Review of challenges in governance as related to

Report
ROAD MAP FOR
STRENGTHENING THE
CARIBBEAN HEALTH WORK
FORCE 2012-2017
Challenges in Governance to be addressed to meet
Milestones of HRH Roadmap
Dr. Sheila Campbell-Forrester
OBJECTIVES

Review the challenges in governance as related to
HRH in the Caribbean


Overview of governance within the context of the
epidemiological, social and the health systems
landscapes
Explore strategies to achieve the milestones of
the HRH Roadmap which address challenges.
SIX BUILDING BLOCKS OF HEALTH
SYSTEMS
Leadership
And
Governance
Service
Delivery
Human
Resources
PEOPLE
Health
Health
Information
Financing
Medicines
and
Technologies
Source: http://whqlibdoc.who.int/publications/2009/9789241563895_eng.pdf
OVERVIEW
The term human resources immediately brings
into focus that people are central to any health
system – as users, providers, administrators and
community etc.
 Logically any HRH Roadmap must be framed
around people and their needs, our response and
their participation.
 However, “each part is equal to sum of the whole”
- all the building block are linked in some way to
create an efficient, cost effective, responsive,
adequately staffed health system will the
necessary tools and technologies that has the
support of the community.


In order for all the parts to become the whole,
Governance and leadership are critical
components to steer the processes and achieve
equity and social justice.
DEFINING GOVERNANCE
Governance is the way Government uses
authority to provide services, make laws and
enforce them.
 Good governance is the effective implementation
of services that are responsive to citizen needs
 Good governance is “epitomized by predictable,
open and enlightened policy making, a
bureaucracy imbedded with a professional ethos,
an executive arm of government accountable for
its actions, and a strong civil society participating
in public affairs; and all behaving under the rule
of the law” World Bank - 1994

LEADERSHIP AND GOVERNANCE
Leadership and good governance provide the
platform for policy, legislation, strategic
planning, monitoring and evaluation.
 The stewardship role promotes accountability,
transparency and limits corruption.
 “Through good governance countries can provide
equitable health systems as they seek to ensure
social protection by providing welfare for citizens
and protecting their natural assets.” WHO 2005
 Good governance can promote sustainable
development through networking and
partnerships as health and development are
inextricably linked.

MANAGEMENT
Ensuring that the vision, mission goals and
strategic objectives of an organization are
determined in a participatory manner,
 The process of seeking to achieve and achieving
value for money,
 Monitoring performance, evaluation of activities,
communicating and adjustment of strategies.
 The ability to effectively, economically and
efficiently perform managerial tasks to maximize
outputs and minimize wastage.

CONTEXT

This Roadmap for Strengthening the Caribbean
Health Workforce outlines:
The epidemiology and demographic landscape
 The social and economic landscape
 The health systems landscape

As the basis for identifying challenges, defining
priorities and maneuvering challenges of HRH.
EPIDEMIOLOGY LANDSCAPE
The epidemiological landscape informs about the
disease burden and the impact on population
health.
 Essential information for HRH strategic
planning, health systems reform/reorientation,
distribution and optimization of health care
teams, financing, quality improvement in service
delivery, governance and leadership.

SOCIAL LANDSCAPE
The social landscape of the region must be
understood against the social determinants.
 Social and economic determinants are a
challenge for the region - social ills - crime and
violence, educational and literacy rates, poverty,
drug use and human trafficking all heighten the
demand for HRH directly and indirectly.

SOCIAL LANDSCAPE
Bahamas has the highest GDP per capita in the
world,
 The rest of the English Speaking Caribbean has
experienced flat or slow growth since the 1990s,
and even contraction since early 2000. (2009
UNDP Human Development Index)

FIVE CHALLENGES IDENTIFIED – TORONTO
CALL FOR ACTION 2006
To strengthen capacity within their Ministries
 To steer human resources planning
 To establish a multi-sector network of
stakeholders for support
 To expand and improve data on the health
workforce
 To assess the landscape regarding universal
access to care, distribution of primary health care
teams, migration within and beyond the
Caribbean region, education and training, and
labor conditions for the health worker.

GOVERNANCE AND MANAGEMENT –THE
STEERING ROLE
Governance and Management is perceived to be
one of the weakest links in the Caribbean:
 Supporting evidence comes from:

The Essential Public Health Functions (EPHF)
Assessment of countries in the Region
 The 20 Goals for HRH Assessment

Areas of weakness identified
EPHF
Regulation and enforcement
x
Quality Assurance
x
Access to services in terms of disproportionate
benefits for those who in addition to state guaranteed
services, have supplementary health insurance
packages (voluntary or arranged).
x
Quality of information/weak information systems
x
Health Financing
x
20 Goals
Human resources unit within the Ministry steering
role
x
Insufficient HR management Capacity for strategic
planning, evidence based policy making, lack of
authority to make critical decisions
x
RESULTS OF THE 20 GOALS FOR HRH
ASSESSMENT
9 Caribbean countries identified their standing
with regard to each of the indicators for HRH
development.
 Two of Nine countries scored 100% with relation
to having achieved a human resources unit
within the Ministry with capacity for monitoring,
evaluation, decision-making, policy
recommendations.
 The two countries identified a number of areas
where their HRH unit needed to scale up their
steering role capacities.

CHALLENGES
Reorientation of preventive and
curative services towards integrated
models of care – gate keeping for e.g.
to manage movement of patients
between primary and secondary care
and appropriate placement and
movement of HR
 Strategic positioning of HRH to
achieve quality care that is efficient,
effective and responsive

OTHER CONCERNS HIGHLIGHTED
Public health leadership and the Steering role
 Public private partnerships and the coordination
with non-health sectors in promotion “health in
all policies agenda”.
 The financial burden on the health system.

GOVERNANCE CHALLENGES
 Organization
of the health system to
support the HRH as all parts are
interlinked:
 Health Policy and regulatory
framework to guide reforms including
public private partnerships
 Regulatory enforcement
 Promoting the “health in all policies”
agenda across government and in non
health sectors.
CONCERNS HIGHLIGHTED
Escalating health costs especially against the
background of the global recession since 2008
 State of the Information System – described as
disintegration between system components; nonestablished or non-enforced processes to collect
and process data; HIS systems being
underfinanced.
 The need for health reforms in how health
systems are organized and financed.

HEALTH SYSTEM CHALLENGES

Organization of the health system to support the
HRH as all parts are interlinked:
Health Policy and regulatory framework to guide
reforms including public private partnerships
 Promoting the “health in all policies” agenda across
government and in non health sectors.

HEALTH SYSTEMS CHALLENGES


Health reforms - Reorientation of preventive
and curative services towards integrated
patient centered models of care – including
gate keeping for managing movement of
patients between primary and secondary care,
more home-based care and appropriate
placement and movement of HR.
Strategic positioning of HRH to achieve
quality care that is efficient, (cost) effective
and responsive
ORGANIZATIONAL CHALLENGES
Integration of quality assurance in HRH and all
other areas of health care for public and private
sectors
 Achieving equity of access, reducing the disparities in
service delivery through the development of essential
packages of care and ensuring the participation of the
community in all aspects of the implementation
(Chile model)
 Meeting health needs across the life course and
applying HRH framework e.g. elderly and men's
health in keeping with the epidemiologic and
demographic transitions

INFORMATION SYSTEMS: MANAGING HRH
DATA WITH HEALTH SYSTEMS INFORMATION

A “chronic disease” of the health system has been
the weak information systems which is an
impediment for rational/effective decision making
especially in this area of HRH. A relevant Road
Map has been endorsed by the Caucus of
Ministers in 2011.

Challenge is the health human resource gap and to
how to address it. What are the priorities and
strategies to inform the manpower strategic plan?
WORLD BANK STUDY 2009 – NURSE
SHORTAGE
Less than 10% of nurses involved in PHC
Substantial attrition due to migration
100
80
60
40
20
0
0 yrs
Jamaica
5 yrs
15 yrs
20 yrs
SERVICE DELIVERY CHALLENGES

Balancing competing priorities against shrinking
economies and at the same time sustaining gains
made. Sustaining HIV/AIDS gains and reaching
to address NCD’s
PRIORITY CHALLENGES IN MANEUVERING
THE CURRENT LANDSCAPES
HRH Steering role in the Ministry of Health –
strengthening strategic planning, evidence based
policy making, monitoring and evaluation and
management of HR.
 Coordination and integration of needs and multi
sector components of HRH planning.
 Improvement in the collection, organization
and management of health workforce data

PRIORITY CHALLENGES IN MANEUVERING
THE CURRENT LANDSCAPES
Development of integrated systems that link
HRH data from various sources and link that
information to other health planning
information, as well as health outcome data.
(Centers of Excellence and integrated networks
into a comprehensive HIS)
 Sustaining HIS with updated quality information
for crafting evidence based policies that answer
real needs. This goal is highlighted in the
CARICOM CCH III.


HRH STOCKS AND FLOWS
Challenge is to address the density ratio of
health professionals to population.
 WHO established a benchmark for a minimum
number of trained professionals (physicians,
nurses and midwives) per population to ensure
an acceptable level of health coverage. Ratio is
25/10,000 ratio.
 Eight of the ten countries who participated in the
baseline measurement reached that standard.
Belize and Jamaica fell below the target –
implications for the region.

HRH STOCKS AND FLOWS
Improved access to quality care based on
quantity, distribution, capacity level,
motivation, and productivity of the
workforce presents a challenge.
 Team work, strong capacities and
competencies for both PHC and STC must be
strengthened
 Working conditions, hours of availability to the
public sector, proximity to the populations, and
capacities available to meet the needs of the
Caribbean people are important challenges to be
addressed

HRH STOCKS AND FLOWS
What are the skills sets required against the
background of changing epidemiological,
demographic and environmental profiles?
 Are task shifting and a combination of skills a
possible solution?
 Movement of HRH within country, within region
and outside of the region is a challenge. How can
address this challenge and stem the loss of
experienced mid-career health professionals,
particularly nurses?
 What policies need to be put in place?

WORKING CONDITIONS

Precarious contracts, such as short term posts
that provide little or no insurance or benefits
create an unstable environment but are often
necessary mechanisms to achieve staffing.

What can be done in the region to improve the
working conditions of health workers?
PARTNERSHIPS
Global and Regional partnerships
 HRH Leadership in the Region- Jamaica, Belize,
T&T
 Opportunities exist to strengthen health systems
and HRH in particular (Global Fund, PEPFAR,
PAHO/WHO etc.)
 Governance structure for CARPHA and its
monitoring role
 Country Cooperation Strategy between PAHO
(technical cooperation) and CARICOM in
monitoring the progress of CCH lll.

QUESTIONS?
Governance is overarching and this forum
provides an opportunity to identify the barriers
to achieving the proposed road map milestones.
 What is the governance structure? Regional ?
Joined up government? HRH in Ministries of
Health? Other Ministries
 What is the political framework?
 What policies are required and how can there be
synergies in the region?

QUESTIONS?
How can we maintain an updated HR policy
inventory and data base ?
 What resources/skills competences are needed
and how can we get to optimal skills mixes?
 Is there a system for defining needs? What are
our needs, what polices are in place to address
these needs?
 How can we best utilize the technical cooperation
available to us to share best practices?
 How coherent is the roadmap?

QUESTIONS?
How can there be true stakeholder participation
in policy and strategic planning? How do they
relate to each other? What systems and
leadership are needed to facilitate these at all
levels?
 Will the road map be cost beneficial?
 Is there capacity to develop Policies and policy
briefs to support the Road map?
 What is the capacity for M&E ?
What is the role of technology?
 Role of the Centers of Excellence ?
 Is there adequate capacity to achieve the goals ?

HRH INITIATIVE
Needs based analysis in collaboration with
PAHO/Dalhousie University with South East
Regional Health Authority as pilot
 HRH 20 goals



Gap analysis (mapping of needs)
40% doctors to PHC*
Minimum Data Set
 Caribbean Center of Excellence (Jamaica)

HRH INITIATIVE -POLICY SHIFT
Rotation of nurses through PHC
 Community Health Worker initiative with the
National Youth Service
 Training of Assistive Health Workers
 Schools training more doctors and nurses
 Curriculum development shift e.g. For
Community health workers and Family
Practitioners
 Incentive package for encouraging health
workers to go to rural PHC areas (starting with
Doctors)
 Jamaica – Cuba bilateral agreement includes
nurses for PHC

Essential Public Health Functions
EPHF 1: Monitoring, evaluation and analysis of health status
EPHF 2: Public health surveillance, research and control of
risks and threats to public health
EPHF 3: Health promotion;
EPHF 4: Social participation in health;
EPHF 5: Development of policies and institutional capacity for
planning and management in public health;
EPHF 6: Strengthening of institutional capacity for regulation
and enforcement in public health;
EPHF 7: Evaluation and promotion of equitable access to
necessary health services;
EPHF 8: Human resources development and training in public
health;
EPHF 9: Quality assurance in personal and population-based
health services;
EPHF 10: Research in public health;
EPHF 11: Reducing the impact of emergencies and disasters on
Score
KOFI ANNAN ON GOVERNANCE
“Without good governance -- without the rule of
law, predictable administration, legitimate
power, and responsive regulation -- no amount of
funding, no amount of charity will set us on the
path to prosperity”.

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