CASE STUDIES FOR

HEALTH SYSTEMS AND POLICY ANALYSIS

CASE STUDY ON HUMAN RESOURCES MANAGEMENT

Additional Duty Hours Allowance in Ghana - Participants’ Guide

The development of sustained African health policy and systems research and teaching capacity requires the consolidation and strengthening of relevant research and educational programmes as well as the development

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of stronger engagement between the policy and research communities. The Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA) will address both of these issues over the period 2011 - 2015. CHEPSAA’s goal is to extend sustainable African capacity to produce and use high quality health policy and systems research by harnessing synergies among a Consortium of African and European universities with relevant expertise. This goal will be reached through CHEPSAA’s five work packages:

1. assessing the capacity development needs of the African members and national policy networks;2. supporting the development of African researchers and educators;3. strengthening courses of relevance to health policy and systems research and analysis;4. strengthening networking among the health policy and systems education, research and policy

communities and strengthening the process of getting research into policy and practice;5. project management and knowledge management.

The CHEPSAA project is led by Lucy Gilson (Professor: University of Cape Town & London School of Hygiene and Tropical Medicine).PARTNERS

Health Policy & Systems Programme, the Health Economics Unit, University of Cape Town, South Africa School of Public Health, University of the Western Cape, South Africa Centre for Health Policy, University of the Witwatersrand, South Africa Institute of Development Studies, University of Dar es Salaam, Tanzania School of Public Health, University of Ghana, Legon, Ghana Tropical Institute of Community Health, Great Lakes University of Kisumu, Kenya College of Medicine, University of Nigeria Enugu, Nigeria London School of Hygiene & Tropical Medicine, United Kingdom Nuffield Centre for International Health and Development, University of Leeds, United Kingdom Karolinska Institutet, Sweden Swiss Tropical and Public Health Institute, University of Basel, Switzerland

CHEPSAA WEBSITEwww.hpsa-africa.org

ACKNOWLEDGEMENTSAn acknowledgement is given to all CHEPSAA partners who contributed to the course development process.

SUGGESTED CITATIONCHEPSAA. (2014). Introduction to Complex Health Systems: Case Study materials. CHEPSAA (Consortium for Health Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org

This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no. 265482). The views expressed are not necessarily those of the EC.

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A Case Study on Human Resources Management in Health Systems

The Additional Duty Hours Allowance in Ghana

There are a number of goals or objectives we would like you to achieve through doing this case study, as listed below:

Learning Objectives of the case study Identify the relevant contextual features of this case; Analyse the mindsets, interests, power and agency of key agents in the situation,

recognizing the socially constructed nature of health systems; Analyse how the introduction of a human resources policy into the health system

disturbed the existing relationships among agents, and was itself affected by those reactions;

Identify intended and unintended consequences of the new policy; Plan strategies to lead implementation of the policy; Plan and deliver a group presentation, using effective group work and

communication skills.

Tasks After reading the case study narrative (pages 7 - 13 of this handout), do tasks A – D below in your small groups, in preparation for a 20 minute presentation about the case study which should cover the following:A. Overview of the case (5 minute presentation) – to include:

1. Key features of the case – Draw a flow diagram showing the main drivers and events of the case and how each stage had consequences, some of which were not intended.

2. Context of the case study - Complete the context analysis form on page 4 identifying the key features of this particular case and how they have contributed to the situation.

B. Identify the hardware and software issues and elements which are most important in shaping this case, using guidance from Aragon’s framework below, and explain how they are linked and interact. (5 minute presentation)

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C. Stakeholder analysis. Identify the key agents in the case, and situating them in the time in the scenario immediately after the first national doctors’ strike , map these in diagram 1, (you can use Form 1 on page 5 below to help your analysis) according to their levels of commitment and power to impact on successful implementation of the change. Draw lines between agents who have a close relationship with each other (e.g. through flow of money or information, lines of command or support). Consider how their position on the map changed over time, and be prepared to explain this, as well as agents’ mindsets and levels of power, and how agents are related to each other. (5 minute presentation)

D. Leading and managing change. Imagine you are working in the national MoH, in a position to lead and influence policy change. As this leader, think about how you can increase buy-in for the change, and thus achieve more successful implementation. Using the concepts and frameworks above and in the session 7 lecture on ‘Leadership of change in health systems’, design 3 strategies to increase other agents’ buy-in. These could include small wins. In developing strategies also think of the ideas raised in the Duncan Green video. (5 minute presentation)

In preparing your presentation remember to do the following: Design the presentation so that the level, language and content are appropriate for your

audience; Make sure you have covered all the required information; Organise your points/ideas in a logically and clearly structured way; Introduce the presentation with an attention catching question or comment, and a brief

preview of the content; Keep to the allocated time (if possible ask a colleague to check the timing for you); Speak clearly and not too fast; Conclude the presentation with a brief re-statement of the main points or a

summarising comment.

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Guidelines for assessment of group presentations

Assessment criteria

The overview of the case is clear and succinct and gives a clear image of what the case is about.

The hardware and software issues at play in the case, and their relationship, are clearly explained.

The roles of actors, their mindsets, interests and power are presented and explained convincingly.The suggested strategies for leading change are well motivated.

Delivery of the presentation (visual and oral) is clear, using appropriate pace and level, and content is coherently and logically structured.

You will use these criteria for assessing the group presentations:

On the next three pages are templates you can use to guide your Context and Stakeholder Analyses.

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CONTEXT ANALYSIS (Remember not all of these issues might be relevant in this particular case!)Contextual feature Specific issues relevant to this experience Impact of these issues on actors (name these) and the case, and

implications for policy implementationMicro contextorganisational climate & culture

other policies

organisational capacity

interpersonal factors

Macro contextsocial & political pressures & interestshistorical & socio-cultural context

economic conditions & policyinternational contextenvironmental factors

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Form 1. Unpacking agent behavioural drivers and powerAGENT Mindsets, values and interests Forms and level of power to influence implementation

What are the core elements of the agent’s ‘mindset’ (beliefs, values, interests driving behaviour in general?)

Given the elements identified in column 1, is actor’s response to the change likely to be committed, compliant, indifferent, resistant, or hostile?

What forms of power can the agent mobilise to support his/her actions around the change?

What power limits does the actor face in taking action around the change?

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The Additional Duty Hours Allowance in Ghana:

Case narrative

Introduction – Ministry of DefenceIn 1998, the "37" Military Hospital in Ghana, part of the Armed Forces Medical Services under the Ministry of Defence, introduced allowances that effectively translated into wage increases for its doctors. The Military hospital decision-making is autonomous of the Ministry of Health and the Hospital responds to the Ministry of Defence as part of the Armed Forces. However it needs to seek approval from the Ministry of Finance for any salary rises – whereas minor allowances can be introduced without ministry of finance approval. Historically efforts tended to be made to provide adequate privileges to the Military to pre-empt dissent. Officers of the Ministry of Defense – including health workers – are not allowed to go on strike.

Public sector doctors’ strikeThere had been long standing discontent among doctors in the public sector, mainly employees of the Ministry of Health, over their extremely low wages. Junior doctors, who on average work longer hours than senior doctors, and are unlikely to have their own private clinic, were particularly restless over the issue. Not surprisingly, they were the first to agitate for and initiate industrial action, using the disparity created between the pay of doctors employed by the Ministry of Defense and that of other public sector doctors as a trigger to take action on their long standing discontent over remuneration. Their action received the backing of their senior colleagues, and the Ghana Medical Association (GMA) declared a nationwide doctors strike to back their demands for pay reform. The GMA presented government with three options: 1) salary increases or 2) compensation for work overload or 3) compensation for long hours worked beyond the standard 40 hours per week in the form of an Additional Duty Hours Allowance (ADHA). All three were ideas that had been floating around the GMA for some time as possible solutions to the simmering discontent over conditions of service.

Doctors employed in the public sector provide a large part of services in the health sector. There is a thriving licensed private sector, but it is predominantly in the metropolitan and larger urban areas, and not affordable for poorer people. In rural areas, apart from the Christian Health Association of Ghana (CHAG), the only other service delivery options are those provided in by the Ministry of Health /Ghana Health Service. The strike therefore effectively brought health service delivery in Ghana to a near stand-still. There was a public outcry; with the press and the public

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generally sympathetic to the doctors and demanding government appease them rapidly so that services could be restored.

Introduction of ADHAGovernment entered into negotiation with the GMA and selected the option of payment of an ADHA. It appears Government picked this option to buy time and also because the Ministry of Finance felt that given their low numbers, such a payment for doctors only (instead of all categories of health workers) would not make much noticeable difference to the government budget for the year. Last but not least, it was felt to be generally true that doctors were indeed working extremely long hours. A Memorandum of Understanding (MOU) was signed between the government and the GMA, to take effect from 1st January 1999, in which it was stated that the ADHA was intended to be “an incentive to compensate for the abnormally poor basic salaries of the Medical and Dental practitioners in the public sector”, and that the agreement was for “160 hours as the average annualized number of hours per month for the payment of the allowance”. Since the GMA represents doctors as well as dentists, the arguments were made for both groups and the ADHA was to be calculated based on an hourly rate, derived from the salary of the medical or dental practitioner in question. The GMA called off its strike; but with the proviso that if by 1st of March 1999 the promised allowances had not been paid, they would resume the industrial action without any warning.

In early February 1999, the Ministry of Health released a memo to all regional directors and other administrative levels containing guidelines for implementing the ADHA policy. The guidelines stated that payment of ADHA was to be done at the facility level with retrospective effect from 1st January 1999. Facilities were to prepare monthly duty rosters for doctors and dentists to ensure 24 hours service. Regional directors of health service and heads of facilities were to monitor implementation arrangements. A review of implementation experiences was planned for May 1999. Funds for the ADHA were approved and released on February 26, 1999 to all the 10 regions and the two teaching hospitals. However administrative and procedural delays meant that by 1st March ADHA had not been paid. A new cycle of dissatisfaction was created due to the ADHA payment delay. On 1st March 1999, junior doctors across the country laid down their tools at what they perceived as a breach of the agreement. They however resumed work on the appeal and reassurance of the GMA (who had been working with government to resolve the administrative problems) that the money had been released and payment was about to commence.

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Nurses’ and other health workers’ grievancesThe decision to give an ADHA to doctors, that led to doctors’ satisfaction and temporary relief to decisions makers, now became the trigger for unintended consequences by further worsening already low nurse satisfaction over their remuneration. Nurses had been watching the doctor’s strike and its outcome from the sidelines. They also had longstanding grievances over inadequate wages. In April 1999, junior nurses began a strike requesting that nurses also be included in the ADHA payments. They were supported by the Ghana Registered Nurses Association (GRNA) and the Nurse Anaesthetists association. A seven day nationwide strike by nurses ground the health sector to a near halt. The strike ended with an agreement between Government and the Nurses Unions to include nurses in the ADHA payments, also with effect from 1st January 1999. Administrative requirements were introduced requesting that the overtime payments be calculated based on duty rosters, authorized by the head of institution and verified by information from the attendance books.

The decision to include nurses in the ADHA payments not only created improved nurse satisfaction; but now in its turn became the trigger to create a feedback loop for reduced satisfaction and related strike action by other health sector workers. Recognizing that their fragmented nature and small numbers made them ineffective in any negotiation to be included in the ADHA payments, the less powerful health worker unions, such as the Government and Hospital Pharmacists Association, the Medical Assistants Association, the Association of Laboratory Scientists and the Association of Health Service Administrators joined forces with the Ghana Registered Nurses Association (GRNA). They labeled themselves the “representatives of health workers other than doctors” and also demanded that the Ministry of Health (MOH) include them in the ADHA allowances, or else they would strike en masse.

By September 1999, in response to the strikes and agitations, virtually all permanent workers in the health sector were included in the ADHA. The MOU for ADHA between government and the other health workers' associations was based on 3 conditions: payment would be for additional hours beyond the standard 40 hours per week; timesheets should be kept by each individual staff; and they should be cross-checked and verified by management before payment. The MOU was signed on the 30th September 1999.

While medical doctors working in teaching Hospitals’ as employees of the Ministry of Health were included in the ADHA, those working as full time lecturers in the medical schools, and therefore employees of the Ministry of Education, were not. Doctors teaching in the Medical Schools threatened to stop teaching, and go back into practice in the MOH to improve their salaries. In response, an MOU was also signed

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between the MOH and the medical school for them to be included in the ADHA payment.

High cost of ADHA, and Payment delaysThe expanded ADHA scheme, including almost all permanent staff in the health sector, did not lead to industrial peace despite the fact that the ADHA payments were often more than the staff salaries themselves and led to a doubling or more of staff incomes. This was because there were repeated delays in payment, leading to further strikes by doctors, nurses and other health workers. As the ADHA claims rose steadily, the MOH introduced regional and institutional financial ceilings on the amount of ADHA to be paid, to limit the rapid growth in costs. This was not completely successful and the ADHA bill continued to rise, with Government continuing to have difficulties in prompt payment, leading to threats of strikes and actual strikes by health workers to enforce payment. The Health sector entered a vicious cycle of payment delay followed by strikes to enforce payment, followed by payment to end strikes and back again. The cycles appeared to have the additional side effect of creating in the mind of the health workers and their unions the idea that the only language government responded to was industrial action rather than dialogue and trust that agreements would be honored.

The repeated delays in payment of ADHA were attributed by government to the non-submission of the required verified time sheets by the respective administrative levels to enable payment. While there were delays in submission of these returns, it was not clear that this was the full story, given that there were cases where even when submissions had been made, there were still delays in payment. It appeared some if not all the delays were due to government challenges in meeting the mounting bills. For example, on at least one occasion when a delegation from the GMA descended on the MOH because of ADHA arrears owed, the Minister for Health was at his wits end and took them to the Minister for Finance. The Minister for Finance was not exactly delighted when he saw them because he had not been informed earlier of the problem. He however kept his head, called his technical staff and told them to look carefully at the MOH budget and find out where they could safely take the money from. Their answer was – the MOH capital budget for the year; that year no new capital project could be undertaken.

There were also ADHA management problems within regions and facilities that fueled the discontent and unrest. The ADHA ceilings often remained constant and did not necessarily change with changes in staffing. There was uneven application of rules on limits and time accounting, so that while some institutions had enough to pay the ADHA, others had too little. Staff compared notes and found that similar categories of staff doing similar work in different institutions sometimes received

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widely varying amounts. Further widening the discrepancies, institutions that generated more funds from out of pocket fees could use those funds to make up for the deficit payments for their staff to maintain some peace and keep services running; while less well-endowed institutions had to make do with whatever they got. Many institutions had staff they employed locally and paid from their internally generated funds, and these (often low paid and unskilled or semi-skilled) staff members were not included in the ADHA payments. These inequities generated by the management of the ADHA created staff dissatisfaction alongside the satisfaction of better remuneration.

Filling of individual time sheets and vetting of hours claimed proved an impossible and unpopular task and a major administrative burden. Many institutions implemented unofficial local “ADHA Committees” to try and manage the administrative burden and reduce staff discontent related to perceived unfairness in allocation.

The ADHA budget rose from about US$ 1.5 million to over US$ 84 million by 20051. The percentage of the recurrent Government of Ghana budget spent on health rose from 10.2% in 2001 to 14% by 2006; with salaries accounting for the bulk of the rise. The percentage of the recurrent budget spent on non salary items fell slightly over the same period from 8.1% to 7%. Salaries were accounting for over 75% of central government allocation to the health sector and once capital investments were also accounted for, less than 10% of central government funds remained for recurrent expenditure. Effectively non salary recurrent expenditure was running on donor funds and internally generated funds from user fees in the health facilities; and as the National Health Insurance scheme picked up after 2004, on national health insurance reimbursements to the facilities. Several donors were uncomfortable with this, as they perceived that their money was substituting for the salary increases.

In addition to the simmering discontent, industrial unrest and a rising wage bill in the health sector due to the ADHA implementation problems, there were mounting concerns that the overall increase in health expenditure did not seem to translate into improvements in key health sector indicators as witnessed by the stagnating / slow decline in maternal and under-five mortality rates. Health sector indicators are influenced by several variables and it is difficult to attribute one particular reason for observed levels, however, given the legitimate concerns about the insufficient improvement in key health indicators, all policies in the sector over this period – including ADHA – were under scrutiny.

1 In 1998; exchange rates were 2250-2350 cedis to the dollar; in 1999 rates were 2350-3550 cedis to the dollar and in 2005 rates were 8900-9500 cedis to the dollar (http://en.wikipedia.org/wiki/Ghana_cedi#Exchange_rate_history. Downloaded 19th Nov 2011)

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Consolidation of ADHA into salariesThe government therefore initiated discussions to consolidate the ADHA into salaries. A job evaluation was commissioned in February 2005 to evaluate the various health sector job portfolios. Government issued the report “Restructuring the ADHA” in September 2005; and a circular formalizing the consolidation of ADHA into salaries. The last ADHA payment was to be in December 2005.

The process of consolidating the ADHA into salaries became the next trigger for industrial unrest in the health sector. This time, the industrial action by doctors, nurses and other health care workers was over the terms of consolidation and delays in the first new salary payment. There were conflicts and strikes over the creation of 2 pay scales – Health Sector pay Scale 1 (HSS1) at a higher level for doctors and Health Sector pay Scale 2 (HSS2) at a lower level for everybody else. Doctors, satisfied for the time being with their negotiated pay scale, did not go on any further strikes. However all other workers in the sector were aggrieved over what they perceived as an unfair policy. They formed a coalition called the Health Workers Group (HWG) and went on crippling strikes demanding a single pay scale and higher consolidated salaries. Between 2006 and 2007 the health sector went through a stormy period as government and the worker unions conflicted over the issues. The Health Workers Unions employed the services of a labour expert and Chief Executive Officer of a labour consulting group to represent them before the labour commission and negotiate with government on their behalf.

In June 2008, the negotiations were finally completed to everyone’s acceptance, if not full satisfaction. There were still two pay scales but the gaps had been narrowed. The first payment of consolidated salary, back-dated to January 2006, was made. The cycles of ADHA related strikes and industrial unrest reached an uneasy calm with unions keeping a watchful eye on the implementation.

Some context Ghana’s GDP per capita is estimated at US$ 1,542. It is an agricultural country and its main exports are cocoa, timber and gold. Most of its estimated twenty four million population is employed in the non-formal sector, and about half the population is below 15 years. A little under 15% of the public sector budget is allocated to health. Mortality of children under five years declined from 155 per 1000 live births in 1983 -1987 to 108 in 1994 -1998; appeared to stagnate at 111 between 1999-2003; but is now declining once more with the 2008 Ghana Demographic and Health survey estimating under five mortality rates at 80 per 1000 live births. Maternal mortality declined from 503/100,000 in 2005 to 451/100,000 in 2008.

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Brain drain and shortages of highly trained and skilled human resource for health has been and remain a problem. Dovlo and Martineau (2004) estimated that between 1986 and 1995, 60% of doctors from the country’s main medical school emigrated – mainly to the US and the UK. Low salaries, which were at the heart of the ADHA saga were and remain one of the many motivators for migration. It is a problem not unique to Ghana.

The average monthly basic salaries for junior and senior doctors in Ghana were about US$ 199 and 272, respectively, at the start of the ADHA saga in 1998. Client to public sector health professional staff ratios were and remain high and workloads heavy, because of staff shortages. Witter et al (2007) in their 2005 survey of health workers providing maternal health related services in two regions of Ghana found mean hours of work per week ranged between 129 for Medical (Physician) Assistants to 54 for community health nurses. Public sector midwifes had 19 deliveries on average per week as compared to 4 for private sector midwifes. In 2002, Ghana was estimated to have 6.2 physicians per 100,000 population as compared to 279 in the US and 164 in the UK (Hagopian et al 2005). A few years before the events described in this paper, doctors had fought without success for overtime payment as was being done in the United Kingdom.

The Health Sector prior to the passage of the Ghana Health Service and Teaching hospitals act in 1995; comprised the Ministry of Health (MOH), which was both the regulator of the public and private sector, the body responsible for health sector policy direction, coordination, monitoring and evaluation; as well as the provider of public sector services. The Ghana Health Service and Teaching Hospitals Act 525 of parliament created an agency model in the health sector. The MOH became a small civil service ministry with responsibility for overall sector policy making, coordination, monitoring and evaluation. The Ghana Health Service (GHS) and Teaching Hospitals became autonomous agencies of the MOH responsible for public sector service delivery. There was a lot of expectation among health workers who believed the autonomous status would enable the GHS to negotiate salary increases outside the constraints of the civil service, but this did not immediately materialize as the legislative instrument was never approved by the various Ministers who could not deal with the concept of autonomy.

There was no labour law at the start of the ADHA saga. It was several years on, in 2003, when the Labour Act 651 was passed by parliament to “consolidate the laws relating to labour, employees, trade unions and industrial relations”. The labour law more or less formalized mechanisms that already existed; but also created a labour commission to mediate disputes. The law allowed strikes and lockouts under certain conditions, but made it illegal for employers or workers engaged in essential services

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to resort to lockouts or strikes in connection with any industrial dispute. It was unclear how the illegality clause was supposed to be enforced. Non complying union leaders could not be arrested by police and neither could the courts cause their arrest. It was also unclear what alternative redress mechanisms considered mutually satisfactory were now provided for essential workers if they still felt their issues had not been addressed despite following the dialogue and conflict resolution mechanisms prescribed by the law.

This case study is based on the following source:

Irene Akua Agyepong, IA, Kodua A, Adjei S and Adam T. (2012) When ‘solutions of yesterday become problems of today’: crisis-ridden decision making in a complex adaptive system (CAS)—the Additional Duty Hours Allowance in Ghana Health Policy Plan 27 (suppl 4): iv20-iv31 doi:10.1093/heapol/czs083

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