Dr. Freddie Ssengooba Dr. Freddie Ssengooba Makerere University, School of Makerere University, School of

Public HealthPublic Health

International AIDS Society , Pre-Conference International AIDS Society , Pre-Conference Cape Town, S. Africa 18Cape Town, S. Africa 18thth July 2009 July 2009

Researching Health Researching Health Workforce Dynamics in the Workforce Dynamics in the

Context of HIV Scale-up: Context of HIV Scale-up: Accumulating Evidence in Accumulating Evidence in Complex Health SystemsComplex Health Systems

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Outline

• Framework –perspectives and domains for health workforce management:

1. Strategic governance,

2. Labour market dynamics,

3. Workforce training and production,

4. Performance management,

• The need for alternative methods for generating evidence for health system-level questions

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Education Sector:Enrollment, carring capacity, curricula for market needs,

faculty vacancies, leaning experiences

Provider Organization:

Attraction, Retention, skill mix, productivity,

work tools & incentives mobility/stability

Health Sector:Workforce size, Equitable deployment, Wages, Job entry & vacancy ratios,

Migration

Performance Management

Social political &

Economic context

Source: Ssengooba, Kiwanuka et al 20093

GHIs

for

HIV

GHIs

for

HIV

4

GHIs for

HIV2

GHIs for

HIVGHIs for

HIV3

GHIs fo

r HIV

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Effects of HIV Programs on Workforce Governance

Research question:

1. How and under what circumstances do HIV programs:

A. strengthen the governance and build consensus among stakeholders and

B. lead to coherent policy and implementation strategies across multiple agencies that may espouse conflicting objectives for HRH developments.

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1.1 Workforce Governance – Emerging issues

1. Unresolved conflicts among multiple stakeholder;

2. Inter-sectoral rivalries; – Health, Education, Public Service, Local Govts.

3. Dis-connected actions by actors; 4. Fragmented control systems for workforce;

management; 5. Pervasive short-cuts to workforce

developments; 6. Competition for scarce workforce;

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1.2 Governance and the workforce:Multiple-institutional bureaucracies

1. Ruling Party manifesto,

2. Public Service Commission

3. Professional Councils

4. Health SWAP donors,

5. HIV Global Initiatives

6. Worker Unions

1. Finance, 2. Education, 3. Health4. Public Service, 5. Local Govt.

1. District Councils2. District Service Commission 3. Chief Executive Officer 4. District Health Office5. Unit Mgt Commitees6. Non State Sector managers7. Donor projects on workforce

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Effects of HIV Programs on Health Sector Roles in Workforce

Management

Research questions

2. Under what conditions do HIV programs strengthen the capacity of the health sector to ensure effective workforce deployment, adequate workforce size, and optimal wage structures.

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2.1 System-level problem: - eg vacant posts in health facilities

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2.2 Inefficient recruitment processes?

Source: Planning Division, Ministry of Health Uganda 2008/09 9

2.3 Health sector workforce system: “Locked” or unattractive?

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2.4 Global Health Financing (GHF) and the Dynamics of Workforce Movement

Govt Facilities

NGO Facilities

Mission Facilities

(n=125)

(n=38)

(n=90)

“Heavy” GHFFacilities

(n=155)

“Light” GHFFacilities

(n=98)

P-Value = 0.011

Source: Ssengooba et al 2009. Effects of Global Health Initiatives on the Workforce in Uganda

73% changed jobIn last 3 years

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2.5 Perceptions of Health Facility Managers:Extent of GHF for Organizational Capacity Developments

( 126 HIV provider facilities in Uganda)

Source: Ssengooba et al 2009. Effects of Global Health Initiatives on the Workforce in Uganda 12

2.6 Salary Differentials: HIV and Non-HIV Health Facilities.

13Source: Ssengooba et al 2009. Effects of Global Health Initiatives on the Workforce in Uganda

Accessibility , Equity, Efficiency, Quality, SustainabilityHealth system performance gaols

Intermediary Agencies for HIV

Programs

Govt. NGO.

Work teams

Govt. NGO.

Organizational level

Govt. NGO./CSO

Sub-national level

Govt. NGO. networks

National level

Context:Global, national &

sub-national

Health system

Key Direct GHI interraction

Indirect GHI interraction 14

How do we accumulate evidence on health system impacts of HIV funds?

3. How do we demonstrate effectiveness of HIV investments on health workforce? a) What are the linkages between HIV

investments and the workforce?b) What frameworks can assist to build the

explanations of these linkages? c) Which are the most critical analytical

domains?d) What methodologies should be employed? e) Is there optimal research capability for this

endeavor?

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3.1 Post-modern research methods are needed for health systems

research “Systemography” ie the ethnography of the health

systems is critical for policy relevance and actions:– System-level observation of events overtime,

– Contextual dynamics and their explanations,

– Comparative frameworks & perspectives for assessments,

– Mixed methods and multi-desciplinary analyses,

– Case-studies and their syntheses,

– Real-time feedback loops between Reseach & Development,• Learning, adjusting and evolving for optimal fit in the contexts

• Can we borrow methods from Complexity Sciences (Complex Adjusting Systems - CAS)?

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Conclusions1. HIV programs need to build strategic governance capacity for

workforce management;2. System-level evidence for effects of HIV programs on the workforce

and health systems need to be synthsized from multiple perspectives;3. Methods need to be diversified to study workforce and health systems

in general;4. Ethnography of health systems (systemography) is needed.5. Local & regional institutions should play “observatory” roles and build

real-time links to policy.

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