Master of Public Health: Introduction to Health Workforce Development – Unit 31
Managing and Supporting Health Workers
INTRODUCTION
We have now discussed the planning aspect of health workforce development, as well as some of the key aspects related to education and training. In WHO’s Working Lifespan cycle, these aspects are captured in the first circle entitled “Entry”. The other two circles are headed “Workforce: Enhancing worker performance” and “Exit: Managing Attrition”.
The two latter circles are incorporated into this last unit – which also provides a very brief introduction to, and overview of, monitoring and evaluation in the human resources sector.
This is a lot of content for one unit, and may be slightly intimidating. However, this is an introductory module, so it will provide an overview of the many and quite complex aspects of what traditionally is called human resource management, and it will leave many gaps. Later this year, or next year, you will do a module dedicated entirely to the topics covered in this unit, so will get a chance to engage with them in much more detail.
There are five study sessions in this unit:
Study Session 1: Issues in Human Resources Management Today.
Study Session 2:Establishing a Supportive Supervisory System.
Study Session 3: Skills session: Writing a policy brief
Study Session 4:Managing health workforce attrition
Study Session 5:Introduction to monitoring and evaluation in HRD
This Unit looks at some of the major challenges facing HRM today, both within and beyond organisations. These challenges are numerous, and our engagement with the subject will be far from comprehensive. The areas chosen are those considered to be the most crucial, including issues of motivation, brain drain and HIV/Aids. Study Session 1 offers an introduction to these themes. Study Sessions 2 and 4 again focus very selectively, but in greater detail, on two particular issues, supervision and attrition, both of which are central to the improvement of human resource management at an organisational level. Session 3 is a skills session, and session 5 gives a very preliminary introduction to monitoring and evaluation in the context of HRH.
The topics chosen for closer investigation clearly indicate our own sense of priorities, based on the literature and our own experience of working with health services at different levels across Africa. While the list may well look different from yours, it is assumed that all believe the topics below are important and warrant closer study.
LEARNING OUTCOMES FOR THIS UNIT:By the end of this unit you should be able to:
Demonstrate a contextual understanding of health human resource management;
Discuss the major challenges facing health human resource management today;
Explain the elements of a responsive supervisory system;
- Understand the purpose and elements of a policy brief;
- Write a policy brief;
Demonstrate an understanding of the key reasons for workforce attrition; and
Understand and discuss some of the strategies used to address and remedy workforce attrition.
- Demonstrate an insight into the rationale and scope of monitoring and evaluation of HRH;
- Develop some M&E questions in the context of your organization.
Unit 3 - Session 1
Issues in Human Resource Management Today
INTRODUCTION
Session 2 in Unit 1 introduced some of the greatest challenges facing human resources internationally in the health sector today. We discussed the challenges of health workers shortages, maldistribution, and the HIV/AIDS crisis. The first session in this unit is, in effect, a follow-up session. It picks up many of the themes raised in Unit 1 Session 2, but from a district and sub-district perspective.
1LEARNING OUTCOMES OF THIS SESSION
By the end of this session you should be able to:
Demonstrate a contextual understanding of health human resource management;
Discuss the major challenges facing health human resource management at district and sub-district level.
2READINGS
You will be referred to the following readings during this session.
Details
Beardsley, S., Johnson, B., Manyika, J. (2006). Competitive advantage from better interactions. McKinsey Quarterly. Issue 2.Sanders, D., Dovlo, D., Meeus, W. & Lehmann, U. (2003). Ch 8 - Public health in Africa. In Beaglehole, R. Global Public Health - A New Era, pp 135-155. Oxford: Oxford University Press.
Kolehmainen-Aitken, R.-L. (2004). Decentralisation’s impact on the health workforce: Perspectives of managers, workers and national leaders. Human Resources for Health, 2(5): 1-11.
Lehmann, U. & Zulu, J. (2004). “You feel like you are fighting a losing battle”. How nurses in Cape Town clinics experience the HIV epidemic. Manuscript: 11 pages.
Kober, K. & van Damme, W. (2004). Scaling up access to antiretroviral treatment in Southern Africa: Who will do the job? The Lancet, 364: 103 - 107.
WHO.(1993). Motivation.In Training Manual on Management of Human Resources for Health.Section 1, Part A. 8 pages.Geneva:WHO.
Van Lerberghe, W., Conceicao, C., Van Damme, W. & Ferrinho, P. (2002). When staff is underpaid: Dealing with the individual coping strategies of health personnel. Bulletin of the World Health Organisation, 80(7): 581 - 584.
3REMEMBERING THE “HUMAN” IN HUMAN RESOURCE DEVELOPMENT
The frequently shifting nomenclature in this field (‘health manpower’, ‘human resources’, ‘health workforce’) reflects the complexity of, and sometimes ambivalence in, the sector. Human resource or health workforce development is about getting the best possible value and enhancing the performance of the key resource in the health system, in the same way as we want to get the best possible value from other resources. But, at the same time, human resources are fundamentally different from all the other resources we manage. As we said in the introduction, HRD is about people – citizens, family members, neighbours. This may sound like a truism, but it is something that can be forgotten in the talk about productivity, efficiency and cost effectiveness.
Management sciences and practices (often much earlier in the private sector than the public sector) are increasingly recognizing that effectiveness and productivity in areas which rely heavily on interaction are strengthened when hierarchies are flattened and workers feel competent, acknowledged and in control.
Beardsley et al (2006) summarise this development as follows:
Managing for effectiveness in tacit interactions is about fostering change, learning, collaboration, shared values, and innovation. Workers engage in a larger number of higher-quality tacit interactions when organizational barriers (such as hierarchies and silos) don't get in the way, when people trust each other and have the confidence to organize themselves, and when they have the tools to make better decisions and communicate quickly and easily.
While we will not go into management theory in this module, I thought it would be of interest at the beginning of this unit to reflect on our own HR management practices and requirements in the health sector against some of the insights from new management sciences.
4Key issues in HR management at district and sub-district level
This section starts with a task.
4.1HIV/AIDS: A Key HR Issue
The HIV/AIDS epidemic presents the greatest challenge yet to health systems in many developing countries. Its impact feeds the brain drain: health workers leave services, exhausted by caring for rapidly growing numbers of very sick patients, and access to fewer resources. And it drains those remaining in the service, until they eventually also leave or get sick.
The following two articles in Task 27 both make the case for urgent attention to the needs of health workers, who are shouldering the main burden of the epidemic.
The first article was written by staff members of the SoPH and accepted for publication by the South African AIDS Bulletin. It focuses primarily on the strains caused by mainstream HIV service. However, the article by Kober and van Damme’s, raises the question of who will staff the anti-retroviral roll-out in Southern Africa. Both articles strongly agree that if the planning and management of human resources, particularly at primary care level, does not receive urgent attention, any treatment programme will have little chance of success.
4.2Motivation: An Important HR Issue
Today, whenever you open a training manual or a publication on HR management problems, motivation has a prominent place in the discussion.
All publications concerned with management issues in the public health sector indicate that motivation of health workers has been declining, often leading to serious deterioration in the quality of care and causing many health workers to leave the sector (one aspect of the ‘brain drain’). There are many obvious reasons for this: deteriorating pay, poor working conditions, work overload, lack of recognition, lack of supervision, the phenomenon of “the grass is always greener on the other side”. But management theory looks at what motivates people to work, not to work, or to work harder. The following reading, another WHO publication, briefly summarises and discusses this theory.
TASK 29 (Self-study) - ANALYSE DEMOTIVATING FACTORS
In many organisations, it is likely that certain actions or procedures create a negative impact on individual staff members.
a) Identify those actions or procedures, at national and local level, which you feel have a negative impact on a large number of staff in the service.
b) Order the list given in Task 28 to show those you believe to be the most damaging down to those that are the least damaging.
c) How does your list compare with the demotivators suggested in the text?
4.3Individual coping strategies
How health workers cope with their living and working conditions is not a topic which receives much attention in academic writing. However, such coping strategies can potentially have a crucially important impact on how health services function. In recent years, a small group of authors started the debate on the inter-relationship between individual health workers’ behaviour and health service performance. Some of the issues have already been raised in the above section on HIV/AIDS. The following reading addresses the issue of coping strategies, and their impact on health services.
5SESSION SUMMARY
This session has provided a broad sweep of some of the key HR management challenges at district and sub-district level. In sessions 2 and 4 we will expand on two specific themes: on supervision in session 2 and on managing health workforce attrition in session 4.
6FURTHER READINGS & REFERENCES
There are many readings available under each of these headings. To pursue any of the above topics in more detail, you should consult the references in the readings used in this session. They all have bibliographies which refer to additional relevant articles and books.
Unit 3 - Session 2
Establishing a Supportive Supervisory System
INTRODUCTION
[This session has largely been taken from the Children’s Vaccine Programme website of PATH (Programme for Appropriate Technology in Health) and has been slightly adapted.]
In all likelihood you are supervising colleagues, and you may well be supervised by someone yourself. If you think back in your career, you may have experienced really good supervision during which you were guided and mentored - and you may have had very poor supervision which focused on inspection and provided you with no feedback. You may also have had experience of not being supervised at all: not knowing what is expected of you, whether you are on the right track, where you are messing up, etc.
Whatever your experience of being supervised has been, you will know that supervision is crucial. In fact, it is an essential and indispensable ingredient to good health system performance. Good supervision can determine whether staff are motivated or not, whether they are performing well or not, whether a programme is growing and sustainable or not.
In the context of the current HR debates, and particularly given the increasing practice of task shifting, supervision becomes even more important than it has been, as we increasingly entrust health workers who have limited skills with sometimes quite complex aspects of health care delivery. The literature confirms that health workers with limited training can perform a range of tasks very satisfactorily IF THEY ARE SUPERVISED REGULARLY AND APPROPRIATELY.
In this session you will engage with PATH’s approach to what they call Supportive Supervision and you will study the case studies they provide. At the end of the following session (session 3 in this unit) you will be asked to write a policy brief to your minister or permanent secretary, arguing the case for improved supervision structures and practices for community health workers in your country.
1LEARNING OUTCOMES OF THIS SESSION
By the end of this session you should be able to:
- Explain the elements of a supportive supervisory system.
2READINGS
You will be referred to the following readings during of this session.
DetailsChildren’s Vaccine Program at PATH. Guidelines for Implementing Supportive Supervision: A step-by-step guide with tools to support immunization. Seattle: PATH (2003). Available at URL [21 Feb 2010]
3THE CORNER STONES OF SUPPORTIVE SUPERVISION
The PATH document identifies several elements which are essential to establishing and/or maintaining good and supportive supervision. A central tenet is that supervision should NOT be punitive but developmental. It should be a learning experience both for the individual being supervised, but also for the supervisor and the organisation who are able to identify areas of concern, emerging problems, service gaps, etc., before they become serious problems.
The PATH document furthermore talks about the following cornerstones of a supervision system:
a)Understandingthe country context and mobilise national support for supervision: This involves understanding and building on existing supervision systems; advocating for financial support and ensuring that supervision becomes part of health and human resource planning and is considered in job descriptions and work load considerations; and working towards the institutionalisation of supportive supervision within the government system. It is here that policy briefs and other advocacy tools are important.
b)Involving supervisors in training: To ensure that identified training needs are addressed, and to facilitate the re-enforcing of training in supervision.
c)Ensuring that supervisors have the ability and support to conduct supervision: This means that supervisors need to be trained to provide supportive supervision (many may have been trained in traditional forms of supervision or not trained at all); that supervision is an explicit part of their work load, rather than something they do by default and when they have time; and that the outcomes of supervision are used for performance improvement and planning.
d)Making staff motivation an integral part of supervision.
4Session summary
This session explored one of the key elements of good HR management, the supportive supervision of staff. Although acknowledged as important by most managers, supervision all too often falls by the wayside under the pressures of day-to-day management. However, all evidence agrees that careful supervision can contribute dramatically to personnel satisfaction and productivity.
5FURTHER READINGS & REFERENCES
The PATH document has a number of annexes which contain tools for different aspects of supervision. I have not included them here, because they make the document too bulky. If you want to make use of or adapt some of them for your own purposes, please you to the website:
Unit 3 - Session 3
Skills session – Learning to write a policy brief
INTRODUCTION
We undertake many forms of writing every day: reports, proposals, academic papers, and so forth. In this course you inevitably will do a lot of academic writing, as a Masters is primarily an academic qualification. In the course of this module you have already engaged in different forms of writing: doing a mind map, answering questions, written reflections. In this session I want to introduce you to a form of writing which policy makers and planners use quite a lot, but which is rarely specifically taught – how to write the POLICY BRIEF.
Policy briefs are frequently used to introduce one or several policy choices (or strategic choices) to address a problem. They are written for people who are influential, busy, and have little time to read – ministers, parliamentarians, permanent secretaries, etc. So a policy brief has to be, as the names says – BRIEF; some will argue, not more than two pages, others will say anything up to about eight pages. This may vary with audience and complexity of the policy suggested. Very importantly, the quality of a policy brief is determined by the clarity of argument, structure and sense of audience. The writer has very limited space to explain the background to the “problem” to be solved, context and rationale, and to motivate one or several policy options to address the problem. So, brevity and clarity are essential.
1LEARNING OUTCOMES OF THIS SESSION
By the end of this session you should be able to:
- write a policy brief,
2READINGS
You will be referred to the following readings in the course of this session.
Details
IDRC (not dated). The Two-pager. Writing a Policy Brief. Available on URLFeb. 2010]
Young, E. and Quinn, L. (not dated). The Policy Brief. Available on URL [21 Feb. 2010]
Prof. Tsai. Guidelines for Writing a Policy Brief. Available on URL: [24 March 2010].
3WRITING A POLICY BRIEF
Several organisations have developed well-written guidelines for constructing policy briefs. I have decided to share three of these with you here, so that you can get a sense of the similarities and differences of how policy briefs are constructed. Two of them are very short (two and three pages respectively). One, developed by the “Research Matters” project of the Canadian International Development Research Centre (IDRC), is a bit longer, because it provides a detailed case example of the development of a policy brief.