human resources for health in post-conflict settings - findings from rebuild research

Findings from ReBUILD’s health worker research

Learning lessons for post-conflict contextsSophie Witter

HEART seminar, 9th June 2016

Research for stronger health systems post conflict

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


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


ReBUILD’s research and partnership

Health financing

Gender &equity

Health workforce

Aid effectiveness

Contractingmodels

Health systems and resilience


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

Health Needs of population

(demand)

Health services

(supply)

Conflict and crisis creates change

How

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isis s

teer

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long

term

dev

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he

heal

th sy

stem

?

Thematicareas

Actors & networks

Policy and power

Vulnerability

Household structure

Accessing healthcare

Resource flows

Attraction/retention

Posting

Policy making

Effects and responses

Institutions

Health workers

Communities

Stro

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hea

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yste

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Research question

Enha

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Background on ReBUILD research on HW incentivesObjective: to understand the evolution of incentives for health workers post-conflict and their effects on HRH and the health sectorResearch 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

http://www.rebuildconsortium.com/media/1209/rebuild-research-protocol-summary-health-worker-incentives.pdf

Background on ReBUILD research on HW deploymentObjective: 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

https://rebuildconsortium.com/media/1211/rebuild-project-4-rural-posting-protocol-summary.pdf

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.


Staff coping strategiesFor 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

faithFor economic crises:• Dual practice• Other income generating strategies• Informal and formal movements of staff – e.g. to lower cost rural areas


Production & trainingDistortion of health worker supply and salaries by the aid industry is a riskForeign 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


https://rebuildconsortium.com/media/1265/rebuild_report_2_v6.pdf

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


Incentive packagesIncentives – 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

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


Mind the (sectoral) gapThe 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 areasNamakula, 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.


http://www.human-resources-health.com/content/14/1/18



Rural retentionRural 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 areasDuring 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

http://www.human-resources-health.com/content/pdf/s12960-016-0099-6.pdf

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.


HRH policies & institutions

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.


Institution-buildingObservations 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-fundingFailure to reformPoor terms and conditionsSystemic weaknesses, e.g. in financial management Failure to develop strong institutional vision and leadershipUnwillingness to decentralise functions like HR

External factors:Funding unpredictable and short-termPoor coordination between donorsShort-term objectivesOver-reliance on external TABy-passing of MoHSBrain drain of staffPer diemsCapacity 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

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-researchBertone, 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

http://globalhealth.thelancet.com/2015/12/14/universal-health-coverage-amid-conflict-and-fragility-ten-lessons-research

http://globalhealth.thelancet.com/2015/12/14/universal-health-coverage-amid-conflict-and-fragility-ten-lessons-research

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


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; patrimonialismDynamic – 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

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22

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.


Health Systems Resilience: Systems’ Analysis

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

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human resources for health in post-conflict settings - findings from rebuild research

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