Emergence of the regionalization of recruitment policy
Although the distribution of health personnel among the different regions in the country has always been a concern for Ministry of Health officials, the issue emerged as a public problem in 2000 after the establishment of the Millennium Development Goals (MDGs), notably in relation to Goal 5 on the reduction of maternal mortality. It became evident that this goal could not be attained without qualified personnel in remote areas, as one of the lead officials at the time confided:
“Practically all the midwives were in the city; yet we need midwives outside of the city to reduce maternal mortality if we hope to achieve MDG 5. From that moment on, we decided to recruit midwives for the regions” (decision maker)
The idea to regionalize the recruitment of health personnel emerged in the Ministry of Health at the Secretary General office based on the identification of this problem and of several windows of opportunity.
The first window of opportunity was the availability of a large number of already-trained officers who wanted to join the public service. In fact, access to health care vocational schools (e.g., for nurses, birth attendants, and midwives) is conditional upon completing the competitive selection process organized annually by the Civil Service Ministry. Following training, the new health officers automatically enter the public service and are assigned to the different regions by the Ministry of Health. However, since the early 2000s, health care training schools, formerly open only to personnel who completed the State’s competitive selection process or the professional exam, were opened to qualified registrants, i.e., applicants who chose not to compete or did not compete successfully but who are committed to paying for their training. Unlike those who passed the entrance exam, qualified registrants did not join the public service upon completing their studies.
In doing so, some were able to receive training for various medical professions, including nurse, midwife, and birth attendant. This system was implemented without a policy to absorb the new graduates such that, at one point, the Ministry of Health found itself overwhelmed by applications to join the public service.
The second window of opportunity was the opportunity given to the Ministry of Health, by the government, to recruit personnel based on needs by allocating a specific budget through what are referred to as ‘the new measures’. Since 2000, the government has allocated additional resources to these two ministries to recruit personnel apart from the recruitment organized by the Civil Service Ministry. Hence, starting in 2002, the Ministry of Health decided to recruit health workers (nurses, midwifes) using these budget allocations to address the shortfall issue limiting the operation of a certain number of districts. For one official:
“The idea of regionalizing the recruitment of workers came out of the finding that some regions were devoid of personnel. We knew that there are people who enrolled individually. They paid, and now they are coming to submit applications to the Ministry; while waiting to truly revise the assignment system and to be able to get more health workers, we will ask these people whether they want to go work in the regions. It was from that moment that recruiting was done to benefit the regions. We started to recruit already-trained personnel.” (decision maker)
The option of regionalized recruitment came about after several meetings in 2001. However, the process remained limited only to central Ministry of Health officials. Neither the regional and district officials, nor the organizations representing health personnel were involved in the formulation process.
The Ministry of Health conducts the regionalized recruitement by a statement which clearly states by region, the number of positions available. This statement specifies that the regionalized staff is recruited to serve only in the area chosen by the candidates. But there is no policy document that specifies the content of this policy, recruitment conditions, departure arrangements in the region, and the career plan for this staff.
The key informants interviewed unanimously acknowledged the absence of written directives governing the status of this new category of worker. One former official explains the reasons for this undefined status:
“We didn’t for a very simple reason: for us this was not something that was going to last; it was temporary. It would last only the time that it took the State to train the maximum number of health officers. What was important was creating a de facto situation with the public service, and the funds to get personnel in underserved regions. Well, now, was it necessary to get it in writing and make a sort of administrative innovation out of it? No, we didn’t think it was worth it.”
This lack of formalized policy content would have repercussions at the implementation stage.
Implementation of the regionalization of recruitment policy
Regionalized officers are recruited through a competitive process. This process is organized by the Civil Service Ministry, through a call for applications, for positions in the different regions. These positions were previously determined by the Ministry of Health, which plans this recruitment while developing the annual budget and provides the list of positions to be filled by region.
The recruitment was organized centrally and the first process took place in 2002. Since then, more than ten competitive processes have been organized and, according to data from the Ministry of Health’s Studies Branch, 3 567 health officers have been recruited for underserved regions.
Regionalization went through several phases of implementation. In the initial years (2002-2004), the policy was limited to the recruitment of workers for the regions, without any possibility of moving to another region. Then, the possibility of a job-for-job exchange of posts was approved for a certain time, and then cancelled. Starting in 2005, a transfer condition was added. Now, regionalized officers can leave the regions after going through a competitive selection process.
Implementation is limited by the absence of clear written guidelines on the administrative management of these workers. The consequence was a chaotic implementation in the very beginning (2002-2003). One manager describes the piecemeal implementation as follows:
“It must be said that this also validates the idea that it was not properly prepared. There was a lot of haste, and the first ones to be recruited and sent to the field, I think that at that time the HR department did not even know how to manage them, and the problems were handled from day to day. The HR would examine a given situation as it would come up, see with the Public Service what was appropriate to do; so if a problem was handled in a way, from then on if this problem reoccured, it would be handled that way, …” (Regional manager)
Another situation that reveals the implementation difficulties related to the lack of written guidelines was the differential treatment, by region, of the possibility for officers with the same profiles to move to another region through the exchange of posts. This was acknowledged by one human resources manager:
“For example, there are situations that arise and one does not know how to manage them. One of these situations is the exchange. They come and say, “I am going to swap with someone.” They are told that they cannot swap, but in reality there is no written rule that says that they cannot exchange posts”.
Variations in the implementation of the exchange of posts system are observed. In fact, while in the Sahel and Southwest regions exchange was not possible, officers have been able to leave their region of recruitment through an exchange.
In addition to the absence of a policy document, there was a lack of information between the central level and the regional and district levels involved in implementation. Initially, regional officers were sent to the regions, yet managers did not have sufficient information on their status. This situation allowed some officers to leave the regions, unbeknown to their managers.
Almost ten years after implementation of this policy (2002-2012), this shortcoming has not yet been corrected, as confirmed by this district manager:
“All I know is that for some years, we have been sent officers and they say that they cannot leave the region... I tried to get information but could not find a single official document that explains this process”.
All managers at all levels (central, regional, and district), acknowledged that they are under pressure from administrative authorities and elected officials, who intervene so that their relatives are not assigned too far from the urban centres.
Regionalized health officers criticized a form of “injustice” that makes them second-class employees. This injustice was felt even more due to the fact that regionalized personnel, unlike those recruited through the direct competitive process, had paid out of their own pocket for their training. A regionalized officer said:
“I believe that everyone must be treated the same way. I do not understand why qualified registrants, who paid for their education out of their own pockets, do not have the same rights as the direct ones who are free in all their movements”.
This opinion was also shared by certain managers, as one conceded:
“The main problem is that in the long run, if we insist that they cannot be assigned anywhere else except over there, it becomes an injustice because these officers had the same training; they are doing the same job. The administration must find a strategy so that both [the regionalized and non-regiolalized officers] can have the same rights, because there is discrimination”.
However, for others, the officers’ position has no merit in the sense that they all knew the implications of taking part in the competitive process. The health officers consider that though they knew, the need for employment was so great that they did not weigh the long-term constraints. One officer declared:
“Since we needed work, we chose, but once we arrived, honestly, we realized that it was not easy”.
As the labor unions representatives, the health officiers consider that with this policy, the Ministry is forging ahead when it comes to human resources management. According to one labor union representative, the policy was put in place because the Ministry of Health was unable to apply the written directives on assignments. For this labor union representative, if every officer spent six years in a rural location, as set out in the written directives, there would have been no need for this policy.