Training and Deploying Human Resources for Health for Maternal ...

Maternal Mortality and Skilled Health Workers/ K'Omudho & Tenambergen 1

ISSN 2159-6743 (Online)

Training and Deploying Human Resources for Health for Maternal, Newborn, and Child Health in Rural Africa: An in-depth policy analysis

Gail Tomblin Murphy, Fastone Goma, Adrian MacKenzie, Stephanie Bradish, Sheri Price, Selestine Nzala, Annette Elliott Rose, Janet Rigby, Chilweza Muzongwe, Nellisiwe Chizuni, Amanda Carey, and Derrick Hamavhwa

Abstract Introduction: The majority of African countries lack sufficient human resources for health (HRH) to deliver basic maternal, newborn, child health (MNCH) care, particularly in rural areas. To inform planning for the scarce HRH available, specifically as it pertains to the Millennium Development Goals and the post-2015 agenda, a rapid systematic review of evidence on training and deployment policies for doctors, nurses and midwives for MNCH in rural Africa was undertaken. Methods: Documents for synthesis and analysis were obtained through a scoping review of 14 peer-reviewed electronic databases and systematic searches of international organization and government websites. In-depth policy analyses were then conducted for sub-set of 8 countries: Ethiopia, Ghana, Mali, Mozambique, Niger, Tanzania, Uganda and Zambia. Results: A paucity of evidence on such policies exists. Beyond policy names and contextual information, little material on actual policy development, implementation, or impact was available. However, multiple cross-cutting political and socio-economic issues affecting the policy process were identified. Conclusion: This lack of evidence hinders objective assessment of policies and the development and management of health care systems, which require clear linkages between evidence, policy, and service provision. Further research into the identified contextual factors and issues of planning-implementation gaps, transparency, limited evidence, research bias, and resource management, among others, is critical to strengthening Africa’s rural health systems through the increased presence of adequately trained HRH for MNCH. Key words: Human resources for health; Policy; Maternal, Child, Newborn health; Deployment; Training; Rural and remote health care; Africa Corresponding author Gail Tomblin Murphy, email address: Gail.Tomblin.Murphy @dal.ca

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Human Resources for Health in Rural Africa/Murphy et al. 2

Training and Deploying Human Resources for Health for Maternal, Newborn, and Child Health in Rural Africa: An in-depth policy analysis The 2015 deadline for achieving the United Nation’s Millennium Development Goals (MDGs) a set of eight objectives set to improve human dignity, equality, equity, and liberating the world from extreme poverty - is fast approaching. Pressure mounts for achieving these goals and setting the roadmap for the coming years. At the forefront of the MDGs, and the post-2015 agenda, is the health and well-being of women, newborns and children (United Nations [UN], 2013a); MDG 4 aims to reduce under-five mortality rate by two thirds while MDG 5 is structured around decreasing maternal mortality by 75% and achieving universal coverage of skilled birth attendance. Although progress has been seen on a global scale with a 45% decline in the maternal mortality rate (MMR) between 1990 and 2013 (UN, 2014), the MMR in developing areas is still 15 fold higher than that of developed regions (UN, 2013b). In the same timeframe the child mortality rate has decreased by a similar magnitude, however half of all child deaths occur in Sub-Saharan Africa (UN, 2014). These disparities underpin the current state of maternal, newborn and child health (MNCH) in Africa, revealing persistent challenges in meeting MDGs 4 and 5 throughout all countries and a need for enhanced access to primary health care, emergency services, reproductive health and family planning (UN, 2013a). Enhanced access hinges only upon the availability of adequately trained health professionals but also on the appropriate deployment of sufficient numbers of adequately trained human resources for health (HRH) to deliver essential services (WHO, 2005). Africa’s human resources for health (HRH) crisis is both chronic and unprecedented. Despite successive resolutions to increase Africa’s HRH by the World Health Organization (WHO) Regional Committee for Africa between 1998 and 2009 (WHO Regional Office for Africa [AFRO], 2012), the continent’s health workforce has in reality continued to decline (WHO AFRO, 2012). Thirty seven African countries - the majority of those on the continent - fall short of the WHO’s minimum recommended HRH density of 2.3 doctors, nurses or midwives per 1,000 population to provide basic health care. With most countries instead averaging less than one doctor, nurse or midwife per 1,000 population, it is estimated that nearly one million additional personnel are required to meet the WHO’s minimum threshold (WHO AFRO, 2012). Arguably the most critical dimension to HRH planning and management for equitable health care provision is how the HRH are developed, trained, and deployed (Tomblin Murphy, 2007; WHO, 2003; Zurn et al., 2004). However, the region’s capacity for HRH training is limited, with 26 countries in Sub-Saharan Africa having one or no medical schools, and existing institutions weakened by poor physical infrastructure, shortages of trained faculty and mentors, and a lack of international accreditation (Frenk & Chen, 2010; Mullan et al., 2010). In rural and remote areas, the crisis is even more acute. Greater demands on the health system due to higher burden of disease and population growth compared to urban areas co-exist with, and strain, the limited resources, human and otherwise, to address them (Joint Learning Initiative, 2004). This low production capacity and inequitable distribution of HRH underscores the importance of effective policy regarding the planning and management of the region’s scarce health workforce. www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


Any meaningful deliberations on setting political priorities for Africa’s health and development beyond 2015 must be grounded in the experiences and lessons learned in pursuing the achievement of the MDGs. However, while evidence on different countries’ policies and experiences exists, the necessary time and resources to review and synthesize such information are prohibitive to many country-level policy makers (Adam et al., 2011). In order to inform the HRH policy and practice process, a systematic review and in-depth analysis of available peerand non-peer-reviewed literature, as well as unpublished policy documents on the training and deployment of HRH for rural MNCH in Africa, was completed. This paper presents the findings from the in-depth policy analysis for a selected sub-set of African countries. METHOD The review’s primary research questions were identified by the research team and validated with an international Advisory Group (AG), comprising health education and HRH policy experts. Guided by the interest of the AG, in the progress towards the MDGs and their translation into the post-2015 agenda, MNCH was identified as the primary area of focus. Doctors, nurses, and midwives were selected as policies and evidence pertaining to these professional groups was anticipated to be more abundant than for other cadres of health providers. Additionally, the breadth of services these three professions provide are essential to MNCH. Research questions What is known about policies to support training and deployment of nurses, midwives and doctors for maternal-child health care in rural Africa? What is currently known about: a) the research, theories, frameworks or other factors that have guided the development of these policies? b) the implementation of these policies? c) the effectiveness/impact of these policies on system, provider and health outcomes? The questions are consistent with the stages of Sabatier and Jenkins-Smith’s policy process (1993): identifying and recognizing the problem, policy formulation, implementation and evaluation. The research questions were addressed using a two-part approach: I. Scoping review Fourteen electronic health and education databases were searched for peer-reviewed papers specific to training and deployment policies for doctors, nurses, and midwives for rural MNCH in African countries with English, Portuguese or French as official languages. Non-peer reviewed documents were identified, using the same scoping and inclusion criteria, from ministry of health (MoH) websites for each country and through directed searches of websites administrated by reputable international health and development NGOs and agencies. The results of the scoping review were used, with AG consultations, to refine the guiding questions for the in-depth policy analysis and contribute to the synthesis. Three or more members of the review team independently evaluated all documents against the inclusion criteria (Table 1) and came to consensus on which papers to include in the analysis. www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


The selected peer- and non-peer-reviewed documents were then reviewed and mapped using data extraction templates, developed by the research team. A full description of the scoping review methods, results and analysis are given in the full report (Tomblin Murphy et al., 2014). Table 1. Inclusion criteria for peer and non-peer reviewed literature scoping Aspect Criteria Language of publication English, French, or Portuguese Years published 1990 – 2013 Type of policy initiative Applied (i.e. not theoretical, but some evidence that the policy has been/continues to be implemented) Country or countries of Any African country whose official languages include focus English, French, and/or Portuguese1 Policy focus Training and/or deployment of providers as it pertains to rural health Type(s) of providers Physicians, nurses, and/or midwives Specific clinical focus Maternal-child health: reproductive health, pregnancy, birth, newborns, childhood disease, and adolescents Jurisdictional focus International or national (e.g. not provincial or districtspecific) Types of data sources Policy documents, policy evaluations, professional protocols/clinical guidelines, literature reviews, peerreviewed research related to policy implementation and/or evaluation 1

With the exception of Ethiopia; identified by the AG as a unique case given its achievement of MDG 4 and the country’s publication of many of its policy documents in English.

II. In-depth policy analysis Applying criteria determined by the research team and AG (Table 2), an eight country sub-set was selected for the in-depth policy analysis: Ethiopia, Ghana, Mali, Mozambique, Niger, Tanzania, Uganda, and Zambia. In addition to the peer- and non-peer-reviewed literature identified in the scoping review, AG and research team members assisted in the identification, selection and retrieval of related policies and policy documents that were not publicly available. Table 2. Criteria for selecting countries for inclusion in synthesis • At least one representative country from each linguistic group of Portuguese, French, and English; • A mix of geographic representation including countries that are land-locked as well as those from the east and west coasts, and from the northern and southern hemispheres; • Countries with a history of in-depth policy analysis, systematic reviews, and/or strong culture of research-to-policy; • Countries in which known-to-the-group stakeholders exist, to allow for access to otherwise unavailable policy documents. The analysis and synthesis was consistent with a ‘realist’ approach to systematic review, which facilitates complex policy synthesis (Pawson et al., 2005). The definition of policy used for this www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


synthesis is “courses of action (and inaction) that affect the set of institutions, organizations, services and funding arrangements of the health system” (Buse et al., 2005, p.5.). Only policies with evidence of implementation were included in the synthesis. Several national documents titled ‘health policy’ described countries’ health priorities and plans for addressing those priorities, whether generally about health or specific to maternal-child or health human resources, but did not include evidence of the actual implementation of these plans. These documents did not meet the inclusion criteria and did not relate to the specific research questions. However, they were reviewed to provide context at the country-level for the analysis. Additionally, individual programs or interventions implemented as part of those broader plans were considered policies and analyzed fully. The policy analysis framework by Hercot et al. (2011), previously applied in studying health care policies in sub-Saharan Africa, was used to guide the extraction and analysis of policy data from the collected documents. This framework distinguishes between the respective contributions of the actual policy substance (content), the systemic factors which may have an effect on the policy (context), the stakeholders who influence it (actors), the way in which policies are initiated, developed, negotiated, communicated, implemented and evaluated (process), and its effects (impacts) - expected and unexpected, positive and negative (Hercot et al., 2011). Evidence published in peer-reviewed, scientific journals was exclusively considered as documentation of the ‘impacts’ component of the framework. The existence of non-peerreviewed evidence (e. g. MoH reports) is noted where available and was used to provide information on the other components of the framework and inform themes that emerged inductively throughout the review. RESULTS The scoping and synthesis of peer and non-peer reviewed literature revealed a paucity of policies specific to the training and deployment of nurses, midwives and doctors for MNCH in rural Africa. Although several identified policies considered each of these factors individually, existing policies tended to be broader than this particular intersection of topics. Each of the eight selected countries had policy documents reflecting recognition of the need to improve MNCH, particularly in rural areas. However, the analysis is specific to those policies that directly consider, but may not be limited to, the training and deployment of nurses, midwives and doctors for MNCH in rural Africa. Very little information about the creation, implementation, or impact of these policies was available. Although policy titles and context information was readily available, in particular there was a stark absence of peer-reviewed scientific evidence relating to the impacts of these policies. Critiquing the quality of the peer-‐reviewed studies cited in terms of their designs, methods, interpretations and so on was outside the scope of this analysis. Nonetheless, most of the literature

acknowledged that the problems for which the policies were intended to address continue to persist. While the review yielded little information on specific policies within its scope, it did reveal a great deal of relevant contextual information about the selected countries. This data was considered to be essential in understanding such policies and is presented as thematic results. www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


Identified Policies What follows is the in-depth analysis and synthesis all identified documents meeting the review criteria for a subset of eight African countries: Ethiopia, Ghana, Mali, Mozambique, Niger, Tanzania, Uganda, and Zambia. Each country has documents designated as National Health Policies, Strategies, or Development Plans. These documents are all similarly structured, commencing with a situational analysis of the country’s leading health issues, then the current state of the health care system, followed by identifying priority issues to be addressed, and finally describing plans to address them. The most recent versions of these documents available from each country all identify the MDGs as a framework for establishing and addressing national priorities within and beyond the health care sector. This indicates that, although important differences between these countries exist, their identified national health priorities are similar. Earlier versions of National Health Policies for some countries were also accessible. Ethiopia’s National Health Policy, enacted in 1993 (Transitional Government of Ethiopia, 1993), has been implemented through a series of Health Sector Development Plans (HSDPs) (Ethiopia Federal MoH, 2005a). The fourth and most recent iteration covers the period 2010-2015 and focuses on MNCH, with specific objectives pertaining to HRH training and deployment (Ethiopia Federal MoH, 2010). Tanzania has a 2007 Health Policy (Tanzania Ministry of Health and Social Welfare [MoHSW], 2007) – identified only in Kiswahili – and Health Sector Strategic Plans that covered the periods of 2003-2008 and 2009 – 2015 (Tanzania MoHSW, 2003a; 2009). Previous National Health Policies were published in 1990 and 2003, however, only draft copies of the latter were publicly available (Tanzania MoHSW, 1990; 2003b). Uganda is on its second tenyear National Health Policy (Uganda MoH, 2010a) and third five-year Heath Sector Strengthening and Investment Plan (HSSIP) (Uganda MoH, 2010b). Zambia’s current 2011-2015 National Health Strategic Plan (Zambia MoH, 2010a) built upon a similar plan for the preceding five years (Zambia MoH, 2005). Occasionally, these later versions make explicit reference to their predecessors, describing progress or, as is more often the case, challenges and progresslimiting system issues. On the whole, however, there was limited information in these documents on how activities laid out in earlier policies or strategic plans have progressed, let alone what their impacts, if any, have been. Specific exceptions are described below. The national health policies for Ethiopia (Ethiopia Ministry of Finance and Economic Development, 2010), Tanzania (United Republic of Tanzania, n. d.), and Uganda (Republic of Uganda, 2009), are explicitly linked with broader national development policies. In Mali, national health strategies are embedded within the Decennial Health and Social Development Plan 2013-2022 (République du Mali Ministère de la Santé et al., 2012). Ghana’s over-arching national policies include the National Population Policy, Ghana Vision 2020, the National Health Policy and Programs of Work. These linkages acknowledge the interdependence of the performance of the health sector with the overall status of the country as a whole – or alternatively, that the workings of a country’s health care system and the workings of its economy, socio-political structures and other systems all affect each other. Although these www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


higher-level national policies were beyond the scope of this review, their relationships with health policies must nonetheless be factored into any health systems analyses. Each country also had national-level policy documents specific to HRH, which in some cases are unequivocally integrated into national health policies in that each explicitly references how it aligns with the other or vice versa, such as Tanzania and Zambia’s National Health Strategic Plan (Tanzania MoHSW, 2003a; 2009, Zambia MoH, 2010) and National HRH Strategic Plan (Tanzania MoHSW, 2008a, Zambia MoH, 2011). Although cited in other government documents, Ethiopia’s and Uganda’s National HRH Policies and Strategic Plans were not found through the search. As specificity in national policies increases, their interrelationships with other policy document of a different nature become more complex, often causing overlap. For example, National Policies on child health were identified for Ethiopia, Ghana, Tanzania, Uganda and Zambia. Instead of a single child health strategy, Zambia has, at various times, had an Integrated Management of Child Illnesses (IMCI) strategy, an Expanded Program for Immunisation (EPI) (Zambia MoH, 2005), and a Reach Every District (RED) strategy for immunization coverage (Zambia MoH, 2010). However, no copies of these policies were available to be reviewed, although they were each referred to in other documents. Uganda has a focused Child Survival Strategy that is referenced in the National Health Policy, although a copy of the Strategy itself was not accessible. Ethiopia too has a Child Survival Strategy; however it specifies that it be read in conjunction with the National Reproductive Health Strategy and National Nutrition Strategy (Ethiopia Federal MoH, 2005b). Tanzania’s National Strategic Plans for child and reproductive health are combined (Tanzania MoHSW, 2008b). Ethiopia, Ghana, Mali, and Uganda also have National Policies or Strategies for reproductive health, which inherently also have implications for child health, as do other National Policies in each country pertaining to malaria, HIV/AIDS, nutrition, poverty reduction, and so on. However, regardless of the variety of policies and combinations thereof, a commonly identified limiting factor in justification and for implementation of virtually all reviewed overlapping policies is the availability of sufficient HRH, with the appropriate training, deployed to the sectors and locations where they are needed. Having reviewed all of these and other relevant documents for each of these countries, 19 descriptions of applied policies pertaining to training or deployment of doctors, nurses, or midwives for MNCH in rural Africa were identified (Table 4).



Table 4. National Policy Initiatives on Training or Deployment of Doctors, Nurses or Midwives for Maternal or Child Health in Rural Ethiopia, Ghana, Mali, Mozambique, Niger, Tanzania, Uganda or Zambia Country Policy Year Implemented Ethiopia Mandatory public service after graduation Differentiated terms and conditions for pay & benefits New Medical Education Initiative 2011 Nurse anaesthetist program 2010 Accelerated training & increased staffing for midwives 2009 Ghana Decentralized medical resident training 2000 Deprived Area Incentive Scheme Allowance (DAIA) 2004 Health Staff Vehicle Hire Purchase Scheme 1997 Community-based Health Planning and Services program 1999 (CHPS) Mali Medicalization of rural areas Mozambique No available information on applied policies meeting criteria Niger Scholarships for rural students 2011 Mobile health teams 2011 District-level surgery training 2005 Tanzania No available information on applied policies meeting criteria Uganda Incentives scheme for human resource in hard-to-reach areas Integrated Management of Childhood Illness (IMCI) 1995 Community-based education and services (COBES) Specialist outreach Building and staffing operating theaters at the level of the ‘‘health subdistrict’’ or health center type IV Zambia One-year rural attachment for trainees 1991 Zambia Health Worker Retention Scheme 2003 Rural and Remote Hardship Allowances Housing Allowance The paucity of identified policies for a particular country should not necessarily be construed as a lack of attention or effort towards the training or deployment of doctors, nurses, or MNCH in rural Africa. The included policies solely reflect the information that was identified and readily available for inclusion in the analysis using the methods and sources outlined above. The policy analysis framework by Hercot and colleagues (2011) policy guided the review and data extraction from available documents. However, the information available through the search was disproportionately limited to the developmental context for various policies, with sparse information on the content, the actors, implementation or impacts of the policies. Consequently, what follows are descriptions of relevant findings related to policy content, development, implementation and evaluation, by country in consideration of their individual context, consistent with the policy cycle framework (Sabatier and Jenkins-Smith, 1993). www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


Table 5. Information Availability by Policy Country Ethiopia

Ghana

Mali Niger Uganda

Zambia

Policy Mandatory public service after graduation Differentiated terms and conditions for pay & benefits New Medical Education Initiative (NMEI) Accelerated midwifery & increased staffing for midwives Nurse anaesthetist program Decentralized medical resident training Deprived Area Incentive Scheme Allowance (DAIA) Health Staff Vehicle Hire Purchase Scheme Community-based Health Planning and Services program (CHPS) Medicalization of rural areas Scholarships for rural students Mobile health teams District-level surgery training Incentives scheme for human resource in hard-to-reach areas Integrated Management of Childhood Illness (IMCI) Community-based education and services (COBES) Specialist outreach Building and staffing operating theaters at the level of the ‘‘health subdistrict’’ or health center type IV One-year rural attachment for trainees Zambia Health Worker Retention Scheme Rural and Remote Hardship Allowances Housing Allowance

Information Available on… Development Implementation

Impacts

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Ethiopia Content Ethiopia’s New Medical Education Initiative (NMEI) involved a revised, modular curriculum and increased medical school enrolment capacity, including at rural sites (Ethiopia Federal MoH, 2013). The accelerated midwifery training and increased staffing (two interventions which are described as a single strategy) reduced the length of midwifery training (although by how much is not clear) and increased staffing standard to two midwives per health centre - many of which are located in rural areas. In addition, a mentorship program for new graduates was designed and implemented in collaboration with the Ethiopian Midwives Association, under which experienced midwives were assigned to the same health centres as new graduates (Ethiopia Federal MoH, 2013). Nurse anaesthetists are trained through one of eleven one-year post-graduate programs or one of six baccalaureate programs. They are then deployed as part of teams with Integrated Emergency Surgery Officers (IESOs) and nurse midwives to primary hospitals and health centres across the country, where much of their work focuses on maternal and neonatal care for residents of rural areas (Ethiopia Federal MoH, 2013). The country’s policies on mandatory public service after graduation and differentiated terms and conditions for pay & benefits are referred to in its third HSDP (Ethiopia Federal MoH, 2005a), although the years of implementation are not given. According to the Plan, “the scheme considers various aspects of employment & training to promote public sector service in rural and remote locations including salary, eligibility for release from public service, eligibility for post-graduate training (e. g. to specialist), and eligibility for transfer. ” One criteria considered in the public policy is the type of district in the required length of public service. For example, graduates must work for four years if they chose to work in an urban district, but only two if they are posted to a remote district (Ethiopia Federal MoH, 2005a). Development Details on the development of Ethiopia’s NMEI or policies on mandatory public service after graduation and differentiated terms and conditions for pay & benefits were not available. The accelerated training and increased staffing for midwives were designed to increase the country’s ability to respond promptly to problems arising during pregnancy and childbirth, and to reduce maternal and neonatal mortality (Ethiopia Federal MoH, 2013). The mentorship component was designed to strengthen the professional competence of new graduates entering practice (Ethiopia Federal MoH, 2013). The nurse anaesthetist program was developed to increase access to their services specifically and to emergency surgery in general (Ethiopia Federal MoH, 2013). Implementation The NMEI has involved expanded training capacity at 11 existing universities and the establishment of 13 additional universities and hospital medical colleges, several of which are in rural areas. The Initiative has resulted in a near tripling of enrolment in Ethiopia’s medical schools (Ethiopia Federal MoH, 2013). The latest available data indicate that 3,190 midwifery students have graduated from the accelerated program thus far, with another 1,190 still in www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


training (Ethiopia Federal MoH, 2013). To implement the nurse anaesthetist program, 60 adult airway trainers, 60 lumbar puncture modules, and over 600 textbooks were distributed to the various training institutions. The most recent data available indicate that the one-year postlicensure and four-year undergraduate nurse anaesthetists programs have produced 96 and 50 graduates, respectively with another 115 and 471 still in training (Ethiopia Federal MoH, 2013). Although not specific to the mandatory public service policy, a mid-term review of progress under Ethiopia’s third HSDP (Independent Review Team, 2008) noted that some zonal levels (zones within regions) have been reluctant to deploy degree holders because of the budget constraints in hiring qualified personnel and so they are mainly deploying middle level health workers. No other information on the implementation of Ethiopia’s policies on mandatory public service after graduation and differentiated terms and conditions for pay & benefits was identified. Impact No peer-reviewed evidence was found through our search on the impacts, if any, of Ethiopia’s NMEI, accelerated training and increased staffing for midwives, nurse anaesthetist program or policies on mandatory public service after graduation and differentiated terms and conditions for pay & benefits. In the case of NMEI, it is important to note that as the Initiative only began in 2011, the additional students have not yet had time to complete their training. Implementation of the nurse anaesthetist program is also very recent, and the accelerated training and increased staffing for midwives is also a relatively new policy. Ghana Content Under Ghana’s decentralized medical training, residents split their time between urban teaching hospitals and more rurally-located regional or district hospitals. The Deprived Area Incentive Scheme Allowance (DAIA) provided additional monetary incentives of between 20-35% of health workers’ basic salary if they were practicing in one of 55 districts designated as deprived, virtually all of which were rural (Lori et al., 2012). Launched in 1997, The Health Staff Vehicle Hire Purchase scheme began as a retention and recruitment initiative. The CHPS program is described by Nyonator et al. (2005) as beginning in 1999 but by the MoH (2012) as originating in 2003. Focused initially on rural districts, CHPS is a national health program designed to reduce geographical barriers to health care – particularly related to MNCH – through mobile community-based care provided by a nurse specially trained as a community health officer (CHO) (Nyonator et al., 2005). Development Ghana’s resident training program for obstetricians and gynecologists was developed in the late 1980s through a partnership between the American College of Obstetricians and Gynecologists (ACOG), the UK’s Royal College of Obstetricians and Gynecologists (RCOG), the Department for International Development of Britain, the Carnegie Corporation of New York, two Ghanaian medical schools, and the government of Ghana. A key feature of the program is a rural district hospital posting for 6 months during the 4th year. Prior to this program, obstetrical specialists were trained primarily in the United Kingdom, often resulting in the expatriation of trained www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


specialists (Klufio et al., 2003). As of 2000, funding for this program is supported through the Ghanaian MoH. The DAIA and staff vehicle purchase scheme were employed to recruit and retain health staff to deprived (mainly rural) areas (Lori et al., 2012). According to Ghana’s MoH (2012), the CHPS program is a response to the majority of Ghanaians living more than 8 kilometers from the nearest health care provider. An experiment in the Navrongo district suggested that the flexible deployment of community health nurses in community outreach activities could substantially improve services over more traditional, rigid service delivery methods; the approach was designated to be scaled up nationally (Nyonator et al., 2005). No information on the development of the other included Ghanaian policies was identified. Implementation Between 1997 and 2009, almost 3500 cars were distributed to health workers through Ghana’s Health Staff Vehicle Hire Purchase Scheme to boost recruitment. Following the promising results of CHPS in Navrongo, the program was tested in Nkwanta district. Upon successful evaluation, the program was expanded to other districts (Nyonator et al., 2005). Responding to a 2009 MoH (2012) study of CHPS, the training of CHOs who form the core of the program was accelerated and expanded to include midwifery training. The study also detailed several factors that have hindered the implementation of the program: CHOs’ time is almost entirely occupied with providing curative services at the expense of preventive or health promotion services, the program is poorly supervised, there is little engagement with community leaders in program planning, and available transport and equipment are inadequate. The authors recommended the establishment of an inter-agency coordinating committee to address these issues (Ghana MoH, 2012). No other information on the implementation of the Ghanaian policies was available through the search. Impact A 2003 study found that doctors who were trained in Ghana, and in particular in rural areas, tended to stay in the country and practice in rural areas (Klufio et al., 2003), suggesting the decentralized medical training – if it is still in place – should help to address the country’s rural doctor shortages. However this study was not specific to the rural residency program. The 2009 study on the CHPS did not describe any actual impacts of the program. No information was available from the search on the impacts of the nation-wide version of the program, although Nyonator et al. (2005) note that the positive results of pilot implementations suggested the program had increased rural service availability in general and immunization coverage specifically. No information on the impacts, if any, of the other Ghanaian policies was available. Mali Information on any policies that met the inclusion criteria for Mali was minimal, and limited to a brief mention in a singular peer-reviewed review article by Dolea and colleagues (2010). Content, development, implementation, impact The only reference to Mali’s medicalization of rural areas program is by Dolea et al. (2010) who describe it as aiming to support doctors setting up their practices in rural areas. It is noted in the www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


same paper that as a result of this policy, 100 doctors were posted in rural areas over a decade, with the average stay of four years. No further information was available in this article, or through the search, on the medicalization of rural areas’ development or impact, if any. Mozambique Content, development, implementation, impact There was no available information through the search on the content, development, implementation or impact of any training and deployment policies for doctors, nurses, or midwives for MNCH in rural Mozambique. Niger Content Under Niger’s district surgery training program, public sector generalist doctors working at district hospitals who perform well on a screening exam undergo twelve months of theoretical and practical training at university and regional hospitals to be able to perform emergency obstetrical and other surgical services. Graduates receive a certificate which entitles them to a salary increase in Niger but is not recognized elsewhere (Sani et al., 2010). The rural scholarship program provides funds for students from rural areas to train in one of four key health professions, two of which are nursing and midwifery, on the condition that they serve for three years in their community of origin in order to receive their degree (République du Niger Ministère de la Santé Publique, 2010). The mobile health teams consist of two nurses, a midwife and a driver who are dispatched for five days per month to provide stop-gap services, mainly for MNCH, in rural areas as a temporary measure to address staffing shortages (République du Niger Ministère de la Santé Publique, 2010). Development Motivated by limited capacity to provide emergency obstetrical and surgical care in remote and rural locations, Niger’s MoH, in partnership with the Faculty of Medicine of Niamey University, launched its district surgery training program as part of the overall country health strategy in 2005 (Sani et al., 2010). The MoH identified the rural health scholarship and mobile health teams programs in its most recent HRH development plan under the specific objective of providing health facilities with 80% of staff based on identified needs (République du Niger Ministère de la Santé Publique, 2010). Implementation Niger’s district surgery program was implemented in 2005, and the first two graduating cohorts (2006 and 2007), produced 41 trained practitioners of rural origin. Approximate cost for the first year of implementation was $100,000 USD, or $4,762 USD per student. Additional sponsorship for the program was provided by the Belgian Technical Cooperation and the Italian Cooperation (Sani et al., 2010). Although no information is available on the actual implementation of the rural scholarship or mobile health teams programs, the most recent national HRH strategic plan (République du Niger Ministère de la Santé Publique, 2010) notes that scholarships are to be www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


issued to 300 young people of rural origins between 2011 – 2014, and an additional 300 between 2016 – 2019 . These scholarships are to be divided across students of four health professions: 100 for health assistants (Agent de Sante de Base), 100 for diploma-level nurses (Infirmier Diplome d’Etat), 25 for lab staff (Laborantin), and 75 for diploma-level midwives (Sage-Femme Diplomee d’Etat). Projected total cost is 4,666,500,000 F. CFA (République du Niger Ministère de la Santé Publique, 2010). The HRH plan also states that the 32 mobile health teams will initially cover up to three districts, with scaling up to the national level upon successful implementation. The total cost of the program over 2011 – 2015 was estimated at 355,200,000 F. CFA, or 2,220,000 per health district over the same period of time. Local partners will take on the additional costs of travel, supplies, and maintenance (République du Niger Ministère de la Santé Publique, 2010). Impact A study of Niger’s district surgery training program found that all graduates have remained in their rural posts, that surgical patient transfer to regional hospitals was reduced from 82% in 2005 (pre-implementation) to 52% in 2006 (post-implementation), and that surgeries performed by graduates in the districts had a mortality rate only slightly higher than those performed at the regional hospitals by fully trained surgeons and gynaecologists (Sani et al., 2010). The study also concluded that, although very successful, the overall impact of the program is limited by inconsistent provision of human resources, essential equipment, and continued training. Further, it suggests that part of the successful retention of graduates is due to the lack of recognition of the program’s credential outside the country, and to other rural incentives that are not described (Sani et al., 2010). No information on the impacts of the rural scholarship or mobile health teams programs was found. Tanzania Content, Development, Implementation, Impact There was no available information through the search on the content, development, implementation or impact of any training and deployment policies for doctors, nurses, or midwives for MNCH in rural Tanzania. Uganda Content Uganda’s incentives scheme for human resources in hard-to-reach areas is referenced exclusively is in its second National Health Policy (Uganda MoH, 2010a), with no details on the schemes provided. The IMCI program is described as having three main components, each of which were designed to complement the other to improve child health in the country: improving case management skills of health workers, improving health system supports for child illness, and promoting family and community practices, with a particular focus on rural areas (Pariyo et al., 2006). The country’s use of the Community-Based Education and Service (COBES) and specialist outreach programs, and the building and staffing of operating theatres in health subdistricts, are described in a paper by Ozgediz et al. (2008) as national interventions having MoH involvement but are not mentioned in any of the government documents reviewed. COBES www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


is intended to provide a more hands-on, representative, community-based clerkship experience and, through early exposure to care in rural facilities, aims to increase the number of graduates willing to serve in rural areas after graduation (Ozgediz et al., 2008). Specialist outreach is conducted periodically – depending on availability of MoH funding – in underserved regions by flying in consultant orthopedic, plastic, or ophthalmologic surgeons from the national hospital, or from international agencies (Ozgediz et al., 2008; Uganda MoH, 2013). No information about the content of the theater building and staffing policy was identified. Development Uganda’s MoH adopted IMCI as part of its child health policy in 1995 as part of its response to high under-5 mortality rates in the country (Pariyo et al., 2006). Ozgediz et al. (2008) suggest that COBES was developed in response to geographic imbalances in the distribution of doctors in Uganda, with over 90% concentrated in urban Kampala while 90% of the population lives in rural areas, leaving surgical services outside the capitol to be provided by medical and anaesthetic officers. Ozgediz et al. (2008) also indicate that the primary impetus for the building and staffing of rural operating theaters was improvement in access to emergency obstetric care. No further information on the development of these policies was available through the search. Implementation The initial training of health personnel for IMCI in Uganda began in 1996 in three districts. The MoH recommended that nurses, midwives, clinical officers and doctors be trained first, followed by nursing aides and assistants. After two years of trials and implementation, the program was designated for national expansion and by 2000 had been introduced in 55 of 56 districts nationally. MoH personnel monitored all training until 2001. Between 2000 and 2002, the program’s implementation was evaluated by a team from Makerere University, the WHO, and Johns Hopkins University (Pariyo et al., 2006). The evaluation noted several factors that hindered the implementation of the program, mainly that most facilities did not have all necessary drugs, that most did not receive any supervisory visits, and that there were some ‘unwritten’ policies among public health workers that were viewed as superseding the IMCI protocols (Pariyo et al., 2006). Under Uganda’s policy of building and staffing operating theatres at the subdistrict level, operations were to be performed by a medical officer, and anaesthesia provided by anaesthetic assistants, for whom an 18-month training program was developed (Ozgediz et al., 2008). No other information on the implementation of these Ugandan policies was available through our search. Impact There is very little information available on the impacts of the Ugandan policies, with the exception of the IMCI program, which has been evaluated. Pariyo et al. (2006) found that HRH trained in IMCI protocols and procedures were better at assessment and diagnosis, and that this effect was stronger for nurse aides and assistants than for nurses, doctors and midwives. They also found variation in that while personnel trained in IMCI protocols provided better education of child caretakers, there was variation in the effects of treatment. Further, they found that initial improvements were not maintained by the end of the study period. They concluded that IMCI training alone was not sufficient to sustainably improve care (Pariyo et al., 2006); a supportive infrastructure, work environments, and political context are also required for the training to be www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


successful (Ozgediz et al., 2008). Other than the fact that there continues to be an inequitable distribution of health workers between urban and rural parts of Uganda, with nearly 70% of medical doctors and dentists, 80% of pharmacists and 40% of nurses and midwives, are in urban areas serving 13% of the population (Uganda MoH, 2010b), no information was available through our search on the impacts, if any, of the other Ugandan policies. Zambia Content Zambia’s requirement of one year’s rural service for trainees of health professional programs is mentioned only briefly in a 1991 MoH collection of policies and reforms. Noting the “skewed distribution of qualified personnel towards urban areas,” it states that, “trainees will do an attachment in a rural setting for a period of one year” (Zambia MoH, 1991). No other information on the policy was available through the search. The ZHWRS was first implemented over ten years later in 2003 to provide a suite of incentives to recruit and retain doctors in rural and remote districts, including a salary top-up, child education allowance, car loan, housing improvement allowance, and professional development eligibility (Koot & Martineau, 2005). Gow et al. (2012) state that, “rural hardship allowance is given to selected health workers who serve in rural and remote areas in places that are ten kilometres from any paved road. This is intended to cushion them against the factors that dissuade health workers from serving in economically disadvantaged areas. ” However, the details of the allowances are described somewhat inconsistently in two documents. According to the 2011-2015 Strategic Plan (Zambia MoH, 2010a), the allowances amount to an extra 20-25% of basic salary, while according to Gow et al. (2011), under these allowances, “Compensation [is] doubled for workers in extreme rural districts and increased by 50 per cent for those in peri-rural districts. ” The housing allowance is mentioned only by Gow et al. (2012) and not in any government documents reviewed; no other information on its content was available through our search. Development Initially funded through a partnership with the Netherlands, the ZHWRS was designed to improve service delivery, increasing the potential to achieve the MDGs, with a particular focus on rural and underserved parts of Zambia (Koot & Martineau, 2005), addressing the inadequacy of staff housing in rural and remote areas (Zambia MoH, 2009) and the urban/rural imbalance in HRH distribution (Zambia MoH, 1991). Implementation The total budget made available to implement the ZHWRS was €2.3 million over the first three years. As of 2005 the scheme was managed by the Central Board of Health (CBoH) without MoH involvement, and a mid-term review found 68 doctors had been contracted under the scheme, and that other than the provincial health director and HR specialist, almost no personnel in the districts knew anything about the scheme (Koot & Martineau, 2005). The CBoH was dissolved in 2005, after which the MoH took over the scheme (Zambia MoH, 2010b). In 2007 the ZHWRS was expanded to include other health workers, including clinical officers, tutors/lecturers, nurses, midwives, environmental health technologists; tutors and lecturers were added to help produce more health personnel (Zambia MoH, 2010b). A 2009 review found that www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


the total number of health workers on the staff retention scheme increased from 656 in 2008 to 860 in 2009, against a target of 1,650, and also noted a need to improve coordination and communication of HR information, particularly on staff postings and the ZHWRS (Zambia MoH, 2009). A more recent review found that, as of 2012, membership in the scheme was 1,023 against a target of 1,400, distributed across all districts. Nurses and midwives are among the professional groups whose participation in the ZHWRS is above target levels, while participation for doctors is below target (Bwalya et al., 2013). Among the challenges reported related to the scheme’s implementation were irregular and late payments of allowances under the scheme, weak monitoring and evaluation practices, particularly poor working conditions in rural areas, and inefficient communication and collaboration between national and district offices. The payment issues appear to be related to delays in receiving funds from the Ministry of Finance, which have led to the scheme incurring unfunded liability (Bwalya et al., 2013). No details on the implementation of the other Zambian policies were found. Impact There was little peer-reviewed evidence identified for the impacts of the Zambian policies. MoH data show that HRH numbers have increased in rural areas since 2005, suggesting the ZHWRS may have been of some benefit, although the inequitable distribution of HRH continues (Zambia MoH, 2010a). In addition, HRH in rural posts in Zambia remain more likely to quit their jobs than their urban counterparts (Gow et al., 2012). A more recent MoH review provides qualitative data suggesting that the ZHWRS is perceived as being a strong retention mechanism and a benefit to health care facilities and education and training institutions, but little quantitative data was available to confirm these perceptions. A lack of adequate funding is described as undermining the sustainability of the program (Bwalya et al., 2013). Thematic Results Outside of the scope of our analysis, but nonetheless directly related to the subject of HRH training and deployment and rural MNCH, a number of recurring issues were described across documents reviewed from multiple countries. These issues may explain, at least partially, why such a disparity exists between the breadth and depth of health strategies proposed in these countries and what is in reality implemented. Key country-specific contextual data is provided in Table 3.



Table 3. Country-Specific Contextual Data (WHO Global Health Observatory, 2015) Country

Population (% Rural)

GDP per capita1

Health spending as % of GDP

Maternal Mortality2

Under 5 Mortality3

Physician density4

Nurse and midwife density

ETH

94,101,000 $1,350 5.1% 420 64 0.025 0.253 (81%) GHA 25,905,000 $3,880 10.7% 380 78 0.096 0.926 (47%) MAL 15,302,000 $1,540 6.8% 550 123 0.083 0.430 (62%) MOZ 25,834,000 $1040 6.6% 480 87 0.040 0.783 (68%) NIG 17,831,000 $910 5.3% 630 104 0.019 0.137 (82%) TAN 49,253,000 $1,750 7.3% 410 52 0.031 0.436 (70%) UGA 37,579,000 $1,370 9.5% 360 66 0.117 1.306 (85%) ZAM 14,075,000 $1,490 6.1% 440 83 0.173 0.784 (61%) 1 Purchasing Power Parity (PPP) international dollars, 2 Per 100,000 live births, 3 Per 1,000 live births4, Per 1,000 population

Health Challenges Despite a wide variation in geography, cultural context, and political background, the countries studied for the in-depth policy analysis had many common health challenges. Overall health system performance is plagued by limited and unequally distribution of adequately trained HRH, weak organizational and physical infrastructure, and dysfunctional referral systems. These challenges results in sub-optimal health care coverage of the countries populations; for example in Niger only one-third of the population has access to health services (WHO, 2006), while in Mozambique the health system, including public, private for profit, and not-for-profit private sectors collectively, covers only about 60% of the population (WHO, 2014). In their national policy documents, all countries referenced the intense burden of preventable communicable and non-communicable diseases; aligning with the MDGs, Malaria, TB, HIV/AIDS, diabetes, hypertension, and peri- and neo-natal conditions, were the most highly attributed with causing poor population health (Ethiopia Federal MoH, 2010; Republic of Ghana MoH, 2007a; Uganda MoH, 2010a; United Nations Development Program [UNDP], 2013; United Republic of Tanzania MoHSW, 2008; Zambia MoH, 2010a; WHO, 2014). While there has been an overall decreasing trend in maternal, newborn and child mortality and morbidity in the Sub-Saharan African region, it is unlikely that any countries studied in depth here will achieve MDG 4 or 5 by the end of 2015, with the exception of Ethiopia and Tanzania (Countdown to 2015, 2014) who have already achieved their MDG 4 targets for under 5 mortality. Further challenges were identified that went beyond the aforementioned conditions, acknowledging systemic and infrastructural factors. All countries referred to issues in supplying clean water and basic sanitation services to their entire population and malnutrition, and their causes - such as drought in Ethiopia and chronic poverty in Niger - were highlighted as up www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


stream contributors to maternal, newborn and child mortality and morbidity (Ethiopia Federal MoH, 2010; Republic of Ghana MoH, 2007a; Uganda MoH, 2010b; UNDP, 2013; United Republic of Tanzania MoHSW, 2008; Zambia MoH, 2010a;WHO, 2014). Niger, alongside Ghana, openly cites low levels of education and literacy as having a negative impact on MNCH (Republic of Ghana MoH, 2007a; UNDP, 2013; WHO, 2006). Some governments of the studied sub-set of countries explored health issues through an economic lens. The importance of sustained economic growth is noted in the National Health Policies of Mozambique, Uganda, Tanzania, and Zambia (Dominguez-Torres & BricenoGarmendia, 2011; Uganda MoH, 2010b; Zambia MoH, 2010a). Regrettably, the resulting GDP growth has not given rise to an equitable reduction of poverty, allowing for the socio-economic gap between rural and urban populations to widen further (United Republic of Tanzania MoHSW, 2003b; 2009; Zambia MoH, 2010; World Bank, 2009). For example in Tanzania approximately 25% of Tanzanians and 39% of those in rural areas live below the poverty line (Tanzania MoHSW, 2009) and approximately 30% of Uganda’s population, the majority again in rural areas, live in poverty (WHO, 2013a). However, there is optimistic recognition of the deep interplay between a healthy population and a thriving economy, demonstrated for example by the theme of Ghana’s current National Health Policy "Creating Wealth through Health" (Republic of Ghana MoH, 2006). Political Stability Some of the countries studied have enjoyed greater political stability than others. For instance, Niger had its inaugural democratic election in 1993, more than thirty years after gaining independence from France. There have been several coups since, requiring the creation of the National Reconciliation Council in 1999, which has been charged with supporting the transition to civilian rule; the current president was elected in 2011. Mali transitioned from a one-party state into a multi-party democracy following a coup in 1991. However, a subsequent military coup in 2012 triggered a continued armed conflict, among other tragic consequences, resulting in the displacement of over 400,000 Malians and an additional 150,000 refugees. Malian and French forces have now recaptured most of the north and a new president was elected in the summer of 2013. However, with fewer functioning health centres in the north, there is limited access to vaccines and prenatal medications; limited referral and emergency transport systems; and delivery of health care has been severely disrupted, resulting in concerns of increased risk for disease outbreaks, maternal mortality and severe malnutrition (International Committee of the Red Cross, 2013; WHO, 2013b). Similarly, Uganda has recently experienced armed conflict in the North, which resulted in the displacement of much of the population into temporary camps with inadequate sanitation, education, or social structures, and disrupted health care delivery by requiring the closure of several facilities (Uganda MoH, 2010b). Implementation of government policies, including health care policies, was also disrupted (Uganda MoH, 2010b). Less recently, civil war in Mozambique between 1977 and 1992 interfered with national health services, including, for example, the complete interruption of the community health Agentes Polivalentes Elementares program in 1989 (Bhutta et al., 2010). Countries possessing a more politically stable landscape, such as Ethiopia, Ghana, Tanzania, Mozambique, and Zambia, do not take such comparative peace for granted. For instance, Zambia www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


explicitly identified continued political stability as a condition for the successful implementation of its HRH plan (Zambia MoH, 2005). Political stability and continuity must be critically considered in policy development as it impacts all aspects of the policy process from planning and prioritizing to funding decisions, resource allocation and evaluation and monitoring. Fiscal consideration In documents where Ministries of Health discussed the reasons why policies and strategies outlined in past plans may have been implemented only partially or not at all, the critically limiting factor tended to be the availability of financial resources. Not only are the available funds inadequate for ensuring the short-term availability of sufficient HRH, equipment and supplies, insufficient funding precludes maintenance or improvements to essential health care delivery (e. g. hospitals) and education (e. g. universities) infrastructure. For example, Zambia’s MoH identifies restrictions on the public wage bill and “inadequate, irregular and consistently decreasing funding for the health sector” as major challenges limiting its ability to implement meaningful reforms (Zambia MoH, 2011b). Further, limited funding threatens the sustainability of the ZHWRS (Bwalya et al., 2013), and has severely restricted the implementation of the National Training Operation Plan (Zambia MoH, 2010a). The 2011 – 2015 HRH Strategic Plan notes that only 17% of the required implementation funds were allocated for the 2006 – 2010 HRH Strategic Plan, severely restricting implementation (Zambia MoH, 2011a). The 2006-2010 plan notes that its predecessor, drafted in 2001, was never implemented (Zambia MoH, 2005). Similarly, Mali’s MoH (2013) references financial constraints and funding uncertainty as limiting the implementation and evaluation of policy in general and its blood services program in particular. Uganda’s MoH (2010b) reports that the proportion of public funds allocated to the health portfolio is below the national target of 15%, but has remained steady. However, it has allocated less than half the estimated funds required to deliver its National Minimum Health Care Package, particularly services for newborns (Uganda MoH, 2010b). Although donor-provided funds and other resources may mitigate funding gaps, they often come with their own challenges, including a lack of alignment with national health priorities. Several identified examples indicate how available funding can enable important initiatives to improve public health care infrastructure. Ethiopia has invested in the creation of additional universities to train health workers, and built health posts and centres to increase accessibility to primary health care (Ethiopian Federal MoH, 2010). They are also working to improve housing for health workers, particularly at the village level for health extension workers (HEWs) (Ethiopian Federal MoH, 2010). Similarly, Zambia has invested in the construction of 26 new district hospitals and 125 new rural health posts (Zambia MoH, 2011b), although some of these remain unutilized because of a lack of equipment (Zambia MoH, 2010b). Recent improvements have not been limited to the health sector. Tanzania, for example, has made substantial improvements to its road network as well as its telecommunications infrastructure (Shkaratan, 2012). Uganda, too, has substantially improved its telecommunications networks and power grid, although efficiency issues persist with the latter (Ranganathan & Foster, 2012). In order to compensate for resource shortages, some countries such as Tanzania and Uganda rely heavily on user fees and other private revenue streams (Haazen, 2012; Uganda MoH, 2013). Such practices may run contrary to the achievement of the MDGs specifically, and the mandates www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


of health care systems more broadly, as those in greatest need of health care can seldom afford to pay for it. In acknowledgement, Ethiopia (Ethiopia Federal MoH, 2013) attempted to reduce or eliminate user fees, despite the fiscal consequences. Niger removed its health user fees in early 2007 for children under five years old and for specific maternal and reproductive health services. However, securing ongoing funding to sustain this move towards equitable access, even for select populations, is challenging (Lagarde, Barroy & Palmer, 2012). National health insurance schemes, such as those implemented in Ghana (Government of Ghana, 2007) and Ethiopia (Ethiopia Federal MoH, 2013), not only are a means to provide more equitable access to basic services, but may also be a means of generating revenue for health care that is less burdensome to vulnerable populations. Resource Management - People, Supplies, Services Making efficient use of the resources they do have is another challenge facing the countries studied, as policy implementation is often described as being inhibited by weak or otherwise inadequate supervision and performance management of personnel and supplies. For example, Ghana’s MoH (2007) identifies inadequate supervision and weak performance management systems as challenges to the implementation of its HR Policies and Strategies for the Health Sector. Further, Tanzania’s MoH and Social Welfare (2008b) identifies inadequate supervision as a challenge to the implementation of training for MNCH. Similarly, inadequate logistics and supply chain management are described as intensifying shortages of essential medications and other critical materials in Tanzania, Zambia and Uganda, where insufficient supplies of drugs have hindered national immunization programs (Tanzania MoHSW, 2007; Uganda MoH, 2010; Zambia MoH, 2009; 2010b). In Zambia, however, the Ministry (2010b) reports that the procurement and distribution systems for drugs have improved significantly in recent years. Effective resource management is fundamental to ensure not only adequate training and deployment but also the provision of quality health care to improve the health of mothers, newborns, and children. Evaluation, Monitoring and Transparency Across the countries studied, there is recognition of the importance of policy evaluation and monitoring to ensuring efficient and effective use of resources and improving the performance of health care systems. However, none of the countries studied consider the current monitoring and evaluation capacities of their health sectors to be adequate. For example, Ethiopia’s MoH (2007) identifies insufficient monitoring and evaluation capacity as an impediment to the implementation of its Health Extension Program. Niger’s HRH Development Plan (République du Niger Ministère de la Santé Publique, 2010b) was created in response to identified challenges including the need for stronger monitoring and evaluation of policy implementation, and better collaboration between government Ministries with respect to HRH training and deployment. Tanzania’s Health Sector Strategic Plan acknowledges that comprehensive monitoring and evaluation and research policies are mandatory for evidence-based decision making and public accountability, however thus far there is no evidence of their development (Tanzania MoHSW, 2009). Related to these challenge are the limitations of the various countries’ national Health Information Systems (HIS), which, for example, are described as insufficient in Zambia (Zambia www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


MoH, 2011a) and Tanzania (Tanzania MoHSW, 2009). In Uganda the existing HIS is described specifically as a hindrance to improving maternal and newborn health service (Republic of Uganda, 2005). It is difficult to find basic HRH indicators for many countries, such as current head counts, vacancy rates, and rural/urban distribution. -In Ethiopia, for example, the number of established posts at various levels of the health system is not currently available (Feysia et al., 2012). Chronically weak evaluation and monitoring mechanism have implications for transparency and thus corruption control. In recognition, efforts are being made to address this challenge by several countries’ governments. For example, Ethiopia’s MoH reports having invested in bolstering its monitoring and evaluation capacity as part of its current HSDP (Ethiopia Federal MoH, 2010). Ghana has developed a national strategic plan that focuses on the importance of increasing transparent governance in achieving its other goals of modernizing their natural resource industries, improving public and private partnerships, and establishing effective decentralization and efficient public service delivery (Republic of Ghana, 2010). Deficient transparency and accountability are of particular concern for countries strongly dependent on donor funds to support their health care and other vital systems. It is in each country’s best interest to prevent and eradicate even the perception of corruption within their governments, particularly pertaining to the use of donor funds. Prevention of corruption is a significant challenge compounded by aforementioned weaknesses in governance, supervision, performance monitoring, and evaluation infrastructures across all of these countries. The Government of Ghana (2009a), for example, specifically notes that its “existing anti-corruption institutions are weak in terms of capacity, coordination and collaboration”, while Zambia’s MoH (2010b) cites “Weaknesses in the systems for and structures for promoting transparency, accountability and access to information” as a challenge to effective leadership and governance. Even in the presence of legitimate, transparent and accurate practices, a significant concern is that government health care is perceived as being corrupt. In Uganda, for example, a recent survey estimated that 43% of Ugandans consider health workers to be corrupt (Uganda MoH, 2010b). Types of corruption in Ethiopia’s health sector described by respondents to a World Bank Study (Lindelow et al., 2005) included absenteeism or shirking of duties, theft of drugs and materials, and illicit charging of patients. At worst, corruption is confirmed in a country’s government. In Zambia, for example, donors suspended financial support to the health sector when corruption was uncovered in 2009, with significant negative consequences for the performance of the country’s health care system (Zambia MoH, 2010b). In response, the Government of Zambia and its Anti-Corruption Commission developed a governance action plan with donor agencies and other partners, which has since been implemented (Zambia MoH, 2009). Similarly, Uganda has adopted a specific Anti-Corruption Strategy and a broader Governance and Accountability Action Plan, supported by the World Bank (Uganda MoH, 2010b). Ethiopia (Plummer, 2012) and Niger (World Bank, 2005) have also partnered with the World Bank to produce independent overviews of the nature and extent of corruption in their respective countries. If successful, these strategies may lead to significant improvements in the health sector performance of these countries. www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


Partnerships The significance of partnerships – within and across government, and between governments, educational institutions, international funding agencies and other NGOs – was a recognized feature in a number of the policy documents examined. In particular, the importance of partnerships in relation to donor funds to the health care systems of Ethiopia, Ghana, Mali, Tanzania, Uganda and Zambia was repeatedly highlighted. A System Wide Approach (SWAp), which centralizes funding from donor and other non-governmental agencies so that it can be allocated across sectors according to shared national priorities, is in place in Ethiopia, Ghana, Mozambique, Tanzania, Uganda and Zambia (Ethiopia Federal MoH, 2010; Saleh, 2013; Tanzania MoHSW, 2009; Uganda MoH, 2010b; Zambia MoH, 2008). External partnerships provide opportunities but may also present challenges. For example, a challenge with the SWAp is that often the use of these funds is outside the control of the MoH. In Zambia, for example, the result is that donor funds go to fund posts and services that are not aligned with national priorities, such as specialized tertiary care, while the MoH lacks the funds to deliver even its Basic Health Care Package (Zambia MoH, 2008). Fostering partnerships between health and other sectors – particularly finance and education – were identified as key objectives in the majority of countries studied. However, efforts to formally strengthen these linkages have had minimal success. In Ghana, for example, an attempt was made years ago to bring the training institutions that had been variously the responsibility of Ministries of Health and Education together under a single regulatory college. However, this policy was never fully implemented (Beciu et al., 2013). Similarly, ineffective collaboration between Zambia’s Ministry of Finance and Planning and the MoH has resulted in the late provision of funds by the former to the latter, which in turn has been identified as having a negative impact on the implementation of ZHWRS (Bwalya et al., 2013). Stronger collaboration between the health and finance sectors, then, may help to ensure adequate health funds are available when they are needed, which in turn will help the health care system to function efficiently. Further, this improved collaboration between sectors can help to ensure that HRH training is aligned with the competencies required in clinical practice, that clinical practices are aligned with the best available evidence, and that new graduates are placed in the most appropriate posts. Partnership between public and private sectors in health is also crucial to their success, particularly in countries like Ghana, Tanzania and Uganda where the private sector provides a large portion of health care services. Several countries have explicitly identified a strengthened, more integrated relationship between the public and private sectors as a key objective of their national health policies. Uganda, for example, specifies “establishing a functional integration within the public and between the public and private sectors in healthcare delivery, training and research” as an objective of its Second National Health Policy (Uganda MoH, 2010a). Niger notes that their health system’s functionality is a result of public health programs being significantly supplemented by private, faith based and non-governmental contributions (République du Niger Ministère de la Santé Publique, 2010a). Ghana’s 2011 review of its Program of Work (Ghana MoH, 2011) similarly describes several processes undertaken to www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


strengthen its Private Sector Policy. However, no information on the impacts of such efforts was found in our review. Another type of partnership with great potential to strengthen the health sector is between government and academia. Policy-research partnerships, particularly with respect to HRH, are advocated by numerous NGOs including the Global Health Workforce Alliance (2013; 2014) as a key mechanism for promoting evidence-informed policy making. To this end, several countries are making concerted efforts to develop and strengthen relationships between Ministries of Health and their various research institutions. Zambia, for example, has developed a National Health Research Strategic Plan (Zambia MoH, 2008) and established the Zambia Forum for Health Research (ZAMFOHR) to strengthen the capacity of Zambia’s researchers and researchusers to produce, synthesize, access, discuss, adapt and ultimately use evidence (Kasonde, 2009). Among the challenges facing such efforts, however, are inadequate existing capacities for research support activities such as training, communications and synthesis (Kasonde & Campbell, 2012).

Decentralization Several of the countries studied are undergoing, or completing, the processes of decentralization, including Ethiopia, Ghana, Mali, Tanzania, Uganda and Zambia. These processes have been designed to increase administrative efficiency while facilitating greater input into policy development and implementation from local participants. Ghana, specifically, employs a mixed model of decentralization through the development of the District Health Management Teams and by contracting out service delivery to the Ghana Health Service, non-governmental agencies, and the teaching hospitals. This method of moving health policy-making closer to the community level is exhibited through Ghana’s CHPS program (Ghana MoH, 2009b). It was concluded in a World Bank study (Garcia & Rajmukar, 2008) that Ethiopia’s decentralized governance structure helped facilitate improvements in service delivery and human development outcomes in general. Another study in Mozambique found that decentralized management of HRH resulted in improvements to the administration of retirements and a better personnel information system, and was perceived as reducing wait times for deployment (Ferrinho & Omar, 2006). Unfortunately, in several countries, including Ethiopia, Ghana, Mali, Mozambique, Tanzania, Uganda and Zambia, the lack of personnel, management capacity and infrastructure at the district levels, required under a decentralized system, has been identified as significantly hampering the rollout of health policies and programs and made it more difficult to ensure accountability within the system (Couttolenc, 2012; Ethiopia Federal MoH, 2013; Ferrinho & Omar, 2006; République du Mali Ministère de la Santé, 2013; Uganda MoH 2010a, 2010b; United Republic of Tanzania, n.d.; Zambia MoH, 2011b). Decentralization may also result in discrepancies in the design and application of policy as interpretations and plans at the district level may differ not only from the national policy guidelines but also between districts. For example, a recent audit in Tanzania found major inconsistencies in the interpretation of a national reproductive health policy at the council level (Tanzania National Audit Office, 2011). Decentralization is a reality for many countries; the challenge is to ensure that there is support to ensure consistency in the www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


interpretation, application, implementation and evaluation and monitoring of policies at all levels. DISCUSSION This is the first policy synthesis of its kind to consider this scope of countries, documents, and languages. Limitations related to the sensitivity of the search strategy are acknowledged. Potentially relevant articles may have been missed as their titles, abstracts, and author-assigned key words did not include the search terms “Africa”, “developing country/countries” or “middle/low income country/countries”. Future work could include the addition of specific African country names into the search strategy. Lastly, given the wide range of terminology used to describe HRH policy options, the search strategy may have missed qualifying documents. Considering the above limitations, caution must be taken in drawing conclusions about the quantity and quality of efforts being made in the represented countries related to training and deployment of doctors, nurses and midwives for MNCH in rural Africa. In addition, the results of the scoping review should not be used as a proxy measure for the existence and implementation of the types of policy in question. Although a broad and multi-faceted search strategy was employed, there were relatively few policies identified pertaining to the training and/or deployment of doctors, nurses and midwives for rural MNCH, not only for the country sub-set but in Africa as a whole. However, this should not be interpreted as a lack of attention or action towards addressing this intersection of issues. There are several important programs being implemented by several countries to address such challenges, some of which did not meet the exact inclusion criteria (for example, because they focused on health workers other than doctors, nurses or midwives). Further, there may also be policies and programs in place within these countries that do meet the inclusion criteria but for which little or no information was found. Government documents from Ghana, Tanzania and Zambia (Ghana MoH, 2006; Tanzania MoHSW, 2008b; Zambia MoH, 2010a), for example, indicate that they too have (or at one point had) Integrated Management of Childhood Illness programs, but further analysis was not possible as no other information about the programs in these countries was available. For the identified policies, a wide discrepancy between the number and scope of policies and strategies that are proposed and what is evidently implemented was apparent, whilst poor MNCH remains prolific in rural Africa. Further, there was little evidence of clear policy direction for those that were implemented. This inconsistency between planning and implementation may be due to any number of economic, social, political, environmental and technological factors, only some of which are subject to the influence of ministries of health. The most frequently cited challenge restricting health sector improvement in the review was underfunding. In April 2001, heads of state of African Union countries met in Nigeria and pledged, under what was called the Abuja declaration, to set a target of allocating at least 15% of their annual budgets to improving the health sector (WHO, 2011). However, according to the most recent WHO data (Table 3), none of the eight countries included in the synthesis are www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


meeting this target. This identified chronic shortage of funding for the health sector is undoubtedly linked to the high debt loads borne by these countries. Moreover, the inadequacies of public infrastructure are not limited to the health sector, as poor roads, insufficient water, electrical, and sanitation systems, and deficient communications networks are ongoing problems faced by each of these countries. Mali’s electrical grid, for example, provides power to only about 17% of its population (Briceno-Garmendia et al., 2011). The situation is worse in Niger, where only 8% of the population has electricity, and only 18% have the use of sanitary latrines, the lowest such rate in Africa (Dominguez-Torres & Foster, 2011). These broader deficiencies in public infrastructure exacerbate the challenges faced by the health sectors as they encourage the most highly-trained health professionals to migrate to more developed regions and countries. Often, funds from donor agencies supplement countries’ own limited resources and account for a significant portion of the health budgets of African countries. While there is evidence that these funds are put to numerous beneficial uses, there is also evidence that these funds could be more effectively employed if better alignment existed in their application. A World Bank study found recently that Zambia’s health sector has become increasingly fragmented by the re-emergence of global disease initiatives and the associated disease-specific focus of donor funds (Picazo & Zhao, 2009). Another study by the World Bank in Tanzania reports that the ‘fragmentation’ associated with donor funds “results in substantial inefficiencies in the use of resources and often-conflicting incentives for the various actors in the health system” (Haazen, 2012). Similarly, Uganda’s MoH (2010b) notes that donor agencies tend to negotiate contributions and plans with the Ministry of Finance, Planning and Economic Development rather than with the MoH, making alignment with donor funds and national health priorities, such as newborn survival (Mbonye et al., 2012), a challenge. Aligning funds with and across ministries, and more specifically with broader national health priorities, would promote efficient use of resources and investment in evidence-informed interventions. Further gains could arise from building capacity within African countries to manage these resources, and to monitor and evaluate the impacts they have when mobilized. The long-standing and apparently universal nature of this lack of funding suggests that some changes in planning are warranted. Either governments must recognize the centrality of an adequately funded health care system to their national prosperity and allocate their limited resources accordingly (this may require renegotiation of terms with creditors such as the International Monetary Fund), or health sector planners must more explicitly recognize that the funds they deem to be necessary are unlikely to become available, and adjust their strategic plans accordingly. Ultimately, some combination of these two strategies may be best. At a minimum, governments seeking to improve the health of their countries must meet the funding commitments made in the Abuja Declaration. The dearth of peer-reviewed evidence documenting the implementation and impacts of HRH policies in Africa may be partially due to the fact that the evidence being generated is often selfpublished by NGOs like the World Bank; there appears to be almost no such evidence published by governments, even where it exists. Thus a large portion of important policy evidence is either www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


not published or scattered across multiple organizational websites, which cannot be systematically searched in a timely manner. This dispersal of evidence greatly limits its benefit to informing future policies and practices. In this context, the potential role of an international organization such as the WHO to facilitate the more systematic documenting of best practices and sharing of other policy evidence across countries could have tremendous benefits. Where there is peer-reviewed evidence, a repeatedly identified bias towards rural HRH training and deployment research carried out in more developed countries exists. This is not only an issue suggesting a lack of research being done where it is needed most (i.e. countries with HRH crises), but also that the majority of the studies being done for rural training and deployment are not generalizable to the less developed world. This suggests a need for increased regional capacity in order for better representation of generalizable and scalable HRH evidence from lowincome countries and an increased alignment between the research agenda and the needs of African policy-makers. There is a need to improve the degree of visibility offered by Ministries of Health in terms transparency and availability of their various policies. The document review indicated the existence of a wide range of policies, programs and other activities pertaining to health care and HRH in general and some related to training and deployment of doctors, nurses and midwives for MNCH in rural areas specifically. However, details on the content, implementation, and impacts of these policies were difficult and/or impossible to obtain. Despite the multi-pronged search strategies described, due to a lack of archiving of policy information on MoH websites, for none of the eight countries studied in depth could we find copies of any of the specific policies included in our analysis, which was therefore limited to evidence from secondary sources. Although it is noted that ensuring the availability of this information may be eclipsed by more urgent priorities, this lack of accessible information precludes any rigorous analysis of the effectiveness of these policies. More broadly, it calls into question the value of these policies, limits the accountability of those responsible for them, and reduces transparency, opening the door for the unchecked corruption affecting the political process of many of the countries studied. This unavailability of information may be the result of consistent underfunding, poor capacity in evaluation and monitoring and weak HIS, which are essential for establishing an evidence base detailing which strategies and initiatives have been successful. Thus, infrastructure to support ongoing monitoring and evaluation should be prioritized in order to inform future decision making not only at the individual country level but across and between regions. Investment in building such capacity, such as through an international body like the WHO, has the potential to pay great long-term dividends. The diversity of policy interventions described in the documents reviewed demonstrates the level of innovation being practiced by African countries in efforts to improve their MNCH. Although some strategies focus on more traditional professions such as doctors, nurses and midwives, there appears to be increasing attention to and investment in newer cadres such as clinical officers and community health workers. Furthermore, we were able to identify more evidence of www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 5, NUMBER 2, 2015


the success of the latter type of initiative in improving health outcomes than of the former. This apparent introduction and use of several new health care cadres with important responsibilities warrants regular and systematic analysis of how the various competencies of all health care providers align with the specific health care services required by the populations in a given country. In this way, training and deployment policies can be adjusted on an ongoing basis to keep pace with changing health needs and contexts. Areas for Further Study There is great potential to build on this synthesis through future work. The main limitations of this review were the availability of information on relevant policies, and the time restrictions to conduct the review. Related to the latter point, expanding the search strategy for peer-reviewed documents to include names of individual African countries would likely yield more relevant papers. Similarly, follow-up searches for information on specific policies and mining references of relevant documents, could produce additional information about them. Further, interviews or focus groups with key informants in the selected countries would likely generate additional insights and relevant documents. Finally, although we have cited government- and NGOpublished reports where applicable, we limited our consideration of the evidence of policy impacts to the peer-reviewed literature. This discounts the wealth of important analyses being done by NGOs such as the World Bank and CapacityPlus, which have great potential to inform the policies considered here but are seldom published in academic journals. CONCLUSION Overall, it is apparent that the Ministries of Health in the studied countries have endeavoured, and continue to explore, a wide range of HRH policy alternatives aimed at improving MNCH among their respective populations. However, the implementation – and therefore the success – of these policies seem to be severely constrained by economic, political, cultural, social, geographic and technological factors largely outside these Ministries’ authority, but not beyond the influence of inter-sectoral collaboration. Nevertheless, it is important to note how little information on what health policies currently exist in these countries – let alone their implementation and impacts – is readily available, or even obtainable through dedicated searching. Policies had to be analyzed based solely on secondary information, as copies of the actual policies themselves were not available. This lack of transparency and accessibility makes objective assessment of these policies – necessary for any meaningful improvement on them in the future – virtually impossible. As identified by this in-depth analysis, further research is required to explore the contextual factors that influence how policy supports and/or thwarts the education and deployment of HRH to care for women, newborns and children in rural Africa.



Acknowledgement This work was made possible and carried out with the support and generous funding from the Global Health Research Initiative, a collaborative funding partnership of the Canadian Institute of Health Research, the Canadian International Development Agency, and the International Development Research Centre. The research team would like to thank our Advisory Group – Dr. Maina Boucar, Dr. Paulo Ferrinho, Ms. Allison Annette Foster, Mr. Solomon Kagulura, Dr. Vic Neufeld, Ms. Jennifer Nyoni, Dr. Francis Omaswa, Dr. Judith Shamian, and Dr. Mohsin Sidat – for their important contributions and support of this work.



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