5% vacancy rate, 2011 Region Fair Good Very good Poor I do not know (IDK) Good % Poor % Federal 3 0 0 2 0 3 60% 2 40% Oromiya 5 1 1 6 0 7 54% 6 46% Addis Ababa City 8 0 0 0 6 8 100% 0 0% Amhara 0 0 0 11 0 0 0% 11 100% Tigray 1 0 0 11 0 1 8% 11 92% SNNPR 10 0 0 1 0 10 91% 1 9% Benshangul G 3 0 0 5 0 3 38% 5 62% Somale 2 0 0 2 1 2 50% 2 50% Total 32 1 1 38 7 % 40% 48% National/Sub- national Public health specialist/ professionals Physician BSc Nurse Health officer Anesthetist BSc Pharmacist BSc Lab Mid wifery Vacancy rate <5% MoH 3 5 5 0 0 0 0 0 3 Oromiya 2 3 6 1 0 0 0 1 1 Addis Ababa City 0 4 13 0 0 3 1 0 1 Amhara 8 6 7 2 0 1 1 0 9 Tigray 4 6 8 0 0 0 6 0 5 SNNPR 3 3 3 1 1 0 1 0 5 Benshangul Gumz 0 3 0 1 0 0 0 0 3 Somale 0 1 3 0 0 1 0 0 1 Total 20 31 45 5 1 5 9 1 28 % 25% 39% 56% 6% 1% 6% 11% 1% 35%
  • 34. 29 Annex 17: Main reasons of employees for leaving the public sector for the private or non- health sector, 2011 Se. No. Reasons Always Usuall y Sometim es Never A Work environment (relationships, values and culture) 10 11 4 55 B Poor living conditions (shortage of basic needs, lack of schooling for children and jobs for spouses 14 15 7 44 C Clear career advancement opportunities/structure 5 2 1 72 D Challenging work and Work overload 12 2 4 62 E Flexibility in work schedule 2 3 4 71 F Salary 73 4 2 1 G Appropriate resources and equipment to perform the job 9 6 4 61 H Employee benefits 32 5 2 41 I Less travel 1 1 4 74 J Supervision 1 2 4 73 K Leadership (management support) 2 3 6 69
  • 35. 30 Annex 18: Rate of income share from par-time for staff working part-time in the private wing in their hospitals, 2011 Annex 19: Employees’ income supplementation schemes, 2011 Annex 20: A strategy/plan for continuous education at national and sub-nationals levels, 2011 National/Sub- national Rate of income share For Professionals For Support staff For Organization (HFs) MoH 70% 15% 15% Oromiya 70% 15% 15% Addis Ababa City 70% 15% 15% SNNPR 70% 15% 15% Somale 70% 15% 15% Amhara 70% 15% 15% Tigray 70% 15% 15% Benishangu Gumz 70% 15% 15% Region Yes No Have any form of income supplementation 80 0 Income supplementation of national government 80 0 Income supplementation increase earnings employees 0 80 National/Sub- national Continuous education (CE) strategy/plan CE programmes match HRH needs Staff in the main HRH categories benefit from CE Y N IDK Total Y N IDK Total Y N IDK Total Federal 2 0 0 2 0 2 0 2 0 2 0 2 Region 13 0 0 13 8 5 0 13 11 2 0 13 Hospitals 14 16 4 34 14 16 4 34 12 17 5 34 Health centers 5 23 3 31 4 22 5 31 3 20 8 31 Total 34 39 7 80 26 45 9 80 26 41 13 80
  • 36. 31 Annex 21: Comments to make the organization a better place to work, 2011 General comments Number of health workers and managers Total % Federal Region Hospitals Health centers Update financial allowance regularly to fit to current living conditions 0 2 6 4 12 15% Provide planned continuous education 0 2 6 4 12 15% In place employee transfer schemes 0 2 2 4 8 10% Avoid pool system for salary disbursement 0 2 1 4 7 9% Make accessible transport services for employees 0 5 5 10 20 25% Make accessible non-financial incentives like house for employees 0 3 3 3 9 11% Private wing in all hospital 0 1 6 0 7 9% Incentive for professionals at Bureau, Zone and Woreda level 0 3 2 0 5 6% National and regional comprehensive incentive package 2 7 9 14 32 40% Tax has to exempted for allowances 0 0 1 0 1 1%
  • 37. 32 Copies of policies and regulations 1. FMoH, Councils of Ministers’ Guidelines for Health Professionals Duty Allowance, April 2008 2. Amhara Regional Bureau of Health, Circular for Physicians Incentive Packages, 2007, 3. Benshangul Gumz Regional Bureau of Health, Circular for Professional Allowance, 2010 4. Addis Ababa City Health Bureau, Regulation of Health Professionals Incentive Packages, 2009 5. Tigray Regional Bureau of Health, Draft Guidelines for Health Professionals Incentive Packages, 2011 6. Oromiya Bureau of Health, Regulation of Health Professionals Incentive Packages, 2009

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