Limitations
This study, conducted through a self-assessment survey, was prone to subjectivity, possible variations in interpretation of the questions and potential respondent bias. To mitigate these risks, two strategies were adopted: (1) the preliminary findings were discussed during a face-to-face workshop, which provided an opportunity to clarify scope of the study and the precise nature and expectation of the questions in the survey and (2) the technical contents of the responses were validated with the support of the WHO staff.
The survey can be considered representative of challenges and opportunities faced by HRH units (or equivalent mechanisms and bodies) in the SEAR. Caution should however be exercised in extrapolating findings to other regions. Data provided through the questionnaires were generally complete, but data on budget and expenditures by HRH units were more limited.
The relatively little sample size (10 countries) limited the scope for analyses exploring the existence of correlations between specific characteristics of HRH units and HRH-related outcomes that could be plausibly associated a priori with effective HRH governance.
Interpretation of findings
Despite these limitations, the analysis was able to assess the HRH units at the national level of countries in the region.
Most countries (70%) indicated having had an HRH unit for more than 5 years. Having a single HRH unit, however, is not the only possible governance arrangement: some respondents reported a fragmentation of the HRH agenda linked to the scattering of responsibilities across different functional units and departments. In the aggregate, these findings would support the interpretation that a central HRH unit would probably be advantageous in most contexts, but that its role can vary and include both models in which it performs directly most or all of the relevant HRH governance functions or—if these are by statute allocated to other units—at the very least performs a coordination role.
In most countries, it was reported that the HRH units reported to a senior level (Director General or Permanent Secretary) in the overall MoH organogram, indicating that, at least in theory, they should have an opportunity to have direct access to the decision-making level. Some responses provided through the questionnaires however indicated that strengthened communication and advocacy would be required to secure the required political support.
In terms of functions performed, the survey indicated that all or the vast majority of countries performed at least some of the core functions, such as HRH planning, policy development and basic HRH data management; other functions were carried out by other departments and mechanisms. More concerning was the finding that some functions were not performed at all in several countries, including, e.g. inter-sectoral and multi-constituency coordination research and monitoring of trends, labour relations with health workers’ representatives. These roles are critical to improve policy dialogue in countries, especially with regard to a more strategic and long-term orientation of the HRH agenda, built and implemented in partnership with other relevant sectors, including education, finance and labour. These findings echo those of earlier literature, which identified examples of inter-sectoral coordination mechanisms to have a positive effect on health workforce governance [
11,
12], as well as the importance of building effective partnerships with development partners [
13,
14] and the private sector [
15,
16].
Therefore, while some flexibility in the structures of HRH units is appropriate, deliberate efforts should be made to ensure that all core functions be performed, irrespective of whether this happens in a single unit or department or as a result of effective coordination across different ones.
Performing effectively the roles assigned requires that HRH units have adequate capacity and resources: the findings of the survey reveal that some HRH units had a very limited staffing complement, while others a relatively large one. This heterogeneity in size most probably reflects differences in the population size of countries and in roles, both in respect of functions and in terms of different division of responsibilities between units at the national level vis-a-vis equivalent bodies at the sub-national levels in the context of decentralized or devolved health systems, which is the typical situation in large and/ or federal countries. The opportunities, implications and drawbacks of decentralization of HRH functions have been discussed elsewhere [
17‐
19]. But there is a need, across different country contexts, to align staffing of HRH units with expected functions; an appropriate functional allocation of staff is as important as the overall size and composition.
In some of the countries, a relatively short average tenure of the head of the HRH unit may contribute to rapidly shifting priorities, institutional instability and inconsistent pursuit of policy objectives. These findings reinforce a concern that HRH planning and development may still largely be seen as a routine administrative function, subject to a rapid turn-over, often as a part of routine civil service rotation schemes. Many respondents reported gaps in the HRH units in terms of specific technical capacity on HRH; conversely, HRH should be best understood as a specialized technical area of public health, which requires years of experience and ideally dedicated training [
20]. Experiences from other contexts underscore the importance of adequate management competencies to ensure the successful design and implementation of HRH policies to improve both health outcomes and harness the employment creation potential of the health sector [
21,
22]. The findings reinforce a need to both strengthen the technical profile of HRH units by increasing the relative proportion of professionals employed and to create an empowering and rewarding work environment that, like for the rest of the health workforce, can foster the attraction and retention of talent [
23].
While a basic HRH information system was reported to be functioning by most countries, data were most typically limited to public sector health workers, and there were substantial limitations found in the systems for HRH data validation, integration and analysis. The mandate, capacity and information systems of HRH units and of national HRH information systems should therefore be expanded to more explicitly include maintaining an overview of strategic information and intelligence on the health workforce at large, whether employed by the public or private sector [
24]. The routine implementation of national health workforce accounts provides a comprehensive framework to advance this agenda [
25].
The availability of material inputs (office space, computers, etc.) did not appear to be a major area of concern in the countries of this region, but availability of adequate financial resources was often reported as insufficient. Given the multiplier effect that the work of HRH units can have through the design and implementation of more cost-effective health workforce policies, their work should be adequately funded and include flexibility to fund priority activities, in addition to fixed recurrent costs (such as salaries).
The reported high dependence on external funding in some countries represented an additional concern, with a risk of displacing domestic investments, volatility of support and sustainability [
26]. But in the case of external dependence of core stewardship functions expected of a Ministry of Health—as HRH governance and policy setting undoubtedly is—there is an additional layer of risk in terms of a distortion by external actors of national priority-setting processes and reduced government accountability to its own citizens [
27]. National Governments should invest adequate domestic resources in their HRH units and put in place safeguards to guarantee their technical autonomy and financial and programmatic independence from external partners.
Workshops were organized in September 2017 and April 2018 to review the preliminary findings of the study and discuss the policy implications. Participating countries welcomed the findings of the study and are considering a number of policy options to improve HRH governance in their countries: two of the three countries that reported not having an HRH unit recognized the importance of having one and are currently in the process of setting it up. Most of the SEAR countries that reported having an HRH unit identified a need to strengthen the capacity of the staff—in both quantitative and qualitative terms—and to overcome the high turn-over affecting leadership positions in the HRH units. At the governance level, countries recognized the importance of creating inter-sectoral coordination mechanisms to be more effective in HRH planning.
Policy implications
The findings of this study can contribute to the broader conceptualization of capacity building initiatives on the HRH agenda in SEAR.
The strengthening of the HRH governance capacity should follow a logical hierarchy, identifying first and foremost the essential functions that the public sector is expected to perform to optimize HRH governance. The definition of expected roles and functions will in turn allow to identify the upstream system-wide factors and the downstream capacity requirements for the strengthening of the HRH units. Among the former, a fundamental enabler is to build political ownership and support for reform and capacity building on HRH governance [
28].
The broader spectrum of factors that determine the outcomes of health policy making in the HRH domain should be considered: health policy making the health workforce domain is influenced by factors linked to health needs, fiscal space, economic policy, employment and labour policies and risks to trigger industrial actions by health workers. However, since opportunities for policy change stem from the iterative relations among the three processes of identifying problems, developing relevant technical solutions and building policy support for the latter [
29], the importance of building sound capacity for analysis of HRH challenges and proposal of appropriate solutions should not be underestimated.
The role and function of the HRH unit should be considered within the unique institutional and governance framework of each country.
Effectively performing the existing functions and considering an expansion of the scope of work of HRH units will however necessitate a staffing complement commensurate to the roles, in terms of both numbers and skills, selected based on skills and merits, and receiving adequate support.
To date, despite a wide recognition of the importance of the health workforce, relatively few experiences have been documented on improving HRH governance, leaving many policy questions unanswered. The findings from this survey shed some light on existing capacity and gaps in public sector HRH governance in the SEAR, but also underscore the importance of further documenting experiences, understanding the political economy of HRH policy making and creating opportunities for mutual learning [
30].