Findings of a mail survey
Human resource management interventions developed by Medicus Mundi (related) organisations
Von Guy Kegels & Bruno Marchal / Medicus Mundi International MMI
In September 2002, Medicus Mundi International commissioned a study with the objective to contribute to developing the background for an action plan that could guide policy action of MMI and inform Medicus Mundi branches on human resources development policies. This study focused on the brain drain, the concept of stewardship and capacity development in the health sector. It included a mail survey to document the experience of Medicus Mundi organisations in the field of human resource management. This paper presents the synthesis of the results of the mail survey and a discussion on the findings.
The national Medicus Mundi branches are supporting a number of NGOs and other partners that are active mainly at provider level: first line health services, district and mission hospitals. A second type of partner organisations are the church hospital or health associations and national coordination bodies. Health workforce management issues are critical determinants of performance at this level.
A limited mail survey was organised at the end of 2002 in an effort to document the experience of European Medicus Mundi branches and their partner organisations in the south. The specific objective of this survey was to gather information on the problems encountered regarding human resource development and capacity building and on the interventions developed to deal with them.
The mail survey consisted of a short, open questionnaire that was sent by mail, fax or email to 10 MM branches in Europe and 30 mostly church-related partner organisations all over Africa. Operational definitions were briefly explained and clarified with some examples.
The validity of the results is limited because of the low response rates. Indeed, only five European MM branches out of 10 responded, while from the south, only four responses out of 30 were obtained. The short deadlines, the slow surface mail communication and difficult email access are probably to blame. These low response rates obviously preclude firm conclusions. However, as we will discuss below, the scope and range of problems and interventions mentioned is quite broad and it matches the issues emerging from the literature review. With these limitations of the data in mind, we will explore in this paper some interesting insights, but do not pretend to present an exhaustive inventory of issues and activities.
Issues regarding human resource
The issues cited by the respondents can be categorised according to the level of the system were they are situated. Given the complexity and the interrelationships between the different determinants of human resources performance, it should be noted that it is not always easy to disentangle the issues listed by the respondents.
At individual level, issues raised pertain to competence, resource availability and motivation of health workers. At organisational/system level, most problems are related to management capacity. Few remarks are made regarding users and community. Indeed, only lack of effective counterbalancing weight is mentioned. The difficult socio-economic conditions of many developing countries are, not surprisingly, mentioned as a cause situated at the external environment-level.
Organisational and system level
and inadequate long-term vision
HRD interventions set up by MM organisations
In this section, we summarily present the interventions developed by MM organisations in the field of human resource development. Where possible, we discuss their (perceived) effectiveness.
Numerous examples were given of supporting medical education and training, a longstanding strategy to improve capacity and competence.
Supporting training programmes: Through improving infrastructure and provision of scholarships, MM Alavia supports a local nursing school. Cuamm supports both the diploma course and the Master in Health Services Management at the Uganda Martyrs University, Nkozi (Uganda). Graduates took up positions at district director level, at hospital director level and in NGOs. In Uganda, UCMB’s programme of scholarships is considered very successful in terms of perceived usefulness, although effectiveness is difficult to assess as it is only in its second year. MM Alavia, Cordaid and Family Life Association of Swaziland have a similar programme. Most of the graduates of the Cordaid supported training programmes took up positions in their employing organisation. Problems with the selection procedure of candidates and drop-out of training contributes to loss of investment. Bonding contracts are attached to scholarships to increase retention. MM Alavia supported capacity development initiatives for traditional birth attendants (TBA), which included providing them with supplies. As a result, TBAs worked in better conditions and were more appreciated by the population.
Continued medical education (CME): MM Castellón supports a programme of continued medical education for auxiliary medical personnel in Nayita (Colombia), which contributed to a better functioning health centre and improved health education. Also Cordaid supports CME programmes in a number of places. Cuamm currently explores the possibilities offered by ICT for continuing education and lifelong learning.
Increasing the availability and motivation of health workers
Although effective and proven strategies to correct health workforce imbalances are rare, MM organisations are currently trying out several innovative approaches.
Retaining staff through financial incentives: Topping up of salaries for a limited number of essential local staff seems effective in retaining staff, at least on the short term. However, for Cordaid, the resulting distortion of local remuneration policies and the low degree of sustainability limits this approach to acute crisis situations. In other cases, Cordaid subsidises the recurrent expenditure of partner organisations to ensure regular salary payments, which contributes more coherently to stabilisation of thousands of local employees. MM Alavia initiated performance management programmes. The financial incentive package proved unsuccessful in improving staff performance, but contributed to retaining staff. Family Life Association of Swaziland is currently working on a similar approach.
Retaining staff through non-financial incentives: MM Navarra and Cordaid support programmes using non-financial incentives to raise operational effectiveness and professional job satisfaction. These include improved working conditions, supplying standard essential equipment and supplies, rationalisation of off-duty schedules and staff transport and housing. This approach was very effective in that it allowed to attract local professionals and to replace expatriate staff by local personnel. In order to respond to the understaffing and rapid turn-over of personnel, some of the hospitals of the Uganda Catholic Medical Bureau have modified the general terms and conditions of service (contracts, pay levels). Uptake of similar schemes by other organisations is slow. Although it is not easy to protect pension funds against inflation, the prospect of social security at retirement has a quite strong influence on recruiting and retaining staff in economically unstable and uncertain situations, as demonstrated by Cordaid in Ghana and Malawi. In other cases, Cordaid is assisting in setting up a system of retirement benefits (for example in a land buying scheme for future pensioners).
Reducing loss of personnel through occupational HIV infection: The Zimbabwean Association of Church-related Hospitals (ZACH) drew up guidelines on prevention and management of needle prick accidents. Cordaid trains local staff on aids prevention and lobbies to give employed (para)medical staff priority in HAART programmes.
Addressing workforce distribution issues: In several countries, Cordaid supported the starting up of training courses for new cadres of auxiliaries to whom duties of higher trained staff are delegated (for example pharmaceutical technologists instead of pharmacists). Despite strong resistance of some professional associations, similar initiatives were taken in Lesotho, Ghana, Malawi, Zambia, Indonesia and Papua New Guinea. Expatriate personnel is sent out to supplement the local staff (Cordaid, MM Alavia, Cuamm). The latter improved its selection process to ensure deployment of qualified and competent expatriate personnel. Cordaid acknowledges that this is a mere drop in the ocean, except in the case of deploying staff at teaching institutions.
Interventions at the organisational level
Formal training: Many interventions aim at strengthening management capacities through formal training (e.g. UCMB and MM Alavia). HR management is specifically included in hospital and health administration training courses (Cordaid). Cordaid also distributes relevant literature on health care facility management and health economics.
Mentoring and coaching: Calcutta Project Basel aims at transferring strategic management and administrative skills through training, coaching and mentoring. MM Navarra uses a similar approach, but focuses also on developing leadership skills: promising individuals are given training and basic resources to develop a personal professional project.
Re-organisation and teambuilding: MM Navarra introduced reorganisation of health providers into teams, focused on common goals and through which exchange of experience is stimulated amongst team members.
Due to the nature and action domain of MM (related) organisations, few interventions are situated at the central level of the health system.
Decentralisation and contracting: Cordaid promotes the strategy of decentralisation and the contractual approach to increase the capacity and decision space of management teams of peripheral centres and hospitals. Where decentralisation of HR decision-making authority is introduced, awareness of the importance of proper HR management rises. Job fulfilment, discipline, good supervision and teamwork are more easily attained, especially if effective community participation allows user pressure on providers.
Due to the low response rate, the previous section presents the responses of only a particular sample of MM organisations. However, the scope of issues and approaches mentioned by the respondents is wide. Even if the level of detail of the information supplied is limited, practically all avenues for action represented by the analytical model that emerged from the literature review (see Marchal & Kegels 2003) have been mentioned somehow.
This survey shows that competence and health worker availability are two main domains in which MM related organisations are active. Supporting training remains a commonly used method to maintain and improve competences. However, MM related organisations also use less formal, but perhaps more effective capacity strengthening methods like on the job training, mentoring and coaching. Staff availability is undermined by the brain drain, both within developing countries and towards higher-income countries. Acknowledging that this represents a major threat to equity and to accessibility and quality of health services, innovative interventions are being carried out to improve the retention of staff.
Some external environmental factors that determine human resource performance are virtually invulnerable to the efforts of NGOs. Because of the relatively few interfaces between most NGOs and the central level of the health system, NGO interventions at the system-level are rather exceptional.
Although both financial and non-financial incentives are frequently called for as a means to influence health worker motivation, much remains unclear on their effectiveness and possible negative effects. Incentives act not only on quality practice, but also on the maintenance of competence and the willingness to be available. It may be useful to consider financial incentives not just as one homogeneous category, but to make the distinction between monetary rewards (salary, overtime, bonuses), compensation for use of personal effects, direct financed (subsidised study leave and tuition) and indirect financed (professional support) incentives.
MM related organisations are often in a position that allows them to a particular margin of freedom, which could be exploited to test innovative approaches. The challenge remains how to seize this opportunity to ensure ‘learning’ from experience, through good documentation of the analysis of the root problems, the choice of the intervention and the assessment of the outcomes without overburdening the core operations.
*Bruno Marchal and Guy Kegels: Current critical issues in Human Resources for Health in developing countries. Which role could Medicus Mundi Internationalis play? Department of Public Health, Institute of Tropical Medicine, Antwerp (2003). Contact: firstname.lastname@example.org, email@example.com.
Reference: Bruno Marchal and Guy Kegels, Which role for Medicus Mundi Internationalis in Human Resources Development? Current critical issues in Human Resources for Health in developing countries. 2003.