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”.