The Ghanaian health system faces a number of major challenges in the recruitment, deployment and retention of health care workers (HCWs). Significant among these is the decision by many young, newly trained professionals to migrate due to a number of reasons, including seeking more attractive work and living conditions abroad. Migration patterns of HCWs over recent years show that Ghana has a relatively high migration rate compared to other African countries, particularly among doctors and nurses. Sixty percent of doctors from the country’s main medical school emigrated between 1986 and 1995. Requests for verification of nurses’ qualifications to work abroad showed annual figures almost double the replacement rates from training institutions. Human resources for health are also poorly distributed, being one of the ingredients of an increasing inequality among the country’s regions and between urban and rural settings. For those HCWs who stay, the incentives for higher productivity and location in remote areas are also low. In 1998, partly in response to these factors as well as industrial agitation from the Ghana Medical Association (GMA) and health worker unions, the Government of Ghana (GOG) introduced the Additional Duty Hours Allowance (ADHA). The original purpose of the ADHA scheme was to compensate doctors for hours worked beyond the standard 40 hours per week or 160 hours per month.

Initially the allowance was only paid to doctors. In 1999 the Nurses Association agitated for and was included in the ADHA. Even though the ADHA scheme arose from industrial action between the GOG and HCW unions, the significant increases to income levels that resulted would seem a powerful intervention to positively affect HCW recruitment, deployment and retention. To explore this question and examine the consequences of the scheme, the Capacity Project partnered with the Ghana Health Service (GHS) to undertake a comprehensive study of the ADHA scheme. The study investigated how the scheme impacted a number of human resources (HR) factors associated with health worker recruitment, deployment, retention and performance—specifically, how the significantly higher income levels resulting from the ADHA scheme influenced job satisfaction, motivation, workplace climate and the relationship between clinical and administrative staff, as well as productivity. The study provides a detailed chronology of the ADHA scheme and explores lessons learned from the way in which the GOG implemented and administered the scheme.

A first hand account from Uganda about the task of computerizing paper files to build a data system that will help make appropriate health plans, programs and goals.

Detailed synopsis of a Human Resources for Health (HRH) workshop (2 modules) to engage and integrate genders in the workplace.

This paper outlines the themes, key elements of success, and the remaining challenges in improving family planning in Rwanda.

Health workforce planning is necessary in order to ensure that trained and knowledgeable health workers are available to deliver healthcare services when and where they are needed. Ensuring adequate human resources for health (HRH) is crucial in order to continue progressing toward the realization of the Millennium Development Goals. The purpose of workforce planning is to determine the most appropriate balance among the mix, distribution and number of health workers. As Thomas Hall has noted, workforce surpluses or shortages can decrease productivity and efficiency, deplete scarce resources and squander worker capabilities. Training health workers requires a significant investment of time and resources; therefore, restoring balance to a system in which the health workforce supply is out of sync with the demand for health services can be a lengthy process. In this context, health workforce projections can be very useful. The aim of this technical brief is to provide a rapid review of different health workforce projection approaches. A list of references serves as a guide for those who would like more information on this subject.

Developing human resources for health (HRH) requires a multidisciplinary and multisectoral approach to ensure that health care consumers have access to high quality, cost-effective services. Professional associations for health care workers can promote high standards of practice, advocate for the needs of both consumers and providers, form networks with other professional associations and liaise with legislative and regulatory bodies. Strengthening professional associations is one strategy for addressing global HRH issues such as out-migration and the lack of an adequate supply of well-trained professionals to deliver HIV/AIDS services. This technical brief discusses various approaches for strengthening professional associations and outlines the benefits and challenges of such efforts.

Mobilization and strengthening of the health workforce is central to combatting health crises in some of the world's poorest countries and for building sustainable health systems. Strengthened Human Resources for Health (HRH) capacity is essential to meeting almost every national and international health objective, as well as the objectives of the United States Agency for International Development (USAID), Global Health Bureau, the President's Emergency Plan for AIDS Relief (PEPFAR), the President's Malaria Initiative (PMI) and the Millennium Development Goals. Improved and expanded HRH is vital to sustaining the gains made in past decades in areas such as family planning and child survival as well as more effectively addressing HIV/AIDS, tuberculosis and malaria. In September 2004, the USAID Bureau for Global Health/Office of Population and Reproductive Health/Service Delivery Improvement Division awarded to IntraHealth International the Human Capacity Development Program to address the HRH challenge, later renamed the Capacity Project. The Capacity Project strengthened human resources to implement quality health programming in developing countries, focusing on: 1) Improving workforce planning and leadership to ensure that the right type and number of health workers are deployed to the right locations; 2) Developing better education and training programs so that health workers have the knowledge and skills to meet the needs of their communities; and 3) Strengthening systems to support workforce performance and encourage workers to remain on the job.

This report summarises the results of a study of health worker satisfaction, working conditions and intent to continue working in the health sector in Uganda. The findings point to the importance of a number of factors that contribute to satisfaction and intent to stay, including differences by cadre, gender, age, sector (public or non-profit) and location. The results suggest several policy strategies to strengthen human resources for health in Uganda. More than 700 health professionals were surveyed in nine districts and 18 health facilities. Three focus groups were conducted in each facility, with health workers separated by cadre (physicians, nurses and allied health). The study was conducted in July 2006 using a team of 20 Ugandan health professionals, most of them recent graduates of or current students at the universities in Kampala. The study was conducted by the USAID-funded Capacity Project with the Uganda Ministry of Health, with support from the US Health Resources and Services Administration and three universities (Makerere, Aga Khan and University of Washington). It was conducted under the oversight of the Uganda Health Workforce Advisory Board, a group of Uganda health system stakeholders.

In 2002, Zanzibar initiated health sector reform. One of the reform’s principal aims was to decentralize the planning, prioritizing and integration of health services to the district level. As part of the push toward decentralization, the reform plan also emphasized improvements at community-level facilities to ensure the availability of high quality services and an essential primary health care package. In 2006, assessment of the reform process resulted in a new strategic plan (the Zanzibar Health Sector Reform Strategic Plan II, or ZHSRSP II). Improving the quality of care and productivity of health care workers at all levels of the health care system is a principal goal in the ZHSRSP II, through strategies such as strengthening human resources for health, improving efficiency through integration of services and decentralizing health service delivery. To support these efforts, the Capacity Project (in partnership with the MOHSW) is carrying out the Zanzibar Project to Support Greater Productivity, a five-phase initiative to investigate productivity in the health care sector and select, implement and evaluate interventions to improve health worker efficiency. The Project completed a baseline study in the summer of 2006, followed in November by a stakeholder workshop to present the study results, analyze the most significant productivity gaps and identify and select interventions to improve productivity.

This is a guideline to replicate and scale-up a human resources promising practice documented by the Capacity Project for outsourcing human resources services (HRS) to obtain a rapid increase and deployment of the health workforce, making HIV services available in a short period of time, especially in underserved areas. The guideline is based on the program implemented by the Ministry of Health and Social Services (MOHSS) of Namibia and the US Centers for Disease Control and Prevention (CDC). Human resources planners and managers will find useful information on the context in which this solution was implemented. Although context varies from country to country, the need for additional human resources to make HIV services available and system regulations that constrain quick management responses are common challenges faced by many low- and middle-income countries. The guideline also analyzes the challenges that test the validity of this innovation, warning health managers and decision-makers of the strategic and implementation pitfalls they may experience, based on the actual difficulties, pros and cons reported by stakeholders who took part in the Namibian program. The guideline also provides an analysis of the critical steps required to ensure a smooth and successful program implementation, considering the initial context, system limitations and implementation challenges.

To support good performance, health care workers need clear job expectations, up-to-date knowledge and skills, adequate equipment and supplies, constructive feedback and a caring supervisor. Workers also need motivation, especially when some of the other factors that support good performance are lacking. Indeed, highly motivated individuals can often overcome obstacles such as poor working conditions, personal safety concerns and inadequate equipment. Given the current challenges related to human resources for health (HRH) in most developing countries, helping workers to be as productive as possible in the face of such obstacles can be an important outcome of increased motivation.

The number of health workers employed is an indicator of a country’s ability to meet the health care needs of its people, especially the poorest and most vulnerable. Resource-constrained countries committed to the Millennium Development Goals are facing up to the reality that shortages and uneven distribution of health workers threaten their capacity to tackle the HIV/AIDS pandemic, as well as the resurgence of tuberculosis and malaria. Worker shortages are linked to three factors: 1) decreasing student enrollment in health training institutions, 2) delays or freezes in the hiring of qualified professionals and 3) high turnover among those already employed. Increasingly, health care managers and organizations are focusing attention on the problem of low retention, recognizing that these losses are costly, negatively effect continuity of care and raise the potential for turnover of remaining employees who suffer stress and burnout from taking on the additional burden of care. Based on an intensive literature review, this technical brief considers challenges and responses related to retention of health care workers, including the causes of turnover, actions to address turnover and emerging evidence on retention approaches. The brief considers retention primarily in the context of sub-Saharan Africa.

The complex and wide ranging challenges related to human resources for health in developing countries necessitate that stakeholders work together through inclusive alliances and networks. The World Health Report 2006, Working Together for Health, advocates the formation of cooperative structures to pool limited expertise and fiscal resources and to promote mutual learning. In theory, establishing and operating such cooperative structures and partnerships appears simple. There is history to look to, best practices to draw upon and a body of literature to read and from which to learn. However, as we all know, partnerships are not created in theory. They are forged in reality with all the complexity, challenge and potential extraordinary accomplishment that human collaboration brings. Therefore, this kit aims to offer those wanting to create a partnership, as well as those already working in one, some easily accessible tools to support that process. Using the wisdom and experience of those in the field as well as what the current literature offers, this toolkit offers some helpful, succinct guidance on identifying potential alliance partners; facilitating a dynamic and helpful kick-off meeting; creating an appropriate memorandum of understanding; and more.

This guideline is for human resources planners and managers in the health sector and sets out the steps required to extend the health workforce by incorporating lay workers (field officers), especially in the delivery of antiretroviral therapy (ART) to home-based clients. The guideline also attempts to describe the critical path required to set up such a program, showing some of the points at which there may be challenges or barriers. This critical path is based on the initial context of the program, which may not be exactly the same as other settings, but it offers a reasonable example of the scope of what has to be considered in starting and sustaining such a program.

Various tools and approaches can help accelerate the process of providing health care workers with the skill sets needed to tackle current health care needs. To this end, the Capacity Project has identified and categorized existing tools and approaches that support health cadres in learning new skills, especially in the area of HIV/AIDS. In this paper, we briefly describe and give examples of these potential resources, providing web links (where available) in the appendices. It should be noted that this is not an exhaustive compilation of resources, nor does the Capacity Project endorse any particular tool or approach.  We discuss four categories of tools and approaches (not all mutually exclusive): 1. Existing short courses and curricula; 2. Guides and tools for course design and curriculum development; 3. Alternative training approaches; 4. Tools for performance support.

Retention continues to be a serious challenge in the human resources for health (HRH) crisis. There is increasingly widespread commitment to initiatives to attract and retain skilled workers, especially in rural areas. However, the factors influencing health workers’ decisions to move from impoverished rural areas to richer and better equipped urban settings and from lowincome countries to those offering higher salaries are complex. Available evidence consistently shows that health workers are ready to leave because of low compensation, lack of practical and educational opportunities, poor working and living environments and inadequate social amenities.  In order to help HRH practitioners address the challenge of retention, the Capacity Project selected information from existing literature to compile a resource paper and a technical brief. The purpose of this brief is to update and document some contributions made from 2005 to 2008 in the area of worker retention.

Through its Community-Based Health Planning and Services (CHPS) initiative, Ghana has deployed more than 310 auxiliary nurses in 53 of the country’s most deprived districts. These nurses, who receive two years of training and the title community health officer (CHO), are part of an innovative approach that shifts staff from low-impact static health centers with limited outreach to high-impact mobile community-supported services. CHOs provide “doorstep” services to underserved rural populations and have improved access to health services for nearly one million Ghanaians (each CHO serves an average of 4,500 people), resulting in substantial improvements in community health.

The consensus from recent debates about how to approach the current human resources (HR) challenges in the health sector is that it is important to have a national strategic HR plan. Perhaps this sounds obvious. However, a number of countries have no plans at all, some have plans that are not strategic and others have excellent plans that were developed but never used. So most have at least some work to do to improve their strategic HR planning processes. Each country faces different HR challenges, and these will change from year to year. All strategic plans are likely to be different and evolving, and there is no single blueprint for their development. This technical brief provides some guidance on HRH strategic planning, illustrated with examples.

The field of health care requires the availability of well-researched knowledge supported by compelling case studies or clinical trials to make sound health-related decisions. This ensures that health innovations and new practices are informed by the best available data and research evidence. However, the same rigor is not necessarily applied in the field of human resources for health (HRH), particularly in using workforce data to make sound strategic, policy and programmatic decisions. As such, a key challenge to human resources (HR) practitioners and policy-makers is to contextualize HR data and information for more effective decision making and subsequently for policy formulation and practice. With external assistance, developing  countries in sub-Saharan Africa are beginning to establish better human resources information systems (HRIS) as part of a comprehensive and integrated response to some of the fundamental challenges posed by the health crisis. While this is a positive development, it is equally important to begin thinking about simple, practical approaches for supporting HR planners and senior decision-makers to be effective leadersand managers of HR data. Data-driven decision-making (DDDM) is an ongoing collaborative process of making informed HR policy and management choices based on appropriate analysis of relevant data and information. The purpose of this technical brief is to present ten fundamental and practical pillars to aid HR managers, practitioners and policy analysts in building a bridge from HR data and reports to effective HR policy and management decisions.

Strong health professional associations have the potential to foster commitment to quality care, reduce staff turnover and forge connections among patients, providers and policy-makers (McQuide et al., 2007). Associations also provide female-dominated professions, such as nursing, with mechanisms to develop and strengthen leadership roles (Zuyderduin et al., 2009). As one component of the Capacity Project’s efforts to strengthen human resources for health (HRH), the Project worked to support professional associations in Ukraine, Kenya and Uganda. Health Professional Associations Initiative were: 1) to promote high standards of practice; 2) to help provide the skills for associations to advocate more effectively for the needs of clients and providers; and 3) to form networks among professionals and professional associations.