Human resource management in health care delivery systems: Challenges, trends and strategies
(By Dr Femi Olaleye MB.ChB., MBA)
Human resource management (HRM)is defined as the “integrated use of procedures, policies, and practices to recruit, maintain, and develop employees in order for an organisation to meet its desired goals.”
HRM includes six major functions:
· Personnel policy
· Performance management
· HR data systems
· HR strategy development
· General leadership and management
HRM in sub-Saharan Africa
The acute shortage of health care workers in sub-Saharan Africa is well-documented, but little attention has been paid to those who have HRM responsibilities; i.e. the individuals who are tasked with developing and leading a productive, motivated, and well-supported health workforce capable of delivering quality and accessible health services.
It is interesting to note that Africa produces up to 25 per cent of the world’s healthcare workforce but retains only 1 per cent of this workforce, despite the huge disease burden plaguing the continent! This deficit is largely from brain drain (internal and external) as a result of poor understanding of HRM issues and the appropriate interventions needed to generate improved performance of the health worker.
The ‘brain drain’ effect
Nigeria (and Africa as a whole) is currently reeling under the negative effect of massive migration of health workers over the past 3 decades. The net effect of this migration is that we are essentially subsidising health care for other nations.
However, there are many reasons for this migration, chief of which are:
· Poor prevailing economic climate.
· Huge financial ‘barriers to entry’ into private practice.
· Lack of opportunities for training and specialisation.
Human resource managers
The lack of well-trained human resource managers mirrors Africa’s shortage of health care professionals, in general. Hence, addressing the shortage of human resource managers is a key factor standing between success and failure in Africa’s effort to alleviate its crushing burden of disease and the imminent inability of African countries in meeting the Millennium Development Goals (MDGs) in 2015.
Building the capacity of human resource managers in the health sector is therefore critical at this time when countries need to scale-up services relating to HIV/AIDS, tuberculosis, malaria, maternal and reproductive health to meet the health challenges facing their populations.
Prevalent HRM gaps
A four-country study (Kenya, Tanzania, Ethiopia and Zambia) funded by USAID found competency gaps in the six major HRM functions in healthcare across all the administrators and managers responsible for HRM and productivity in these countries.
HRM challenges identified by the respondents (n=98) include:
· Understaffing (67 per cent)
· Lack of staff satisfaction on the job (65 per cent)
· Lack of skilled HRM staff (63 per cent)
· Poor working conditions for staff with HR responsibilities (60 per cent)
· Staff grievances (52 per cent)
These competency gaps and challenges are severely limiting the capacity of health service organisations and healthcare professionals to meet the needs of their populations.
Bridging the HR competency gap
After the study, the following recommendations were made:
· Create a professional cadre of HR managers with responsibility for the welfare of health staff.
· Provide in-service orientation and training on effective HR management practices to health managers at various levels who have HR responsibility.
· Put proven, practical tools directly into the hands of HRM health managers.
· Review national-level HR policy to identify and address obstacles that inhibit effective HRM.
· Strengthen HR information systems to collect timely data for informed decision-making.
· Develop and implement training programs in HRM at local management schools.
· Review the pre-service and in-service training and provide courses on HRM, general management, and leadership.
To drive progress in human resource management within the health care sector, there is the need to conduct an evidenced-based assessment. One of such is the landmark study titled Human Resource Management Interventions to Improve Health Workers’ Performance in Low & Middle Income Countries. The study systematically reviewed 48 published studies on HRM from 1997 to 2007 to find out the particular intervention strategies that were employed, the time of deployment, the contextual success factors, the mechanisms that influenced or triggered change and the results. They found that, with continuing education, the proportion of health care providers correctly performing specific tasks improved by 18 per cent to 39 per cent, depending on tasks and type. Also, training in communication showed improvement in the short-term. Continuing education of untrained (auxiliary) nurses was found to improve their performance –even outperforming physicians in certain tasks.
These improvements in the health workers’ performance were found to be triggered by three mechanisms, namely: (1) improved knowledge and skills; (2) critical awareness on the functioning of health services; and (3) an empowerment to implement change.
It was equally found that for success to happen there was the need for a participatory approach to be deployed. The course contents should be developed based on local problems, while relevant materials must be adapted to fit the local situation.
Another critical finding was that practising the tasks in the field under supervision during the training greatly improved performance. Also, the development of a cascade training scheme with health care workers being trained as trainers greatly improved the success of the continuing education programme.
A study investigating the role of supervision in public facilities (stock management and treatment protocols)was evaluated and it showed a difference of about 14 per cent to 47 per cent in adherence to various aspects of stock management protocols and standard treatment guidelines, compared to the control groups.
A critical contextual factor, though, was the presence of regular drug supplies. In other words, the availability or non-availability of relevant resources (in this case, drug supplies) greatly affected adherence to the guidelines.
It was found that when the supervision was done in a participatory manner, with mutual respect between supervisors and health workers, the workers gained increased skills and knowledge. Also, the health workers gained a sense of belonging.
Payment of incentives
Four studies evaluated the results of paying incentives to health workers,three of which introduced user-fees and paid staff from patients’ fees, community cost-sharing schemes or DRF. The studies indicated that paying incentives can improve performance of a facility and can increase job satisfaction, staff motivation and patient satisfaction.
In Cambodia, payment of staff accompanied by other interventions, such as organisational changes, increased the average number of deliveries significantly from 319 to 585 per month, and the average bed occupancy rate from 51 per cent to almost 70 per cent.
Certain contextual factors influenced the success of the interventions:
· The utilisation of services was not necessarily influenced by user fees when patients were accustomed to paying informal fees.
· The utilisation of certain services dropped in urban areas in Uganda and in rural Nigeria after introduction of user fees.
· In the Nigerian study, delay or non-payment of salaries and drug stock-outs caused a decline in staff motivation over time, with a negative influence on performance.
Some observations and inferences were also drawn from the studies:
· Linking individual salary to functioning of health facilities can improve staff performance.
· The mechanism that enabled this link was staff motivation, leading to development of staff initiatives to improve quality or to increased presence at work and reduced absenteeism.
· In Cambodia, staff motivation to develop initiatives appeared to be a result of staff awareness that they were able to influence use and quality of care and of staff empowerment to introduce change.
· Self-confidence to continue developing initiatives for change was created when these changes actually improved quality of care.
· On the contrary, in Nigeria, the study showed that staff were motivated to increase drug sales and financing, due to government focus on cost recovery and health workers’ interest for revenue generation.This led to over- and irrational prescribing behaviour and a preference for curative services at the expense of health preventive services and community health promotion.
Effects of decentralisation of HRM functions
Two studies – one in Mozambique and the other in China –investigated the impact of decentralisation of HRM functions
The studies showed that decentralisation of HRM functions could have a positive impact, but complementary interventions to create an enabling environment were required. These include management training, changes in bureaucratic procedures and appropriate preparation in structures and staffing.
In Mozambique, it was found that the political interference of district administrators influenced transfers of health workers, and administrative constraints prevented adequate performance evaluation.
In China, managers faced problems in addressing appropriate recruitment, due to social pressure to recruit (incompetent) relatives and friends and they faced organisational pressure to increase hospital income.
The role of regulation
One study (In Laos) evaluated the effectiveness of regulatory interventions such as inspection visits, selective punishments and provision of regulatory documents on the practice of private pharmacies.
Evaluation occurred immediately after the interventions and showed improved practices, as follows:
i. An increase of 34 per cent in the availability of essential dispensing material and of 19 per cent in order in the pharmacies.
ii. Adding intensive supervision of drug inspectors caused a significant change only in availability of essential dispensing material.
Quality Improvement interventions
Seven Quality Improvement (QI) interventions were identified, all using a participatory approach, analysing performance data by staff involved in service delivery, identification and implementation of local opportunities to improve performance.
Research indicated that QI interventions improved the performance of tasks and case management, and that they could be successful in different contexts.For example, QI implemented in hospitals in Ghana and Jamaica caused significant changes in obstetric care in both countries, such as an increase from 65 per cent to 93 per cent of patients with genital tract sepsis treated with broad-spectrum antibiotics.
Critical implementation aspects of the interventions contributing to success include:
· Involving staff, communities and local health authorities in setting standards – possibly through audits and clinical meetings.
· Receiving support from the management of the facility and senior officials.
· Using available funds and developing feasible plans for local teams
It was found that improvements from QI interventions were due to increased job satisfaction, improved staff morale due to feedback meetings,and community involvement and ownership. Another additional mechanism that led to the observed changes includes increased knowledge, due to training and acceptance of indicators and willingness to adhere to self-set standards.
The review of published HRM interventions offers an opportunity to gain a better understanding of how different HRM interventions can improve performance, depending on circumstances and groups of health workers.
To improve health workers’ performance, health managers need insight into the context within which interventions achieved results elsewhere and an understanding of the mechanisms that triggered change.
The general principle that financial incentives trigger motivation, which leads to improved performance, can be misleading because such incentives produced negative outcomes in terms of over-prescribing and over-treating when health workers were solely rewarded by cost-recovery and revenue generation.
Non-financial rewards, such as improved patient satisfaction or patient outcomes, improved quality of care, improved relations with colleagues and managers, recognition and appreciation were only to a limited extent implemented and researched. Various studies have shown that health workers perceive non-financial incentives as more important motivators than financial incentives. It will be interesting to evaluate the use of non-financial rewards to improve performance.
The most often published HRM intervention was continuing education, despite the available evidence of limited success of ‘training’ as a single HRM intervention. Examples of additional HRM components that could bring about change are mainly related to staff motivation and feeling obliged to change by both users and providers of healthcare.
Research in high-income countries shows that “bundles of interlinked human resource practices” that are aligned to the strategy and mission of an organisation are effective in enhancing workers’ performance. These best practices need to be shared across board and evaluated for effectiveness before being adapted for different settings and scenarios.
Finally, to gain a better understanding of outcomes of HRM interventions, the mechanisms that caused change, and the context within which this change occurred, as well as a combination of further qualitative and quantitative research methods, are essential.
Dr. Femi Olaleye is the MD/CEO of Optimal HealthCare (Nig), Optimal Cancer Care Foundation and Wish for Africa (UK).