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Findings from ReBUILD’s
health worker research
Learning lessons for post-conflict contexts
Sophie Witter
HEART seminar, 9t...
Overview
• Background on ReBUILD
• Findings on impact of conflict on health staff
• Production, attraction, distribution, ...
Background on ReBUILD
Post conflict is a
neglected area
of health
system research
Opportunity
to set health
systems in a
p...
ReBUILD’s research and partnership
Health
financing
Gender &
equity
Health
workforce
Aid
effectiveness
Contracting
models
...
Health Needs
of population
(demand)
Health
services
(supply)
Conflict and crisis
creates change
Howcandecisionsmadeearlypo...
Background on ReBUILD research on HW incentives
Objective: to understand the evolution of incentives for health workers
po...
Background on ReBUILD research on HW deployment
Objective: to identify ways to improve deployment systems to rural areas
u...
Immediate effects of conflict and crisis:
impact on existing staff
• Collapse in HR and HR information systems
• Staff may...
Staff coping strategies
For conflicts and Ebola:
Health staff targeted in both (but for different reasons)
• Practical – h...
Production & training
Distortion of health worker supply and salaries by the aid industry is a risk
Foreign staff can fill...
Deployment
• No special changes were made to deployment related policies to
accommodate the change in context due to confl...
Incentive packages
Incentives – need to ensure a balanced package over time, once the intensity of the conflict
experience...
Complex remuneration
Bertone, M. and Witter, S. (2015) The complex remuneration of Human Resources for Health in low incom...
Mind the (sectoral) gap
The conflict/post-conflict dynamics can affect the balance of attraction and
retention across sub-...
Rural retention
Rural health workers face particular challenges, some of which stem from the difficult terrain, which add
...
The gendered health workforce
• Lack of balance: in all contexts women predominate in nursing and midwifery
cadres; are un...
HRH policies & institutions
Thinking longer-term - windows of opportunity
& path dependency
• While there may be a ‘window of opportunity’ for fundame...
Institution-building
Observations from Sierra Leone, 2002-16 – case study of MoHS
• Periods of support, but focus is short...
Do no harm….
Fundamentally, institutions have to be internally constructed BUT
donors have a duty to not disrupt:
• Not cr...
In order to do that….
Even when services are weak and there is a focus on meeting direct
needs, in the aftermath of confli...
State-building and HRH: a conceptual framework
State-building =
Strengthened
social contract
Capacity and
willingness for
...
HRH and state-building
• The concept of state-building itself is highly contested, with a rich vein of scepticism
about th...
Health Systems Resilience: Systems’ Analysis
Adaptation strategies – many focused on health staff
• adjusted staff working hours and conditions of
service
• temporary ...
BUILDING BACK BETTER
A NEW E-RESOURCE: WWW.BUILDINGBACKBETTER.ORG
Thank you
Website:
www.rebuildconsortium.com
Contact:
nick.hooton@lstmed.ac.uk
@ReBUILDRPC
Human Resources for Health in Post-Conflict settings - Findings from ReBUILD research
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Human Resources for Health in Post-Conflict settings - Findings from ReBUILD research

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Presentation given in June 2016 by Sophie Witter on the ReBUILD programme's findings on Human Resources for Health in Post-Conflict settings, at a meeting exploring cross-sectoral learning on human resources in health and education sectors in fragile settings

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Human Resources for Health in Post-Conflict settings - Findings from ReBUILD research

  1. 1. Findings from ReBUILD’s health worker research Learning lessons for post-conflict contexts Sophie Witter HEART seminar, 9th June 2016 Research for stronger health systems post conflict
  2. 2. Overview • Background on ReBUILD • Findings on impact of conflict on health staff • Production, attraction, distribution, retention and motivating health staff post-conflict/crisis – longer term perspectives • Gender and HRH • HRH policy-making and institutions • Finally, some resources Research for stronger health systems post conflict
  3. 3. Background on ReBUILD Post conflict is a neglected area of health system research Opportunity to set health systems in a pro-poor direction Useful to think about what policy space there is in the immediate post-conflict period Choice of focal countries enable distance and close up view of post conflict Decisions made early post-conflict can steer the long term development of the health system Research for stronger health systems post conflict
  4. 4. ReBUILD’s research and partnership Health financing Gender & equity Health workforce Aid effectiveness Contracting models Health systems and resilience Research for stronger health systems post conflict Consortium partners • College of Medicine and Allied Health Sciences (CoMAHS), Sierra Leone • Biomedical Training and Research Institute (BRTI), Zimbabwe • Makerere University School of Public Health (MaKSPH), Uganda • Cambodia Development Research Institute (CDRI) • Institute for International Health and Development (IIHD), Queen Margaret University, UK • Liverpool school of Tropical Medicine (UK) Consortium affiliates working in additional countries: Cote d'Ivoire, Nigeria and South Africa; Sri Lanka, Gaza and Liberia
  5. 5. Health Needs of population (demand) Health services (supply) Conflict and crisis creates change Howcandecisionsmadeearlypost-conflictor crisissteerthelongtermdevelopmentofthe healthsystem? Thematic areas Actors & networks Policy and power Vulnerability Household structure Accessing healthcare Resource flows Attraction/retention Posting Policy making Effects and responses Institutions Health workers Communities Strongerhealthsystemspostconflictandcrisis Research question Enhancedvulnerability Gender
  6. 6. Background on ReBUILD research on HW incentives Objective: to understand the evolution of incentives for health workers post-conflict and their effects on HRH and the health sector Research tools Cambodia Sierra Leone Uganda Zimbabwe 1. Stakeholder mapping √ √ 2. Document review √ √ √ √ 3. Key informant interviews √ 33 √ 23 + 18 √ 25 √ 14 4. Life histories with HWs √ 24 √ 23 + 39 √ 26 √ 34 5. Quantitative analysis of routine HR data √ √ √ 6. Survey of health workers √ 310 + 266 (and logbooks) √ 227 Witter, S., Chirwa, Y., Namakula, J., Samai, M., Sok, S. (2012) Understanding health worker incentives in post-conflict settings: study protocol. ReBuild consortium. http://www.rebuildconsortium.com/media/1209/rebuild-research-protocol-summary-health-worker-incentives.pdf Research for stronger health systems post conflict
  7. 7. Background on ReBUILD research on HW deployment Objective: to identify ways to improve deployment systems to rural areas used by large employers (FBO and government) of health personnel in post conflict contexts Research tools Uganda Zimbabwe 1. Document review √ √ 2. Key informant interviews √ 25 √ 17 3. In-depth interviews with managers √ 10 √ 11 4. In-depth interviews with HWs (including job histories) √ 25 √ 67 5. Quantitative analysis of routine HR data √ 6. Personnel record review √ Martineau, T., Rutebemberwa, E., Mangwi, R., Chirwa, Y., Raven, J. (2012) Understanding deployment policies and systems for staffing rural areas: study protocol. ReBUILD consortium. https://rebuildconsortium.com/media/1211/rebuild-project-4-rural-posting-protocol-summary.pdf Research for stronger health systems post conflict
  8. 8. Immediate effects of conflict and crisis: impact on existing staff • Collapse in HR and HR information systems • Staff may have been targeted - reduced in number, not well distributed, often carried out roles above their station, traumatised • But also positive aspects which can be built on – developed coping strategies which allowed them to survive, personal and community- based • These should be recognised and rewarded • Where staff have been targets during conflict, psychosocial support is needed Namakula, J. and Witter, S. (2014) Living through conflict and post-conflict: experiences of health workers in northern Uganda and lessons for people- centred health systems. Health Policy and Planning, vol. 29, pp ii6–ii14. Research for stronger health systems post conflict
  9. 9. Staff coping strategies For conflicts and Ebola: Health staff targeted in both (but for different reasons) • Practical – hiding, task shifting, removing uniform, international support etc. • Psychosocial – community support, support from colleagues, religious faith For economic crises: • Dual practice • Other income generating strategies • Informal and formal movements of staff – e.g. to lower cost rural areas Research for stronger health systems post conflict
  10. 10. Production & training Distortion of health worker supply and salaries by the aid industry is a risk Foreign staff can fill severe gaps in the local workforce (usually at senior level) • However complaints about skills, appropriateness and capacity of expatriate health workers are commonplace, as is resentment against their higher salaries, powerful positions and decision- making freedom • Higher pay to diaspora staff during the Ebola crisis in SL have led of tensions, as well as concerns about longer term sustainability Training is important but can be mishandled • e.g. over-production of poorly trained staff with risks for future sector • alternatively, investment in IST which brings in resources but is not effective on performance Introduction of new HRH policies as a response to post conflict staffing may generate problems in the long-run (e.g. introduction of Primary Care Nurses without clear career pathways in Zimbabwe) The nature of the longer term political settlement will of course determine the extent of confidence in the government and willingness to engage in public sector employment. • The T-word is key Witter, S., Tulloch, O. & Martineau, T. (2012) Health workers’ incentives in post-conflict settings – a review of the literature and framework for research. https://rebuildconsortium.com/media/1265/rebuild_report_2_v6.pdf Research for stronger health systems post conflict
  11. 11. Deployment • No special changes were made to deployment related policies to accommodate the change in context due to conflict and crisis • However, local managers interpreted the rules flexibly to fill vacant posts and to avoid resignation or absconding of staff who were unhappy with their posting. • Sub-national managers have greater decision-space (due to weaker policy enforcement capacity) for deployment during crises e.g. using secondment to staff rural areas • Flexibility in implementing deployment policies may contribute to increased retention in hard-to-reach areas: workers’ preferences need to be taken into account for deployment • Bonding – has worked effectively in the past in countries like Uganda and Zimbabwe, but not viable in times of crisis Research for stronger health systems post conflict
  12. 12. Incentive packages Incentives – need to ensure a balanced package over time, once the intensity of the conflict experience recedes, which prioritises those who serve in hard-to-reach areas but also ensures equity across conflict lines. • Consultation of staff is key in developing these policies; good communication within facilities and within the sector is a ‘low hanging fruit’ • Also reinforcing supervision and improving working conditions • Aspects which require more organisational change can receive less priority than financial incentives, which donors find easier to finance In PC settings, similar motivations for staff and changing aspiration over the career cycle to more stable settings but even greater tendency to fragmentation of incentive structures • Linked to multiple actors? • Incentive policies tend to be piecemeal, poorly funded and implemented. • No feedback loops. • Policies often crafted with external inputs but limited traction. • Some areas of reform particularly hard to address, like management reforms • Some countries experience increased patronage/interference with postings and promotions. Phases: fragmentation initially may be adaptive, but when to harmonise (e.g. TL – on to payroll quite quickly). Also opportunities to learn and innovate - e.g post-Ebola Sla; able now to capitalise on interest; use evidence from past. Witter, S., Wurie, H. And Bertone, M. (2015) The Free Health Care Initiative: how has it affected health workers in Sierra Leone? Health Policy and Planning journal, 1-9 Research for stronger health systems post conflict
  13. 13. Complex remuneration Bertone, M. and Witter, S. (2015) The complex remuneration of Human Resources for Health in low income settings: policy implications and a research agenda for designing effective financial incentives. Human Resources for Health, 13; 62. Bertone, M., Lagarde, M., Witter, S. (2016) Performance-Based Financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone. Under revision for BMC Health Services Research. Bertone, MP and Lagarde M. 2016. “Sources, Determinants and Utilization of Health Workers’ Revenues: Evidence from Sierra Leone.” Health Policy and Planning - Multiple actors and fragmented incentive policies – need to understand better what this means for overall remuneration of health workers, and consequences for health worker motivation and performance Some insights from our research into how health workers use and value different income streams • e.g. PBF in SL is not substantial in volume (around 10% of overall PHW remuneration) but seen as a complement, with less sense of entitlement compared to the official salary • provides extra money which can be used for emergencies or reinvested in income generating activities • less known and therefore vulnerable to family claims • but also reduced in value by delays, shortfalls, lack of transparency Absolute and relative average income by cadre and by component, including PBF payments (n=266), Sierra Leone Research for stronger health systems post conflict
  14. 14. Mind the (sectoral) gap The conflict/post-conflict dynamics can affect the balance of attraction and retention across sub-sectors within health, distorting the provision of care. • e.g. in northern Uganda, during the conflict, the PNFP sector remained more functional, including in terms of supporting staff with pay. • The public sector was boosted in the post conflict phase due to increased investments under the PRDP, consolidation of allowances and introduction of hard to reach allowances. The salaries also became more regular while pension continued to be provided. • Our findings suggest that retention within the PNFP sector has had to rely on more personal factors, such as loyalty and family ties, while many still working in the PNFP sector express the intention to leave, if circumstances permit. • In Zimbabwe, the public sector has been unable to offer the same terms and conditions for staff, given the crisis; the municipalities have independent income source and so employ more senior staff to do less demanding roles in urban clinics, adding to shortages in other areas Namakula, J., Witter, S. and Ssengooba, F. (2016) Health worker experiences of and movement between public and private not-for-profit sectors - findings from post conflict Northern Uganda. Human Resources for Health, 14:18. http://www.human-resources-health.com/content/14/1/18 Chirwa, Y., Witter et al. (2016) Understanding health worker incentives in post-crisis settings: policies to attract and retain health workers in Zimbabwe since 1997: health worker survey findings. ReBUILD report. Research for stronger health systems post conflict
  15. 15. Rural retention Rural health workers face particular challenges, some of which stem from the difficult terrain, which add to common disadvantages of rural living (poor social amenities etc.). • Poor working conditions, emotional and financial costs of separation from families, limited access to training, longer working hours (due to staff shortages) and the inability to earn from other sources make working in rural areas less attractive. • Moreover, rules on rotation which should protect staff from being left too long in rural areas are not reported to be respected. • Incentives for rural areas limited political focus – especially ineffectual? • Insecurity By contrast, poor management had more resonance in urban areas, with reports of poor delegation, favouritism, and a lack of autonomy for staff. Tensions within the team over unclear roles and absenteeism are also significant demotivating factors in general. Local staff & mid-level cadres more likely to work in remote areas During economic crisis, rural areas can have advantages (e.g. Zim – lower costs, able to subsist etc.) To work in remote areas workers need: • recognition of role and achievements in challenging circumstances • practical measures to improve their security • provision of decent housing, working conditions, training and pay • trust, communication and teamwork Wurie, H., Samai, M., Witter, S. (2016) Retention of health workers in rural and urban Sierra Leone: findings from life histories. Human Resources for Health, 14 (3). http://www.human-resources-health.com/content/pdf/s12960-016-0099-6.pdf Research for stronger health systems post conflict
  16. 16. The gendered health workforce • Lack of balance: in all contexts women predominate in nursing and midwifery cadres; are under-represented in management positions and tend to be more clustered in lower paying positions • Gender roles, shaped by caring responsibilities at the household level, also affect attitudes to rural deployment and women in all contexts faced particular challenges in accessing both pre- and in-service training as compared to their male counterparts • Conflict and coping strategies within conflict emerged as a key theme, with gendered strategies and experiences also shaped by poverty and household structure • Most HRH regulatory frameworks did not use the PC moment to address gender. Key priority areas for addressing gender equity in the health workforce in FCAS include (1) ensuring gender is integrated into policy and (2) fostering dialogue and action to support change for gender equity within institutions and households. Witter, S., Namakula, J., Wurie, H., Chirwa, Y., So, S., Vong, S., Ros, B., Buzuzi, S. and Theobald, S. (2016) The gendered health workforce: mixed methods analysis from four post-conflict contexts. Submitted to special edition of Health Policy and Planning on gender and ethics. Research for stronger health systems post conflict
  17. 17. HRH policies & institutions
  18. 18. Thinking longer-term - windows of opportunity & path dependency • While there may be a ‘window of opportunity’ for fundamental restructuring post-conflict, this was not found in the immediate post-conflict period in any of our focal countries • the weakness of institutions and dominance of reconstruction efforts meant that more fundamental reforms came later, when political mandate, external support and capacity were combined • Depending on the degree of destruction and loss of staff, the reconstruction of the HRH can take decades • e.g. in Cambodia, where the need to focus on increasing numbers took a considerable time, followed by a decade of management reforms and now a start to regaining control from NGOs and external bodies over policy and incentive schemes • This may have been the result of key decisions in the post-conflict period – contracting out services to NGOs, for example Bertone, M., Samai, M., Edem-Hotah, J. and Witter, S. (2014) A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002- 2012. Conflict and Health, 8:11. Research for stronger health systems post conflict
  19. 19. Institution-building Observations from Sierra Leone, 2002-16 – case study of MoHS • Periods of support, but focus is short term • Capacity building in MoHS is not effective Internal factors: Chronic under-funding Failure to reform Poor terms and conditions Systemic weaknesses, e.g. in financial management Failure to develop strong institutional vision and leadership Unwillingness to decentralise functions like HR External factors: Funding unpredictable and short-term Poor coordination between donors Short-term objectives Over-reliance on external TA By-passing of MoHS Brain drain of staff Per diems Capacity building focused on individuals, not institutions ‘Can donors really build institutions in fragile and post- conflict states?’ Witter, S. Presentation to World Bank Fragility Forum 2016 Research for stronger health systems post conflict
  20. 20. Do no harm…. Fundamentally, institutions have to be internally constructed BUT donors have a duty to not disrupt: • Not creating parallel structures and power bases • Not offering salaries that attract all of talent out of core institutions • Not circumventing mandated decision-makers in MoHS (donors commonly play off different stakeholders in MoHS) • Providing funds in a way that does not undermine role of MOHS (direct to NGOs, with no MoHS oversight etc.) Witter, S. (2015) Universal Health Coverage amid conflict and fragility: ten lessons from research. http://globalhealth.thelancet.com/2015/12/14/universal-health-coverage-amid-conflict-and-fragility- ten-lessons-research Bertone, M. and Witter, S. (2015) An exploration of the political economy dynamics shaping health worker incentives in three districts in Sierra Leone. Social Science and Medicine, volume 141, pp56- 63. Research for stronger health systems post conflict
  21. 21. In order to do that…. Even when services are weak and there is a focus on meeting direct needs, in the aftermath of conflict, the building back of national capacity and institutions needs to begin • Within DP agency • Build staff capacity in-country • Reduced staff turnover • Build better institutional memory • Better coordination and learning across DPs • Need to learn better as a group – often internally incoherent in policies • More focus and reflection on and understanding of the drivers of change in institutions Research for stronger health systems post conflict
  22. 22. State-building and HRH: a conceptual framework State-building = Strengthened social contract Capacity and willingness for service delivery (‘expected functions’) Legitimacy (‘political settlement’) Providing security and stability (‘survival functions’) Possible HRH linkages Enablers Institutional capacity: ability to employ, pay and manage HRH directly or regulate via contracts with 3rd parties Effective intersectoral coordination of MoH, especially with public administration, civil service, finance Presence of funded, effective, responsive and acceptable public servants and CHWs, following public goals HRH adequate and matched to population needs, not just in areas favoured by ruling group Integration of HRH from opposing sides post-conflict. Provision of employment in non-discriminatory way. HRH serving all, without discrimination Capacity in HRH production and training Effective HRH and financial management systems Ability to manage contracts with P/PNFP sectors Proper transfer of functions from NGOs to government post-emergency Adequate, regular pay and reasonable terms and conditions; Control of informal fees Clear and effective policies for community agents HRH treated as neutral, non- ideological – not used as cover /seen as being used for sectarian goals International context – reinforcing or destabilising (via recognition, support, protection or their opposites) Note that: Relations run in both directions (causally) Can be positive or negative (virtuous and vicious circles) Risks: elite capture; state uses power oppressively; patrimonialism Dynamic – change according to different phases of post-conflict or post-crisis Ability to mobilise resources; enabled by longer term, flexible external support National and local HRH leadership ; committed and able to learn Human,institutionalandeconomicdevelopment Stable political settlement 22
  23. 23. HRH and state-building • The concept of state-building itself is highly contested, with a rich vein of scepticism about the wisdom or feasibility of this as an external project • Empirical evidence for most of the linkages is not strong, which is not surprising, given the complexity of (and of measuring) the relationships. • Nevertheless, some of the posited relationships are plausible, especially: • between development of health cadres and a strengthened public administration, which in the long run underlies a number of state-building features • reintegration of factional health staff post-conflict is also plausibly linked to reconciliation and peace-building Witter, S., Benoit, J-B, Bertone, M, Alonso-Garbayo, A., Martins, J., Salehi, A., Pavignani, E., Martineau, T. (2015) State-building and human resources for health in fragile and conflict-affected states: exploring the linkages. Human Resources for Health special edition. Research for stronger health systems post conflict
  24. 24. Health Systems Resilience: Systems’ Analysis
  25. 25. Adaptation strategies – many focused on health staff • adjusted staff working hours and conditions of service • temporary task-shifting • security measures facilitating health worker travel • adaptations to service delivery priorities and modalities • adapted drug procurement and supply chains etc. While these potential provide valuable insight into potential strategies for adoption in other settings, they are generally very much context- dependent. Ager, A, Lembani, M, Mohammed, A, Ashir, G M, Abdulwahab, A, de Pinho, H, Delobelle, P and Zarowsky, C Health service resilience in Yobe state, Nigeria in the context of the Boko Haram insurgency: a systems dynamics analysis using group model building. Conflict and Health, 2015, 9:30
  26. 26. BUILDING BACK BETTER A NEW E-RESOURCE: WWW.BUILDINGBACKBETTER.ORG
  27. 27. Thank you Website: www.rebuildconsortium.com Contact: nick.hooton@lstmed.ac.uk @ReBUILDRPC

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