WB Regional HRH Analytical Papers

The Africa HRH program team is producing a number of research papers and tools that focus on various HRH issues at the regional level in Africa. The following papers are planned, currently ongoing or completed. These research papers discuss various issues related to HRH at a broad regional level and are meant to inform governments, donors and academia working on HRH in the Africa region.

HRH in Africa, New Issues and Findings: Agnes Soucat: description of paper forthcoming

Handbook on Monitoring and Evaluating the Health Workforce: With special applications for low and middle income countries. The goal of the handbook, is to provide a comprehensive reference on health workforce measurement strategies and analytical tools so that countries will be able to collect and analyze health workforce data more effectively. This, in turn, will help build the knowledge base needed to guide, accelerate and improve country action.  The handbook is expected to be of use for staff responsible for health work force statistics and planning at national and sub-national levels. It will also be of interest to the research community, professional associations, and bilateral and multilateral institutions that are active in health workforce information system and planning. The Handbook is a joint publication between the World Bank, WHO, and USAID.

Africa Health Labor Market Toolkit: Joint publication with WHO and USAID. Practical, easy-to-use, definitive reference for health labor market research and analytical methodologies to be used in the diagnosis and mitigation of health worker shortages in Africa. The “Africa Labor Market HRH Toolkit” is expected to be of use to governments and partner organizations and institutions working on health workforce policy, management, information systems, statistics and planning in Sub-Saharan Africa and beyond.

Africa Health Worker Crisis: Options for Removing Bottlenecks to HIV/AIDS Prevention, Diagnosis, Treatment and Care: Kate Tulenko and Mansoor Farahani: The Bank’s Africa Health Workforce team was requested to write this background and options paper in preparation of the Africa Region’s five year strategy in “HIV/AIDS Agenda for Action 2007-2011”. The Team was asked to answer the following questions regarding the Africa’s health worker shortage and HIV/AIDS epidemic: What is the context/rationale for addressing human resources for health (HRH) from an HIV/AIDS perspective? Where does it fit into the Africa HIV/AIDS story line? What in HRH has worked and what has not in contributing to the AIDS response? What are the particular bottlenecks to better addressing the Africa HRH crisis? What results might be expected in five years from the global response, not just the Bank's contribution? What are the operational implications for the World Bank and what specific concrete recommendations should be made? The paper represents the synthesis of existing knowledge and best practices and was not intended to involve new field research.

Qualitative Research to prepare quantitative analysis: absenteeism among health workers in two African countries: Pieter Serneels, Magnus Lindelow and Tomas Lievens discuss methodological issues in a chapter for a book on research in health service delivery edited by Markus Goldstein and Jishnu Das. To date, most work in economics on absenteeism has been quantitative in nature. While it has identified a number of correlates of absenteeism, it has also raised a number of questions of both methodological and substantive nature. How should absenteeism in the health sector be conceived and modeled in developing countries? What is the relevance of existing theoretical models for understanding absenteeism in those countries? What issues arise in measuring both absenteeism itself and its determinants? These questions are the focus of this paper. It argues that qualitative research can help provide a more complete understanding of absenteeism, including the role of institutional and psychosocial factors that are have so far not been captured in quantitative work. But it also acknowledges and discusses some important limitations of qualitative work—it is not representative in a statistical sense, results are sensitive to methodological choices, and it does not provide any quantitative nor otherwise precise information on the relative importance of different factors in explaining outcomes.

Alternative Health Workforce Skill Mix: The efficient use of the health workforce in many countries is associated with innovative approaches to ‘skill mix’ changes. ‘Skill mix’ refers “to the mix of staff in the workforce or the demarcation of roles and activities among different categories of staff”. Most of the policy attention on using skill-mix changes to improve health system performance has been on the mix between physicians, nurses and mid-level cadres of workers. This study focuses on innovative skill mix approaches, and examines the possibilities, drivers, facilitators and constraints of skill mix innovation in the health workforce. Given the low numbers and inefficiencies of health workers across SSA, such information will benefit governments across SSA who aim to make more efficient use of their existing health workforce on the ground. The study is led by Paulo Ferrinho.

Health workers and HIV/AIDS: Pieter Serneels and Tomas Lievens. Early studies in the US and Europe have suggested that HIV/AIDS diverts health worker career choices to services with less intense patient contact and clinical work. Little is known however how HIV/AIDS impacts on health worker motivation, performance and career choices in developing countries. This paper analyses qualitative data from Rwanda, collected from 56 health workers and 25 users, amongst which a group of 9 PLWA. It explores how health worker’s knowledge of HIV/AIDS transmission and on the job presence of post-accident prophylaxis impacts on health worker behavior and career orientation. Health worker behavior towards patients suspected to be HIV positive, especially in terms of attitude, willingness to treat and administered treatment, is set against the existing labor market institutions in the health sector in Rwanda.

Human Resources for Health costing tool and user manual: The tool is a generic tool for people within the public health sector to use in order to cost out certain initiatives, like wage hikes or new bonus packages. The costing tool consists of two main parts; a “quick-tool” and a more detailed set of sheets where a larger range of variables are calculated. The Quick-tool: The quick-tool is a set of fields in which to calculate three different scenarios. It gives the option of entering variables such as health worker number and increases, wage rises, bonus packages, per diems and duty rates. All calculations are made with the possibility of using a discount rate. The main costing tool: This tool is a set of fields in which a total of twelve different scenarios are calculated. 9 of these scenarios are based on HW output from training institutions, varying attrition rates (3 options) and varying wage packages (3 options). A further 3 scenarios are based on population projection and a fixed health-worker to population ratio, a fixed attrition rate and varying wage packages (3 options). The tool also gives the option of entering the variables of duty rates, bonus packages and three levels of Per Diem packages, depending on the “zone” where the worker is based. All calculations are made with the possibility of using a discount rate. The tool and manual was designed by Dieter Gijsbrechts.

Global Component on Fiscal Issues in Hiring Health Workers: This component examines the (i) process that determines the budgeted wage bill for health workers in the public sector, including the role of wage ceilings (ii) contracting arrangements for employing health workers in the public sector (iii) begins to examine the extent to which donor aid is funding remuneration (salary, allowance) for health workers in the public sector. These three areas of analytic work are motivated in part by persistent claims that wage bill ceilings – claimed to be ‘imposed’ by the IMF – and civil service hiring arrangements are often a barrier to improving health workforce performance. A recent mapping by the IMF has indicated that of the 30 countries that have a PRGF-supported program, 14 have some form of public sector wage bill conditionality as part of the program. This includes 11 out of 18 African countries. The form of conditionality and the extent to which sectors such as health and education are exempt from these conditionalities varies widely across countries. However, even when it does exist, public sector wage bill conditionality does not directly determine the wage bill of the health sector. There is a need to map out the budgetary process that determines the overall wage bill for health workers in the public sector. A better understanding of this process will help policy makers in ‘making the case’ for investments that improve health workforce performance.  Country studies were carries out in Zambia, Kenya, Rwanda and Dominican Republic (see description of studies conducted in Africa countries below) along with background studies on wage bill trends in the health sector and donor aid policies supporting human resources for health. This work is led by Marko Vujicic.

How Effective Is Community-Based Primary Health Care (CBPHC) in Improving the Health of Children? A Review of the Evidence: The aim of this review is to compile the evidence concerning the effectiveness of community-based approaches to improve perinatal and neonatal health; to prevent and treat childhood pneumonia, diarrhea and malaria; to improve the nutritional status of children; and to promote breastfeeding, hand-washing, immunizations, and family planning.  CBPHC includes the following 3 types of interventions: (1) Communications with individuals, families and communities to improve key practices; (2) Social mobilization and community involvement for planning, delivering and using health services; (3) Provision of health care in the community, including preventive services (e.g., immunizations) or curative services (e.g., community-based treatment of pneumonia). The document database includes 130 documents describing specific programs and 40 review articles. Bahie Mary Rassekh is leading the study.

A Systematic Review of Community Empowerment Strategies in Health Focusing in Low- and Middle-Income Countries Globally. The aim of this systematic review is to evaluate the evidence of community empowerment interventions on health outcomes and includes an analysis of community-based health worker training, supervision, and remuneration on study effect size. The strength of the review is the ability to collate the body of literature on this broad topic and provide evidence of measured health and empowerment outcomes.  The study includes 307 articles that fit the inclusion criteria, including rigorous intervention, outcome, and methodology criteria. Bahie Mary Rassekh is leading the study.