Development of the conceptual framework
Thinking on human resources in the health sector in sub-Saharan Africa leads to develop adapted tools. The first step consists in context-oriented human resources and their management within the entire health system and its actors, internally as well as externally. As recent works remind it, for the comprehension of the social world, to extract any element from its context is eminently dangerous. In fact we face a health system in which it becomes essential to replace all interrogations about the place and role of the professionals [
11]. The human resource management should be relocated within the entire aspects of the organizational modalities and improvement of medical systems (States' policies to staffs and populations of therapeutic practices and their initial trainings) to provide answers to recurring interrogations which raise concern and difficulties to obtain quantitative and qualitative adequacies for health care professionals with the needs of objective and perceived care for the populations. This questioning is not added to many explanations on dysfunctions of the African medical systems but opens way to the formulation of objectives for changes aiming at a better effectiveness in the health care system.
The search for a greater effectiveness regarding nursing practices and their recourse opens to the second step. This one is the opposite to break with actions burst in sectors of technical performances and scattered in distinct skills. In the approach to improve medical systems, there is not question any more to dissociate spatio-temporal dimensions in liaison with sectors of operation separating, for example, the local and immediate levels of operative functions for health care structures, on the one hand, and levels including organization and decision of the health care systems, on the other hand. These approaches by sectorial activities produce changes, which can only intervene within the medical system, without modifying its structure and its functioning, nor the links and their effects between its elements.
These two steps are found within a systemic approach of human resources in the health care sector. The systemic vision, supported by a research-action inter-sectorial approach, puts in perspective human resources in its interactions with all components of the medical systems. It opens a way towards a representation of changes, which suppose the overall progress of the system, to which they apply. The aim is the development of a new model of knowledge from the two human resources capacity building projects in central Africa concerning the field of health:
The first project, initiated three years ago in the Democratic Republic of Congo (DRC), recommends to support initial teaching in health sciences in the secondary level of education at the national level. In a first stage, the project develops coherence, relevance and understanding for a significant number of actors and stakeholders of strategic orientations, founders of the reform of the nurse sciences program required by the Department of Health Sciences Education within the Ministry of Health. In 2005, this reform is on the way. The whole process enables autonomy of teachers, as well as of learners, managers, department staff and supervisors.... It is by a methodological work calling upon concepts such as active pedagogies, skilled-based approach [
13,
14], organizational learning, thinking and self-assessment, built by partnership and interrelationships between all the actors together, giving greater importance to improving health care quality and their perceptions within the framework of Structures for primary health care.
The second project in progress is a national support to schools of nurse sciences in Rwanda. The steps and methods are similar to those launched in DRC. The interest carried to human resources passes by a second reading of the training package related to health sciences (professional, higher and academic levels). The search for a better adequacy between trainings and health professional expectations as well as those of the public regarding care, underlines the necessity to train nurses in technical secondary level on the skill-based approach. The project is also involved in an in-depth work with the various local and national actors: teachers, internship supervisors, directors of educational establishments, learners, and Ministries. It articulates, indeed, several organizational and institutional levels: local learning environments complying with medical standards, human resource requirements planning and training schemes.
When projects for general thinking are located and specific to a category of professionals (nurses), actors and fields are relocated in the entire medical environment including the populations, social and political supervisors. The stake is not just the detailed observation of actors and their relations with the health care systems, but to go in fine beyond traditional explanatory models of health care (dis)functioning in Africa focused on districts. The different sites contribute by developing an analysis framework on more complex realities than simple setting in linear equation between, on the one hand, the medical standards planned by national institutions, and, on the other hand, the assessment of local requirements in human resources without integration neither for their training modalities nor for the expectations expressed by the populations.
A grid of analysis is suggested where human resource management, including for nurses of primary health care structures, falls under the overall medical system and the diversity of its political actors, health care professionals or not. These components are considered within their dynamic interactions, as much undergone as built. It makes it possible to avoid separating artificially human resource management, perspectives for planning, training education, and evaluation. Persistent dichotomies between spheres of health and education are checked through penalizing field-based discordances between professionals' skill profiles and their needs while meeting populations-expressed expectations. The perspectives for efficient changes of a health system assumes improving different adequacy levels which are to avoid reduced searching " for oasis of rationality" [
12], limited to dimensions of each health district, and to the implementation of sectorial projects launched together in space and time.