Background

A discussion paper presented at the Third Global Forum on Human Resources for HealthFootnote 1 (HRH) in November 2013 concluded that there was No Health without a Workforce [1]. The paper acknowledged that progress had been made in addressing the “health workforce crisis” described in the World Health Report 2006: Working Together for Health [2] but concluded that much more effort was needed to develop a “skilled, well-trained and motivated workforce” in order to achieve universal health coverage (UHC), a goal set by the United Nations General Assembly in December 2012 [3]. The organizers of the Recife Forum, the Global Health Workforce Alliance, the World Health Organization (GHWA-WHO), the Pan-American Health Organization, and the Government of Brazil, challenged participating countries and organizations to make specific commitments to improve the availability, accessibility, acceptability, and quality of their health workforce; representatives of 57 countries and 27 organizations did so. Commitments covered areas such as education, employment, management, deployment, motivation, and retention of health workers.Footnote 2

The objective of this paper is to assess progress of the early stages of implementation of the Recife commitments and to identify barriers and facilitators to such progress. Indonesia (Southeast Asia Region), Sudan (Eastern Mediterranean Region), and Tanzania (Africa Region) were selected from the range of countries that made commitments. We first present background information on the three countries and then the criteria for their selection, the information sources, and the strategy of analysis of the evidence collected. The findings are then presented for each country, followed by broader lessons learned.

Table 1 presents basic health, workforce, and expenditure indicators on the three countries for the most recent year available, which is usually 2013. Table 2 presents contextual information on the health workforce situation in the three countries.

Table 1 Basic health and care system statistics 2013: Indonesia, Sudan, and Tanzania
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Table 2 The health workforce policy context in Indonesia, Sudan, and Tanzania
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Case presentation

Methods

Selection of country cases

The selection of countries was intentional, based on the following criteria for inclusion: to be from different WHO regions, to be of different economic level (see Table 1), and to have indicated progress in an informal monitoring of commitments conducted by WHO in mid-2014. The selection was limited to three countries because of resource constraints and because the study was defined as a pilot to inform a future research strategy for a broader follow-up.

Information search and sources

An initial web search was conducted in reference databases (PuBMed, Eldis) and web sites of WHO, World Bank, national ministries of health, and bilateral agencies (AusAIDFootnote 3, USAID) active in these countries to collect information from peer-reviewed articles, reports, and official documents in English, to help describe the situation of the health workforce in the country. Search terms were human resources/health workforce policies, data, and issues in the three selected countries for the period from 2000 to 2014. Most relevant information on topics relating to the commitments made in Recife was found in the gray literature. We did not expect to find published literature on the follow-up of the Recife commitments; the objective was to look for papers that helped understand the health workforce context in the three selected countries; in the web sites of WHO, the World Bank, AusAid, and USAID, we found country profiles, administrative documents, and project reports on the activities of these organizations in the three countries. The most useful sources were the web sites of national ministries and agencies of health; the main relevant policy documents were available in English. These are included in the list of references.

In addition to documents, information was collected in the field by five country-based co-authors with direct knowledge of HRH policy initiatives. One is a leader of the HRH Observatory in Sudan; two are WHO country staff, in Indonesia and Tanzania, whose mandate includes HRH; and two were high-ranking government officers in these latter two countries. A template for the collection of information was developed which covered actions explicitly taken to meet the Recife commitments, e.g., policy changes, management decisions, investments, actors involved in the design and implementation of these actions, results observed, facilitators/obstacles, and lessons learned. Data collection occurred between October 2014 and March 2015.

In this paper, we first describe the interventions which took place after the end of 2013 which can be linked to the Recife commitments. We then briefly discuss enabling and constraining factors that influenced commitment implementation, including their contents, actors involved, the policy processes, or the broader context.

Results

While based on a common invite and global process linked to the Third Global Forum on HRH, the processes and contents of the commitments, as well as the monitoring and follow-up activities we conducted, were highly country-specific. The findings of the analysis are therefore presented separately by country.

Indonesia

Indonesia made two commitments: for each, five specific objectives were set, some with a timeline and others without (Table 3). Commitments were set at the national level; in addition, initiatives in line with the Recife commitments took place at the decentralized level, in particular with the support of AusAID. For instance, the Provincial Health Office in East Java promoted the adoption of a regulation (PERDA No. 7, 2014) to facilitate the recruitment of health personnel and to better define their roles and responsibilities, giving local governments the authority to deploy health workers on the basis of their own analysis of needs [4].

Table 3 Recife commitments, corresponding objectives, and progress reported: Indonesia
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The commitments were aligned to the Ministry of Health Strategic Plan 2010–2014 and based on the Indonesia Human Resources for Health Development Plan 2011–2025 (HRH Plan). The Recife commitments and objectives corresponded to proposals already made, in order to address deficiencies at the levels of availability, accessibility, and performance of health workers [4].

Representatives from government, professional associations, academia, health facilities, and international agencies participated in the formulation of the HRH Plan as members of a Country Coordination and Facilitation (CCF) Committee. Given the link of the commitments with the HRH Plan, the process of their adoption was a participative one which brought together numerous actors. Their implementation was planned in collaboration with national stakeholders and with development partners, mainly the WHO and AusAID, whose support accelerated the creation of a HRH Observatory and the strengthening of the HRH information system. Overall, there has been progress in implementing the actions in the commitments, with multiple interventions leading to complete or partial achievement of their objectives (Table 3). This was done in partnership with various health sector stakeholders in continuity with actions already planned to respond to the growing demands of the health system.

Sudan

The decision to make formal commitments at the Recife Forum was in continuity with previous policy interventions in the health sector, as the debate on the critical role of the health workforce was already going on.

The Federal Ministry of Health (FMOH) based its Recife commitments on the National Human Resources for Health Strategic Plan 2012–2016, focusing on improving the performance of health workers and on pre-service education. The main strategies were to strengthen management by increasing the number of managers with fit-for-purpose competencies and to expand the accreditation of education institutions and the upgrading of curricula (Table 4). These commitments fitted in the existing policy agenda and were therefore well accepted. Following the Recife commitments, HRH issues were pushed higher on the political agenda, as illustrated by the subsequent creation of a health workforce committee by the National Council for Health Care Coordination, chaired by the President of the Republic, which elevated health workforce issues as a whole-of-government issue rather than merely a health sector one.

Table 4 Recife commitments, corresponding objectives, and progress reported: Sudan
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After Recife, the Health Workforce Observatory and the FMOH HRH department received additional financial support to improve their infrastructure and technical capacity. This was facilitated by the signing of agreements in 2014 with GAVI and the GFATM which gave priority to health workforce strengthening. These agreements included measures to improve the quality of training and continuing professional development of health workers and of managers and to address the issues of attraction and retention of qualified personnel in regions with unmet needs [5, 6].

Medical education reform and the design of a continuing professional development (CPD) policy and of a process of recertification were supported by national institutions, including the Academy of Health Sciences, the Sudan Medical Council, and the Public Health Institute. External partners, e.g., WHO and the University of Leeds (England), provided technical assistance, particularly in the training of health managers.

Even though improvements in the health workforce situation are reported, major challenges remain: there is education room for further improvement in the quality of nursing, midwifery, and allied health and in the strengthening of accreditation mechanisms and of HRH management systems, and above all, the benefits of capacity-building efforts are eroded by the emigration of a significant number of graduates, especially medical specialists, managers, and technicians [7].

Tanzania

Tanzania’s Recife commitments were identified at a National Conference on “Health Workforce: Crucial to Meeting the Development Goals”Footnote 4 in September 2013. More than 420 participants from government, civil society, faith-based and other private organizations, academia, and development partners participated and agreed to the adoption of three commitments (Table 5). The definition of the commitments was inspired by Malaysia’s “Big Fast Results” approachFootnote 5 (called Big Results Now in Tanzania) which consists of identifying key areas where significant results can be obtained rapidly. This was applied to all sectors of the economy. In health, the process of identification of priorities and objectives started with a 6-week “Lab workshop” which involved 100 stakeholders from government, the private sector, civil society, and development partners. This led to the Recife commitments being well supported by the government and by stakeholders.

Table 5 Recife commitments, corresponding objectives, and progress reported: Tanzania
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The commitments made by Tanzania include objectives targeting very specific density rates and targets for the number of health professional graduates to produce within a period of 3 years. However, the type of health workers these objectives refer to is not specified. The three commitments focus on improving the availability and accessibility of health workers in underserved regions, combining measures to increase the allocation of posts, even if modestly, to attract and retain new graduates, and to review the scopes of practice to allow workers with less training to perform tasks traditionally reserved to higher trained ones. Since November 2013, the implementation of the HRH Strategic Plan 2014–2019 and of the Production Plan for 2014–2024 has started. The Health Sector Strategic Plan IV (2015–2020) includes the Recife commitments [8]. The Ministry of Health and Social Welfare (MoHSW), in collaboration with line Ministries and with development partners, established a mechanism to monitor and report on these commitments and their related objectives, as part of the HRH Strategic Plan 2014–2019.

In spite of an average growth of 7% of its gross domestic product in the last 5 years, Tanzania’s health sector depends on external resources for close to 40% of total expenditure [9]. The lack of resources makes it difficult to increase the number of qualified health workers to the level proposed by national plans. Even though more health workers are educated, many end up emigrating or working in other sectors, which makes the achievement of the objectives announced in Recife difficult to attain.

Discussion

The commitments made in Recife by representatives of Indonesia, Sudan, and Tanzania’s governments can be analyzed as policy statements. Reflecting on the work of various authors [10–13], we examine how policies are shaped by the interaction between their content, the processes of their adoption and implementation, the actors involved, and the context in which they take place. This is useful to structure the information collected, acknowledging that the short period of time covered and the volume and nature of the information do not permit broad generalizations.

Context

The three countries already had a HRH plan or equivalent document, from which their commitments were in fact derived. Indonesia had a HRH Development Plan for 2011–2025, Sudan one for 2012–2016, and Tanzania one for 2008–2013 and a subsequent one for 2014–2019, which incorporates the Recife commitments. The Recife Forum offered an opportunity, or in the words of Reich [11] a “political moment,” to give additional visibility to the HRH policy agenda in the three countries and to further engage policy-makers themselves and stakeholders who composed the delegations attending the international conference. In spite of a challenging political and economic environment, health workforce issues were already high on the three countries’ health policy agenda, which created a favorable environment to accept to make commitments in Recife and to initiate their implementation.

Content

In terms of content, the three countries’ commitments focused on the availability of health workers, on their geographical accessibility, on the quality of their education, and on strengthening governance, information systems, and management of the health workforce. This was seen as critical to improve the performance of the health service system. In Indonesia and Tanzania, a broad range of occupational groups were targeted. In Sudan, the focus has been mainly on physicians, which can be explained by the fact that the country is losing a significant proportion of its physicians to emigration. Sudan has also given specific attention to the availability of qualified managers and technicians. In Indonesia, the issue of accessibility to health workers is seen as the greatest challenge in view of the geography of the country and of the ethnic composition of the population. These are important challenges, but other complex issues, such as the extent and impact of dual practice or the review of scopes of practice, have not been included.

Process

The processes of adoption and of early implementation of the interventions proposed in the commitments varied from country to country. In Tanzania, a consultation of stakeholders was convened in order to reach a consensus on HRH policy objectives. The Big Results Now strategy used in this country was not specific to the health sector, where it was applied well after other sectors [14]. It aligned well with GHWA and WHO’s objective of encouraging countries to make commitments in Recife. In Sudan, the HRH Observatory already had the mandate to define health workforce policy objectives and was a sort of “policy entrepreneur” [11] which took the lead in formulating the commitments in consultation with representatives of stakeholders who are part of the Observatory. At the level of implementation, Tanzania and Sudan organized workshops and training activities to reinforce the capacities of managers and of government and stakeholder organizations’ technical staff to facilitate implementation. In Indonesia, the weak technical capacity remains a major challenge.

Actors

In the three countries, the Ministry of Health led the design and implementation of the commitments and their related objectives, but various national stakeholders, such as other ministries and government agencies, professional organizations, and education institutions, also participated actively. The support of external actors was determinant in every country: in Indonesia, a comprehensive partnership agreement with the Government of Australia, covering the period between 2011 and 2016, provided the resources and technical support to implement the Recife commitments. Sudan has benefited from the technical support of the University of Leeds; in Tanzania, USAID-funded technical assistance by the non-governmental organizations IntraHealth International and its Capacity Plus program, and by Management Sciences for Health, supported the process of health workforce development. In the three countries, WHO played an active role in bringing and keeping health workforce issues on the policy agenda and in supporting policy and decision-makers in the formulation of their HRH strategies.

Limitations

The study has limitations: first, at this stage, quantitative data are limited in most cases and progress in implementing the commitments can only be assessed primarily on the basis of qualitative information, such as policy decisions, establishment of governance mechanisms, or statements of policy-makers. Second, as in all case studies, the external validity of the findings remains weak. Third, the selection criteria introduced a bias by targeting only countries reporting “progress” in implementing their Recife commitments in the informal follow-up of mid-2014; therefore, the findings should not be interpreted as representative of the situation in the broader group of 57 countries that made commitments but rather as illustrative of the potential of the commitment process to contribute to advancing the HRH agenda. There would be an obvious benefit in looking at the experience of countries which have not been able to make progress as planned in order to identify the barriers they have encountered. There is also a potential bias due to the proximity of some of the co-authors with government decision-makers; these may have wanted the findings to reflect well on what their country has done to achieve Recife commitments. This was addressed by triangulating findings from different information sources and validating them with documentary evidence. The involvement of WHO staff in the analysis was sought also to provide an independent perspective that could validate the information provided by other stakeholders. Finally, we assessed interventions at the national level, whereas there were also measures at the decentralized level in the three countries. For example, in Indonesia, provincial governments have the responsibility of managing their health workforce and many have taken initiatives such as opening education institutions adapted to their specific needs and creating their own stakeholder platforms in support of health workforce development [15].

In order to go beyond the descriptive approach presented here, further research will be required to answer questions such as the following: to what extent the various categories of stakeholders contributed to following up on the commitments? For instance, what has been the influence of external actors? Did the actions identified in this review produce the expected effects? Depending on the answer, what were the factors (relating to context, actors, processes) that explain success or failure? This type of deeper analysis will be possible when more time has passed and adding field work to document analysis.

Conclusions

At the global level, most countries experience problems of health worker availability, accessibility, and performance; these typically include an insufficient number of qualified health workers, imbalances in their skill mix, in their distribution by levels of service and by geographical regions, the lack of alignment between education content and processes and service needs, or a weak regulation of private practice. However, there is no blueprint for policy changes which countries can rely on to address these deficiencies. Each country’s historical, economic, and political context and health needs are specific, as illustrated by the three country examples, and therefore, policy options need to be adapted accordingly. Countries can learn from the experience of others, but in the end, they have to design their own HRH strategies.

The factors that lead to the success or failure of HRH initiatives may vary, but the existence of a strong and continuous commitment of decision-makers has been recognized to be a critical enabler of effective action anywhere [1]. Our review suggests that the commitment process had some success in creating a window of opportunity for accelerated action on health workforce development, as evidenced by progress in implementation of several follow-up actions and by the subsequent inclusion of these commitments in national strategic and monitoring frameworks. The existence of policy documents that explicitly recognize and document HRH problems and that set out explicit relevant policy goals and targets, the involvement of the main stakeholders, and the availability of external support were the main facilitating factors that enabled countries to engage in the commitment process and to use it in addressing known HRH challenges. These findings are consistent with the broader evidence on HRH policy change which has repeatedly underscored the importance of including explicit HRH policy objectives in national plans and strategies and of broadening the participation of different sectors and constituencies and aligning their support with the national agenda [1, 16, 17].

The example of Sudan also suggests that the existence of a dynamic coordination mechanism, such as an HRH Observatory, can facilitate the whole process by creating a platform to bring together the main actors involved in health workforce development at the national level and providing technical support to the design and implementation of HRH interventions. The commitment process showed clearly that lack of awareness or ambition on the part of national governments or their international partners is not the problem. Country strategies—and the HRH commitments which were largely based on them—recognized the magnitude of the challenges and proposed ambitious responses. The main challenges which countries face are to mobilize political will and maintain the support of decision-makers, as their leadership is essential in the following: ensuring effective intersectoral governance and collaboration; protecting public interest from undue influence of special interests; relaxing restrictive public sector and civil service policies when these prevent providing health workers with adequate incentives and motivation; enabling the emergence of technical excellence by adopting and reinforcing meritocratic selection criteria for senior positions in the public health sector administration; and in mobilizing financial resources for the health workforce investment agenda, aligning education, finance, labor, and health policies [18].