Ira Magaziner Ed Wood, Clinton Health Access Initiative Human Resources for Health October 13, 2011

Overview of CHAI – How we work in partnership with Governments as a change-agent on catalytic projects that result in massive and lasting change

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HUMAN RESOURCES FOR HEALTH; HIV/AIDS; Effectiveness/Efficiency of Global

Health Spending; Malaria; Vaccines; Maternal, Newborn and Child Health

Entrepreneurial approach to help create a world where everyone has equitable access

to high quality health care

1) Act as close and trusted strategic governments advisors; ensure governments have ownership and receive credit for successes

2) Focus on key systemic bottlenecks to allow governments to offer sustainable public health services nationwide

3) Apply a business-minded skill set and knowledge base

VISION

APPROACH

FOCUS AREAS

Principles of how CHAI works and achieves impact on its programmatic focus areas

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DEGREE of impact - Break previous common understanding of what is possible in terms of speed, scale, efficiency, quality

SCALE of impact - National and/or global

BREADTH of impact – Reshape the way governments and partners approach an issue

SUSTAINABILITY of impact - Phase out activities without any erosion of the impact achieved

CHAI’s GUIDING PRINCIPLES

Strong relationships of trust with partner governments – accelerates the pace at which change can occur within government systems

Identify and address market inefficiencies – demand, supply, utilization

Focus on strong management and organization of ambitious and complex processes to accelerate roll-out

Unique staffing model mix - people with experience in business and traditional public health and clinical skills

Respond quickly to opportunities - flexible decision-making , staffing model, entrepreneurial culture

CHAI’s CORE COMPETENCIES

CHAI’s approach to HRH

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Partner with the government to understand root of the local HRH crisis

Rooted in analytical understanding of country’s supply, demand and utilization of health workers

All projects must address key government priorities Interventions are targeted and government financial

resources more effectively prioritized

Comprehensive approach - strengthens each component of the health worker pipeline: training, hiring and deployment, productivity, and attrition

Creates a portfolio of interventions that delivers both immediate positive effects and medium- to long-term results

Helps governments utilize funds more efficiently by avoiding interventions that silo parts of the pipeline

All projects must strengthen national HR systems

Prioritize practical interventions that governments and partners can implement under existing systems with limited additional resources

Focus on high-leverage activities that prove a concept, serve as an enabling element to jumpstart scalable interventions and processes, accelerate implementation of other critical interventions

Optimize use of resources across partners Avoid doing what others are already doing well

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CHAI’s approach to HRH is anchored on program goals that are based on system root causes of the HRH crisis

Inadequate supply of health workers - constrained by limited output from training institutions, high attrition

Insufficient demand for health workers - suboptimal civil service hiring processes and limited financing for civil service posts

Inefficient utilization of health workers in the system

System Root Causes

Enable more patients to receive appropriate care from a qualified healthcare worker – at a national scale

INCREASE the NUMBER of qualified new healthcare workers

OPTIMIZE the DISTRIBUTION of healthcare workers to reflect the distribution of clinical need

MAXIMIZE the

PRODUCTIVITY and UTILITY of existing healthcare workers

CHAI’s HRH Program Goals

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Time to see measured impact is longer-

term

Shorter- term

Impact of CHAI’s comprehensive approach to HRH: Zambia example

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Train, graduate, and deploy almost 4,000 healthcare workers

Helped the Zambian MoH double the growth rate of its workforce (from 4% to 8%)

Mobilize more than $16 million for national HRH priorities

Contribute almost 60% of the MOH workforce increase since 2008

Impact of comprehensive approach: Example interventions and Zambia case study

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Program Goal Example Interventions Impact in Zambia

INCREASE the NUMBER of qualified new healthcare workers (pre-service training)

Develop school-specific operational and costing plans to double training targets

Identify novel approaches to accelerate training time of high-priority cadres

Highlight new strategies to train more workers given existing financial or physical resources

Student enrollment increased by 150% New training program that cuts training time

in half: 160 midwives (24% of all midwifery graduates in 2009 and 2010, increased national midwifery growth rate from 1% to 10% annually); 17 tutors who can train 250+ nurses/midwives

Malawi, Lesotho: Leveraged operational planning methodology for nurses/midwives

OPTIMIZE the DISTRIBUTION of healthcare workers to reflect the distribution of clinical need

Job fair to accelerate the speed and equity with which new graduates are hired and deployed (based on unique Excel demand-based optimization model)

2,800+ health workers recruited / deployed—half to underserved, rural areas

Malawi, Liberia: Leveraged unique data-driven approach to determine optimal distribution of health workers needed to provide greatest coverage of health services

MAXIMIZE the PRODUCTIVITY and UTILITY of existing healthcare workers

Create National Community Health Worker Strategy (CHW) and design implementation roll-out

Strengthen management skills of hospital administrators

Recruit, train and deploy 330 CHWs - serves 165 unmanned health posts; access for 577,000 Zambians who live in rural areas with no access to a trained clinician

Goal: produce 5,000 CHWs, 33% increase in the overall health workforce

CHAI’s Approach in Practice: Develop policies in planning to reshape government HRH priorities

14,748 180

19,035 1,2843,630

725 3,826

2,6773,321

18,499

20,861 39,360

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

Total HCWs

in 2009

Total Hired

from

Abroad

Total

Intakes

(from Tis)

Total Did

not

graduate

Total

Graduated

but not

entering

workforce

Total

Retiring

Total

Involuntary

attrition

Total

Voluntary

attrition

Total Back

to School

Total in

2018

Remaining

gap

Target

CHAI will focus on the most

challenging root cause

drivers that are not being

fully addressed in the current response

What is the magnitude of the

HRH crisis in-country?

Root Cause Drivers Analysis

Current efforts focused on voluntary attrition, but pre-service and not entering workforce are greatest preventable drivers

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5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

2009 2011 2013 2015 2017 2019 2021 2023 2025 2027 2029 2031 2033 2035 2037 2039 2041 2043 2045

No Interventions

No Interventions and 0% Voluntary Attri tion

Target

Pipeline Analysis

At current output MoH targets will never be reached

Even at ‘fantasy’ output (0% attrition, other variables constant), targets would only be reached in 2045

Inflow Outflow

Example: National training operational plans set bold training targets, mobilize financial resources for scale-up and identify practical steps to achieve targets (Zambia, Malawi, Lesotho)

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Example: National Training Operational Plan School-specific

operational plans for all training institutions

nationwide - costs all resources required to reach training targets

Aggregate data to national level

Harmonized national training operational plan from which MoH and all partners can implement

training scale-up and mobilize resources

Example: Workforce optimization analyses used to deploy graduates and re-entry health workers in national job fairs to the underserved areas (Zambia, Malawi, Liberia)

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Example: National Training Operational Plan

Excel demand-based model to determine

optimal distribution of health workers needed

to provide greatest coverage of health

services

National policy with deployment

prioritization by district, health facility and type

of health worker

Targeted recruitment and deployment of new

graduates

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2011

2009

Example: Ethiopia Health Management Initiative

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Train hospital CEOs (through Masters of Hospital Administration Program in partnership with Yale University) on how to effectively and efficiently manage hospitals to deliver quality health services

81 CEOs enrolled or graduated

Includes HR management training on recruitment, motivation, retention and performance monitoring to increase productivity of health workforce

Launched by Federal Ministry of Health

Developed with 62 different partners (health and other government sectors, NGOs, etc)

Guidelines focus on 13 key hospital management areas (patient flow; leadership and governance; management of HR, medical records, facilities, finances, quality, reporting, medical equipment; services in nursing care, pharmacy, laboratory, infection prevention)

Collaborations in-country among multiple partners is required to execute successful HRH interventions

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Training Institutions

Regulatory bodies

Bilateral donors, implementing partners

Government partners

Ministry of Health Ministry of Education Ministry of Finance Cabinet Ministry of Works and

Supply Ministry of Science

Technology and Vocational Training

DFID CIDA SIDA WHO USAID EU World Bank

Nursing/midwifery schools Schools of Medicine Universities Biomedical colleges Paramedical schools

Medical council/boards Nursing council Professional

associations Union bodies

Government priorities and local situation determine which program goals we focus on

Where CHAI is putting its HRH expertise to work

Zambia: intensive 3-year programmatic work

Malawi, Lesotho, Liberia, Haiti:

technical program support Ethiopia, Rwanda: Targeted HRH

program

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Our vision to move the HRH agenda

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Expand core countries

Emphasize focused themes

Collaborate with multilaterals

Global shortage of 3.5M health workers Africa has 11% of the world’s population, 24% of its disease burden, but just 3%

of its health workers

Opportunity

WHO GHWA GFATM

Expand support for comprehensive programming Apply lessons learned from successful interventions to

additional countries where there is an urgent need to concretely solve the HRH shortage and meet MDGs 4, 5 and 6 targets Midwives - Reduce maternal mortality by scaling-up

production and rationalized distribution Community health workers – Integration into the

formal health workforce and national scale-up

Thank you

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