Human resources
A critical issue
Human resources and their development are the backbone of any health system. It is people who manage and deliver health care services to the population. They must be competent, motivated and effective in carrying out their tasks.
Much emphasis has been given in the past by many vertical programmes to improving health staff competencies, to provide them not only with the knowledge but also with the skills required to discharge their functions. In-service training has often been seen as the “solution” to problems in care delivery.
While upgrading health staff skills is critical, there are a number of other important issues related to human resources that need to be addressed to improve not only health providers’ provision of better services in the long-term but also to ensure their presence where they are most needed.
Improving pre-service education has the potential “to produce” more competent health cadres for the tasks they will need to carry out in a more sustainable way.
“Production” of human resources, however, needs also to be tailored to country and geographical needs.
Addressing the issue of human resources is critical to ensuring access to services, their performance and sustainability. The Regional office for the Eastern Mediterranean has therefore been encouraging countries to develop child health policies which address also the issue of human resources, to create a favourable environment for the delivery of quality child care.
Attention is drawn to the management, production and in-service capacity building of human resources, as outlined below.
Management
Management of human resources is of vital importance.
It includes among others:
good coordination mechanisms between the ministry of health and the ministry of education;
health provider distribution plans by category and area, to ensure access to care according to area needs;
motivational schemes and transfer policies to attract and retain health providers in the public health sector, guarantee continuity of services and reduce absenteeism, and decrease their high turnover, especially after in-service training; and
maintaining a database on trained staff.
As an example of actions taken to address the issue of high turnover of trained staff, a ministerial circular was issued in the Syrian Arab Republic requesting health providers trained in IMCI to remain assigned to the same facility for at least a year after the training and until they could be replaced by another provider also trained in IMCI.
In addition to the review of some of these concerns by some countries during the introduction of the IMCI strategy, the child health policy initiative is seen as an important undertaking and opportunity to address these issues with more action-oriented policy commitment.
Production
Pre-service education is the first step of human resources’ professional development and a key investment for long-term sustainability of quality interventions.
Pre-service education also prepares health professionals for both the public and private sectors, offering a unique opportunity to provide them with the same basic knowledge and skills and influence their attitudes.
Education needs to be of high quality, properly funded, regularly evaluated, tailored to priority public child health needs based on epidemiological evidence, and geared to ‘produce’ cadres of health professionals proportionate to needs and based on a clear production planning policy.
This Region has been pioneering initiatives to enhance the teaching of child health elements in pre-service education in medical and allied health professional schools, with great emphasis on a skill-based approach to the outpatient management of child illness and health.
In-service training
In-service training is the area which has most often been supported over the years, usually through external financial support.
In-service training remains a major component of the IMCI strategy, for which a standard training package and approach have been developed and used in countries implementing IMCI.
Indicators for quality training have been developed in countries and monitored to keep training up to the set standards.
Despite this, many issues remain: in-service training as an approach needs to be conceived together with interventions addressing also management of human resources and pre-service education, as described above.
In-service training should eventually become an approach to upgrade health provider knowledge and skills rather than fill in existing weaknesses in pre-service education.
High turnover of trained staff in certain countries also requires a continuous training process to ensure the maintenance of the same level of training coverage.
A policy on in-service training would clearly identify priority training areas and financial resources, and be the basis for training plans, to be closely coordinated with sectors and partners involved at all levels.
Currently, the resources to fund most in-service training in child health programmes and IMCI in most countries in the Region have come from donors and international agencies. This makes their future uncertain when such resources decrease or become unavailable. On the other hand, there are also examples of a strong commitment to training in IMCI, like the one from Oman, which used its own funds to support it.
Another issue is the duration of IMCI training, which lasts for 11 days in its standard format. The course follows an approach which includes much exposure to clinical practice, to enable the participants to strengthen their clinical and communication skills. However, this duration causes health providers to be away from their facilities for a relatively long period of time—almost two weeks, including travel time, makes the cost of each course substantial and tends to limit the speed at which a higher coverage can be attained in the country. It is also demanding for the facilitators.
Alternative approaches have been introduced and tried in a few countries in the Region to reduce the duration of IMCI courses. When developing alternative approaches, an effort has been made to ensure there is no compromise on the quality standards of training, which must respond to the same quality criteria of the 11-day training. Inevitably, the amount of clinical practice provided in a shorter course decreases. However, it should be noted that these approaches have targeted physicians, i.e. a category of health professionals expected to have good clinical background in these countries.
The approaches have been very country-specific and therefore cannot automatically serve as models for other countries, especially when the contexts in which they have been introduced differ.
The shorter IMCI courses for physicians include:
a seven-day course introduced in Egypt, after several years of implementation of the 11-day course and the development of experienced cadres of facilitators; and
a 9-day course in Tunisia.
Follow-up visits after this IMCI training have yielded encouraging results. More standard evaluations are needed to document their effectiveness.
Some countries, such as Egypt, Syrian Arab Republic and Tunisia, have also developed shorter, 4-day competency-oriented IMCI training courses for selected categories of health providers (e.g. nurses), emphasizing in training the practice of those skills required for the newly assigned tasks (e.g. triage of sick children).
IMCI clinical training for nurses, Egypt
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IMCI pre-service education: guide to evaluation