Background
Indicator\country | Indonesia | Sudan | Tanzania |
---|---|---|---|
Population (000) | 249 866 | 37 964 | 49 253 |
Gross national income per capita (USD)a
| 3 580 | 1 550 | 630 |
Life expectancy at birth (men) | 69 | 61 | 61 |
Life expectancy at birth (women) | 73 | 65 | 65 |
Maternal mortality (per 100 000 live births) | 190 | 360 | 410 |
Under-5 mortality (per 1 000 live births) | 29 | 77 | 52 |
Infant mortality (per 1 000 live births) | 25 | 51 | 36 |
N. of physicians per 10 000 (2007–2013) | 2.0 | 2.8 | 0.3 |
N. of nurses and midwives per 10 000 (2007–2013) | 13.8 | 8.4 | 4.4 |
Total expenditure on health (US$ PPP) as % of GDP (2012) | 3.0 | 6.7 | 7.1 |
Public expenditure as % of total health expenditure (2012) | 39.6 | 22.5 | 39.0 |
Expenditure on health as % of total Government expenditure (2012) | 6.6 | 11.1 | 11.2 |
Indonesia | Sudan | Tanzania |
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Availability
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Availability
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Availability
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The production of qualified health workers has increased significantly in the last 10 years. The number of medical schools went from 40 in 2003 to 72 (of which 43 were private) in 2013; there were 33 736 physicians in 2010 and 81 131 in 2014, an increase of 140% [19]. There are 313 diploma, 275 bachelor, and 9 master nursing programs formally recognized.b There were 169 697 nurses working in health facilities in 2010 and 295 508 in 2014, an increase of 74%.
Accessibility
The imbalanced distribution and the insufficient quality of the health workforce are major challenges [20] and an obstacle to achieving universal health coverage [21]. Among the 9 550 health centers, 9.8% are without doctors, 23% are without nutritionists, and 61.7% have no health promotion workers [19]. The geographical distribution of nurses and midwives is less uneven than that of doctors, but there are still important variations [19, 22]. The specificities of the numerous islands and of rural areas outside the main island of Java pose additional challenges to health workforce policies [23‐25].
Policy and regulation
The current government’s three priorities for HRH are as follows: production, distribution, and improving the quality and performance of health workers by ensuring that education and training institutions meet national standards [4]. In 2014, one third of medical undergraduate programs were not accredited, and the situation was similar in other health professions. A national examination was introduced in 2013 for medical, nursing, and midwifery students as a condition of access to the register; a similar exam is planned for pharmacy and dentistry graduates [23]. | The availability of physicians, nurses and midwives is low in spite of the rapid growth of medical schools from 4 in 1990 to 28 in 2006, and to 34 in 2012, producing about 3 000 doctors per year; the number of nursing and midwifery schools rose from 18 in 2006 to 55 in 2013.
Accessibility
There are major variations in the geographical distribution of health workers: 65% of specialist physicians and 58% of technicians are in the capital, where about 20% of the population lives. Emigration of health workers is a major challenge for the country, particularly among physicians. Not only new graduates but also experienced physicians have left the country to work in Saudi Arabia, the USA, and the UK—though numbers registered there have diminished in recent years because of restrictions on hiring health personnel from poor countries—and also Irelandc [26‐28]. The public sector employs 62% of all health workers, the private sector 34%, and the military, university, police, and voluntary sectors 1% each. It is estimated that 90% of health professionals work in both the public and the private sector [26].
Policy and regulation
The Ministry of Higher Education is responsible for pre-service training. The Sudan Medical Council registers doctors, pharmacists, and dentists, and the National Council for Medical and Health Professions regulates the rest of the qualified health workforce. There is a National Human Resources for Health Strategic Plan 2012–2016 which identified the main challenges as “developing capacity for HRH planning and policies, augmenting equitable distribution, improving performance management systems, improving health workforce production, education and training and strengthening HRH functions at decentralized levels” [29, 30]. There has been a HRH Observatory since 2007 (http://www.who.int/workforcealliance/members_partners/member_list/nhrhobs_sudan/en/) and a Council for Coordination, composed of representatives of ministries, training institutions, the medical council, trade unions, aid agencies and the private sector, meets quarterly to discuss HRH issues [27]. | The Ministry of Health and Social Welfare (MoHSW) recognized that shortage of personnel and imbalances in the geographical distribution and in the skill mix of health workers are a major impediment to achieving the health MDGs [31, 32]. In March 2013, there were 64 449 health workers of all categories, including 12 074 in the private sector,d represented 36.4% of the requirement according to MoHSW standards; qualified workers included 1 135 medical doctors, 1 741 assistant medical officers, 5 950 clinical officers, and 14 096 nurses and midwives [33]. The upgrading and expansion of training institutions is ongoing. Schools of nursing doubled enrollment in 2011. For many years, Tanzania has trained assistant medical officers, a cadre between clinical officer and medical doctor; as the degree is not internationally recognized, their retention rate is high [34].
Accessibility
The number of nurses and doctors per capita is low; nationally, it is increasing for both categories, but in 5 out of 25 regions, it was lower in 2015 than in 2014. Between 2010 and 2015, the number of new staff posted in public services was 77% of available positions (new employment permits approved) [35]. Recruitment in public services is made difficult by the competition from the not-for-profit private sector [36] and by emigration [37]. 74% of physicians work in urban areas, where their ratio to population is 17 times higher than in rural areas; 8% of health facilities are not functional because of the absence of personnel [33]. Absenteeism, low productivity [38‐40]; difficulty in recruiting and retaining personnel, and management deficiencies [31] are considered as the main HRH problems.
Policy and regulation
To improve performance, the Tanzania National eHealth Strategy 2013 – 2018
e proposes to give healthcare workers access to continuous professional development through e-learning and digital resources. Better remuneration of workers in the health sector is needed [39, 41], as are improved management practices and career development opportunities [42]. |
Case presentation
Methods
Selection of country cases
Information search and sources
Results
Indonesia
Recife commitments | Objectives | Progress reported |
---|---|---|
1: “To harmonize supply and demand of health workers in improving the quality of health workers”f
| 1.1: “to develop an annual HRH requirement plan as the reference/ consideration in processing the licensing of education institutions” | Accreditation of schools of medicine and dentistry started in 2009 by the National Board for accreditation of higher education institutions; it was extended to schools of pharmacy, nursing, midwifery, nutrition, and public health in 2011. The change introduced in 2014 was that the licensing of education institutions became the responsibility of an independent Accreditation Agency for Health Professional Education Institutions (LAM-PT.Kes) |
1.2: to develop an integrated HRH information system, using a HRH observatory approach as the reference by March 2014 | A HRH Observatory has been established by the Ministry of Health in November 2014g and training of its personnel started in January 2015; funding was provided by WHO and 10 professionals participated. | |
1.3: to produce an annual HRH requirement plan by December 2013, and then every December | The upgrade of the HRH information system started in 2014, with funding from the Department of Foreign Affairs and Trade of Australia (DFAT). The Annual Planning for HRH for 2015 has been developed in collaboration with multiple stakeholders, including DFAT and WHO. This planning is based on the HRH Plan 2011–2025. | |
1.4: to develop a distance learning program to upgrade the education level of nurses and midwives from Diploma 1 to Diploma 3 level in remote regions | Distance learning activities for nurses and midwifes have been conducted in two provinces: East Nusa Tenggara, with funding from Australia, and East Kalimantan, with funding from the regional government. The digitalization of training modules was initiated at the end of 2014. | |
1.5: to develop a health workforce registration mechanism through competency certification (using exit exam as the certification exam) to ensure the competency of HW before registering to the health professional council | A national exit exam is in place for medicine and dentistry. XA similar exam was introduced for nurses and midwifes in 2014.h It is planned to extend this mechanism to other health professions in 2016. | |
2: “To improve the HRH distribution and retention” | 2.1 and 2. 2: affirmative action by provision of scholarships with bonding service to health workers in remote and underserved areas by December 2014 and to develop Guidelines of Scholarship with bonding service for remote underserved areas by June 2014 | A program of scholarships for students accepting to work in remote regions was implemented in 2014. |
2.3: to recruit students from remote and underserved regions from November 2013 onwards | Recruitment of students from these regions has started in 2014. | |
2.4 and 2. 5: to develop a task shifting model for health workers in remote areas by April 2014 and to develop Recommendations and Guidelines on task shifting by April 2014 and modules and curriculum of training by September 2014 | Recommendations for task-shifting and training modules have been developed in 2014 as planned. |
Sudan
Recife commitments | Objectives | Progress reported |
---|---|---|
1: “To enhance performance” | 1.1: “to improve the availability of adequate number of health managers, who have appropriate competencies and skills” | The Federal Ministry of Health (FMOH) mandated the Public Health Institute to implement diploma and master programs in public health, health services, hospital and disaster management, and human resources development; 400 candidates, mostly staff of state ministries of health, were enrolled in 2014. More than 300 obtained a diploma and reintegrated to their position at federal and state levels. |
1.2: “to enhance performance through the efficient critical management support systems - planning and budgeting; financial management; personnel management, infrastructure & logistics management; procurement and distribution of drugs and other commodities; information management and monitoring” | The FMOH invested in strengthening the planning, budgeting and monitoring, and information and personnel administration systems, but their full potential is yet to be realized, especially at decentralized levels. The FMOH and state ministries of health, with the support of the WHO and other partners, created a “planning platform” in 2014; it meets periodically and organizes training to build management capacity. | |
1.3: to enhance performance through an enabling working environment: degree of autonomy, clear definition and communication of roles and responsibilities, fit between the roles and structures, existence of national standards, rules and procedures, regular meetings, and supportive supervision; | Despite efforts to develop standards, rules, and procedures, progress in improving the working environment is slow. In 2015, the Cabinet issued a directive on improving work environment and retention to address the health worker migration to Gulf States. This was based on recommendations of the Federal Ministry of Health. | |
1.4: to enhance performance through updating the Continuing Professional Development (CPD) policy that in-service training/ continuous medical education is accredited as a means for licensing and relicensing; | In 2015, the Federal Ministry of Health, in collaboration with the Sudan Medical Council, initiated a policy process to develop guidelines for the accreditation of CPD and its linkages to licensing and promotion. A broad consultation is in process, and the adoption of the guidelines is planned to take place before mid-2016. | |
2: “To enhance quality of pre-service education” | 2.1: “to enhance the quality of pre-service education through improved postgraduate and undergraduate curricula for medical, dental and pharmacist disciplines” | The FMOH, with support from WHO and the Sudan Medical Council, initiated a reform of medical education to align it with health service needs and strategies. A pilot curricular reform started in four medical schools; reform of dental and pharmacy curricula has yet to start. At the postgraduate level, the curricula of 20 postgraduate medical specialty programs were reviewed in 2014. The Sudan Medical Specialization Board (SMSB) is currently updating the curricula of other postgraduate programs. The SMSB is also leading a reform through a new strategy prepared in 2015 focusing on the expansion of training sites, decentralization of training management, introduction of nursing specialties, and strengthening accreditation. The SMSB increased added 10 new specialty programs, including nursing and midwifery. |
2.2: “To enhance quality of pre-service education through improved pre-service curricula for the allied medical and health professions” | The Academy of Health Sciences (AHS) is currently updating nursing, midwifery, and laboratory, medical, dental, and pharmacy assistants’ programs. In 2015, three new branches of the AHS were added at the locality level. In addition, over 800 community midwives went through a crash program and were deployed to underserved areas in 2015. | |
2.3: “To enhance quality of pre-service education through the accreditation of postgraduate and undergraduate training facilities for medical, dental and pharmacist disciplines” | The Sudan Medical Council accreditation program, first established in 2008, has organized teams to conduct field visits to all medical schools in 2015. There are still no accreditation decisions, but the experience has triggered changes and facilitated resource mobilization for infrastructure and program development. The Council joined the World Federation of Medical Education “accrediting the accreditors” program; it has now applied to be accredited. There is no accreditation of dental and pharmacy schools, but standards for dental and pharmacy schools were reviewed and finalized in 2015 by the Sudan Medical Council. In 2015, the Sudan Medical Specialization Board developed standards for accrediting training sites and trainers. Application of these standards is underway [43]. |
Tanzania
Recife commitments | Objectives | Progress reported |
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1: “To increase the availability of skilled health workers at all levels of health service delivery from 46 % to 64 % by 2017 based on staffing levels of 2013” | 1.1: “To increase the density of health worker to population of the districts with below national average of 1.47 health workers per 1,000 population in 5 regions (Kigoma, Tabora, Rukwa, Shinyanga and Singida) from 0.73 health worker per 1,000 population to the national average” | During fiscal years 2013/2014 and 2014/2015, the 5 regions, which represent 18.5% of the total population, were allocated 20% of 19 566 new posts. Countrywide, the density of skilled health workers increased to 0.903 in 2014/15 after new posts were filled. In all 5 regions, the density has increased: Kigoma from 0.37 to 0.61, Tabora from 0.34 to 0.67, Rukwa from 0.54 to 0.70, Shinyanga from 0.57 to 0.62, and Singida went from 0.60 to 0.73, thus reaching the national average for 2013, but it remains below that of 2015. Out of 25 regions, 10 remained below the national average, 1 is “borderline,” and 14 are above [44]. There is also a proposal to legislate that students trained on public funds will not be registered until they have completed a compulsory 2-year period in rural areas. |
1.2: “To continue increasing production of skilled Health and Social workers from 4,364 in 2012 to 9,000 by 2017” | A Production of Health Workers Plan (2014–2024) has been approved; it outlines HRH objectives for the medium-term and provides a framework for short-term plan development. In 2014, the enrollment of allied health workers at certificate and diploma levels was 5 569, an increase of 77% respective to the previous year (3 143). For nurses and midwives, the increase was more modest (7.7%, from 5 135 to 5 533), and for doctors, pharmacists, dentists, and nursing officers, there was a decline from 1 890 to 1 810 [45]. | |
1.3: “To rationalize employment permits for health and social workers based on production and needs in all areas of technical professions” | The MoHSW developed a detailed 5-year recruitment plan which includes the expected production of health workers in each year [46]. | |
2. “To increase financial base (Other Charges and Private sector investment) to operationalize the pay and incentive policy by 2017” | No specific objectives were specified | Tanzania has developed a plan to increase financial resources to attract and retain qualified health workers, and various measures are being taken: -A pay and incentive policy for public sector employees has been adopted, including subsistence, extra duty, risk, and on-call allowance increases; -Increase of opportunities for capacity building and professional development and establishment of distance learning centers; -Improvements in working environment at the level of accommodation, equipment, availability of medicines and supplies, and renovation and expansion of infrastructures; -Provision of basic amenities in rural areas: water, electricity, and transport; -Sensitization of students to apply to health training |
2: “To develop and implement a Task Sharing Policy on HRH by 2017” | 2.1: “To develop an operational guideline based on consolidated 2013 WHO guidelines on task sharing to enhance existing Production and Quality Assurance Systems by 2015” | A Task Sharing Policy Guideline [47] was endorsed by the MoHSW on 2 February 2016. These Policy Guidelines will scale up agreed task-sharing practices at all levels of the health care delivery system (dispensary, health center, and district hospital). The Guidelines cover the development of a regulatory framework, the provision of supervision, mentoring, follow-up at regular intervals, and the definition of roles and associated competencies. |
2.2: “To implement a system-wide approach that includes representation from other departments across different health cadres including professional associations, regulatory bodies, training institutions, accreditation bodies and policy makers to decide on common areas for task sharing across healthcare cadres by 2017” | The process of developing the Task Sharing Policy and Guidelines (see 2.1) was participatory. In September 2014, a stakeholder forum was convened, during which a research synthesis and evidence on task-sharing were presented, initial inputs on task-sharing were solicited, and practices and experiences with task-sharing were shared. Additional consultations involved professional councils, boards, and associations in 2015. The next step is to develop an implementation plan. |