dr. freddie ssengooba makerere university, school of public health
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Researching Health Workforce Dynamics in the Context of HIV Scale-up: Accumulating Evidence in Complex Health Systems. Dr. Freddie Ssengooba Makerere University, School of Public Health International AIDS Society , Pre-Conference Cape Town, S. Africa 18 th July 2009. Outline. - PowerPoint PPT PresentationTRANSCRIPT
Dr. Freddie Ssengooba Dr. Freddie Ssengooba Makerere University, School of Makerere University, School of
Public HealthPublic Health
International AIDS Society , Pre-Conference International AIDS Society , Pre-Conference Cape Town, S. Africa 18Cape Town, S. Africa 18thth July 2009 July 2009
Researching Health Researching Health Workforce Dynamics in the Workforce Dynamics in the
Context of HIV Scale-up: Context of HIV Scale-up: Accumulating Evidence in Accumulating Evidence in Complex Health SystemsComplex Health Systems
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Outline
• Framework –perspectives and domains for health workforce management:
1. Strategic governance,
2. Labour market dynamics,
3. Workforce training and production,
4. Performance management,
• The need for alternative methods for generating evidence for health system-level questions
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Education Sector:Enrollment, carring capacity, curricula for market needs,
faculty vacancies, leaning experiences
Provider Organization:
Attraction, Retention, skill mix, productivity,
work tools & incentives mobility/stability
Health Sector:Workforce size, Equitable deployment, Wages, Job entry & vacancy ratios,
Migration
Performance Management
Social political &
Economic context
Source: Ssengooba, Kiwanuka et al 20093
GHIs
for
HIV
GHIs
for
HIV
4
GHIs for
HIV2
GHIs for
HIVGHIs for
HIV3
GHIs fo
r HIV
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Effects of HIV Programs on Workforce Governance
Research question:
1. How and under what circumstances do HIV programs:
A. strengthen the governance and build consensus among stakeholders and
B. lead to coherent policy and implementation strategies across multiple agencies that may espouse conflicting objectives for HRH developments.
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1.1 Workforce Governance – Emerging issues
1. Unresolved conflicts among multiple stakeholder;
2. Inter-sectoral rivalries; – Health, Education, Public Service, Local Govts.
3. Dis-connected actions by actors; 4. Fragmented control systems for workforce;
management; 5. Pervasive short-cuts to workforce
developments; 6. Competition for scarce workforce;
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1.2 Governance and the workforce:Multiple-institutional bureaucracies
1. Ruling Party manifesto,
2. Public Service Commission
3. Professional Councils
4. Health SWAP donors,
5. HIV Global Initiatives
6. Worker Unions
1. Finance, 2. Education, 3. Health4. Public Service, 5. Local Govt.
1. District Councils2. District Service Commission 3. Chief Executive Officer 4. District Health Office5. Unit Mgt Commitees6. Non State Sector managers7. Donor projects on workforce
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Effects of HIV Programs on Health Sector Roles in Workforce
Management
Research questions
2. Under what conditions do HIV programs strengthen the capacity of the health sector to ensure effective workforce deployment, adequate workforce size, and optimal wage structures.
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2.1 System-level problem: - eg vacant posts in health facilities
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2.2 Inefficient recruitment processes?
Source: Planning Division, Ministry of Health Uganda 2008/09 9
2.3 Health sector workforce system: “Locked” or unattractive?
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2.4 Global Health Financing (GHF) and the Dynamics of Workforce Movement
Govt Facilities
NGO Facilities
Mission Facilities
(n=125)
(n=38)
(n=90)
“Heavy” GHFFacilities
(n=155)
“Light” GHFFacilities
(n=98)
P-Value = 0.011
Source: Ssengooba et al 2009. Effects of Global Health Initiatives on the Workforce in Uganda
73% changed jobIn last 3 years
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2.5 Perceptions of Health Facility Managers:Extent of GHF for Organizational Capacity Developments
( 126 HIV provider facilities in Uganda)
Source: Ssengooba et al 2009. Effects of Global Health Initiatives on the Workforce in Uganda 12
2.6 Salary Differentials: HIV and Non-HIV Health Facilities.
13Source: Ssengooba et al 2009. Effects of Global Health Initiatives on the Workforce in Uganda
Accessibility , Equity, Efficiency, Quality, SustainabilityHealth system performance gaols
Intermediary Agencies for HIV
Programs
Govt. NGO.
Work teams
Govt. NGO.
Organizational level
Govt. NGO./CSO
Sub-national level
Govt. NGO. networks
National level
Context:Global, national &
sub-national
Health system
Key Direct GHI interraction
Indirect GHI interraction 14
How do we accumulate evidence on health system impacts of HIV funds?
3. How do we demonstrate effectiveness of HIV investments on health workforce? a) What are the linkages between HIV
investments and the workforce?b) What frameworks can assist to build the
explanations of these linkages? c) Which are the most critical analytical
domains?d) What methodologies should be employed? e) Is there optimal research capability for this
endeavor?
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3.1 Post-modern research methods are needed for health systems
research “Systemography” ie the ethnography of the health
systems is critical for policy relevance and actions:– System-level observation of events overtime,
– Contextual dynamics and their explanations,
– Comparative frameworks & perspectives for assessments,
– Mixed methods and multi-desciplinary analyses,
– Case-studies and their syntheses,
– Real-time feedback loops between Reseach & Development,• Learning, adjusting and evolving for optimal fit in the contexts
• Can we borrow methods from Complexity Sciences (Complex Adjusting Systems - CAS)?
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Conclusions1. HIV programs need to build strategic governance capacity for
workforce management;2. System-level evidence for effects of HIV programs on the workforce
and health systems need to be synthsized from multiple perspectives;3. Methods need to be diversified to study workforce and health systems
in general;4. Ethnography of health systems (systemography) is needed.5. Local & regional institutions should play “observatory” roles and build
real-time links to policy.
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