Recruitment, deployment and retentionby Tim Martineau(T.Martineau@liv.ac.uk)

Liverpool School of Tropical Medicine, UKMeeting on the Regional Strategy and Initiatives on Human Resources for Health 24-26 August 2009, WPRO, Manila1We planned the two presentations in this session to link together. This one is a broader scene-setting presentation; Carmens will be specifically about the WHO work on retention.There are a high number of vacant posts in the health service, especially in rural areas

This problem has been reported by a number of countries represented here. This is common to most countries high, mid or low income. The far west in this example is very remote and the capital city is in the Central region.

2We cant just solve the problem by scaling upThough this is what many responses to the problem of shortage are doing. Flooding the market wont usually work.3Systems for staffing posts are often ineffective and outdated

The weak systems cause big delays and may end in good candidates being lost in recruitment or, once in post, through resignation.4But we must make the best of the current and potential supply of staff

We cant afford to waste current and potential staff.

5We need better systems for filling vacant posts

I will first provide some basic concepts related to this area

then I will look at the some of the systems used recruitment, deployment and retention and related challenges;

and finally look at a few examples of innovation in each of the 3 areas. 6First we need to appreciate the main concepts of workforce dynamics

Ill talk about the following 3 areas:

Workforce flowsSystems for managing the flowsThe labour market as the context in which the flows take place and in which attempts are made to manage the flows.7The workforce flows can be represented as route from recruitment to resignation

Explain Vujicic diagram and that there is a similar one in WHR06 shown already by other presenters.

lets have a closer look at the diagram ...

8

Entry into the workforce (direct if o/s training docs from PNG, China and Cuba; ref to discussion on code); and prior to that, entry into training.

Deployment within the workforce.

Exit from the workforce

9We need appropriate systems to manage the flows effectively

The idea of just turning the tap on or off may seem ideal from employers perspective (but perhaps not from HW perspective? but often a pump is needed to make things flow).

We also need to make sure that the precious water doesnt leak in the pipe and that it goes where it should do once its come out of the tap. One could go on with the analogy!

But remember, we are dealing with human behaviour and often weak managers, so it not that simple.10The labour market is an important part of workforce dynamics Other countries3 points:

1. Employers have the upper hand in a loose labour market: employees have more leverage in a tight labour market

2. There are a range of Push and pull factors that influence employee choice and behaviour. These factors relate to personal and social situation (e.g. Access to education for children), the work environment (ability to do a satisfying job) and the labour market (availability of options).

3. The dynamics include movements between and with segments of the labour market, and within large organisations (internal labour market); and out of the national labour market.11Then we turn to the systems for influencing the workforce dynamics and the challenges We will keep more posts filled using a mixture for recruitment, deployment and retention systems. There is some overlap with these in terms of their contribution to better staffing. For example, more careful selection in the recruitment process may identify people more likely to accept deployment to rural areas.

Note that the Regional strategy provides a useful glossary explaining these terms.

12Recruitment The purpose of recruitment: Process of searching for personnel to enter a particular job or position. (Source: Regional strategy on HRH 2006-2015) This also links to the production side.

There are many challenges to make a job attractive enough to recruit someone especially in difficult areas. Thats why we need to understand the push and pull factors and respond to them as best we can.

But we also waste time and people with inefficient and lengthy recruitment processes.

13Filling a vacancy can be a complex business!Source: Report of the Joint Design Mission to the Kenyan Health Sector, 2007.

Abbreviations:PSC = Public Service CommissionDPM = Department of Personnel Management (central government)PMO/DMP = Provincial and District Medical Office

Note: this is a good illustration of how the complexity of the process in public service organisation, but it also illustrates how HR function is spread across a number of different bodies in government.

It can take a long time fill a vacant post.

14Deployment Deployment: Process of assigning personnel among areas or regions, or types and levels of services. (Source: Regional strategy on HRH 2006-2015). To meet the PHC objectives discussed yesterday, the aim is to improve coverage.

In the old days when salaries were comparatively better, fewer jobs available and managers could make systems work, deployment of nurses might have been done by the chief nurse with a wall chart and a good knowledge of her nurses. No computers needed.

Now things are more complex. The labour market has changed in many countries, the value of salaries fallen and individual aspirations increased (i.e. the push and pull factors have changed).

Computerisation may help somewhat, but not if there is pressure to misuse the systems.15

I cant find your file! Good systems can be distortedSometimes its not very clear to outsiders why systems dont wok effectively. It may be because some of the stakeholders interests are not clearly aligned with the health goals.

There are major problems with posts being blocked by people on secondment. 16RetentionRetention: Maintaining personnel within the health system. This is often done by offering adequate monetary and/or non-monetary incentives. (Source: Regional strategy on HRH 2006-2015) This will reduce vacancies, but we also want to keep good talent to build the organisation.

Retention strategies often do not discriminate between good and poor performers.

Also, allowances and incentives are often not used strategically to address retention problems. For example, in the Dominican Republic, after a worker leaves a location, the geographic allowance turns into a permanent component of the workers wage, contrary to the stated policy. (Source: Vujicic, M. and et al (2009). Working in Health. Financing and Managing the Public Sector Health Workforce.)17We can learn how to improve our systems from innovations tried by othersOne of the reasons for accepting the invitation to join your meeting was that I have not done much work recently in the region and was curious to find out what is going on here. Much of my work is currently in Africa. So its from there that most of the examples from my personal experience come from. I will share a few in this short presentation. None is perfect and all have risks associated with them.

But from the evidence of the group discussion, there are clearly good examples that can be shared across this region.18Recruitment examples The newly established College of Medicine in Malawi had difficulty in being able to recruit enough candidates who met the entry requirements. The main areas of weakness was in science as there are few qualified teachers and very little lab equipment for teaching. A two year donor-funded pre-med course was developed and now there area sufficient entrants (but the programme is reliant on donor funding).

Several people in Group 2 (VN and Vanuatu) mentioned this innovation being used.19

Widening participation thereby increasing entry into the labour market. Malawi has also taken steps of widen participation of minority groups. Most nurses were female until recently, as men couldnt access training. 9/41 women in intake of nursing students in Malawi for 2007 since male hostels constructed in about ?2005.

It is important to monitor the impact of all these innovations. Some training institutions had started to introduce quotas, as they were concerned by the dramatic change.

20Streamlining the recruitment process (Kenya Emergency Hiring Programme)

About 1,200 health sector jobs were advertised in May 2006 by the PSC, but by January 2007, the interviews for a number of staff groups had yet to be conducted, according to the PSC. However, one informant indicated that by April these interviews had still not taken place.

Capacity Project was launched in May 2006 under the donor-supported Emergency Hiring Program. This recruitment process was carried out using recruitment procedures that were similar to those of government. But the process was computerized, and recruitment authority was delegated by the PSC to the Ministry of Healths Department of Human Resources. It took only 10 days to create a short list of 2,600 health staff from a total of 7,000 applicants. The first successful recruits were in their posts by September 2007less than five months after the jobs were advertised.21Deployment examplesApplying to posts rather than a pool (Kenya EHP); addressing push/pull factors

Regulation and incentives: Worked in Thailand but regulation/bonding now removed strategic use of incentives; now need to understand student preferences and adjust policies and strategies accordingly.

Malawi relief system (small scale) funded from per diems sign of innovation at district level and tailored to push/pull factors.22Retention examples23Zambian Health Workers Retention Scheme (c.2005) This scheme has a mix of incentives: some related more to attraction - financial benefits, accommodation; others more to retention PG training available at the end of the contract. More likely to work than relying on a single incentive, but more complex to manage. At the time of the mid-term review attraction had been successful (68 doctors posts out of the targeted 80 has been filled since 2003). It was too early to say if retention worked; 4 had left. But no performance appraisal was being done a risk of expensive retention scheme for little increase in performance including productivity?

The mid-term review monitored progress. Government and donors were satisfied. More funds invested in expanding the scheme for doctors and other selected groups (no details available). Uncertain if anything was done about the lack of performance appraisal. Its important to follow-up as well as monitor.

District managers were taking matters into their own hands for other cadres, as there was no central support. They were using very innovative methods from their own funds e.g. renovation of accommodation; solar panels; shopping and bank trips; financing 2-year training with bonding.

I will leave more examples to Carmen24Diagnose problems with recruitment, deployment and retention systems

Simple systems audit approach will help e.g. Process mapping25Search for innovative solutions to reduce the number of vacant posts

And there are probably plenty of solutions as we found in some of the group work - within the region.26Make sure you monitor the implementation and impact of your improved systems

Things may have worked in one context, but may not work so well in yours. Some adjustment may be needed.

Good luck with filling your vacancies!27NameTitle

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Adapted from: Vujicic et al, 2004

NameTitle

NameTitle

NameTitle

NameTitle

NameTitle

NameTitle

Team TitleNameTitle

Company NameCompany NameDepartment NameThe height of the text box and its associated line increase or decrease as you add text. To change the width of the comment, drag the side handle.

High School

Health training institute

Other training

Adapted from: Vujicic et al, 2004