The role of government

Human resource planning for health by geographic area, type of expertise, category of worker, gender, and various time horizons is an essential public sector activity (Box 6-3). Nearly every African country needs -to strengthen its ability to perform such planning, particularly to determine staffing needs at health centers and district hospitals. This means that national governments must have employees with technical skills in preparing projections, setting norms, and

- Visit all the health posts and health centers in the district to establish active working relationships of staff, especially of government clinics, with the hospital

- Organize monthly meetings of senior clinical and management staff: to discuss issues affecting the care of patients, concerns of staff, and efficient running of health services within the hospital and the district as a whole and to find solutions to them

- Conduct daily administrative rounds of ancillary hospital departments, such as catering and maintenance, to learn about operational problems. Within six months, a discernible improvement was observed by staff of the hospital, the regional director-of health services, the headquarters of the Ministry of Health, and generally by persons seeking care at health facilities in the district. Services offered free to the hospital, thanks to the initiative of the local health leader, included loan of a tractor for the hospital garden; sale of essential provisions to staff at concessionary prices on the hospital premises; and donation of material to make bed-species and pajamas for patients. By working directly with institutions in his area, the district medical officer was able to tap resources normally not available to the Ministry of Health for local use. Source: Amonoo-Lartsen 1990.

As health care systems become more diversified institutionally, it is important that public sector planning take into account all health personnel, including those working in the private sector and those who work for nonprofit or charitable institutions, such as religious missions. Particular attention should be paid to training senior cadres to provide better leadership on health matters, including research. Leadership in health requires not only a comprehensive knowledge of health matters as such but also some fundamental knowledge of such related. subjects as pharmacology, economics, financial analysis, and public works construction and maintenance. Ministries of health should also encourage the establishment and work of voluntary associations of public health personnel.

It would be unrealistic, however, to expect public sector health care workers to increase their work load significantly without additional compensation and reliable payment of wages and salaries. Because civil service salaries are unlikely to undergo significant improvements in the near future, national authorities will need to give local health managers greater autonomy in salary decisions. Local retention of fees is one means of increasing compensation and ensuring regular payment of salaries at well-functioning health centers. Other salary possibilities include wage supplements for night duty and holiday work and supplying housing so that key staff members can live near the facilities where they work. The resources needed for such changes must in part be found by reducing the numbers of unskilled support personnel and by purging from the payroll the names of those no longer working. This is being done in Guinea.

BOX 6-3. STRENGTHENING HUMAN RESOURCES PLANNING AND MANAGEMENT IN LESOTHO'S MINISTRY OF HEALTH

Lesotho is undertaking a systematic program to strengthen its management of health personnel. Actions planned include:

- Development, implementations and maintenance of human resource management information systems for personnel administration, planning, and training

- On-the-job training for development of the personnel planning process in the Ministry of Health to provide senior managers with the information and planning framework necessary to make decisions on staffing and training priorities

- Design and implementation of a system for selection placement, and monitoring of training activities. Development and use of a personnel manual · Design and implementation of a computerized personnel management information system (PMIS), in coordination with the Ministry of Public Service· Training of Ministry of Health staff in using computers and in running the PMIS.

Incentive payments in well-functioning health centers have become a feature of systems of community financing of health care in a number of African countries, including Congo, Kenya, Guinea, and Nigeria. With sixty-four health centers for more than 900,000 people, Guinea appears to have the most widespread practice of local incentive payments (UNICEF 1992c). Resources mobilised by the community to pay incentives have ranged from around 10 percent to nearly 50 percent of normal salary levels. Successful health districts have also applied a variety of techniques to recognize the best performers. In Ghana, the Ministry of Health established a prize fund to provide incentives for superior performance by individual health workers and health teams. In Mali, health districts are required to meet specific performance criteria to receive full government and donor support for their district health plans.

Training must be adapted to practical needs at the district and community levels, and health training should be given to others in the community, especially schoolteachers and agricultural extension workers. Much more attention. should be paid to the study of society, demography, and the community, as well as to the principles and practices of health leadership. At the same time, should be less oriented toward western models of medical practice. Governments trying to build up district-based systems also need to rationalize and consolidate health training schools, make them multidisciplinary, and show them how to foster the development of the district health team concept and better health leadership. Madagascar is taking action along these lines by decentralizing functions and putting them under field supervision.

Finally, as a part of long-term investment in capacity-building, male and female teachers in health care need to have periodic opportunities to improve their skills. They should also be able to obtain basic academic journals in their fields. Better compensation of teachers at health training institutions should be part of the improvement of salaries and incentives for all health workers.

African governments also need to take traditional healers into account in planning the use of human resources for health. There are approximately l0,000 traditional healers in Zaire and more than 3,000 traditional birth attendants who practice actively in the informal sector. The Ministry of Health has set up a unit to gain a better understanding of their roles and to weed out harmful practices. About 12,000 traditional healers are registered in Zimbabwe. A significant share of the rural population depends solely on them in Ghana, Benin, Nigeria, Senegal,, and Zambia, among other countries. While some modern health care givers systematically reject traditional practices, Nigeria’s health policy makes

BOX 6-4. COOPERATION BETWEEN TRADITIONAL HEALERS AND MODERN HEALTH CARE PROVIDERS

The establishment of registered associations of traditional healers is a first step toward collaboration between the informal sector and modern health care systems in Sub-Saharan Africa. More than twenty African countries have registered associations of traditional healers, including Nigeria, Ghana, Senegal, Benin, Cd’Ivoire, Zimbabwe, and Zambia. The degree of cooperation between traditional and modem practices of care vanes from country to country. However, a number of collaborative programs between biomedicine and African indigenous health practitioners exist, such as the Araromi program in Nigeria, the Marnpong Center for Scientific Research into plant medicine, the "Alkaloid Unit" at the University of Science and Technology in Kumasi, and the Primary Health Training for Indigenous Healers (PRHETIH) at Techiman , all in Ghana Research in plant medicine and traditional-healing is also taking placing in Niger and Zimbabwe. Much more needs to be done to promote development of appropriate training for traditional providers, especially traditional birth attendants) Research and dissemination of information on the strengths and limitations of traditional medicine are also needed to enable modern health workers to understand the social and psychological rationale behind traditional practices, to become sensitive to traditional beliefs concerning health and health care, and to collaborate with these practitioners. Studies have shown that traditional healers are skilled in helping people to cope with the psychological and social stress that often accompanies rapid social and economic change. Policies need to build on the cultural norms and practices that facilitate this process, to promote greater cooperation among practitioners in the informal sector and those in the modern sector room for training traditional practitioners to increase their skills and effectiveness and promote their integration into the existing national health system. In Ghana, Nigeria, and Zimbabwe,- retraining programs have made it possible for some traditional healers to use modem treatment modalities, such as oral rehydration (Box 6-4). Also, AIDS prevention programs are increasingly drawing on the help of traditional healers.

Conclusion

Although the numbers of those who deal with health problems have grown markedly since independence, there are still fewer on a per capita basis in Sub- Saharan Africa than in other areas of the world. The numbers of those with health skills in most countries remain imbalances in relation to needs, and deployment, compensation, and motivation are weak. Many more trained people are needed to carry out the tasks of policy analysis, planning and budgeting (Box 6-5).

The paramount need is for better supervision at the district level. The task at the national level will be to create an environment for effective management at the lower level. Personnel policies, including preparation of job descriptions and supervision norms, are central to this work and will require genuine collaboration of health, and with ministries of finance and planning and civil service commissions.

BOX 6-5. DEVELOPING HUMAN RESOURCES FOR HEALTH LEADERSHIP AND RESEARCH IN SUB-SAHARAN AFRICA

Despite the evident need,' senior-level training institutions and opportunities for health leadership and research in Africa-are scarce. Few universities or other institutions offer training to prepare people for these roles. In recognition of the unmet need, new and strengthened graduate programs are being established in some African countries, such as Zimbabwe and Nigeria, with an emphasis on field -oriented training, based on partnerships between universities and government departments responsible for public health programs. The development of such programs is responsive to the need to emphasize practically oriented disease prevention and- development programs at the district level. In anglophone countries, the increasing emphasis on public health has been nurtured by training in community medicine. This has existed for many years in Ghana, Nigeria, Kenya, and Uganda, New programs in public health have been created-or are in development at the Universities of Ibadan, Accra, and Nairobi. New public health training programs have been developed at the University of the Western Cape in Capetown and through the University of Zimbabwe. Among francophone countries, several training programs have evolved from a WHO-sponsored school of public health in Cotonou. The University of Kinshasa opened a school of public health in 1986, and the Universities of Abidjan and Dakar have developed training programs at the diploma or master's level. A school of public health—the Centre Inter-Etats d’Enseignement Superieur en SantCIESPAG)- has been initiated at the University of Brazzaville, and one is under consideration in Cd'Ivoire. Building on these and other initiatives, governments and donors need to collaborate at-the national and inter-country levels to prepare and finance plans to strengthen health leadership and research capacity) Fortunately, new programs that have evolved over the last five years are being increasingly recognized by donors as suitable alternatives to training outside Africa.

Source: Bertrand 199