Sophie Witter

Health after conflict – Rebuilding the system 13th December 2016Wellcome Trust, London

Background on HW incentives research

• Objective: to understand the evolution of incentives for health workers post-conflict and their effects on HRH and the health sector• Stakeholder mapping• Document review• Key informant interviews• Life histories with health workers• Qualitative analysis of routine HR data• Survey of health workers

• Conducted in all 4 study countries• Cambodia, Sierra Leone, Uganda, Zimbabwe

Background on HW deployment research

• Objective: to identify ways to improve deployment systems to rural areas used by large employers (FBO and government) of health personnel in post conflict contexts• Document review• Key informant interviews• In-depth interviews with managers• In-depth interviews with health workers (including job

histories)• Qualitative analysis of routine HR data• Personnel record review

• Conducted in 2 countries• Uganda and Zimbabwe

Some findings from the research

Motivation to join the profession

• Rich mix of motivations for joining the profession:• ‘personal calling’• exhortations of family and friends • early experiences of the health care sector• desire for social status / respect (e.g. uniforms)• economic factors

• These allow low income participants to access health professions, to which they are then likely to show considerably loyalty. • The lessons learned from these cohorts, which had

remained in service through periods of conflict and crisis, can influence recruitment and training policies in similar contexts

Immediate effects of conflict and crisis:impact on existing staff

• Collapse in HR and HR information systems• Staff may have been targeted - reduced in

number, not well distributed, carried out roles above their station, traumatised• Also positive aspects – coping strategies

(personal & community-based) allowed them to survive• Should be recognised and rewarded• Psychosocial support needed where staff have

been targets

Staff coping strategies• For conflicts and Ebola:• Health staff targeted in both (different reasons)• Practical – hiding, task shifting, removing uniform,

international support etc.• Psychosocial – community support, support from

colleagues, religious faith

• For economic crises:• Dual practice• Other income generating strategies• Informal/formal staff movements – e.g. to lower

cost rural areas

How to support staff and systems

• Enforcement of protection for health staff during conflicts is urgently needed internationally• At national level, particularly in fragile/crisis-prone

countries, contingency planning for crises is needed• Include practical measures such as effective

communications systems to support staff and communities with real-time advice and reassurance• Social media tools appreciated in SL, but came late.

• Include back-up systems to ensure continuity of pay and drugs supply

• Give clear discretion for local management decisions on needed changes to services/staffing.

Production & training• Distortion of HW supply/salaries by aid industry

• Foreign staff fill gaps in local workforce (senior level)• Complaints & resentment common (skills/capacity;

salaries/power/decision-making freedom)

• Training important but can be mishandled • Over-production of poorly trained staff • investment in IST – resources but not effective on performance

• New HRH policies introduced as response to post conflict staffing may generate problems later• Nature of political settlement determines confidence

in government & willingness to join public sector • The T-word is key

Deployment• No special policy changes in response to

conflict/crisis• Local managers interpreted rules flexibly• Sub-national managers have greater decision-

space • Flexibility in implementation may increase

retention in hard-to-reach areas: need to take workers’ preferences into account• Bonding – effective in past; not viable in crisis

Incentive packages• Fragmentation of incentive structures

• Linked to multiple actors• Piecemeal, poorly funded/implemented, no feedback loops • Policies crafted with external inputs have limited traction• Management reforms particularly hard to address

• Need balanced incentive package over time• Prioritising hard-to-reach areas• Consultation/communication are key – low-hanging fruit• Reinforcing supervision; improving working conditions• Aspects needing organisational change receive less priority

than financial incentives (easier to finance)• Phases: fragmentation initially may be adaptive, but

when to harmonise?

Complex remuneration

PBF in Sierra Leone• Only ~10% of overall

remuneration, but seen as a complement - less sense of entitlement

• used for emergencies or for income generating activities

• less vulnerable to family claims• but reduced in value by delays,

shortfalls, lack of transparency

What do multiple actors & fragmented policies mean for overall remuneration, motivation and performance?

Absolute and relative average income by cadre and component, including PBF (Sierra Leone)

Managing health worker marketsMind the (sectoral) gap• Conflict/post-conflict dynamics affect attraction/retention

across health sub-sectors, distorting provision of care.• In northern Uganda:

• PNFP sector more functional during the conflict• Public sector boosted in post conflict phase: increased investments

under the PRDP; consolidation of allowances; hard-to-reach allowances; salaries more regular; pension still provided.

• Retention within the PNFP sector has had to rely on more personal factors (loyalty, family ties). Many still working in the PNFP sector express intention to leave, if circumstances permit.

• In Zimbabwe:• Public sector unable to offer same terms and conditions for staff• Municipalities with independent income source employ senior staff for

less demanding roles in urban clinics, adding to shortages in other areas

Rural retention• Rural health workers face particular challenges• Poor working conditions, separation from families, limited

access to training, longer working hours (staff shortages), inability to earn from other sources.• Rules on rotation are often not respected. • Incentives for rural areas receive limited political focus –

especially ineffectual • Insecurity

• Local staff & mid-level cadres more likely to work in these areas (local attachment; limited mobility)• During economic crisis, rural areas can have

advantages (lower costs, able to subsist)• Urban areas – reports of poor delegation, favouritism,

and a lack of autonomy for staff. Tensions over unclear roles and absenteeism.

The gendered health workforce• Lack of balance: • Women predominate in nursing & midwifery• Under-represented in management; mainly low payed

positions• Gender roles• Shaped by caring household responsibilities• Affects attitudes to rural deployment • Particular challenges in accessing training

• Coping strategies within conflict emerged as a key theme• Gendered strategies/experiences also shaped by

poverty and household structure• Most HRH regulatory frameworks did not use the

post-conflict moment to address gender.

Thinking longer-term - windows ofopportunity & path dependency

• May be a ‘window of opportunity’ for restructuring post-conflict, but not found in the immediate post-conflict period in any of our focal countries• Fundamental reforms came later, when political

mandate, external support and capacity were combined• Depending on the degree of destruction and loss

of staff, the reconstruction of the HRH can take decades• Cambodia: focus on increasing numbers took long time,

followed by a decade of management reforms. Now starting to regaining control from NGOs and external bodies over policy and incentive schemes• As a result of key decisions in post-conflict period –

contracting out services to NGOs?

Human resources for health andstate-building

• Concept of state-building itself highly contested• Empirical evidence for most of the linkages is not

strong• Not surprising, given the complexity of the

relationships, and of measuring. • Nevertheless, some posited relationships are

plausible:• between development of health cadres and a

strengthened public administration• reintegration of factional health staff post-conflict

plausibly linked to reconciliation and peace-building

Conclusions & recommendations 1• Health markets are more complex in fragile and

post-conflict settings. • Policies must ensure avoid distorting the health

labour markets and draining staff from hard-to-serve areas.• International support should focus on reinforcing

and rewarding resilience, and providing decision spaces and flexibility for good staff to thrive and drive forward better health care services for all.• Investments in the immediate post-conflict period

have a duty to consider longer term implications.

Conclusions & recommendations 2• Incentive packages for staff in hard-to-serve areas

should focus on more than short-term financial measures, and include • recognition of their role and achievements in

challenging circumstances• practical measures to improve their security• provision of decent housing, working conditions,

training and pay• measures to re-establish trust, better communication

and teamwork. • Remuneration policies need to take into account

the different facets of pay which matter to health.• Improved gender equity in the health workforce

requires integrating gender into policy and action to improve gender equity within institutions and households.

Forthcoming references

Plus the following references for forthcoming articles: • Slide 5 – motivation to join the profession:

Witter, S., Wurie, H., Namakula, J., Mashange, W., Chirwa, Y., Alonso-Garbayo, A. Why do people become health workers? Analysis from life histories in four post-conflict and post-crisis countries. Submitted to Social Science and Medicine.

• Slide 8 – Supporting staff through crisesWitter, S., Wurie, H., Chandiwana, P., Namakula, J., So, S., Alonso-Garbayo, A., Ssengooba, F., Raven, J. (2016) How do health workers experience and cope with shocks? Learning from four fragile and conflict-affected states on resilience in the health workforce. Submitted to Health Policy and Planning

• Slide 15 – The gendered health workforceWitter, S., Namakula, J., Wurie, H., Chirwa, Y., So, S., Vong, S., Ros, B., Buzuzi, S. and Theobald, S. (2016) The gendered health workforce: mixed methods analysis from four post-conflict contexts. Submitted to special edition of Health Policy and Planning on gender and ethics.

• Slide 16 – Windows of opportunityWitter, S., Bertone, M., Chirwa, Y., Namakula, J., So, S., Wurie, H. (2016) Evolution of policies on human resources for health: opportunities and constraints in four post-conflict and post-crisis settings. Forthcoming with Conflict and Health.

All references available in ReBUILD brief: Establishing a responsive & equitable health workforce post-conflict & post-crisis: lessons from ReBUILD research