Human Resource for Health

1. Question). Consider your country situation on health workforce problems and define a
process of strategic planning that you might propose to improve the human resource policies
in your country.
Answer:
Nepal is a low income country that lies in the southern slopes of the Himalayan mountain ranges.
It is a landlocked country with a surface area of 1,47,181 km².The population of Nepal is about
29.3 million. In Nepal, Health sector is facing major challenges as a result of rapid population
growth, the transformation of diseases, growing population of elderly and impact of pollution and
several crises. These challenges have resulted in difficulties for Nepal for achieving SDGs and
reaching UHC by 2030.
At the center of every health system are health workers. Their Knowledge, skills, motivation play
a crucial role in delivering health services to those in need. HRH are critical component of health
system strengthening(WHO,2007). Several HRH factors such as size, composition and distribution
of healthcare workforce, workforce training and migration of HW influence the success and
capacity of health system to provide equitable, high quality health care services. However, many
countries are grappling with enormous human resources for health policy challenges, such as how
to address shortages and surpluses and how to improve skills, geographical distribution and
performance of health workers. In 2006, the WHO has identified Nepal as one of 51 countries with
critical shortage of human resource for health, so various strategies are to be undertaken to solve
these problems of HRH.
Situation Analysis
Global
 In 2013, global health workforce was estimated to be 43 million
 WHO estimates that in order to achieve UHC and SDG there must be 4.5 doctors, nurses
and midwives per 1000 populations.
 Globally estimated health workforce shortage is 7 million with an estimate increase to 12.9
million by 2035. (Deficiencies exacerbated by skill-mixed and misdistribution).
Regional
 Areas under global map with fewest health workers relative to general population:
southeast Asian region and sub-Saharan Africa.
 WHO estimate that there is shortage of 4.2 million health workers in south-east Asian
region itself (Shortage is expected to rise to 6.1 million by 2030.)

2. National
In the health sector, the government of Nepal has 417 sanctioned post titles and 31 occupation
groups. An HRH assessment report of 2013 and other national data shows the following situation
of HRH in Nepal:
I. Stock of HRH
 Among the technical cadres, paramedical health workers are the largest group in the public
health sector.
 Public health workers comprise of only about 1% of the total health workforce.
 Doctors make up about 12% of the private health sector workforce and 5% of the public
health workforce and 8% of the total.
 More than 80% pharmacists, 75% dentists and 60% doctors are working in the private
sector.
 Doctors and nurses have increased to greater proportion in 2015 as compared to 2012.
ii. Health Worker Population Ratio
 Nepal is found to have 0.17 doctors per 1000 population and 0.50 nurses per 1000
population. This represents 0.67 doctors and nurses per 1000 population, which is
significantly less than WHO recommendation of 2.3 doctors, nurses and midwives per
1000 population.
 There are only 1 public health workers for every 100,000 populations.
iii.HRH Production
 Nearly 200 training institutions are providing proficiency certificate level training courses
for health workers.
 Nepal’s health training institutions are producing a large number of health workers
annually with approximately 10,000 graduating each year
 Between 2009 and 2011, over 32,000 health workers were produced.
 Over 7,000 doctors graduated from 2009 to 2011.
 Over 600 public health professionals are graduated each year.

3. Problem Analysis: An anlaysis with problem tree
Limited evidence based Inadequate coordination More concentration in Improper
Information for realistic of HRH initiaves . urban than rural areas collaboration
HRH plans. Weak advocacy for Weakened system for of MOHP,
Research findings not HRH during Budgeting HRH recruitment,retention,professional
Shared among stakeholders. Process. Career development and bodies for
Available sources for HRH Unclear delinated areas utilization. accreditating
data are disintegrated of manegerial authority HI.
,untimelyupdated, responsibilty and Improper
analyzed and utilized. Accountability. Quality of
Lack of mnitoring and curriculum
evaluation Of HRH.
Issues in HRH
Development
Unclear HRH plans
and policies
Lack of leadership and
advocacy
Mismatched between
demand and supply
Lack of production of
quality HRH
Failure of Health
system
Conflicts and
teamwork-
nonexistent
High rate of
turnover and low
morale of HP.
Poor HRH
performance
Hindrance in reaching
SGDs and UHc.
High rate of
abseentism
Incompetent
personnel in
market place.
Unidentified health
needs and service
coverage.
Primary
causes
secondary
causes
Primary
effects
Secondar
y effects

4. Response Analysis
The provisions for HRH in major planning document of Nepal are:
I. Health Service Act (1994)
• The health service act (1997) makes provision for the management of health workers
employed by the MOHP and provides guidance on the recruitment, deployment,
promotion, and discipline of health workers.
ii. National HRH Strategic Plan
• In 2011, Ministry of Health and Population developed the 2011-2015 HRH Strategic Plan.
• This plan aimed to ensure equitable distribution of appropriately skilled human resources
for health (HRH) to support the achievement of health outcomes in Nepal and in particular
for the implementation of the Nepal Health Sector Program.
• HRH Strategic Plan (2011-2015) contained a range of strategies and activities to achieve
this aim and the following planned outputs:
 Appropriate supply of health workers for labor market needs;
 Equitable distribution of health workers;
 Improved health worker performance; and
 Effective and coordinated human resource planning, management and development
across the health sector.
iii. Second Long-Term Health Plan (1997-2017)
The Second Long-Term Health Plan planned the following activities regarding HRH:
 Decentralization of HRH planning within the national guidelines of the “HRH Master Plan
Conducting periodic assessment of the need to supply of health personnel in coordination
with relevant sectors, ministries, organizations and professional bodies.
 Production of HRH based on projected needs rather than capacity of training institutions
 Provision of subsidies in pre-service education to candidates from remote areas and to
promote gender equity.
iv. Thirteenth Periodic Plan
• The thirteenth periodic plan of Nepal places management of human resource as one of the
major strategies.
v. NHSP I (2004-2010) – The Nepal Health Sector Program 2004-2010 implemented following
major intervention to address HRH challenge:
• Two-year bond for medical graduates who studied MBBS under government scholarship
to service in public peripheral facilities.
• Policy and long-term plan on SBA.
• Incentive packages to retain doctors, nurses and technicians.

5. vi. NHSP-III Strategic Plan (2015-20)
• The NHSP-III strategic plan has defined nine outcomes for the health sector of which
strengthening HRH is one among the first outcomes.
• There are two outputs concerning HRH for achieving the outcome of strengthening HRH
 Output 1a.1: Improved staff availability at all levels with focus on rural retention and
enrollment.
 Output 1a.2: Improved human resource education and competencies.
Stakeholder Analysis
Primary: The benefitted groups are citizens who gets competent and qualified health professionals,
Medical students, Health professionals who will get better education, training programs that
support their workforce performance.
Secondary:
I. Decision makers: National planning commission, MOHP, MOE, HURIC unit(MOHP)
ii.Funding agencies: DFID Nepal, WHO Nepal, GHWA, Nepal public health foundation
iii.Implementing agencies: DOHS, NHTC, Nursing councils, Professional bodies, Medical
councils, Universities, local media.
Gap Analysis
 Nepal is found to have 0.17 doctors per 1000 population and 0.50 nurses per 1000
population. This represents 0.67 doctors and nurses per 1000 population, which is
significantly less than WHO recommendation of 2.3 doctors, nurses and midwives per
1000 population.
 There are only 1 public health workers for every 100,000 populations.
 More than 80% pharmacists, 75% dentists and 60% doctors are working in the private
sector.
 The public health workforce is quite well distributed across the 7 provinces in relation to
the population distribution. For the private sector HRH, the Province1, Province 4,
province 7 regions have relatively fewer health workers in relation to their population.
 The Terai region has only about 36% of health workers when it accounts for 50% of the
country’s population.

6.  HRH planning in Nepal is a centralized process focusessing on the public sector with
minimal input from lower levels and consequently limited sensitivity to local needs.
 HRH requirements in Nepal are determined by staffing norms and numbers of sanctioned
posts. Neither approach accurately reflects actual need.
 Lack of effective coordination, consultation and collaboration among the numerous
committees and individual’s ministries, organizations and agencies involved in planning,
production & use of HRH i.e. between MOH, national planning commission, ministry of
education, universities, private sectors etc.
 Unplanned/uncoordinated growth of public and private medical schools and the
establishment of new degree or training programmes within existing institutions. The new
medical schools, new degree and training programmers often are established without
consideration of the health sectors HRH requirements.
 HURIC data is not effectively linked to planning of health personnel.
 In Nepal, majority of the public health workforce is still governed by the Health Service
Act, 1977/98; while significant number of administrative and management staffs who are
deployed to the public health sector are governed by the Civil Service Act, 1993.
 Nepal Health policy 2071 has stated that there are provisions for one doctors along with 23
health workers for every 10,000 populations. This policy seems over ambitious regarding
distribution of Health Workers and health institutions with no particular road map and
resources achieving them.
 Recipient government and donors only fund activities in national health sector plan but not
contribute to development of whole health system.

7. Recommendations
1.Improve the capacity for HRH planning in the health sector by:
• Establishing evidence-based staffing norms for all levels of human resources for health
based on workload analysis.
• Developing innovative approaches for knowledge management regarding human resources
policies, planning, data management and dissemination for evidence-based decision-
making.
• Improving data management capacity to provide accurate and timely information on
numbers, cadres, qualifications, deployment, transfer and attrition of health staff in order
to make effective HR decisions.
2.Strengthen Human Resource Management (HRM) for effective Essential Health Provider
delivery at all levels by:
• Recruiting staff according to staffing norms for all cadres.
• Creating and clarify job descriptions and career paths for all health cadres.
• Generating evidence-based needs through HRH research.
• Strengthening health systems management at all levels on effective HRM practices.
• Institutionalizing performance based management tool (leveraging an effective appraisal
system, merit-based processes and supportive supervision) at all levels.
3.Improve retention of health care workers at all levels, particularly in hard to staff areas
by:
• Lobbying for sustainable approach for top-up allowances and support a phase-in strategy
to integrate top-up allowances into salaries.
• Lobbying for improved staff welfare and amenities including housing, infrastructure, and
public transport and recreation facilities in all areas prioritizing hard to reach/staff areas.
4.Strengthen HRH training and development by:
• Increasing the number of key health workers being trained.
• Increasing the number of tutors and clinical instructors being trained.
• Lobbying for expansion of an internship program for all health workers.
• Reviewing existing in-service training scheme, develop and pilot the scheme to ensure
transparency.
• Scale up the training of specialists for human resources for health.
• Strengthening cost-effective training through innovative areas such as e-learning, distance
learning, applied and part-time learning.

8. 5.Support capacity building of health training institutions by:
• Supporting training institutions in developing cost-effective interventions to increase
student intakes.
• As key stakeholder, participating in the reviews of the curricula for training of health
workers to address the needs of the MOHP.
Strengthen capacities for HRH stewardship in policy, partnerships and monitoring and
evaluation at national level by:
• Reviewing existing HR Acts and Policies giving priority to Acts/Policies that inconsistent
with HR national policies.
• Developing National Human Resource for Health strategy and Policy.
• Identifying and implementing innovative approaches to capacity building of key HR
functions at all levels.
• Promoting multi-stakeholder cooperation through a Human Resources Observatory and
other platforms.
• Strengthening partnership agreements with other health service providers.
Thus to reach SDGs and UHC by 2030, useful strategies must include performing a gap analysis,
evaluating the emotional intelligence of the health workforce, bridging the diversity gap, and
improving the future success and performance.

9. References
1.World Health Organization. WHO Global Atlas of the Health workforce. Available from:
http://www.who.int/globalatlas
2.Government of Nepal. National Health Policy 1991. Ministry of Health, Government of Nepal; 1991.
3. WHO SEARO. Health Systems Development- Human Resources for Health. [Electronic] 2008 [updated
June18, 2008; cited 2012 February 16]; Available from: https://www.who.int/
4. Ministry of Health and Population (MoHP) [Nepal], Nepal Health Sector Program II (NHSP- II) 2010- 2015
Kathmandu: Ministry of Health and Population, Government of Nepal 2010.
5. Ministry of Health and Population (MoHP) [Nepal]. Nepal Health Sector Programme Implementation
Plan II (NHSP-IP II) 2010-2015 Final Draft. Kathmandu: Ministry of Health and Population, Government of
Nepal 2010.
6. Dussault G, Franceschini MC: “Not enough there, too many here: understanding geographical
imbalances in the distribution of the health workforce” Human Resource for Health 2006; 4: 12-20
7.Blair George, Human Resource Information System Assessment Report: Nepal Ministry of Health and
Population and NHSSP II, Strengthening Health System-Improving Services 2011. 10. Dixit H: Training of
doctors in Nepal1998 Journal of Human Resources for Health Development.
8.Shrestha C, Bhandari R. Insight into Human Resources for Health Status in Nepal, Health Prospect 2012.