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A Synthesis and Systematic Review of Policies

on Training and Deployment of Human

Resources for Health in Rural Africa

WHO/PAHO Collaborating Centre on Health Workforce Planning &Research

University of Zambia School of Medicine

A Synthesis and Systematic Review of Policies on

Training and Deployment of Human Resources for

Health in Rural Africa

April 2014

Copyright, 2014, Dalhousie University and University of Zambia

A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa

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Acknowledgements

This work was carried out with the support from the Global Health Research Initiative (GHRI), a

collaborative research funding partnership of the Canadian Institutes of Health Research, the

Canadian International Development Agency, and the International Development Research

Centre.

The research team would like to thank our Advisory Group – Dr. Maina Boucar, Dr. Paulo

Ferrinho, Ms. Allison Annette Foster, Mr. Solomon Kagulura, Dr. Vic Neufeld, Ms. Jennifer

Nyoni, Dr. Francis Omaswa, Dr. Judith Shamian, and Dr. Mohsin Sidat – for their important

contributions and support of this work. We would also like to thank the GHRI for providing the

funding to support the work described in this report.


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Research Team

This report was produced through a collaborative research partnership of faculty, students and

staff at the University of Zambia School of Medicine and Dalhousie University’s WHO/PAHO

Collaborating Centre on Health Workforce Planning and Research. Individual team members are

listed below.

Dalhousie University

Dr. Gail Tomblin Murphy

Dr. Sheri Price

Adrian MacKenzie

Stephanie Bradish

Annette Elliott Rose

Janet Rigby

Amanda Carey

University of Zambia

Dr. Fastone Goma

Dr. Selestine Nzala

Nellisiwe Chizuni

Derrick Hamavhwa

Chilweza Muzongwe


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Contents

Acknowledgements ...................................................................................................................... 1

Research Team ............................................................................................................................ 2

Brief ............................................................................................................................................ 4

Executive Summary ..................................................................................................................... 5

1.0 Background and Context ....................................................................................................... 10

2.0 Research Questions and Objectives ........................................................................................ 11

3.0 Project Approach .................................................................................................................. 12

3.1 Overview .......................................................................................................................... 12

3.2 Scoping Review ................................................................................................................ 13

3.2.1 Peer-reviewed Literature ............................................................................................. 14

3.2.2 Non-Peer-Reviewed Literature .................................................................................... 15

3.3 Synthesis .......................................................................................................................... 15

3.4 Engagement Strategies ...................................................................................................... 17

3.5 Capacity Building Activities .............................................................................................. 17

3.6 Validation Activities .......................................................................................................... 18

3.7 Methodological Challenges................................................................................................ 18

4.0 Results ................................................................................................................................. 19

4.1 Scoping Review ................................................................................................................ 19

4.2 In-Depth Review ............................................................................................................... 26

5.0 Discussion ............................................................................................................................ 50

6.0 Key Messages ....................................................................................................................... 59

Appendix 1: Appraisal tool for peer-reviewed literature ................................................................ 61

Appendix 2: Evaluation templates for non-peer-reviewed literature............................................... 62

Appendix 3: Summary of peer-reviewed literature included in the review ...................................... 64

Appendix 4: List of additional literature reviewed by country ....................................................... 68

Appendix 5: Advisory Group Terms of Reference ........................................................................ 80

Appendix 6: List of websites searched in scoping for country sub-set ............................................. 83

Appendix 7: Sources of country-specific statistics ......................................................................... 84

References ................................................................................................................................. 86

Synthèse et examen systématique : Politiques sur la formation et le éploiement de ressources

humaines en santé en Afrique rurale - Sommaire ........................................................................... 104

Síntese e revisão sistemática: Políticas sobre formação e distribuição de RHS na África rural Resumo executivo .................................................................................................................... 110


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Brief

The health of mothers and children – the subjects of two Millennium Development Goals – are

central to any country’s overall well-being. However, recent estimates show few African

countries are on track to achieve these goals. This is largely because Africa is enduring human

resources for health (HRH) crisis, with most countries in the region lacking sufficient personnel

to deliver basic health care to their populations, especially in rural areas. Effective planning for

and management of the scarce HRH available, particularly pertaining to maternal and child

health, are thus of paramount importance to Africa’s governments. To inform such planning, a

systematic review of available evidence on training and deployment policies for doctors, nurses

and midwives for maternal-child health in rural Africa was completed.

A wide range of training and deployment strategies for doctors, nurses, and midwives have been

implemented to improve maternal and child health in rural Africa. There is also increasing

investment in cadres such as clinical officers and community health workers, and we were able

to identify more evidence of the success of these initiatives in improving outcomes than of those

focused on doctors, nurses or midwives. The increasingly widespread use of such new

professions warrants regular systematic analysis of how the respective competencies of the

various health cadres align with the specific services required by the populations they serve.

There is a need to improve the visibility offered by Ministries of Health regarding their policies.

For none of the countries studied in depth could we find copies of any of the specific policies

included in our analysis. The analysis was therefore limited to secondary sources. There is a

dearth of peer-reviewed evidence of policy implementation or impacts. A large portion of policy

evidence is either not published or scattered across organizational websites which cannot be

systematically searched, greatly limiting its benefit to inform future policies and practices. The

potential of an international organization such as the WHO to facilitate more systematic

documenting and sharing of policy evidence across countries could have tremendous benefits.

There is a large apparent discrepancy between the policies and strategies proposed by these

countries and what is actually implemented, which may be due to any of a wide range of factors

outside the influence of Ministries of Health. For example, none of the eight countries studied in

depth are meeting the commitment to increase government funding for health to at least 15%

made under the 2001 Abuja declaration, and underfunding is the most immediate barrier to

health sector improvements. This situation necessitates either reconsideration of the importance

of the health sector to the development of these countries, and associated allocation of resources,

or more realistic health sector planning that accounts for this long-standing ‘underfunding’. In

addition, there is evidence that the donor funds crucial to Africa’s health sector could be used

much more effectively if their application was more closely aligned with national health

priorities. Finally, although shortages of resources are a major problem, so too is a lack of

capacity to effectively manage those resources, or to monitor and evaluate the impacts of their

use. Investment in building such capacity may therefore pay important long-term dividends.


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Executive Summary

Background

The eight Millennium Development Goals (MDGs) released in 2000 are considered an

international blueprint aimed at improving the health and well-being of the world’s most

vulnerable people. The health and well-being of women, newborns and children is at the

forefront of many policy and planning discussions related to MDGs 4 and 5. As the date for

achieving the MDGs looms closer, many progress reports, particularly those in many African

countries, show that there continue to be challenges in meeting MDGs 4 and 5. This is largely

because Africa is enduring a human resources for health (HRH) crisis, with most countries on the

continent lacking sufficient personnel to deliver basic health care to their populations, especially

in rural areas. The capacity of these countries to respond to this crisis is severely constrained by

inadequacies in funding and infrastructure. Effective planning for and management of the scarce

HRH available, particularly pertaining to maternal and child health, are thus of paramount

importance to Africa’s governments. To inform such planning, a systematic review of available

evidence on training and deployment policies for doctors, nurses and midwives for maternal-

child health in rural Africa was completed.

Approach

The primary question guiding the review was: What is known about policies to support training

and deployment of nurses, midwives and doctors for maternal-child health care in rural Africa?

Additional questions included: What is currently known about (a) the development, (b) the

implementation, and (c) the impacts of these policies?

Guided by an international Advisory Group, a two-part approach was used, the first of which

was a scoping review of available evidence pertaining to the questions from all of Africa. The

second was a more in-depth synthesis of policies from a subset of African countries, including

Ethiopia, Ghana, Mali, Mozambique, Niger, Tanzania, Uganda and Zambia.

Only policies for which there was some evidence of application/implementation were included in

the synthesis. Further, individual programs or interventions implemented as part of those broader

plans were considered policies and fully analyzed in the review. Only evidence from research

published in peer-reviewed scientific journals was considered to constitute the ‘impacts’

component of the framework. However, the existence of other evidence from non-peer-reviewed

sources (e. g. Ministry of Health reports) is noted where available and was used to provide

information on the other components of the framework.

Due to the limited policy documentation available for analysis, caution must be taken in drawing

conclusions about the quantity and quality of strategies being undertaken in African countries

related to training and deployment of doctors, nurses and midwives for maternal/child health in

rural areas. This issue is explored in more depth in the results and discussion sections, where

specific examples of policies identified during the review as not meeting the inclusion criteria,

but which are nonetheless promising, are described.


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Results

The electronic database searches returned a total of 548 peer-reviewed articles, of which 122

were duplicates. The remaining 426 unique articles were combined with the 87 articles as

identified by the Zambian research team and Advisory Group members, totalling 513 articles to

be reviewed. Of these articles, 37 met the inclusion criteria. The final body of articles covered 13

countries, representing each region of Africa. Ghana had the highest representation with 9 peer-

reviewed articles, followed by South Africa and articles addressing multiple nations, each with 5.

There were four articles from Ethiopia, and the remaining 10 countries had one to three apiece.

Selected articles came from 22 different journals. The most frequent contributors were the

Bulletin of the World Health Organization, Health Policy and Planning, Reproductive Health

Matters, and Human Resources for Health. The vast majority of the peer-reviewed articles were

published from 2003 on, suggesting the impact that the introduction of the Millennium

Development Goals in 2000 has had on priority setting for research and policy. Furthermore, this

data reveals that momentum is building for research that relates to both HRH and MDGs 4 and 5.

Specific representation of doctors, nurses, and midwives in the literature was fairly equitable.

However, many of the selected articles included the providers implicitly based on the high-level

nature of the policies, such as those pertaining to national health policies and, health sector

reforms. Policies focused exclusively on training and deployment represented the minority,

whereas those that addressed both areas, either directly or as embedded components of broader

policies, were in the majority. The remainder of the literature pertained to policies which were

not explicitly designed to address MDGs 4 and 5 in rural areas through training and/or

deployment of the selected providers, but had relevance for MDGs 4 and 5 embedded within or

implied as components of a more comprehensive policy mandate, such as national child health

policies. The excluded articles, although not meeting every aspect of the inclusion criteria,

demonstrated the diversity of work being done in and around the policy process as it relates to

the training and deployment of HRH to improve maternal and child health in rural areas.

At the time of the review, the assessed Ministry of Health websites for the African countries

belonging to the three linguistic groups showed a large variation in terms of functionality and

relevant document availability. Some websites are quite comprehensive in material supplied.

Other Ministries of Health did have operational websites, but there were inconsistencies in

documents provided and their accessibility. For example, several countries’ Ministries of Health

had the foundation and structure for a fully informative website, but broken links, sections

designated as “under construction”, and a lack of posted policy documents reduce its ability to

inform. Further, some ministerial websites were not located at all.

The scoping of the selected websites produced a wide variety of pertinent and applicable

literature for the country sub-set: professional guidelines and protocols, independent policy

evaluations, conference notes and proceedings, and additional peer-reviewed literature. These

documents were used to inform the country context piece of the analysis, and furthermore to

identify potentially relevant policies to guide specific inquiries to our advisory committee for

additional information.


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Our review revealed a paucity of policies specific to training and deployment of doctors, nurses

or midwives for maternal or child health in rural Africa. We did, however, identify several

policies that considered each of these factors, which are described in detail in the body of the

report.

Beyond the names of the various policies and the broad contexts in which they were developed,

very little information about the creation, implementation, or impact of this work was available

through our search. In particular there is a paucity of peer-reviewed scientific evidence relating

to the impacts of these policies. However, most of the literature acknowledged that the problems

for which the policies were intended to address continue to persist.

Discussion

Despite an extensive and multi-faceted search strategy, there were relatively few policies

identified on the training and/or deployment of doctors, nurses and midwives for maternal and

child health in rural areas of these countries. The included policies reflect the information that

was identified and readily available for inclusion in our analysis using the methods and sources

outlined above. However, this should not be interpreted as a lack of attention or action towards

addressing these issues. There are several important programs being implemented by several

countries to address these issues that did not meet the exact inclusion criteria. Two of these about

which there was considerable information were Ethiopia’s Health Extension Program and the

Tanzania Essential Health Intervention Project, which are described in more detail in the body of

the report.

Overall, it is clear that the Ministries of Health in the countries studied have attempted, and

continue to explore, a wide range of HRH policy options aimed at improving maternal and child

health among their respective populations. However, the implementation – and therefore the

success – of these policies seem to be severely constrained by economic, political, social,

geographic and technological factors outside these Ministries’ direct influence. Further, the

alignment of implemented policies with broader national strategies is often unclear. That said, it

is important to note how little information on what health policies currently exist in these

countries – let alone details about their implementation and impacts – is readily available, or

even attainable through dedicated searching. The policies had to be analyzed based solely on

secondary information, as copies of the actual policies themselves were not available. This lack

of visibility and accessibility of information makes an objective assessment of these policies –

necessary for any meaningful improvement on them – virtually impossible.

Areas for Further Study

There is great potential to build on this synthesis in future work. The main limitations of this

review were the availability of information on relevant policies, and the timeframe available to

conduct the review. Related to the latter point, as noted above, expanding the search strategy for

peer-reviewed documents to include names of individual African countries would likely yield

more relevant papers. Similarly, follow-up searches for information on specific policies, once

identified, could produce additional information about them, as could mining the references of


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relevant documents. Further, interviews or focus groups with key informants in the selected

countries would likely yield additional insights and relevant documents. Finally, although we

have cited government- and NGO-published reports where applicable, we limited our

consideration of the evidence of policy impacts to the peer-reviewed literature. This excludes the

wealth of important analyses being done by NGOs such as the World Bank and CapacityPlus,

which have great potential to inform the kinds of policies considered here but are seldom

published in academic journals.

Key Messages

Giving due consideration to the review’s methods and limitations, several key messages emerged

repeatedly and clearly enough to be brought to the forefront.

1. The planning-implementation gap: A wide range of strategic HRH and broader health

system policy interventions appear to have been implemented to improve the training and

deployment of doctors, nurses, and midwives for maternal and child health in rural Africa.

However, there is a wide apparent discrepancy between the number and scope of policies and

strategies that are proposed and what is evidently implemented, and poor maternal and child

health remains widespread in rural Africa. Further, we often found little evidence of clear

policy direction for those policies that were implemented. This discrepancy between planning

and implementation may be due to any number of economic, social, political, environmental

and technological factors, only some of which are within the sphere of direct influence of

Ministries of Health.

2. Underfunding: None of the eight countries studied in depth have met their health sector

funding commitments made under the Abuja declaration in 2001, and underfunding is the

most frequently cited challenge limiting improvements to the health sector. Increasing

funding allocations to meet this commitment is essential to the health of these countries’

populations.

3. Policy Visibility: There is a need to improve the degree of visibility offered by Ministries of

Health in terms of their various policies. Despite the multi-pronged search strategies

described, due to a lack of archiving of policy information on Ministry of Health websites,

for none of the eight countries studied in depth could we find copies of any of the specific

policies included in our analysis, which was therefore limited to evidence from secondary

sources.

4. Unavailability of Evidence: There is a dearth of peer-reviewed evidence documenting the

implementation and impacts of HRH policies in Africa. This may be partially due to the fact

that the evidence being generated is often self-published by NGOs like the World Bank; there

appears to be almost no such evidence published by governments, even where it exists. Thus

a large portion of important policy evidence is either not published or scattered across

multiple organizational websites which cannot be systematically searched in a timely

manner, therefore greatly limiting its benefit to inform future policies and practices. In this


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context, the potential role of an international organization such as the WHO to facilitate the

more systematic documenting of best practices and sharing of other policy evidence across

countries could have tremendous benefits.

5. Research bias: The peer-reviewed evidence included in the review shows a repeatedly

identified bias towards rural HRH training and deployment research carried out in more

developed countries. This is not only an issue suggesting a lack of research being done where

it is needed most (i.e. countries with HRH crises), but also that the majority of the studies

being done for rural training and deployment are not generalizable to the less developed

world.

6. Innovation: The variety of policy interventions described in the documents reviewed

demonstrates the level of innovation being practiced by African countries in efforts to

improve their maternal and child health. Although some strategies focus on more traditional

professions such as doctors, nurses and midwives, there appears to be increasing attention to

and investment in newer cadres such as clinical officers and community health workers.

Furthermore, we were able to identify more evidence of the success of the latter type of

initiative in improving health outcomes than of the former.

7. Aligning services and competencies: The introduction of several new health care cadres

with important responsibilities warrants regular and systematic analysis of how the various

competencies of all health care providers align with the specific health care services required

by the populations in a given country. In this way, training and deployment policies can be

adjusted on an ongoing basis to keep pace with changing health needs and contexts.

8. Alignment of donor funds: Funds from donor agencies make up a large portion of the

health budgets of African countries, and there is evidence that these are put to numerous

beneficial uses. However, there is also evidence that these funds could be used much more

effectively if their application was more closely aligned with broader national health

priorities to fund evidence-informed interventions.

9. Management, monitoring and evaluation: Although shortages of resources in general are a

chronic and widespread problem, so too is a lack of capacity for effective management of

those resources, and to monitor and evaluate the impacts they have when mobilized.

Investment in building such capacity, such as through an international body like the WHO,

thus has the potential to pay great long-term dividends.


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1.0 Background and Context

The eight Millennium Development Goals (MDGs) were released in 2000 and are considered an

international blueprint aimed at improving the health and well-being of the world’s most

vulnerable people by 2015 (United Nations, 2013a). The health and well-being of women,

newborns and children is at the forefront of many policy and planning discussions related to

MDGs 4 and 5. The target for MDG 4 is to reduce the under-five mortality rate by two thirds, by

2015. MDG 5 is structured around two key targets: reducing maternal mortality by 75% and

achieving universal coverage of skilled birth attendance by 2015. The maternal mortality rate

(MMR) has declined globally by almost 50% since 1990; however the MMR in developing areas

is still 15 times that in developed regions (United Nations, 2013b). As the date for achieving the

MDGs looms closer, many progress reports, particularly those in many African countries, show

that there continue to be challenges in meeting MDGs 4 and 5 (United Nations, 2013a). An

analysis of the current state of maternal, newborn and child health in Africa reveals a need for

enhanced access to primary health care, emergency services, reproductive health and family

planning. Critical to achieving such enhanced access is the availability and appropriate

deployment of sufficient numbers of adequately trained health human resources (HRH) to deliver

those services (WHO, 2005).

Africa faces a long-standing and unprecedented human resources for health (HRH) crisis. Thirty

seven countries in the region – representing the bulk of the continent – have less than the World

Health Organization (WHO)’s minimum recommended density of HRH to provide basic health

care to their populations (Figure 1), averaging less than one doctor, nurse or midwife per 1,000

population (WHO Regional Office for Africa, 2012). Despite successive resolutions by the WHO

Regional Committee for Africa in 1998, 2002, and 2009 to expand the continent’s health

workforce (WHO Regional Office for Africa, 2012), Africa’s regional HRH density actually

declined between 2005 and 2010 (WHO Regional Office for Africa, 2012). The crisis is

particularly dire in rural areas, where there are significant population health issues and severe

shortages of HRH and other resources to address them (Joint Learning Initiative, 2004).

It has been estimated that nearly one million additional personnel are needed to bring Africa up

to the minimum recommended density of 2.3 doctors, nurses or midwives per 1,000 population

(WHO Regional Office for Africa, 2012). Such numbers are particularly daunting considering

the limitations of the region’s capacity for HRH training. For example, 26 of the countries in

sub-Saharan Africa have one or no medical schools (Frenk & Chen et al., 2010). Despite

widespread emphasis on scaling up medical education as part of broader health system

strengthening, these institutions are hindered by weak physical infrastructure, shortages of

qualified faculty, and lack of external accreditation (Mullan et al., 2010). This underscores the

importance of effective policy regarding the planning and management of the region’s scarce

HRH.


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Figure 1: Health Workforce Densities in Africa

While there are a number of different dimensions to how a country’s HRH are planned and

managed, perhaps the most critical are how HRH are developed, trained, and deployed once

ready for practice (Tomblin Murphy, 2007; WHO, 2003; Zurn et al., 2004). While information

on different countries’ policies and experiences exists, gathering and reviewing all that

information is often beyond the time and resource constraints of many country-level policy

makers (Adam et al., 2011). Therefore, in an effort to synthesize existing evidence to inform

HRH policy and practice, a systematic review and in-depth analysis of available peer- and non-

peer-reviewed literature, as well as unpublished policy documents on the training and

deployment of HRH for maternal-child care in rural Africa, was completed.

2.0 Research Questions and Objectives

Key Question: What is known about policies to support training and deployment of nurses,

midwives and doctors for maternal-child health care in rural Africa?

Additional questions included:

What is currently known about. . .


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a) the research, theories, frameworks or other factors that have guided the development of these

policies?

b) the implementation of these policies?

c) the effectiveness/impact of these policies on system, provider and health outcomes?

Maternal and child health were identified as focus areas because of the interest of the World

Health Organization, the GHRI (funders of this work), and developing countries in the MDGs,

particularly those related to health. In consultation with the GHRI, it was agreed that the focus of

the review and synthesis would be on HRH policies pertaining to MDGs 4 (improving maternal

health) and 5 (improving child health) in rural Africa. Specifically, the professions considered

would be doctors, nurses and midwives. Doctors, nurses, and midwives were chosen because it

was anticipated that there would be more evidence about policies pertaining to these professional

groups than other cadres of health care providers, and because the availability of the services

they provide are especially essential to maternal and child health.

Objectives

1) To conduct a scoping search/summary review of the literature on training and deployment

policies/planning of health workforce for maternal-child care in rural areas across Africa

2) To conduct a more in-depth systematic review of the training and deployment policies for

maternal-child care in HRH in a sub-set of African countries

3) To build capacity in conducting systematic reviews

3.0 Project Approach

3.1 Overview

The primary review question and sub-questions for this review were identified by the research

team and validated with an international Advisory Group of leaders in the health education and

policy fields (see section 3.5). This included finalizing the specific parameters and content of the

policy interventions and the context of interest. The research and guiding questions were

developed and refined through several iterations based on the results of the scoping review and

consultations with the Advisory Group (Grimshaw, 2010).

We addressed our research and guiding questions using a two-part approach. The first of these

was a scoping review of available evidence pertaining to the questions from all of Africa. The

second was a more in-depth synthesis of policies from a subset of African countries, including

Ethiopia, Ghana, Mali, Mozambique, Niger, Tanzania, Uganda and Zambia, which were chosen

based on criteria listed in Table 1.

The process used in this project was consistent with a ‘realist’ approach to systematic review,

which is helpful for complex policy synthesis (Pawson et al., 2005). For the purpose of this

synthesis, policy is defined as “courses of action (and inaction) that affect the set of institutions,

organizations, services and funding arrangements of the health system” (Buse et al., 2005, p.5.).


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Table 1: Criteria for selecting countries for inclusion in synthesis

At least one representative country from each linguistic group of Portuguese, French,

and English;

A mix of geographic representation including countries that are land-locked as well as

those from the east and west coasts, and from the northern and southern hemispheres;

Countries with a history of in-depth policy analysis, systematic reviews, and/or strong

culture of research-to-policy;

Countries in which known-to-the-group stakeholders exist, to allow for access to

otherwise unavailable policy documents.

Further, only policies for which there was some evidence of application/implementation were

included in the synthesis. For example, there are national documents titled ‘health policy’ which

describe countries’ health priorities and plans for addressing those priorities, whether generally

about health or specific to maternal-child or health human resources. These documents did not

meet the inclusion criteria and did not relate to the specific research questions. They were,

however, reviewed to provide country-level context to the analysis. In addition, individual

programs or interventions implemented as part of those broader plans were considered policies

and fully analyzed in the review.

The areas of focus of each guiding question are consistent with the stages of the policy process

described by Sabatier and Jenkins-Smith (1993), which include identifying and recognizing the

problem, policy formulation, implementation and evaluation. In consultation with the Advisory

Group, it was determined that the policy analysis framework by Hercot et al. (2011) would be

used to guide the extraction and analysis of policy data from the collected documents. It should

be noted that this framework was used only as a guide to our approach, and that themes emerged

inductively from the reviewed documents.

3.2 Scoping Review

An initial scoping review, consisting of a brief examination of the published non peer-reviewed

and peer-reviewed literature, was conducted to help guide the development and verification of:

Criteria for document inclusion/exclusion (Table 2);

Key words and databases to be used in the searches of the peer-reviewed and non-peer

reviewed literature;

Learning objectives for undergraduate and graduate students participating in the work.

Once the selection criteria and process were confirmed, relevant published and accessible non-

peer-reviewed and peer-reviewed literature was retrieved. The search strategy for the scoping

review included electronic database searches and a search of online sources for non-peer

reviewed literature. The results of each search were further narrowed according to the inclusion

criteria (Table 1), abstracts were reviewed and then, if the initial criteria are met, the full


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documents were retrieved for full review and mapped according to their year of publication and

country(ies) of focus.

3.2.1 Peer-reviewed Literature

Searches of the following online databases were conducted: PubMed, CINAHL, EconLit,

PsychArticles, PsychInfo, Informa Health Care e-books, the Cochrane Library, ABIinform, Web

of Knowledge, PAIS, JSTOR, Business Source Complete, ERIC and EMBASE. In consultation

with a Dalhousie University information scientist, the following key words were identified and

used in various combinations with Boolean operators (and, or, not): health care delivery, health

planning, health policy, policy, population health care needs, health workforce, health human

resources, care providers, manpower, personnel, nurses, doctors, midwives, shortage, turnover,

deployment, regulation, training, education, incentives, recruitment, retention, attrition, maternal,

newborn, child, infant, adolescent, maternal-child care, rural, isolated, low resource, Africa,

developing country, low income country, middle income country. Where available and

appropriate, MeSH terms, wildcards, and explosion search strategies (sub-terms and derivatives)

were used.

Potentially relevant articles identified in the scoping were pulled. Each article was mapped with

respect to country of focus, document type, policy initiative, jurisdictional focus, provider type,

and nature of policy with the tool given in Appendix 1. Once mapping was completed, initial

exclusions of citations were made if they were not available in full text, published prior to 1990,

and did not refer to an African country whose official national languages include English,

French, or Portuguese. The only exception was Ethiopia, whose official languages include none

of those listed above. However, Ethiopia publishes many of its health policy documents in

English, and was identified by the Advisory Group as a unique case for consideration due to its

achievement of MDG 4 in 2013.

Further articles were identified for consideration by the Zambian research team as well as the

Advisory Group based on their personal familiarity with particular African countries. These

citations were pooled with those initially found in the database searches. From this pool, articles

were subjected to an initial abstract review to remove those which clearly did not meet the

inclusion criteria. For the remaining articles, three members from the research team reviewed the

title, abstract, and full text, independently applying the selected inclusion criteria based on the

guiding research questions (Table 2). Discrepancies in reviewers’ decisions on inclusion and

exclusion were resolved through group deliberation until consensus was reached.

Table 2: Inclusion criteria for peer and non-peer-reviewed literature scoping

Aspect Criteria

Language of publication English, French, or Portuguese

Years published 1990 – 2013

Type of policy initiative Applied (i.e. not theoretical, but some evidence that the

policy has been/continues to be implemented)


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Country or countries of

focus

Any African country whose official languages include

English, French, and/or Portuguese1

Policy focus Training and/or deployment of providers as it pertains to

rural health

Type(s) of providers Doctors, nurses, and/or midwives

Specific clinical focus Maternal-child health: reproductive health, pregnancy, birth,

newborns, childhood disease, and adolescents

Jurisdictional focus International or national (e.g. not provincial or district-

specific)

Types of data sources Policy documents, policy evaluations, professional

protocols/clinical guidelines, literature reviews, peer-

reviewed research related to policy implementation and/or

evaluation

3.2.2 Non-Peer-Reviewed Literature

Phase I

A directed search of websites operated by ministerial bodies responsible for health planning and

policy for each country in the designated linguistic groups was conducted. Websites were located

via Google and navigated by tabs and menus (i.e. policies, publications, legislation, guidelines

etc.) available on the homepage. Ministry websites were evaluated based on whether they were

operational, hosted publicly available policy documents, and if so, were they accessible for

download. Documents were scanned and pulled as guided by the inclusion criteria (Table 2).

Where the National Health Policy, National Strategic Health Plan, National Strategic Plan for

Human Resources for Health and/or similar documents were not available on ministerial

websites, targeted searches using Google for each country were used to locate these documents,

if available elsewhere.

Phase II

In consultation with the Advisory Group, relevant and reputable websites of professional

associations, research networks, international and national organizations were identified for

further non-peer reviewed literature searching. Unique search strategies were developed for each

website based on individual navigability; either commencing with relevant topic tabs (i.e.

maternal child health, human resources for health, education, training and deployment, health

workforce, policy etc.) or country tabs. Details of websites searched in both phases are provided

in Appendix 6. Data extraction tools used on documents obtained from both phases of the non-

peer-reviewed literature scope are given in Appendix 2.

3.3 Synthesis

The in-depth review concentrated on the subset of eight countries selected. In addition to the

published non-peer reviewed and peer-reviewed literature identified in the scoping review,

1 With the exception of Ethiopia as noted above.


Page | 16

research and Advisory Group members assisted in the identification, selection and retrieval of

related policies and policy documents that were not publicly available.

All peer-reviewed documents were read and evaluated independently by no fewer than three

members of the review team against the inclusion criteria, who then came to consensus on which

papers would be included in the analysis. The selected peer-reviewed papers, along with the

collected non-peer-reviewed documents for the included countries, were then reviewed and

mapped using data extraction templates for both research and non-research literature, developed

by the research team.

Information from documents on specific policies that met the inclusion criteria were mapped

using an additional template designed according to the policy analysis framework described by

Hercot and colleagues (2011). This framework (Figure 2) distinguishes between and delineates

the respective contributions of the actual substance of the policy (content), the systemic factors –

political, economic, social or cultural, both national and international – which may have an effect

on the policy (context), the stakeholders who influence it (actors), the way in which policies are

initiated, developed or formulated, negotiated, communicated, implemented and evaluated

(process), and its effects (impacts), expected and unexpected, positive and negative (Hercot et

al., 2011).

Figure 2: Policy Analysis Framework (from Hercot et al., 2011)

For the review of the published, peer-reviewed literature, a full critique of the quality (sampling,

data collection, methods, analysis and conclusions) for each study was not completed as the

intent was to focus on identifying the specific challenges to developing, implementing and

evaluating policies related to HRH for maternal-child care in rural Africa. However, in keeping

with the research questions, the team noted any research, theories, frameworks or other factors

that influenced policy development and implementation. The policy information gathered in

these templates was then reviewed and summarized according to the guiding questions.

Only evidence from research published in peer-reviewed scientific journals was considered to

constitute the ‘impacts’ component of the framework. However, the existence of other evidence

from non-peer-reviewed sources (e. g. Ministry of Health reports) is noted where available and

was used to provide information on the other components of the framework.


Page | 17

3.4 Engagement Strategies

The research team established an Advisory Group for the review process, consisting of

international leaders in the field of health and social policy representing research institutions,

professional associations, knowledge translation groups, and agencies for social change. The role

of the Advisory Group (see Terms of Reference in Appendix 5) was three-fold: to review and

suggest improvements to the review’s methods and tools, to assist with the acquisition of

otherwise unavailable policy documents, and to provide insight into interpretations of the

review’s findings.

Members of the group included:

Dr. Maina Boucar, Regional Director, West Africa Region, USAID ASSIST Project,

University Research Co. LLC, Niger

Dr. Paulo Ferrinho, Director, Instituto de Higiene e Medicina Tropical Universidade Nova de

Lisboa, Portugal

Ms. Allison Annette Foster, Senior Advisor for Quality Improvement, and Lead, Health

Workforce Development, University Research Co. LLC, USA

Mr. Solomon Kagulura, NPO/MPN, World Health Organization, Zambia

Dr. Vic Neufeld, Special Advisor, Canadian Coalition for Global Health Research, Canada

Ms. Jennifer Nyoni, HRH Advisor, WHO Regional Office for Africa, Republic of the Congo

Dr. Francis Omaswa, Executive Director, African Centre for Global Health and Social

Transformation, Uganda

Dr. Judith Shamian, President, International Council of Nurses, Switzerland

Dr. Mohsin Sidat, Dean, Faculty of Medicine, University Eduardo Mondlane, Mozambique

The group was engaged chiefly through individual and paired phone and email discussions as

well as a group teleconference meeting. Individual and paired teleconferences were preferred to

those with the entire membership because these facilitated necessary country-specific dialogue,

and also because of the various time zones and poor telephone connections.

In addition, members of the research team took advantage of their attendance at relevant

international gatherings – including the UN General Assembly, the Global Health Workforce

Alliance (GHWA) Third Global Forum on HRH in Recife, Brazil, and a meeting of the Research

component of the Africa Health System Initiative (AHSI-RES) participants in Nairobi, Kenya –

to link with Advisory Group members and other colleagues to gain their perspectives and

insights on the project.

3.5 Capacity Building Activities

One of the key objectives for this project was to build capacity in the skills required for

conducting systematic reviews among faculty and students at both the University of Zambia and

Dalhousie University. Building research capacity within this framework provided a good

opportunity for faculty and students to gain more contextual understanding of global health


Page | 18

research as well as direct skills related to systematic reviews, scholarly writing and building

partnerships.

Specific capacity-building activities included:

Capacity-building activity #1: a training session on completing a systematic review was

offered for students and faculty of Dalhousie University and the University of Zambia.

Capacity-building activity #2: ongoing, hands-on experience in designing systematic

review criteria and conducting an initial review.

Capacity building activity #3: repeated group meetings of students/faculty to review

policy mapping and analysis.

Capacity building exercise #4: development of materials (presentations, papers, policy

briefs etc.) to disseminate the results of the review.

3.6 Validation Activities

Advisory Group members were invited to participate early in the project and provided ongoing

advice, support and feedback at all stages of the project. Through existing partnerships, key

country-level stakeholders were also engaged early in and throughout the project to validate the

selection of relevant national policies related to HRH deployment and training for maternal-child

providers (doctors, nurses and midwives) in rural Africa. Advisory Group members, in their

capacities as global health leaders, provided insight into relevant international documents to

inform the review, and also reviewed this report.

3.7 Methodological Challenges

To our knowledge this is the first policy synthesis of its kind to consider this breadth of

countries, documents, and languages. Limitations related to the search strategy’s sensitivity were

identified. Many titles, abstracts, and author-assigned key words of would-be relevant articles

did not include the search filters “Africa”, “developing country/countries” or “middle/low

income country/countries” and were therefore missed. A library scientist was consulted to

identify means of overcoming these limitations. Although, due to time restrictions, no additional

searches could be performed for this scoping review, future work could include the addition of

specific African country names into the search strategy.

In consideration of the above limitations, caution must be taken in drawing conclusions about the

quantity and quality of work being conducted in the represented countries related to training and

deployment of doctors, nurses and midwives for maternal/child health in rural Africa. In

addition, the results of the scoping review should not be used as a proxy measure for the

existence and implementation of the types of policy in question. This issue is explored in more

depth in the results and discussion sections, where specific examples of policies identified during

the review but not meeting the inclusion criteria, although nonetheless promising, are described.


Page | 19

4.0 Results

4.1 Scoping Review

4.1.1. Peer Reviewed Literature

The electronic database searches returned a total of 548 peer-reviewed articles, of which 122

were duplicates. The remaining 426 unique articles were combined with the 87 articles as

identified by the Zambian research team and Advisory Group members, totalling 513 articles to

be appraised. Of these articles, 37 met the inclusion criteria (Figure 3).

Figure 3: Scoping Review Results


Page | 20

The final body of articles covered 13 countries, representing each region of Africa as well as the

designated linguistic groups (Figure 4). Ghana had the highest representation with 9 peer-

reviewed articles, followed by South Africa and articles addressing multiple nations, each with 5.

There were four articles from Ethiopia, and the remaining 10 countries had one to three apiece.

Figure 4: Number2 of peer-reviewed articles by country

Selected articles came from 22 different journals (Figure 5). The most frequent contributors were

the Bulletin of the World Health Organization, Health Policy and Planning, Reproductive Health

Matters, and Human Resources for Health.

Figure 5: Contributing source journals for peer-reviewed articles

2n=32 as some articles mentioned more than one country

0

1

2

3

4

5

6

7

8

9

10

0

1

2

3

4

5


Page | 21

Year of publication is shown in Figure 6, and demonstrates that the vast majority of the peer-

reviewed articles were published from 2003 on. This trend shows the potential impact that the

introduction of the Millennium Development Goals in 2000 has had on priority setting for

research and policy. Furthermore, this data reveals that momentum is building for research that

relates to both HRH and MDGs 4 and 5.

Figure 6: Peer-reviewed articles by year of publication

Specific representation of doctors, nurses, and midwives in the literature was fairly equitable.

However, many of the selected articles included the providers implicitly based on the high-level

nature of the policies, such as those pertaining to national health policies, health sector reforms.

Policies focused exclusively on training and deployment represented the minority, whereas those

that addressed both areas, either directly or as embedded components of broader policies, were in

the majority. The individual policies are identified below, and complete list of the peer-reviewed

literature used is available in Appendix 3.

POLICY FOCI OF PEER-REVIEWED LITERATURE

Training

In Ghana, a specialist training program for obstetrics and gynecology was launched by a

partnership between Ghanaian medical schools, the Royal College of Obstetricians and

Gynecologists and the American College of Obstetricians and Gynecologists with the aim to

counteract the repatriation of skilled professionals who were training abroad. Of the 38

specialists successfully completing the program between its initiation in 1989 and 2006, 37

remained to practice in Ghana, the majority in the public health sector (Anderson et al., 2007).

Further studies of the same program brought attention to the high-caliber of the specialists

produced, the unique curriculum with a community-based approach, the favourable cost-benefit

evaluation of the program, and that the trainee’s service is not lost if trained domestically. In

recognition of its success, the Government of Ghana has taken on the program (Klufio et al.,

2003; Marley et al., 1995).

0

1

2

3

4

5

6

7

8


Page | 22

Nigeria’s Life Saving Skills training policy for midwives, paired with interpersonal skills for all

providers and provision of equipment and supplies, resulted in large gains for maternal and

neonatal health through reduction of post-partum haemorrhage, prolonged labour, and stillbirths

(Kwast, 1996).

Deployment, recruitment, and retention

The scoped literature identified two strategies that South Africa has employed for deployment

and retention of HRH in rural areas and the public sector: the Rural Allowance policy and

Occupation-Specific Dispensation Incentive strategy, the latter rolled out initially for nurses

(Ditlopo et al., 2012; Ditlopo et al., 2011). A review of evaluated recruitment and retention

schemes mentions the presence of a financial incentive scheme in Niger targeted at doctors,

pharmacists and dental surgeons, and a “medicalization of rural areas” program in Mali, although

no other information on these programs is given (Dolea et al., 2010).

Temporary employment contracting systems with fixed terms, locations and roles, with the

option of renewal, have a demonstrated ability to increase deployment. Kenya’s Emergency

Hiring Plan, initially managed by the private sector, then handed off to the national government,

deployed 830 new health staff hires to 219 public health facilities over a six month period

(Adano, 2008). The same plan analyzed using nurse distribution showed a resulting recruitment

of 1836 additional nurses since 2005, with the most remote areas of the country benefiting most

(Gross et al. 2010). Under Senegal’s Plan Cobra, a contracting system which allowed for short

term hire while still being eligible for benefits given if recruited traditionally through the

Ministry of Public Service resulted in 365 new HRH contracts issued between 2006 and 2008,

and the re-opening of 122 health posts (Zurn et al., 2010).

Dual-focused policies

Often the policies that emerged from the scoping review addressed both training and

deployment. The HRH crisis in Malawi motivated the Emergency Human Resources Program, in

support of the 2004 Essential Health Package, with five main facets: improving incentives for

recruitment and retention of staff with salary top-ups, developing domestic training capacity,

using international volunteer HRH as a stop-gap measure, and providing international technical

assistance to bolster planning and management capacity and skills, and improving monitoring

and evaluation (Palmer, 2006). Zambia’s Ministry of Health applied a similar political tactic to

address HRH shortages by improving training, deployment, and retention through the 10-year

Strategic Plan for Human Resource for Health (Gow et al., 2011). Longombe’s (2009)

comparison study between rural and urban medical schools in the Democratic Republic of the

Congo demonstrated that training and deployment can be tackled in tandem with 81% graduates

of the rural medical schools choosing rural postings, compared to only 24% of those graduating

from urban areas.

A literature review by Frehywot and colleagues (2010) identified multiple compulsory service

programs for rural posting or retention that inherently address deployment, but have training

components incorporated. The scope of the review was international, which included 11 African


Page | 23

countries: Ethiopia, Ghana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South

Africa, Zambia, and Zimbabwe. The compulsory years of service for the identified strategies in

the African countries ranged from one to four, with few offering the option of a “buy-out”. The

bulk of the programs applied to doctors and nurses, and all included one or more of the following

incentives: licence to practice (in both public and private sectors), graded salaries, preference for

post-graduate training, scholarships, career advancement, housing, child education, and medical

assistance.

Embedded policies

The remainder of the literature addressed policies which were not explicitly designed to address

MDGs 4 and 5 in rural areas through training and/or deployment of the selected providers.

However this literature had relevance for MDGs 4 and 5 embedded within or implied as

components of a more comprehensive policy mandate. For example, high-level, structural

policies such as the Decentralization in Ghana and Ethiopia were evaluated for their effects on

national sexual and reproductive health service and workforce density, deployment, and attrition

respectively (Mayhew, 2003; Michael et al., 2010). The health sector reform in Tanzania,

Decentralization and a Sector-Wide Approach, aimed to achieve equity in care, and was

successful in reducing the disparity in births attended by skilled providers between socio-

economic groups e.g. urban and rural (Kengia et al., 2013).

Rural specific policies with aspects of HRH deployment were also identified. Curry at al. (2012)

sought to un-pack and define the roles of government and community members for the improved

implementation of The Millennium Rural Initiative in Ethiopia, which had clear implications for

the health of rural and remote maternal and child health. The Rural Health Improvement

Program of Niger aimed to increase coverage of national Primary Health Care through upgrading

rural health facilities and dispatching of newly trained village health teams; the former having a

significant impact on maternal and child health (Magnani et al., 1996).

Increased political attention on maternal and child health implicitly calls for increased attention

to HRH issues. Uganda’s 20% decrease in neonatal mortality between 2000 and 2010 was

attributed to its constellation of evolving policies – Health Sector Strategic Plan, Minimum

Health Care Package, Roadmap to Accelerating the Reduction of Maternal and Neonatal

Mortality, and the Child Survival Strategy - many of which called for increased training and

deployment of HRH to meet the strategic objectives (Mbonye et al., 2012). Similar to Uganda’s

broad policy response, Rwanda, having declared sexual and reproductive health as a

development priority, has implemented a Sexual and Reproductive Health Policy (under the

Health Sector Policy), Facility-based Childbirth Policy, and a National Family Planning Policy;

all of which require a robust HRH supply. In light of this, and the HRH shortages resulting from

the 1994 genocide, the national government has responded by increasing the number of trained

doctors, nurses, and midwives for the public sector between 2005 and 2008, with the majority in

rural areas (Bugagu et al., 2012).


Page | 24

Ghana’s National Reproductive Health Service Policy and Standards, revised in 2003, outlined

new regulations for the delivery of reproductive health services and required associated training:

essential obstetric care, Life Saving Skills, Safe Motherhood, and manual vacuum aspirations

and post-abortion care. Three papers identified in the scoping review examined this policy

through the lens of abortion provision; whether post-abortion care training is cost-effective,

which cadres are providing the service, and overall barriers to its implementation (Andersen

Clark et al., 2010; Aniteye & Mayhew, 2013). A similar analysis was conducted on abortion

provision in South Africa after legislation qualified midwives as providers, and program-specific

training was delivered. As of 2003, 135 midwives had completed training; safe abortion

provision went from 714 in 1997 to 5,168 in 1999. Deployment was not addressed in this policy;

however it demonstrated a unique strategy of utilizing midwives, a provider with a significant

pre-existing presence in rural communities (Sibuyi, 2013). Additionally in South Africa, the

Cervical Screening policy mandated the training of nurses in Pap smear provision, again

recognizing the vast potential of upgrading skills of previously deployed HRH (Kawonga &

Fonn, 2008).

The excluded body of articles, although not meeting every aspect of the inclusion criteria,

demonstrated the diversity of work that is being done in and around the policy process as it

relates to the training and deployment of HRH to address the need for improved maternal and

child health in rural areas. For example: theoretical policies evaluated using various modeling

techniques and discrete choice experiments (Ageyi-Baffour et al., 2013; Lagarde and Cairns,

2012; Kolstad, 2011; Blaauw et al., 2010); pilot programs conducted and evaluated for potential

scale-up (Pirkle et al. , 2013; Spector et al. , 2013); literature reviews conducted to take inventory

of what is known and which knowledge gaps existed (Reynolds et al., 2013; Bucagu et al.,

2012); and in-depth situational analyses to better inform policy priorities (George et al., 2012;

Wuehle & Coulibaly, 2011). Additionally, there was a significant amount of articles which were

not included as they focused on providers outside the criteria (e.g. traditional birth attendants,

community and health extension workers, clinical officers etc.) suggesting their importance in

the management of MDGs 4 and 5 in rural settings, and a possible direction for future work.

Lastly, the HRH crisis and its effects were examined through various approaches, such as

rigorous research, review, or narrative from a number of different perspectives – ethical,

anthropological, sociological, and biomedical – which indicates that attempts are being made at

creating a rich description of this phenomenon. This growing evidence base may then inform

policy across the entire process to be more relevant, and therefore effective.

4.1.2 Non-Peer Reviewed Literature

Phase I

At the time of scoping, the assessed Ministry of Health websites for the African countries

belonging to the three linguistic groups showed a large variation in terms of functionality and

relevant document availability. South Africa and Ghana’s Ministry of Health/Ghana Health

Service websites are quite comprehensive in material supplied, and Mozambique’s Human


Page | 25

Resources Observatory, as hosted by the Ministry of Health website, was exemplary. Several

other Ministries of Health did have operational websites, but there were inconsistencies in

documents provided and their accessibility. For example, several countries’ Ministries of Health

had the foundation and structure for a fully informative website, but broken links, sections

designated as “under construction”, and lack of posted policy documents reduce their ability to

inform. Further, some ministerial websites were not located at all. To further illustrate the

variation in the kinds of information available on various countries’ Ministry of Health websites,

Table 3 summarizes what was found on those of the 8 countries included in the synthesis at the

time of the review.

Table 3: Information available on selected countries’ Ministry of Health websites

Country

Poli

cy d

ocu

men

ts

Str

ate

gic

pla

ns

Poli

cy m

on

itori

ng

an

d/o

r ev

alu

ati

on

s

Pro

fess

ion

al

pro

toco

ls/

clin

ical

gu

idel

ines

Oth

er

Ethiopia

www.moh.gov.et/english/resources/Pages/home

page.aspx

✔

✔

✔

✔

✔

Ghana

www.moh-ghana.org/pub_content.aspx?id=2

www.ghanahealthservice.org/index.php

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

Mali

www.sante.gov.ml/

✔

✔

✔

✔

Mozambique

www.misau.gov.mz/index.php/legislacao

www.misau.gov.mz/index.php/observatorio-de-

orhs

✔

✔

✔

✔

Niger

www.msp.ne/

Tanzania

www.moh.go.tz/index.php/explore/policies

www.tanzania.go.tz/documents

✔

✔

✔

✔

Uganda

www.health.go.ug/mohweb/?page_id=170

www.library.health.go.ug/publications/health-

workforce

✔

✔

✔

✔

✔

✔

✔

✔

Zambia

www.moh.gov.zm/

✔

✔

✔

Phase II


Page | 26

The scoping of the selected websites produced a wide variety of pertinent and applicable

literature for the country sub-set: professional guidelines and protocols, independent policy

evaluations, conference notes and proceedings, and additional peer-reviewed literature. These

documents were used to inform the country context piece of the analysis, and furthermore to

identify potentially relevant policies to guide specific inquiries to our advisory committee for

additional information. No official government policy documents were available through the

website scoping, and could therefore not contribute to the in-depth analysis portion of the report.

However, it should be noted that many of the official government policy documents located via

directed Google searches, as specified in the methods section, were hosted on websites

administrated by international organizations, such as UNFPA and WHO.

4.2 In-Depth Review

This project sought to document what is known about the policies to support training and

deployment of nurses, midwives and doctors for maternal-child health care in rural Africa.

Specifically, the focus of the in-depth policy synthesis involved policies within a subset of eight

countries: Ethiopia, Ghana, Mali, Mozambique, Niger, Tanzania, Uganda, and Zambia. Our

scoping and synthesis of grey and peer-reviewed literature revealed a paucity of policies specific

to this exact focus. Although we did identify several policies that considered each of these

factors, existing policies tended to be broader than this specific intersection of topics. Each of the

eight selected countries had policy documents reflecting recognition of the need to improve

maternal and child health, particularly in rural areas. However, we have only included in our

analysis those policies that directly consider, but may not be limited to, the training and

deployment of nurses, midwives and doctors for maternal-child health care in rural Africa.

Beyond the names of the various policies and the broad contexts in which they were developed,

very little information about the creation, implementation, or impact of these policies was

available through our search. In particular there is a paucity of peer-reviewed scientific evidence3

relating to the impacts of these policies. However, most of the literature acknowledged that the

problems for which the policies were intended to address continue to persist.

While the review yielded little information on specific policies within its scope, it did reveal a

great deal of relevant contextual information about the selected countries, which we consider this

contextual information to be essential to understanding those policies. We therefore present

country-specific summaries of this information before the results pertaining directly to the

research questions. Key quantitative data about the selected countries is provided in Table 4.

3 Critiquing the quality of the peer-reviewed studies cited in terms of their designs, methods, interpretations

and so on was outside the scope of this analysis.


Page | 27

Det

ails

on t

he

sourc

es o

f th

ese

stat

isti

cs a

re p

rovid

ed i

n A

ppen

dix

7.

4 P

urc

has

ing P

ow

er P

arit

y (

PP

P)

inte

rnat

ional

do

llar

s 5 D

oct

ors

, nurs

es,

mid

wiv

es

(hea

dco

unt)

per

1,0

00

po

pula

tio

n

6 F

rom

HR

H t

rain

ing p

rogra

ms,

as

% o

f #

of

esta

bli

shed

po

sts

7 P

rop

ort

ion o

f gra

duat

es

fro

m h

ealt

h t

rain

ing p

rogra

ms

who

ente

r em

plo

ym

ent

wit

h g

over

nm

ent

hea

lth s

erv

ices

8 P

er 1

00

,00

0 l

ive

bir

ths

9 P

er 1

,000

liv

e b

irth

s

Tab

le 4

: C

ou

ntr

y-S

pec

ific

Con

textu

al

Data


Page | 28

Ethiopia

Ethiopia is a federal republic located in the eastern region of Africa referred to as the Horn of

Africa, with wide ethnic and language diversity. After decades of political instability, a

transitional government was established in 1991 and a Constitution ratified in 1994, followed by

the first democratic election in 1995. Since this time, Ethiopia has had political stability. Ethiopia

has suffered droughts that, in the 1980s, affected over eight million people and contributed to

approximately one million deaths. Nutritional disorders continue to be a major health problem

for Ethiopia, which in combination with preventable communicable diseases, account for over

90% of child deaths (Ethiopia Federal Ministry of Health, 2010). Life expectancy is low (54

years), with high maternal mortality rates (350/100,000 live births). While child mortality rates

have dropped significantly, they are still high relative to other countries.

Implementation of Ethiopia’s Health Policy is guided by the federally developed, Health Sector

Development Plan (HSDP) 1995-2015, currently in its fourth and final five-year stage (Ethiopia

Federal Ministry of Health, 1993). Training and deployment of HRH is integrated in the HSDP,

with specific HRH strategies and plans further detailed in the country’s HRH Strategy 2006-

2010 and HR2020 (Campbell & Settle, 2009). Within Ethiopia’s decentralized system, provision

of health services is the responsibility of the Woredas (districts) with policy and technical

support provided by Regional Health Bureaus (RHB). National policies are developed by the

Ministry of Health, in partnership with the RHBs, Woredas and other stakeholders such as donor

agencies (Ethiopia Federal Ministry of Health, 2013a). Health services are provided using a

multi-tiered system: primary health care units (health posts and a health centre), primary

hospitals constitute the primary care level, general hospitals constitute the secondary care level,

and specialized referral hospitals constitute the tertiary care level (Ethiopia Federal Ministry of

Health, 2010). Health services in Ethiopia are financed by four main sources: government (both

federal and regional), bilateral and multilateral donors, non-governmental organizations, and

private contributions, under a “one plan, one budget and one report” principle of its Sector-Wide

Approach (SWAp) (Ethiopia Federal Ministry of Health, 2011).

Ethiopia has increased its supply of health workers significantly over the last few decades,

through expanded training capacity (creating additional institutions, increasing the uptake of all

the institutions), and the introduction of new cadres (e.g. Health Extension Workers) and

retention strategies (such as allowing for private wings, pay structures, etc.). However, despite

the overall increases in health workers, there is still an acute shortage of doctors and midwives;

the nurse density ratio is 1:2,311 (Ethiopia Federal Ministry of Health, 2013b). Deployment of

health care workers is managed at the regional level and is often constrained by the inadequate

resource allocation by regions, resulting in inadequate absorption (Ethiopia Federal Ministry of

Health, 2013b).

The Ministry of Education is responsible for all higher education, including that of health

professionals. The Ministry and the regional education bureaus are responsible for the

accreditation of private, degree-, diploma- and lower-level training institutions and programs. All

health training institutions (public and private) adhere to criteria set by the Federal Ministry of


Page | 29

Education (AHWO, 2010). Doctors and nurses are trained through 47 public and private

institutions offering health science programs with an additional 8 medical schools and a

nursing/midwifery institution (AHWO, 2010). Midwives are trained at 13 colleges (Ethiopia

Federal Ministry of Health, 2013b). In-service programs are provided by 35 local training

institutions.

Ghana

The Republic of Ghana is divided into ten administrative/political regions which are further

divided into 170 District Assemblies, which develop, plan and mobilize resources for programs

and strategies for the development of the district. With a stable political landscape, Ghana has

developed a national strategic plan that focuses on modernizing their natural resource industries,

improving public and private partnerships, transparent governance, effective decentralization and

efficient public service delivery (Republic of Ghana, 2010). Similar to its neighbouring

countries, Ghana has high rates of communicable diseases such as HIV/AIDS and increasing

rates of non-communicable diseases such as hypertension and diabetes. Ghana also faces high

levels of child mortality from malaria and other diseases, exacerbated by low levels of literacy,

poor sanitation, under-nutrition and substance use (WHO, 2013). As such, the theme of its

current National Health Policy is "Creating Wealth through Health"(Republic of Ghana Ministry

of Health, 2007a).

The Ghana Ministry of Health (MoH) advocates and formulates national health policy and is

responsible for monitoring and evaluating progress towards its targeted outcomes. The Ghana

Health Service (GHS) is an autonomous government agency, allied with the MoH, responsible

for coordinating the delivery of health services. District Health Management Teams (DHMTs) in

every district are responsible for the supervision of local health services and the implementation

of plans and policies (Ghana MoH, 2010). HRH policy development, planning and distribution,

coordination of pre-service training, and monitoring and evaluation are the responsibility of the

Human Resource for Health Development Directorate (HRHDD), supported by the Policy,

Planning, Monitoring & Evaluation Directorate, under the MoH. The MoH, GHS and the

teaching hospitals own and manage about 49% of the health facilities in Ghana, the remainder

being privately owned and operated (Republic of Ghana Ministry of Health, 2007b).

Ghana’s health sector has had three major policy changes over the last decade: 1) a national

approach to donor funding (Sector-Wide Approach or SWAp), which centralizes funding from

non-governmental and donor agencies and 2) a mixed model of decentralization through the

development of the DHMTs and by contracting out service delivery to the GHS, non-

governmental agencies (via GHS), and the teaching hospitals. In addition, a publicly funded

National Health Insurance Scheme (NHIS) was introduced in 2003, which aims to provide

equitable access and financial coverage for basic health care services to the people of Ghana

(Saleh, 2013).

Pre-service training for health providers, the main focus of the country’s first HRH strategy

(Ghana Ministry of Health, 2002; Saleh, 2013) is shared between the MoH and the Ministry of


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Education. There are a total of 82 health training institutions (76 public and 6 private) in Ghana,

including 4 medical schools. Many health-training institutions find it challenging to

accommodate increases in enrolment because their physical, technical and organizational

capacities are inadequate, and no comprehensive pre-service training/education policy has been

developed to date (Beciu et al., 2013). Although the national HRH plan (Republic of Ghana

Ministry of Health, 2007a) states that policies are in place to support the training needs,

frequency of training, curricula and career progression for in-service training, details about these

policies are not provided.

Although staffing ‘norms’ were developed in the early 1990s, recent efforts to revise these could

not be completed (Republic of Ghana MoH, 2006). An analysis of the HRH situation in 2006 by

the HRHDD found that only 40% of ‘critical staff’ were currently in place (Republic of Ghana

Ministry of Health, 2006). Numbers of midwives, nurses and doctors increased by 300%, 5%,

and 50%, respectively, between 2003 and 2009; however the overall supply of each of these

professions remains inadequate (Ghana Ministry of Health, 2011). There is currently no formal

mechanism in place for the deployment or distribution of graduates from the medical schools or

other training institutions, although recently an inter-agency committee coordinated by the

HRHDD has been created to coordinate HRH distribution (Republic of Ghana Ministry of

Health, 2007b). The MoH noted in 2007 that the available funding for HRH only supports about

20% of their recruitment needs (Ghana Ministry of Health, 2007), and costing for the most recent

HRH plan has not been completed (Republic of Ghana Ministry of Health, 2011). Plans from a

previous HRH plan to develop and implement incentive packages for staff in underserviced areas

were not completed, and there is no clear commitment in current plans (Republic of Ghana

Ministry of Health, 2011).

Mali

Mali was a one-party state for many years until a coup in 1991 resulting in a multi-party

democracy. A more recent military coup in 2012 followed armed conflict in the north of country,

as a result of which there was substantial displacement of the population. Malian and French

forces have now recaptured most of the north and a new president was elected in the summer of

2013. However there is still concern about the increased risk for disease outbreaks, increases in

maternal mortality and an increase in severe malnutrition (International Committee of the Red

Cross, 2013; WHO, 2013b).

From a health governance perspective, all health sector activities in Mali are governed by the

Ministry of Health’s 10-year Health and Social Development Plan (PDDSS) and the 5-year

Health Sector Development Program (PRODESS) (République du Mali Ministère de la Santé,

2009a). Anew health strategy plan has been drafted for 2013-2022 with particular focus on

MDGs 4, 5 and 6. A Human Resources Development Policy for Health (PDRHS) (République

du Mali Ministère de la Santé, 2009b), a National Strategic Plan to Reinforce the Health System

(PSNRSS) (République du Mali Ministère de la Santé, 2008b), and a document outlining public-

private partnerships are said to be in development (Lamaiux et al., 2013). An estimated 80% of

curative services are provided in the private sector where 50% of doctors are practicing. Despite


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the low density of doctors relative to its population, the Ministry of Health recently described the

current production and recruitment of them, along with pharmacists and health technicians, to be

sufficient, and indicated an intention to focus on the training of other health care providers such

as specialists (République du Mali Ministère de la Santé, 2008).

Since early in the millennium, the government of Mali has supported a policy for decentralized

services for education, water procurement and health. As such, the government of Mali health

service structure is pyramidal with the base built on Community Health Centers (CSCOMs),

which provide a minimum health package (PMA), are considered private entities, and managed

as non-profit organizations by Community Health Associations (ASACOs) (Lamiaux et al.,

2013). Funding is piecemeal from cost recovery and community contributions as well as

subsidies from public funds or non-governmental agencies.

Mozambique

Mozambique has been politically stable, compared to other African countries, since the armed

conflict that followed its independence in 1992. The country is administratively divided into

eleven provinces, which in turn, are divided into a capital and districts and the latter into

administrative posts. Despite recent steady economic growth (Dominguez-Torres & Briceno-

Garmendia, 2011), most of the country lives in poverty (World Bank, 2009). Mozambique is also

greatly affected by malaria, malnutrition, TB and HIV/AIDS as well as limited access to clean

water and sanitation. While there have been decreases in maternal and child mortality (WHO,

2013a), it is unlikely Mozambique will achieve MDGs 4 or 5 (UNDP, 2013).

The health system includes public, private for profit, and not-for-profit private sectors, which

collectively cover about 60% of the population (WHO, 2013a). The health system relies on

government and donor contributions for financing. Over 25 development partners are working in

Mozambique’s health sector (WHO, 2013a), and Mozambique has implemented a SWAp

(System Wide Approach) to facilitate the coordination of efforts between donors and government

policies and strategies within the context of the Absolute Poverty Reduction Plan of Action

(PARPA) and delivery of the sector strategic plan (PESS) (República de Moçambique Ministério

da Saúde, 2013). Thirty percent of external funding is channelled through a Common Fund

Mechanism (Prosaude) (WHO, 2013b).

Various policy documents set out the national health policy for Mozambique, including the Five-

Year Government Program (2010-2014), the National Economic and Social Plan (NESP), the

Health Sector Strategic Plan, and the Medium Term Expenditure Framework (MTEF) (República

de Moçambique Ministério da Saúde, 2013).

While the Ministry of Health (MoH) is responsible for setting health sector policies,

implementation is done at the provincial and district levels. Mozambique is among the countries

facing severe health workforce shortages, particularly doctors. Multiple ministries and agencies

(government and non-government) are involved in the training, recruitment, hiring, deployment,

and payment of the health workforce (Ferrinho & Omar, 2006); República de Moçambique


Page | 32

Ministério da Saúde, 2008). Universities and those Higher Degree Institutes that graduate doctors

and other health cadres are under the responsibility of the Ministry of Education, with great

support from the Ministry of Health, particularly in regard to allowing health facilities to be used

as clinical training sites and in some cases sponsoring the trainees. Mid-level health professions

are trained in institutes and centres run by the training Department within the National

Directorate for Human Resources within the Ministry of Health, which is also responsible for all

health professional post-graduate training. Provincial health directorates manage these training

institutions through three-year plans (República de Moçambique Ministério da Saúde, 2008) and

all are publicly funded. Serious concerns have been expressed about the quality of training of

HRH in Mozambique, and output of medical school graduates has been erratic (Ferrinho &

Omar, 2006).

There was an overall increase in the health workforce from 25,683 health workers in 2006 to

35,503 (54% of whom were health professionals) in 2011. There has been a 72% increase in

national doctors (as opposed to foreign) since 2005 (569 to 979) (WHO, 2014).

Niger

One of the poorest countries in the world (United Nations Development Program, 2013) and

wrought with political instability, Niger did not have its first democratic election until 1993, over

thirty years after its independence from France. Since 1993, there have been several coups

leading to the creation of the National Reconciliation Council in 1999, which has been

responsible for supporting the transition to civilian rule. The current president was elected in

2011.

Niger has multiple health problems related to communicable and non-communicable diseases,

limited access to clean water, basic sanitation and nutrition and low levels of education.

Similar to other African countries, Niger has a chronic lack of resources and a small number of

health providers relative to the population (WHO, 2006a). The government hospitals and the

public health programs are managed by the Ministry of Health with health care significantly

supplemented by programs via private, faith-based and non-government agencies. Because

political stability has only occurred recently, publicly-funded health care is still very much in

development in Niger. Health policy is implemented via the health development plans (WHO,

2006b; République du Niger Ministère de la Santé Publique, 2010a). The current health plan is

in-line with the national poverty reduction strategy and focuses solely on the MDGs.

(République du Niger Ministère de la Santé Publique, 2010a). Health user fees were removed in

early 2007 for children under five years old and specific maternal and reproductive health

services. However, securing ongoing funding to sustain the removal of user fees, even for select

populations, is challenging (Lagarde, Barroy & Palmer, 2012). Overall health system

performance is plagued by limited and unequally distributed HRH, inadequate infrastructure,

impediments to HRH recruitment and dysfunctional referral systems. This has resulted in only

one-third of the population having access to health services (WHO, 2006a).


Page | 33

There is particular focus on training and education, recruitment and management and planning of

health care providers in the most recent Niger National Health Plan (République du Niger

Ministère de la Santé Publique, 2011). Key goals include increasing HRH (particularly for

maternal-child health and in rural centres), strengthening the capacity of health workers,

planning additional education and training, increase the use and skill of a monitoring plan and

developing “predictive management of human resources”. It was noted that the implementation

of the 2005 – 2010 health plan yielded significant gains in HRH, including the recruitment of

over 1200 medical officers, more accurate data, the use of monitoring tools, increased

decentralization of human resources management and revisions to training curricula (République

du Niger Ministère de la Santé Publique, 2011). The Niger HRH Development Plan (République

du Niger Ministère de la Santé Publique, 2010b) was created in response to identified challenges

including the need for stronger monitoring and evaluation of policy implementation, and better

collaboration between government Ministries with respect to HRH training and deployment.

Health care training reform began in 2008 and focused on revision of admission requirements,

aligning training with the needs of the health system, the development of a competency-based

approach to training, enhanced faculty and new strategies for organizing and monitoring

initiatives. However, challenges related to inadequate infrastructure, equipment and teaching

skills remain. Although training increased between 2005 and 2009, the MoH has noted concerns

about market saturation as new graduates seek positions in urban areas and often in the private

sector (République du Niger Ministère de la Santé Publique, 2010b). Additional training for

specialization of medical and paramedical staff is also a key concern.

Tanzania

The United Republic of Tanzania, a union between Tanganyika and Zanzibar, is the most

populous country in Eastern Africa (WHO, 2013). Following Independence in 1961, Tanzania

has exhibited sustained economic growth and political stability. However GDP growth has not

resulted in the equitable reduction of poverty; as reported in the most recent Health Sector

Strategic Plan, approximately 25% of Tanzanians, and 39% in rural areas, live below the poverty

line (United Republic of Tanzania Ministry of Health and Social Welfare, 2009). Positive trends

have been seen in the decrease of under-five and infant mortality rates, although high rates of

maternal mortality, HIV/AIDS, malaria, and TB persist (United Republic of Tanzania MoHSW,

2008; WHO, 2009, 2013). Underpinning these trends are malnutrition, poor access to improved

sources of drinking water and sanitation, and a widening divide in the health and socio-economic

status between the urban and rural populations. (United Republic of Tanzania MoHSW, 2009)

Setting the overall socio-economic development and National Health Policy context are the

Tanzanian Development Vision 2025, Local Government Reform Program, and the Strategy for

Growth and Reduction of Poverty (United Republic of Tanzania MoHSW, 2008). The Local

Government Reforms Program resulted in two national bodies with responsibility of the health

sector: The Ministry of Health and Social Welfare (MoHSW) to develop policies, guidelines, and

lead health sector reform, and the Prime Minister’s Office for Regional Autonomy and Local

Governance to implement the policies and services in the districts and below. Charged with


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adoption of policies are Regional and Council Health Management Teams (COWI, 2007; United

Republic of Tanzania MoHSW, 2008). Financing for the health system is drawn from

Governmental budget allocations, SWAp development partner contributions, user fees, and the

National Health Insurance Fund. The National Health Plan is to be realized primarily through the

Health Sector Strategic Plan, Primary Health Services Development Program, and HRH

Strategic Plan (WHO, 2009, 2013).

The HRH crisis in Tanzania has been largely due to the Retrenchment Policy, Employment

Freeze, Civil Service Reform, and migration of skilled workers (United Republic of Tanzania

MoHSW, 2008). Staffing shortages in the public and private health sectors stand at 65% and

85%, or 53,214 and 37,508 health professionals, respectively. Shortages are most severe in rural

areas, where the HRH are strained further by demands on the health system due to higher burden

of disease and population growth compared to urban areas (United Republic of Tanzania

MoHSW, 2008).

According to the HRH Strategic Plan, the capacity of the 116 public and private health training

institutions is intended to be aligned with the demands of the national health system. However,

only 16% of the 23,474 staff produced between 1995 and 2005 were absorbed by the public

sector. Demands will increase along with the implementation of the 2007 National Health Policy

calls for a dispensary in every village, a health center in every ward, and a district hospital in

each district; an additional 5,162 dispensaries, 2,074 health centers and 8 district hospitals which

need to be staffed. In order to adequately staff these facilities, an additional 88,829 health

professionals are required (United Republic of Tanzania MoHSW 2007, 2008).

Concerns have been raised about training institutions’ abilities to meet accreditation standards.

There is no training scheme for post-graduate and specialist training, and the professional

development needs of individual staff are not well understood. The MoHSW is attempting to

address these issues, in addition to building capacity for planning and management at the local

levels of implementation, through Zonal Training Centres. Unfortunately, success is limited due

to low resources, infrastructure, and staffing, among other factors (COWI, 2007; United

Republic of Tanzania MoHSW, 2008).

Uganda

Uganda is a presidential republic, having achieved independence from the United Kingdom in

1962. Uganda has experienced intermittent armed conflict since independence, which has

adversely affected the well-being of the country’s population and hindered implementation of

government policies, including health care policies (Uganda Ministry of Health, 2010b). The

past few years, however, have been relatively peaceful, coinciding with a period of substantial

macro-economic growth (Uganda Ministry of Health, 2010b). Approximately 30% of the

population lives in poverty, with little access to clean water and sanitation (WHO, 2013).

Leading causes of morbidity and mortality in Uganda include malaria, malnutrition, HIV/AIDS

tuberculosis, and peri- and neonatal conditions (Uganda Ministry of Health, 2010b). Although


Page | 35

Uganda spends 9% of its GDP on the health portfolio, only about 1% comes from public funds;

the remainder comes from private and donor funds (Uganda Ministry of Health, 2013). The

current National Health Policy derives its mandate from the country’s National Development

Plan (Uganda Ministry of Health, 2010). Health care in the country is overseen by the Ministry

of Health at the national level, which partners with a number of donor agencies and countries to

help fund its health care programs, using the Sector-Wide Approach (SWAp). The country’s 100

districts and their sub-districts are responsible for more localized administration of health care,

under direction from the national ministry. The proportion of public funds allocated to the health

portfolio has remained steady in recent years but below the national target of 15%, meaning there

are insufficient funds to deliver the National Minimum Health Care Package (Uganda Ministry

of Health, 2010a).

Following a national recruiting effort, the number of unfilled established posts in Uganda’s

public health care system has decreased from 49% in 2010 (Uganda Ministry of Health, 2010a)

to 37% in 2013 (Uganda Ministry of Health, 2013). The gap is worse in rural areas, where

poverty, poor sanitation and malnutrition are more common (Uganda Ministry of Health, 2013)

yet most districts have less than the minimum number of required staff (Uganda Ministry of

Health, 2010a). A number of strategies and goals to address this situation are described in

national policy documents, and the Second National Health Policy notes that an increase in

salaries for civil servants preceded an increase in attrition among staff at non-government

facilities (Uganda Ministry of Health, 2010b).

Uganda’s Ministry of Education and Sports took over responsibility for the country’s publicly-

funded health training institutions from the Ministry of Health in 1998; the Ministry of Health

remains the primary employer of Uganda’s health professionals (Uganda Ministry of Education

and Sports, 2011). There are a total of 36 accredited schools for health professionals, which are a

mixture of government-owned and private-not-for-profit institutions. The exceptions are the

three schools each that train doctors and clinical officers, which are government-owned (Uganda

Ministry of Education and Sports, 2011). Government-owned schools have insufficient

infrastructure or instructors to accommodate the numbers of students they have enrolled; this

does not appear to be an issue in the private schools (Uganda Ministry of Education and Sports,

2011).

Zambia

Zambia is a presidential republic, having achieved independence from the United Kingdom in

1964. The country’s political climate has been largely peaceful and stable since then, particularly

since its current constitution was ratified in 1991. Its economy has achieved substantial macro-

economic growth in recent years, although these gains have yet to show much impact at the

population level (Zambia Ministry of Health, 2010); most of the country lives in poverty, with

little access to clean water and sanitation (Zambia Ministry of Health, 2010; WHO, 2013).

Malnutrition is widespread and a leading cause of child deaths in the country (Zambia Ministry

of Health, 2010; WHO, 2013).


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Zambia faces a variety of other health challenges, particularly HIV/AIDS and malaria, which

culminate in short life expectancy and maternal and child mortality among the highest in the

region (WHO, 2013). To respond to these challenges, the current national health strategic plan

derives its mandate from the country’s Sixth National Development Plan and Vision 2030

(Zambia Ministry of Health, 2010), and includes as an integrated component its National HRH

Strategic Plan (Zambia Ministry of Health, 2010; 2012). Health care in the country is overseen

by the Ministry of Health at the national level, along with the Ministry of Community

Development and Maternal and Child Health for some services. Zambia partners with a number

of donor agencies and countries to help fund its health care programs, using the Sector-Wide

Approach (SWAp). The country’s 10 provinces and 105 districts are responsible for more

localized administration of health care, under direction from the national ministries.

Although Zambia’s supply of HRH has increased in recent years, over 40% of the nearly 60,000

established posts in the public health care system remain unfilled, including 61% of posts for

doctors, 55% for midwives, and 45% for nurses (Zambia Ministry of Health, 2013). The gap is

worse in rural areas, where poverty, poor sanitation and malnutrition are more common (Zambia

Ministry of Health, 2010; WHO, 2013) yet health care facilities have few – if any – formally

trained health workers to staff them (Zambia Ministry of Health, 2010). Several strategies have

been devised to address this shortage; however implementation of them has been severely

limited by insufficient funding. The most recent HRH Strategic Plan, covering the period 2011-

2015, notes that only 17% of the funds required to implement the previous Plan, developed for

2006-2010, were allocated; its implementation was minimal (Zambia Ministry of Health, 2010).

The 2006-2010 plan notes that its predecessor, drafted in 2001, was never implemented (Zambia

Ministry of Health, 2005).

The Ministry of Health is largely responsible for deployment of Zambia’s HRH, while it shares

responsibility for training with several other Ministries. The country’s largest medical school, at

the University of Zambia, which includes programs for nursing and other professions, and the

Copperbelt University School of Medicine, which includes a program in dentistry, are the

responsibility of the Ministry of Education, Technical Education and Vocational Training and

Early Education. This is the Ministry overseeing the programs at Evelyn Hone College of Art

and Applied Sciences as well. The Ministry of Health is responsible for all other public HRH

training programs (Zambia Ministry of Health, 2010). As of 2010 there were 22 pre-service, 7

post-basic and 16 post-graduate training programs for health professionals offered across 39

public, private-for-profit, and mission/religious institutions in Zambia. Together these programs

produce approximately 2,300 graduates per year, 80% of whom are absorbed into the public

health care system (Zambia Ministry of Health, 2010). Net of attrition and other losses,

Zambia’s public health care system has been adding approximately 1,200 new personnel per year

against a staffing deficit of nearly 25,000 unfilled posts (Zambia MoH, 2010; 2013). Attempts to

increase training outputs through the National Training Operational Plan developed in 2008 have

had minimal success due to a lack of funding for its implementation; although some individual

programs and institutions have made progress in increasing their respective outputs, they are


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limited by lack of infrastructure and shortages of qualified instructors (Zambia Ministry of

Health, 2010).

Identified Policies

The following section describes the findings of our in-depth analysis and synthesis of all

available documents meeting the review criteria4 for a subset of eight African countries including

Ethiopia, Ghana, Mali, Mozambique, Niger, Tanzania, Uganda, and Zambia. As noted above, the

policy analysis framework developed by Hercot and colleagues (2011), previously applied in

studying health care policies in sub-Saharan Africa, guided the review and synthesis of available

documents. However, as will be shown below, the information available through our search was

almost entirely limited to the context in which various policies have been developed, with very

little information on the content, the actors, implementation or impacts of the policies. What

follows are descriptions of relevant findings related to policy identification, development,

implementation and evaluation, consistent with the policy cycle framework (Sabatier and

Jenkins-Smith, 1993).

Each of the countries studied have documents which they have designated National Health

Policies, Strategies, or Development Plans. These documents are all similarly structured, laying

out first a situational analysis of the leading health issues of the country, then the current state of

the health care system, followed by identifying priority issues to be addressed, and finally

describing plans to address them. The most recent versions of these documents available through

our search from each country all focus on the MDGs as a framework for establishing and

addressing national priorities within and beyond the health care sector. This means that, although

there are important differences between these countries, their identified national health priorities

are similar.

For some countries earlier versions of National Health Policies were identified through our

search. Ethiopia’s National Health Policy was enacted in 1993 (Transitional Government of

Ethiopia, 1993) and the implementation of the policy is through a series of Health Sector

Development Plans (HSDPs) (Ethiopia Federal Ministry of Health, 2005a). The fourth and most

recent of these covers the period 2010-2015 and has a specific focus on maternal and child

health, with specific objectives pertaining to HRH training and deployment (Ethiopia Federal

Ministry of Health, 2010). Tanzania has a 2007 Health Policy (Tanzania Ministry of Health,

2007) – which was available through our search only in Kiswahili – and a Health Sector

Strategic Plan which covered the period 2003-2008 (Tanzania Ministry of Health, 2002). Prior to

these there were National Health Policies published in 1990 and 2003 (in draft form). Uganda is

on its second ten-year National Health Policy (Uganda Ministry of Health, 2010a) and third five-

year Heath Sector Strengthening and Investment Plan (HSSIP) (Uganda Ministry of Health,

2010b). Zambia’s current 2011-2015 National Health Strategic Plan (Zambia Ministry of Health,

2010a) was preceded by the plan for the preceding five years (Zambia Ministry of Health,

4An applied policy intervention specifically related to training and deployment of doctors, nurses and midwives to

rural areas for maternal & child health


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2005a). Some of these later versions make some explicit reference to their predecessors,

describing progress or, as is more often the case, system issues and other challenges that have

limited progress. Uganda’s current HSSIP for 2010-2015, for example, makes repeated reference

to the previous HSSIP which covered 2006-2010. On the whole, however, there is little

information in these documents on how activities laid out in earlier policies or strategic plans

have progressed, let alone what their impacts, if any, have been. Specific exceptions are

described below.

The national health policies for some of these countries, such as Ethiopia (Ethiopia Ministry of

Finance and Economic Development, 2010), Tanzania (United Republic of Tanzania, n. d.), and

Uganda (Republic of Uganda, 2010), are also explicitly linked with broader national

development policies. In Mali, national health strategies are embedded within the Decennial

Health and Social Development Plan 2013-2022 (République du Mali Ministère de la Santé et

al., 2012). In Ghana, over-arching national policies include the National Population Policy,

Ghana Vision 2020, the National Health Policy (2007) and Programs of Work that are released

annually and every five years. These linkages demonstrate the recognized interdependence of the

performance of the health sector with the overall status of the country as a whole – in other

words, the workings of a country’s health care system and the workings of its economy, socio-

political structures and other systems all affect each other. Although these higher-level national

policies are outside the scope of our review, their interdependence with health policies must

nonetheless be factored into any analyses of health systems, as will be described later in this

section.

Each country also has national-level policy documents specific to HRH, which in some cases are

explicitly integrated into the former in that each makes direct reference to how it aligns with the

other or vice versa, such as Zambia’s National Health Strategic Plan (Zambia Ministry of Health,

2010) and National HRH Strategic Plan (Zambia Ministry of Health, 2011). Although described

in other government documents, neither Ethiopia’s nor Uganda’s National HRH Policies or

Strategic Plans were available through our search.

As national policies become more specific, their interrelationships with other kinds of policy

documents become more complex and often overlap. For example, National Policies on child

health were identified through our search for Ethiopia, Ghana, Tanzania, Uganda and Zambia.

Instead of a single child health strategy, Zambia has, at various times, had an Integrated

Management of Child Illnesses (IMCI) strategy, an Expanded Program for Immunisation (EPI)

(Zambia Ministry of Health, 2005), and a Reach Every District (RED) strategy for immunization

coverage (Zambia Ministry of Health, 2010). However, no copies of these policies were

available to be reviewed; they were referred to in other documents. Similarly, Uganda has a

focused Child Survival Strategy which is referred to in its National Health Policy, although a

copy of the Strategy itself was not accessible. So does Ethiopia; however it specifies that it be

read in conjunction with the National Reproductive Health Strategy and National Nutrition

Strategy (Ethiopia Federal Ministry of Health, 2005). Similarly, Tanzania’s National Strategic

Plans for child and reproductive health are combined (Tanzania Ministry of Health, 1994; 2002).


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Ethiopia, Ghana, Mali, and Uganda also have National Policies or Strategies for reproductive

health, which inherently also have implications for child health, as do other National Policies in

each country pertaining to malaria, HIV/AIDS, nutrition, poverty reduction, and so on. However,

identified as a limiting factor to virtually all of these overlapping policies is the availability of

sufficient HRH, with the appropriate training, deployed to the sectors and locations where they

are needed.

Having reviewed all of these and other relevant documents for each of these countries, we

identified descriptions of 19 applied policies pertaining to training or deployment of doctors,

nurses, or midwives for maternal or child health in rural Africa. An overview of these policies is

provided in Table 5.

Table 5: National Policy Initiatives on Training or Deployment of

Doctors, Nurses or Midwives for Maternal or Child Health in

Rural Ethiopia, Ghana, Mali, Mozambique, Niger, Tanzania, Uganda or Zambia

Country Policy Year

Implemented

Ethiopia Mandatory public service after graduation

Differentiated terms and conditions for pay & benefits

New Medical Education Initiative 2011

Nurse anaesthetist program 2010

Accelerated training & increased staffing for midwives 2009

Ghana Decentralized medical resident training 2000

Deprived Area Incentive Scheme Allowance (DAIA) 2004

Health Staff Vehicle Hire Purchase Scheme 1997

Community-based Health Planning and Services program

(CHPS)

1999

Mali Medicalization of rural areas

Mozambique No available information on applied policies meeting criteria

Niger Scholarships for rural students 2011

Mobile health teams 2011

District-level surgery training 2005

Tanzania No available information on applied policies meeting criteria

Uganda Incentives scheme for human resource in hard-to-reach areas

Integrated Management of Childhood Illness (IMCI) 1995

Community-based education and services (COBES)

Specialist outreach

Building and staffing operating theaters at the level of the

‘‘health subdistrict’’ or health center type IV

Zambia One-year rural attachment for trainees 1991

Zambia Health Worker Retention Scheme 2003

Rural and Remote Hardship Allowances

Housing Allowance

The paucity of identified policies for a particular country should not necessarily be construed as

a lack of attention or effort towards the training or deployment of doctors, nurses, or midwives


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for maternal or child health in rural Africa. The included policies reflect the information that was

identified and readily available for inclusion in our analysis using the methods and sources

outlined above. That said, because there were very few individual policies identified in the

review, with very little information along with disparity in content, a synthesis of key themes

emerging across these policies was not possible. The results of this phase are therefore limited to

detailing the information available to answer our research questions. Accordingly, the following

discussion presents the findings of the synthesis under the headings of: Policy Content; Policy

Development, Policy Implementation, Policy Impact and Other Policies.

Policy Content

Ethiopia’s New Medical Education Initiative (NMEI) involved a revised, modular curriculum

and increased medical school enrolment capacity, including at rural sites (Ethiopia Federal

Ministry of Health, 2013). The accelerated midwifery training and increased staffing (the two

interventions are described as a single strategy) reduced the length of midwifery training

(although by how much is not clear) and increased the midwife staffing standard to two

midwives per health centre; many of these centres are in rural areas. In addition, a mentorship

program for new graduates was designed and implemented in collaboration with the Ethiopian

Midwives Association, under which experienced midwives were assigned to the same health

centres as new graduates (Ethiopia Federal Ministry of Health, 2013). Nurse anaesthetists are

trained through one of eleven one-year post-graduate programs or one of six baccalaureate

programs. They are then deployed as part of teams with Integrated Emergency Surgery Officers

(IESOs) and nurse midwives to primary hospitals and health centres across the country, where

much of their work focuses on maternal and neonatal care for residents of rural areas (Ethiopia

Federal Ministry of Health, 2013). The country’s policies on mandatory public service after

graduation and differentiated terms and conditions for pay & benefits are referred to in its third

Health Sector Development Plan (Ethiopia Federal Ministry of Health, 2005a), although the

years in which they were implemented are not given. According to the Plan, “the scheme

considers various aspects of employment & training to promote public sector service in rural and

remote locations including salary, eligibility for release from public service, eligibility for post-

graduate training (e. g. to specialist), and eligibility for transfer. ” One criteria considered in the

public policy is the type of district in the required length of public service. For example,

graduates must work for four years if they chose to work in an urban district, but only two if they

are posted to a remote district (Ethiopia Federal Ministry of Health, 2005).

Under Ghana’s decentralized medical training, residents spend time at teaching hospitals (which

are in urban areas) as well as regional or district hospitals (which are in more rural parts of the

country). The Deprived Area Incentive Scheme Allowance (DAIA) provided additional

monetary incentives from 20-35% of health workers’ basic salary if they were practicing in one

of 55 districts that were considered deprived, virtually all of which were rural (Lori et al., 2012).

The Health Staff Vehicle Hire Purchase scheme began in 1997 as a retention and recruitment

initiative. The CHPS program is described by Nyonator et al. (2005) as beginning in 1999 but by

the Ghana Ministry of Health (2012) as originating in 2003. Initially focusing on rural districts,

CHPS is a national health program designed to reduce geographical barriers to health care –


Page | 41

particularly maternal and child care – through mobile community-based care provided by a nurse

specially trained as a community health officer (CHO) (Nyonator et al., 2005).

The only reference to Mali’s medicalization of rural areas program is in a paper by Dolea et al.

(2010) where it is described as aiming to support doctors setting up their practices in rural areas.

Under Niger’s district surgery training program, public sector generalist doctors working at

district hospitals who perform well on a screening exam undergo twelve months of theoretical

and practical training at university and regional hospitals to be able to perform emergency

obstetrical and other surgical services. Graduates receive a certificate which entitles them to a

salary increase in Niger but is not recognized elsewhere (Sani et al., 2010). The rural scholarship

program provides funds for students from rural areas to train in one of four key health

professions, two of which are nursing and midwifery, on the condition that they serve for three

years in their community of origin in order to receive their degree (République du Niger

Ministère de la Santé Publique, 2010b). The mobile health teams consist of two nurses, a

midwife and a driver who are dispatched for five days per month to provide stop-gap services,

mainly maternal and child care, in rural areas as a temporary measure to address staffing

shortages (République du Niger Ministère de la Santé Publique, 2010b).

Similarly, the only reference to the existence of Uganda’s incentives scheme for human

resources in hard-to-reach areas is in its second National Health Policy (Uganda Ministry of

Health, 2010b), but no details on the schemes are provided. The IMCI program is described as

having three main components, each of which were designed to complement the other to

improve child health in the country: improving case management skills of health workers,

improving health system supports for child illness, and promoting family and community

practices, with a particular focus on rural areas (Pariyo et al., 2006). The country’s use of the

Community-Based Education and Service (COBES) and specialist outreach programs, and the

building and staffing of operating theatres in health subdistricts, are described in a paper by

Ozgediz et al. (2008) as national interventions having Ministry of Health involvement but are not

mentioned in any of the government documents reviewed. COBES is intended to provide a more

hands-on, representative, community-based clerkship experience and, through early exposure to

care in rural facilities, aims to increase the number of graduates willing to serve in rural areas

after graduation (Ozgediz et al., 2008). Specialist outreach is conducted periodically – depending

on availability of MoH funding – in underserved regions by flying in consultant orthopedic,

plastic, or ophthalmologic surgeons from the national hospital, or from international agencies

(Uganda Ministry of Health, 2013; Ozgediz et al., 2008). No information about the content of the

theater building and staffing policy is available through our search.

Zambia’s requirement of one year’s rural service for trainees of health professional programs is

mentioned only briefly in a 1991 Ministry of Health collection of policies and reforms. Noting

the “skewed distribution of qualified personnel towards urban areas,” it states that, “trainees will

do an attachment in a rural setting for a period of one year” (Zambia Ministry of Health, 1991).

No other information on the policy is available through our search. Over ten years later, the


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ZHWRS was first implemented in 2003 to provide a suite of incentives to recruit and retain

doctors in rural and remote districts, including a salary top-up, child education allowance, car

loan, housing improvement allowance, and professional development eligibility (Koot &

Martineau, 2005). Gow et al. (2012) state that, “rural hardship allowance is given to selected

health workers who serve in rural and remote areas in places that are ten kilometres from any

paved road. This is intended to cushion them against the factors that dissuade health workers

from serving in economically disadvantaged areas. ” However, the details of the allowances are

described somewhat inconsistently in two documents. According to the 2011-2015 Strategic Plan

(Zambia Ministry of Health, 2010b), the allowances amount to an extra 20-25% of basic salary,

while according to Gow et al. (2011), under these allowances, “Compensation [is] doubled for

workers in extreme rural districts and increased by 50 per cent for those in peri-rural districts. ”

The housing allowance is mentioned only by Gow et al. (2012) and not in any government

documents reviewed; no other information on its content is available through our search.

The next subsections describe what is known about the development, implementation, and

impacts of the included policies. The availability of information on these aspects of each policy

is summarized in Table 6.

Table 6: Information Availability by Policy

Information Available on…

Country Policy Development Implementation Impacts5

Ethiopia Mandatory public service after

graduation

Differentiated terms and

conditions for pay & benefits

New Medical Education

Initiative (NMEI)

Accelerated midwifery &

increased staffing for midwives

Nurse anaesthetist program

Ghana Decentralized medical resident

training

Deprived Area Incentive

Scheme Allowance (DAIA)

Health Staff Vehicle Hire

Purchase Scheme

Community-based Health

Planning and Services program

(CHPS)

Mali Medicalization of rural areas Niger Scholarships for rural students

5 As noted above, for the purposes of this review, only information published in peer-reviewed scientific

journals was considered as evidence of policy impact.


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Mobile health teams

District-level surgery training

Uganda Incentives scheme for human

resource in hard-to-reach areas

Integrated Management of

Childhood Illness (IMCI)

Community-based education and

services (COBES)

Specialist outreach Building and staffing operating

theaters at the level of the

‘‘health subdistrict’’ or health

center type IV

Zambia One-year rural attachment for

trainees

Zambia Health Worker

Retention Scheme

Rural and Remote Hardship

Allowances

Housing Allowance

Policy Development

No details on the development of Ethiopia’s NMEI or policies on mandatory public service after

graduation and differentiated terms and conditions for pay & benefits were available. The

accelerated training and increased staffing for midwives were designed to increase the country’s

ability to respond promptly to problems arising during pregnancy and childbirth, and to reduce

maternal and neonatal mortality. The mentorship component was designed to strengthen the

professional competence of new graduates entering practice (Ethiopia Federal Ministry of

Health, 2013). The nurse anaesthetist program was developed to increase access to their services

specifically and to emergency surgery in general (Ethiopia Federal Ministry of Health, 2013).

Ghana’s resident training program for obstetricians and gynecologists was developed in the late

1980s through a partnership between the American College of Obstetricians and Gynecologists

(ACOG), the UK’s Royal College of Obstetricians and Gynecologists (RCOG), the Department

for International Development of Britain, the Carnegie Corporation of New York, two Ghanaian

medical schools, and the government of Ghana. A key feature of the program is a rural district

hospital posting for 6 months during the 4th year. Prior to this program, obstetrical specialists

were trained primarily in the United Kingdom, often resulting in the trained specialists not

returning home to Ghana (Klufio et al., 2003). As of 2000, funding for this program is supported

through the Ghanaian MoH. The DAIA and staff vehicle purchase scheme were employed as

incentives to recruit and retain health staff to deprived (mainly rural) areas (Lori et al., 2012).

According to Ghana’s Ministry of Health (2012), the CHPS program is a response to the fact that

most Ghanaians live more than 8 kilometers from the nearest health care provider. An


Page | 44

experiment in the Navrongo district suggested that the deployment of community health nurses

in community outreach activities could substantially improve services over more traditional,

rigid service delivery methods, and so the approach was designated to be scaled up nationally

(Nyonator et al., 2005). No information on the development of the other included Ghanaian

policies was available through our search.

No information on the development of Mali’s medicalization of rural areas program was found

through our search.

Motivated by limited capacity to provide emergency obstetrical and surgical care in remote and

rural locations, Niger’s Ministry of Health, in partnership with the Faculty of Medicine of

Niamey University, launched surgery at the district level as part of the overall country health

strategy in 2005 (Sani et al., 2010). The Ministry of Health identified the rural health scholarship

and mobile health teams programs in its most recent HRH development plan under the specific

objective of providing health facilities with 80% of staff based on identified needs (République

du Niger Ministère de la Santé Publique, 2010b).

Uganda’s Ministry of Health adopted IMCI as part of its child health policy in 1995 as part of its

response to high under-5 mortality rates in the country (Pariyo et al., 2006). Ozgediz et al. (2008)

suggest that COBES was developed in response to geographic imbalances in the distribution of

doctors in Uganda, with over 90% concentrated in urban Kampala while 90% of the population

lives in rural areas, leaving surgical services outside the capitol to be provided by medical and

anaesthetic officers. Ozgediz et al. (2008) also indicate that the primary impetus for the building

and staffing of rural operating theaters was improvement in access to emergency obstetric care.

No other information on the development of these policies is available through our search.

Initially funded through a partnership with the Netherlands, the ZHWRS was designed to

improve service delivery, increasing the potential to achieve the MDGs, with a particular focus

on rural and underserved parts of Zambia (Koot & Martineau, 2005), addressing the inadequacy

of staff housing in rural and remote areas (Zambia Ministry of Health, 2009) and the urban/rural

imbalance in HRH distribution (Zambia Ministry of Health, 1991).

Policy Implementation

The NMEI has involved expanded training capacity at 11 existing universities and the

establishment of 13 additional universities and hospital medical colleges, several of which are in

rural areas. The Initiative has resulted in a near tripling of enrolment in Ethiopia’s medical

schools (Ethiopia Federal Ministry of Health, 2013). The latest available data indicate that 3,190

midwifery students have graduated from the accelerated program thus far, with another 1,190

still in training (Ethiopia Federal Ministry of Health, 2013). To implement the nurse anaesthetist

program, 60 adult airway trainers, 60 lumbar puncture modules, and over 600 textbooks were

distributed to the various training institutions. The most recent data available indicate that the

one-year post-licensure and four-year undergraduate nurse anaesthetists programs have produced

96 and 50 graduates, respectively with another 115 and 471 still in training (Ethiopia Federal


Page | 45

Ministry of Health, 2013). Although not specific to the mandatory public service policy, a mid-

term review of progress under Ethiopia’s third Health Sector Development Plan (Ethiopia

Federal Ministry of Health, 2008) noted that some zonal levels (zones within regions) have been

reluctant to deploy degree holders because of the budget constraints in hiring qualified personnel

and so they are mainly deploying middle level health workers. No other information on the

implementation of Ethiopia’s policies on mandatory public service after graduation and

differentiated terms and conditions for pay & benefits is available through our search.

As a recruitment strategy, between 1997 and 2009, almost 3500 cars were distributed to health

workers through Ghana’s Health Staff Vehicle Hire Purchase Scheme. Following the promising

results of CHPS in Navrongo, the program was tested in Nkwanta district. When that was

deemed successful, the program was expanded to other districts (Nyonator et al., 2005). In

response to a 2009 Ministry of Health (2012) study of CHPS, training of the CHOs who form the

core of the program was accelerated and expanded to include midwifery training. The study also

detailed several factors that have hindered the implementation of the program: CHOs’ time is

almost entirely occupied with providing curative services at the expense of preventive or health

promotion services, the program is poorly supervised, there is little engagement with community

leaders in planning the program, and available transport and equipment are inadequate. The

report recommended the establishment of an inter-agency coordinating committee to address

these issues (Ghana Ministry of Health, 2012). No other information on the implementation of

the Ghanaian policies is available through our search.

Dolea et al. (2010) note that as part of Mali’s medicalization of rural areas program, 100 doctors

were posted to rural areas over a ten-year period, with an average time in post of four years.

Niger’s district surgery program was implemented in 2005, and after the first two graduating

cohorts (2006 and 2007), produced 41 trained practitioners from rural origins. Approximate cost

for the first year of implementation was $100,000 USD, or $4,762 USD per student. Additional

sponsorship for the program was provided by the Belgian Technical Cooperation and the Italian

Cooperation (Sani et al., 2010). Although no information is available on the actual

implementation of the rural scholarship or mobile health teams programs, the most recent

national HRH strategic plan (République du Niger Ministère de la Santé Publique, 2010b) notes

that scholarships are to be issued to 300 young people of rural origins between 2011 – 2014, and

an additional 300 between 2016 – 2019 . These scholarships are to be divided across students of

four health professions: 100 for health assistants (Agent de Sante de Base), 100 for diploma-level

nurses (Infirmier Diplome d’Etat), 25 for lab staff (Laborantin), and 75 for diploma-level

midwives (Sage-Femme Diplomee d’Etat). Projected total cost is 4,666,500,000 F. CFA

(République du Niger Ministère de la Santé Publique, 2010b). The HRH plan also states that the

32 mobile health teams will initially cover up to three districts, with scaling up to the national

level upon successful implementation. The total cost of the program over 2011 – 2015 was

estimated at 355,200,000 F. CFA, or 2,220,000 per health district over the same period of time.

Local partners will take on the additional costs of travel, supplies, and maintenance (République

du Niger Ministère de la Santé Publique, 2010b).


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The initial training of health personnel for IMCI in Uganda began in 1996 in three districts. The

MoH recommended that nurses, midwives, clinical officers and doctors be trained first, followed

by nursing aides and assistants. After two years of trials and implementation, the program was

designated for national expansion and by 2000 had been introduced in 55 of 56 districts

nationally. MoH personnel monitored all training until 2001. Between 2000 and 2002, the

program’s implementation was evaluated by a team from Makerere University, the WHO, and

Johns Hopkins University (Pariyo et al., 2006). The evaluation noted several factors that

hindered the implementation of the program, mainly that most facilities did not have all

necessary drugs, that most did not receive any supervisory visits, and that there were some

‘unwritten’ policies among public health workers that were viewed as superseding the IMCI

protocols (Pariyo et al., 2006). Under Uganda’s policy of building and staffing operating theatres

at the subdistrict level, operations were to be performed by a medical officer, and anaesthesia

provided by anaesthetic assistants, for whom an 18-month training program was developed

(Ozgediz et al., 2008). No other information on the implementation of Ugandan policies was

available through our search.

The total budget made available to implement the ZHWRS was €2.3 million over the first three

years. As of 2005 the scheme was managed by the Central Board of Health (CBoH) without

MoH involvement, and a mid-term review found 68 doctors had been contracted under the

scheme, and that other than the provincial health director and HR specialist, almost no personnel

in the districts knew anything about the scheme (Koot & Martineau, 2005). The CBoH was

dissolved in 2005, after which the MoH took over the scheme (Zambia Ministry of Health,

2010a). In 2007 the ZHWRS was expanded to include other health workers, including clinical

officers, tutors/lecturers, nurses, midwives, environmental health technologists; tutors and

lecturers were added to help produce more health personnel (Zambia Ministry of Health, 2010a).

A 2009 review found that the total number of health workers on the staff retention scheme

increased from 656 in 2008 to 860 in 2009, against a target of 1,650, and also noted a need to

improve coordination and communication of HR information, particularly on staff postings and

the ZHWRS (Zambia Ministry of Health, 2009). A more recent review found that, as of 2012,

membership in the scheme was 1,023 against a target of 1,400, distributed across all districts.

Nurses and midwives are among the professional groups whose participation in the ZHWRS is

above target levels, while participation for doctors is below target (Bwalya et al., 2013). Among

the challenges reported related to the scheme’s implementation were irregular and late payments

of allowances under the scheme, weak monitoring and evaluation practices, particularly poor

working conditions in rural areas, and inefficient communication and collaboration between

national and district offices. The payment issues appear to be related to delays in receiving funds

from the Ministry of Finance, which have led to the scheme incurring unfunded liability (Bwalya

et al., 2013). No details on the implementation of the other Zambian policies were found.


Page | 47

Policy Impacts

No peer-reviewed evidence was available through our search on the impacts, if any, of Ethiopia’s

NMEI, accelerated training and increased staffing for midwives, nurse anaesthetist program or

policies on mandatory public service after graduation and differentiated terms and conditions for

pay & benefits. In the case of NMEI, it is important to note that as the Initiative only began in

2011, the additional students have not yet had time to complete their training. The nurse

anaesthetist program has also only been recently implemented, and the accelerated training and

increased staffing for midwives is also a relatively new policy.

A 2003 study found that doctors who were trained in Ghana and in particular in rural areas,

tended to stay in the country and practice in rural areas (Klufio et al., 2003), suggesting the

decentralized medical training – if it is still in place – should help to address the country’s rural

doctor shortages. However this study was not specific to the rural residency program. The 2009

study on the CHPS did not describe any actual impacts of the program. No information is

available from our search on the impacts of the nation-wide version of the program, although

Nyonator et al. (2005) note that the positive results of pilot implementations suggested the

program had increased rural service availability in general and immunization coverage in

particular. No information on the impacts, if any, of the other Ghanaian policies was available.

No information on the impacts of Mali’s medicalization of rural areas program was available

through our search.

A study of Niger’s district surgery training program found that all graduates have remained in

their rural posts, that surgical patient transfer to regional hospitals was reduced from 82% in

2005 (pre-implementation) to 52% in 2006 (post-implementation), and that surgeries performed

by graduates in the districts had a mortality rate only slightly higher than those performed at the

regional hospitals by fully trained surgeons and gynaecologists (Sani et al., 2010). The study also

concluded that, although very successful, the overall impact of the program is limited by

inconsistent provision of human resources, essential equipment, and continued training. Further,

it suggests that part of the successful retention of graduates is due to the lack of recognition of

the program’s credential outside the country, and to other rural incentives which are not

described (Sani et al., 2010). No information on the impacts of the rural scholarship or mobile

health teams programs was found.

There is very little information available on the impacts of the Ugandan policies, with the

exception of the IMCI program, which has been evaluated. Pariyo et al. (2006) found that HRH

trained in IMCI protocols and procedures were better at assessment and diagnosis, and that this

effect was stronger for nurse aides and assistants than for nurses, doctors and midwives. They

also found variation in that while personnel trained in IMCI protocols provided better education

of child caretakers, there was variation in the effects of treatment. Further, they found that initial

improvements were not maintained by the end of the study period. They concluded that IMCI

training alone was not sufficient to sustainably improve care (Pariyo et al., 2006). Other than the

fact that there continues to be an inequitable distribution of health workers between urban and


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rural parts of Uganda, with nearly 70% of medical doctors and dentists, 80% of pharmacists and

40% of nurses and midwives, are in urban areas serving 13% of the population (Uganda Ministry

of Health, 2010a), no information was available through our search on the impacts, if any, of the

other Ugandan policies.

Similarly, there was little peer-reviewed evidence available through our search on the impacts of

the Zambian policies. Ministry of Health data show that HRH numbers have increased in rural

areas since 2005, suggesting the ZHWRS may have been of some benefit, although the

inequitable distribution of HRH continues (Zambia Ministry of Health, 2010). In addition, HRH

in rural posts in Zambia remain more likely to quit their jobs than their urban counterparts (Gow

et al., 2012). A more recent MoH review provides qualitative data suggesting that the ZHWRS is

perceived as being a strong retention mechanism and a benefit to health care facilities and

education and training institutions, but little quantitative data was available to confirm these

perceptions. A lack of adequate funding is undermining the sustainability of the program

(Bwalya et al., 2013).

Other Policies

During our review we came across descriptions of several policies and programs aimed at

improving maternal and child health in these countries that did not meet one or more of our

inclusion criteria. These included, for example, Mozambique’s Agentes Polivalentes Elementares

(APE) program and Uganda’s Village Health Teams program, which are both designed to

improve the accessibility of essential health services in rural areas, but are based more around

community health workers as opposed to the professions included in our review (Bhutta et al.,

2010). Two such programs about which there was considerable information available were

Ethiopia’s Health Extension Program (HEP) and the Tanzania Essential Health Intervention

Project (TEHIP).

Ethiopia’s Health Extension Program

Ethiopia has lowered its child mortality rate by an estimated two-thirds, meeting the MDG4

target in advance of 2015, although the neonatal mortality rates have not been reduced

sufficiently (UN Inter-Agency Group for Child Mortality Estimation, 2013). This demonstrated

progress toward achieving this MDG has in part been associated with Ethiopia’s Health

Extension Program (Ethiopia Federal Ministry of Health, 2013; Banteyerga et al., 2011).

The government introduced the Health Extension Program (HEP) in 2003as part of its second

Health Sector Development Plan in order to specifically address the lack of community-level

primary health care, particularly in rural areas (Health Extension and Education Center, 2007).

The HEP aims to increase community-level primary health care through a defined package of

services within four major program areas: family health services, disease prevention and control,

hygiene and environmental sanitation, and education and communication (Teklehaimanot &

Teklehaimanot, 2013). The objectives of the HEP include improving access and equity to

preventive essential health interventions at the village and household levels, ensuring ownership

and participation by increasing health awareness, knowledge, and skills among community


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members, promoting gender equality in accessing health services, improving the utilization of

peripheral health services by bridging the gap between the communities and health facilities

through Health Extension Workers (HEWs), reducing maternal and child mortality and

promoting healthy life styles (Health Extension and Education Center, 2007).

The HEP was piloted in 2002/03 in 5 regions and the initial results showed improvements in

sanitation, contraceptive utilization, and vaccinations, leading to full scale up (Ethiopian Federal

Ministry of Health, 2005). Overall, the program has produced 16 service packages, available in

Amharic and English, and distributed them to training institutions, regional health bureaus and

other stakeholders in the regional states (Ethiopian Federal Ministry of Health, 2005). The

delivery of key maternal, neonatal and child health interventions to the community, aligned with

the National Child Health Strategy, is primarily through the HEP (Health Extension and

Education Center, 2007).

The program primarily involves the utilization of health extension workers (HEWs) who provide

education and basic services to households, mostly through outreach services and through health

posts. Recruited as HEWs are adult women with at least grade 10 education and who will work

in the village in which they reside. Training consists of a one-year program involving

coursework and field work, with ongoing supervision by skilled health workers. Other key

components of the HEP include the construction and supplying of health posts in kebeles

(municipalities), staffed by 2 HEWs. As of 2011, more than 30,000 HEWs have been trained and

deployed across the country (Ethiopian Federal Ministry of Health, 2011). In 2008, the FMOH

began to plan for upgrading the skills and knowledge of HEWs and in 2011/12, 1,289 HEWs

completed the upgrading program, with another 2,240 enrolled in 2012/13 (Ethiopian Federal

Ministry of Health, 2013b).

The HEP, particularly the health extension workers, has received widespread acceptance by the

communities, including elders, religious leaders, agricultural extension workers and schools,

resulting in successful expansion of health coverage (Banteyerga et al, 2011). While this

initiative has provided community-level services and resulted in progress on a number of health

indicators (including child mortality), challenges still exist in terms of antenatal care, delivery

being attended by skilled workers, contraceptive acceptance and use, and post-partum visits.

Other challenges identified include: insufficient materials and supplies, inadequate means of

communication and transportation for adequate supervision, lack of capacity at Woreda level for

supervision, monitoring & evaluation, and a weak referral system (Teklehaimanot &

Teklehaimanot, 2013). Despite these ongoing challenges, the HEP has shown to have positive

impact on health outcomes (Karim et al., 2013; Teklehaimanot & Teklehaimanot, 2013) and

remains the key program for community-level health care. Although this initiative does not focus

on training and deployment of doctors, nurses or midwives, it is a clear example of the kinds of

far-reaching programs being implemented by African governments with demonstrated success in

promoting maternal and child health in rural areas.


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The Tanzania Essential Health Intervention Project

The Tanzania Ministry of Health and Social Welfare, in partnership with IDRC, first

implemented the Tanzania Essential Health Intervention Project (TEHIP) in 1997. Recognizing

that it is often a lack of district-level planning capacity as opposed to resources that limits

delivery of health services, and the particular importance of evidence-based planning when

resources are limited, TEHIP aimed to couple research and development for improved health

gains in resource limited settings. This was to be achieved through the use of a toolkit designed

to strengthen the capacity of District Health Management Teams (DHMT) to make evidence-

informed policy decisions. The toolkit incorporates four items – a burden of disease profile tool,

district health accounts tool, district health services mapping tool, community voice tool, and

cost-effectiveness and district cost information system tool – which generate the basic evidence

needed by DHMTs to plan effectively.

In 1997, TEHIP was piloted in two rural districts to inform potential scale-up. Initial impacts of

the toolkit adoption showed significant changes in the policy process and content. The DHMTs

approach to planning, with budget allocations and program selection, began to reflect the

priorities illustrated in the community disease profiles and best-buy programs. This new

approach resulted in increases in the overall health status of residents of the pilot districts; for

example, the decision by DHMTs in both districts to fund and implement the Integrated

Management of Childhood Illness resulted in a 55% decrease in child mortality in the study area

between 1998 and early 2003.

The impact of TEHIP reached beyond the toolkit. An Integrated Management Cascade strategy

was applied to create stronger linkages between supervisors and a dispersed community health

workforce. New partnerships were formed between communities and government bodies to

encourage citizen participation in health facility rehabilitation in exchange for national funding

for community health workers and essential drugs and supplies. Supplemental funding offered

under the TEHIP project that was not readily absorbed by the pre-existing health services was re-

directed into HRH training, capacity building among existing management, transportation, and

communication infrastructure, with future service expansion in mind.

The MoHSW, based on the early success TEHIP, called for the scale-up of certain programmatic

aspects and tools. Upon the development of a prototype to inform national scale-up, funding was

provided by the UN and IDRC to bring TEHIP above the district level to two regions. Although

TEHIP does not fit within the inclusion criteria for this analysis, it has clearly demonstrated that

the Tanzanian Ministry of Health and Social Welfare has identified a mechanism to improve the

health of its population by promoting evidence-informed planning at the district level.

5.0 Discussion

Overview

Despite an extensive and multi-faceted search strategy, there were relatively few policies

pertaining to the training and/or deployment of doctors, nurses and midwives for maternal and


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child health identified not only in these countries but in Africa as a whole. However, this should

not be interpreted as a lack of attention or action towards addressing these issues. As noted

above, there are several important programs being implemented by several countries to address

these issues, some of which did not meet the exact inclusion criteria. Further, there may also be

policies and programs in place within these countries that do meet our inclusion criteria but for

which we found little or no information. For example, government documents from Ghana,

Tanzania and Zambia indicate that they too have (or at one point had) Integrated Management of

Childhood Illness programs, but because no other information about the programs in these

countries was available, no further analysis was possible.

Several recurring issues, outside the scope of our analysis but nonetheless directly related to the

subject of HRH training and deployment, were described across documents reviewed from

multiple countries. These issues may explain, at least in part, why there seems to be such a

disparity between the breadth and depth of health strategies proposed in these countries

compared to what appears to actually be implemented. These issues include fiscal considerations,

resource management, monitoring and evaluation, competing priorities, political stability,

decentralization, the importance of partnerships, and transparency and access to information.

Fiscal Considerations

In April 2001, heads of state of African Union countries met in Nigeria and pledged, under what

was called the Abuja declaration, to set a target of allocating at least 15% of their annual budget

to improve the health sector (WHO, 2011). However, according to the most recent WHO data

(Table 4), none of the eight countries included in the synthesis are meeting this target. Perhaps

not coincidentally, in documents where Ministries of Health discussed the reasons why policies

and strategies outlined in past plans may have been implemented only partially or not at all, the

critically limiting factor tended to be the availability of financial resources. Not only are the

available funds inadequate for ensuring the short-term availability of sufficient HRH, equipment

and supplies, their inadequacy precludes maintenance or improvements to essential health care

delivery (e. g. hospitals) and education (e. g. universities) infrastructure. For example, Zambia’s

Ministry of Health identifies restrictions on the public wage bill and “inadequate, irregular and

consistently decreasing funding for the health sector” as major challenges limiting its ability to

implement meaningful reforms (Zambia Ministry of Health, 2011a). To cite more specific

examples, a lack of available funds threatens the sustainability of the ZHWRS (Bwalya et al. ,

2013), and has severely limited the implementation of the National Training Operation Plan

(Zambia Ministry of Health, 2010). Similarly, Mali’s Ministry of Health (2013) notes that

financial constraints and funding uncertainty limit the implementation and evaluation of policy in

general and its blood services program in particular. Uganda’s Ministry of Health (2010a) reports

that it is allocated less than half the estimated funds required to deliver its Basic Health Care

Package, particularly services for newborns. Although funds and other resources from donor

agencies may somewhat mitigate funding gaps, they often come with their own challenges,

including a lack of alignment with national health priorities (see ‘Partnerships’ below).


Page | 52

This chronic shortage of funding for the health sector is undoubtedly linked to the high debt

loads borne by these countries. Moreover, the inadequacies of public infrastructure are not

limited to the health sector, as poor roads, insufficient water, electrical, and sanitation systems,

and deficient communications networks are ongoing problems faced by each of these countries.

Mali’s electrical grid, for example, provides power to only about 17% of its population, among

the lowest in the world (Briceno-Garmendia et al., 2011). The situation is worse in Niger, where

only 8% of the population has electricity, and only 18% have the use of sanitary latrines, the

lowest such rate in Africa (Dominguez-Torres & Foster, 2011). These broader deficiencies in

public infrastructure exacerbate the challenges faced by the health sectors as they encourage the

most highly-trained health professionals to migrate to more developed countries.

The availability of funding enables several important initiatives to improve public health care

infrastructure as evidenced by several identified examples. Ethiopia, for instance, has invested in

the creation of additional universities to train health workers, and built health centres and health

posts to increase accessibility to primary health care (Ethiopian Federal Ministry of Health,

2008). They are also working to improve housing for health workers, particularly at the village

level (e. g. housing for HEWs) (Ethiopian Federal Ministry of Health, 2010b). Similarly, Zambia

has invested in the construction of 26 new district hospitals and 125 new rural health posts

(Zambia Ministry of Health, 2011), although some of these remain unutilized because of a lack

of equipment (Zambia Ministry of Health, 2010). Improvements have also been made beyond the

health sector. Tanzania, for example, has made substantial improvements to its road network as

well as its telecommunications infrastructure (Shkaratan, 2012). Uganda, too, has substantially

improved its telecommunications networks as well as its power grid, although efficiency issues

persist with the latter (Ranganathan & Foster, 2012).

To make up for shortages of allocated resources, some countries such as Tanzania and Uganda

rely heavily on user fees and other private revenue streams (Haazen, 2012; Uganda Ministry of

Health, 2013). Such practices may run contrary to the achievement of the MDGs in particular,

and the missions of health care systems more broadly, as those in greatest need of health care can

seldom afford to pay for it. Recognizing this, countries such as Ethiopia (Ethiopia Federal

Ministry of Health, 2013) and Niger (Lagarde et al., 2012) have attempted to reduce or remove

user fees, despite the consequent fiscal challenges. National health insurance schemes, such as

those introduced in Ghana (Government of Ghana, 2007) and Ethiopia (Ethiopia Federal

Ministry of Health, 2013), can be means of generating revenue for health care that is less

burdensome on those in need.

The long-standing and apparently universal nature of this lack of funding suggests that some

changes in planning are warranted. Either governments must recognize the centrality of an

adequately funded health care system to their national prosperity and allocate their limited

resources accordingly (this may require renegotiation of terms with creditors such as the

International Monetary Fund), or health sector planners must more explicitly recognize that the

funds they deem to be necessary are unlikely to become available, and adjust their strategic plans

accordingly. Ultimately, some combination of these two strategies may be best. At a minimum,


Page | 53

governments seeking to improve the health of their countries must meet the funding

commitments they made in the Abuja Declaration.

Resource Management: People, Supplies, Services

The countries studied are also challenged to make efficient use of the resources they do have;

another identified challenge to policy implementation is weak or otherwise inadequate

supervision and performance management of personnel and supplies. For example, Ghana’s

Ministry of Health (2007) identifies inadequate supervision and weak performance management

systems as challenges to the implementation of its HR Policies and Strategies for the Health

Sector. In addition, Tanzania’s Ministry of Health and Social Welfare (2008) identifies

inadequate supervision as a challenge to the implementation of training for maternal, newborn

and child health. Similarly, inadequate logistics and supply chain management are described as

exacerbating shortages of essential medications and other critical materials in Tanzania, Zambia

and Uganda, where insufficient supplies of drugs have hindered national immunization programs

(Tanzania MoHSW, 2007; Uganda Ministry of Health, 2010; Zambia Ministry of Health, 2009;

2010b). In Zambia, however, the Ministry (2010b) reports that the procurement and distribution

systems for drugs have improved significantly in recent years. Effective resource management is

essential to ensure not only training and deployment but also the provision of quality health care

to improve population health.

Evaluation and Monitoring

There is recognition across the countries studied of the importance of evaluation and monitoring

to ensuring efficient and effective use of resources and improving the performance of health care

systems. However, none of the countries studied consider the current monitoring and evaluation

capacities of their health sectors to be adequate. For example, Ethiopia’s Ministry of Health

(2007) identifies inadequate monitoring and evaluation capacity as an impediment to the

implementation of its HEP.

Related to this challenge are the limitations of the various countries’ national Health Information

Systems (HIS), which, for example, are described as inadequate in Zambia (Zambia Ministry of

Health, 2011a). In Uganda (Uganda Ministry of Health, 2010), the existing HIS is described

specifically as a hindrance to improving maternal and newborn health service (Republic of

Uganda, 2005). As Table 4 indicates, it is difficult to find basic HRH indicators for several of the

countries studied. In Ethiopia, for example, the number of established posts at various levels of

the health system is not currently available (Feysia et al., 2012).

Inadequate evaluation and monitoring systems also have implications for these countries in terms

of their ability to be transparent and to address corruption (see ‘Availability of Information’

below). However, efforts are being made to address this challenge. For example, Ethiopia’s

Ministry of Health has invested in increasing its monitoring and evaluation capacity as part of its

current Health Sector Development Plan (Ethiopia Federal Ministry of Health, 2010a).

Evaluation and monitoring is also essential towards establishing an evidence base – which can be

shared across countries – detailing which strategies and initiatives have been successful.


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Infrastructure to support ongoing monitoring and evaluation can inform future decision making

not only at the individual country-level but across and between regions.

Competing Priorities

The successful implementation and sustainability of a policy depends not only on the merits of

the policy itself, but also – and perhaps more so – on the context in which it is developed and

implemented. This is particularly so in the countries studied, each of which faces multiple

challenges and competing priorities as they attempt to make positive change. In Uganda, for

example, the scale up of IMCI was limited as the training was found not to be adequate on its

own to improve child health; a supportive infrastructure, work environments, and political

context are also required for the training to be successful (Ozgediz et al., 2008). An evaluation of

the cervical screening policy in South Africa indicated that technological and task-shifting

interventions were not sufficient on their own to improve health outcomes, and required the

concurrent addressing of other HRH issues such as training, attrition, skill mix, and workload

management for success (Kawonga & Fonn, 2008). Nigeria, in recognition of the importance of

multi-faceted strategies, implemented their Life Saving Skills training policy for midwives in

tandem with provision of equipment and supplies, as well as training all associated providers

with communication and interpersonal skills. This integrated approach resulted in stronger team

building and more supportive management as well as gains in maternal and infant health (Kwast,

1996).

Political Stability

Some of the countries studied have enjoyed greater political stability than others. Perhaps the

most dramatic example is Mali, where recent armed conflict resulted in, among other tragic

consequences, the displacement of over 400,000 Malians and an additional 150,000 refugees.

With fewer functioning health centres in the north, limited access to vaccines and prenatal

medications and limited referral and emergency transport systems, delivery of health care has

been severely disrupted, and there is still concern about the increased risk for disease outbreaks,

increases in maternal mortality and an increase in severe malnutrition (International Committee

of the Red Cross, 2013; WHO, 2013b). Similarly, recent armed conflict in northern Uganda

resulted in displacement of much of the population into temporary camps with inadequate

sanitation, education, or social structures, and disrupted health care delivery by requiring the

closure of several facilities (Uganda Ministry of Health, 2010). Less recently, civil war in

Mozambique between 1977 and 1992 caused much disruption of health services, including, for

example, the complete interruption of the APE program in 1989 (Bhutta et al., 2010).

The more politically stable countries do not take their comparative peace for granted, however.

Zambia, for example, explicitly identifies continued political stability as a condition for the

successful implementation of its HRH plan (Zambia Ministry of Health, 2005). Political stability

is a critical consideration as it impacts all aspects of policy work from planning and prioritizing

to funding decisions, resource allocation and evaluation and monitoring.


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Decentralization: Advantages and Challenges

Several of the countries studied have recently undergone, or are still undergoing, processes of

decentralization, including Ethiopia, Ghana, Mali, Tanzania, Uganda and Zambia. These

processes have been designed to increase administrative efficiency while facilitating greater

input into policy development and implementation from local participants. In some instances,

decentralization has had some success in moving health policy-making closer to the community

level, such as through Ghana’s CHPS program (Ghana MoH, 2010). A World Bank study

(Garcia & Rajmukar, 2008) concluded that Ethiopia’s decentralized governance structure helped

facilitate improvements in service delivery and human development outcomes in general.

Another in Mozambique found that decentralized management of HRH resulted in improvements

to the administration of retirements and a better personnel information system, and was

perceived as reducing wait times for deployment (Ferrinho & Omar, 2006). However in several

countries, including Ethiopia, Ghana, Mali, Mozambique, Tanzania, Uganda and Zambia, it is

noted that the lack of personnel, management capacity and infrastructure at the district levels,

required under a decentralized system, has significantly hampered the rollout of health policies

and programs and made it more difficult to ensure accountability within the system (Ethiopia

Federal Ministry of Health, 2008; Couttolenc, 2012; République du Mali Ministère de la Santé,

2013; Ferrinho & Omar, 2006; United Republic of Tanzania, n.d. ; Uganda Ministry of Health

2010a, 2010b; Zambia Ministry of Health, 2011b). Another result of decentralization is

incongruence in the design and application of policy as interpretations and plans at the district

level may deviate not only from the national policy guidelines but also result in great variations

between districts. In Tanzania, for example, a recent audit found major inconsistencies in the

interpretation of a national contraceptive policy at the council level (Tanzania National Audit

Office, 2011). Decentralization is a reality facing many countries; the challenge is to ensure that

there is support to ensure consistency in the interpretation, application, implementation and

evaluation and monitoring of policies at all levels.

Partnerships

The importance of partnerships – within and across government, and between governments,

educational institutions, international funding agencies and other NGOs – was a recognized

feature in a number of the policy documents examined. In particular, the importance of

partnerships in relation to donor funds to the health care systems of Ethiopia, Ghana, Mali,

Tanzania, Uganda and Zambia was repeatedly highlighted. A System Wide Approach (SWAp),

which centralizes funding from donor and other non-governmental agencies so that it can be

allocated across sectors according to shared national priorities, is in place in Ghana, Tanzania,

Uganda and Zambia.

Partnerships provide opportunities but may also present challenges. For example, a challenge

with the SWAp is that often the use of these funds is outside the control of the Ministry of

Health. In Zambia, for example, the result is that donor funds go to fund posts and services that

are not aligned with national priorities, such as specialized tertiary care, while the Ministry of

Health lacks the funds to deliver even its Basic Health Care Package (Zambia Ministry of Health,

2008). A recent World Bank study found that Zambia’s health sector is being increasingly


Page | 56

fragmented by the re-emergence of global disease initiatives and the associated disease-specific

focus of donor funds (Picazo & Zhao, 2009). Another World Bank study in Tanzania reports that

the ‘fragmentation’ associated with donor funds “results in substantial inefficiencies in the use of

resources and often-conflicting incentives for the various actors in the health system” (Haazen,

2012). Similarly, Uganda’s Ministry of Health (2010) notes that donor agencies tend to negotiate

contributions and plans with the Ministry of Finance, Planning and Economic Development

rather than with the Ministry of Health, making alignment with donor funds and national health

priorities such as newborn survival (Mbonye et al., 2012) a challenge.

Improving partnerships between health and other sectors – particularly finance and education –

were identified as key goals in most of the countries studied. However, efforts to formally

strengthen these linkages have had minimal success. In Ghana, for example, an attempt was

made years ago to bring the training institutions that had been variously the responsibility of

Ministries of Health and Education together under a single regulatory college. However, this

policy was never fully implemented (Beciu et al., 2009). Similarly, a lack of effective

collaboration between Zambia’s Ministry of Finance and Planning and the Ministry of Health

has resulted in the late provision of funds by the former to the latter, which in turn has been

identified as having a negative impact on the implementation of ZHWRS (Bwalya et al., 2013).

Stronger collaboration between the health and finance sectors can help to ensure adequate health

funds are available in a timely manner, which in turn will help the health care system to function

efficiently. Improved collaboration between the health and finance sectors can help to ensure that

HRH training is aligned with the competencies required in clinical practice, that clinical practices

are aligned with the best available evidence, and that new graduates are placed in the most

appropriate posts.

Partnership between public and private sectors in health is also crucial, particularly in countries

like Ghana, Tanzania and Uganda where the private sector provides a large portion of health care

services. Several countries have explicitly identified a strengthened, more integrated relationship

between the public and private sectors as a key objective of their national health policies.

Uganda, for example, specifies “establishing a functional integration within the public and

between the public and private sectors in healthcare delivery, training and research” as an

objective of its Second National Health Policy (Uganda Ministry of Health, 2010). Similarly,

Ghana’s 2011 review of its Program of Work (Ghana Ministry of Health, 2011) describes several

processes undertaken to strengthen its Private Sector Policy. However, no information on the

success of such efforts was found in our review.

Another type of partnership with great potential to strengthen the health sector is between

government and academia. Policy-research partnerships, particularly with respect to HRH, are

advocated by numerous NGOs including the Global Health Workforce Alliance (2011) as a key

mechanism for promoting evidence-informed policy-making. To this end, several countries are

making concerted efforts to develop and strengthen relationships between Ministries of Health

and their various research institutions. Zambia, for example, has developed a National Health

Research Strategic Plan (Zambia Ministry of Health, 2008) and established the Zambia Forum


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for Health Research (ZAMFOHR) and established the Zambia Forum for Health Research

(ZAMFOHR)to strengthen the capacity of Zambia’s researchers and research-users to produce,

synthesize, access, discuss, adapt and ultimately use evidence (Kasonde, 2009). Among the

challenges facing such efforts, however, are limited existing capacities for research support

activities such as training, communications and synthesis (Kasonde & Campbell, 2012).

Availability of Information

As noted above, the countries studied describe a wide range of policies, programs and other

activities pertaining to health care and HRH in general and training and deployment of doctors,

nurses and midwives for maternal and child health in rural areas specifically. However, details

on the content, implementation, and impacts of these policies are very difficult to obtain. This

unavailability of information may be the result of a variety of factors, including the limited

health information systems and inadequate communications infrastructures noted above.

Although it is noted that ensuring the availability of this information may be eclipsed by more

urgent priorities, this lack of accessible information precludes any rigorous analysis of the

effectiveness of these policies. More broadly, it calls into question the value of these policies,

and limits the accountability of those responsible for them.

Lacking transparency and accountability are of particular concern for countries strongly

dependent on donor funds to support their health care and other key systems. It is in each

country’s best interest to prevent and eradicate even the perception of corruption within their

governments, particularly pertaining to the use of donor funds. Prevention of corruption is a

significant challenge compounded by aforementioned weaknesses in governance, supervision,

performance monitoring, and evaluation infrastructures across all of these countries. The

Government of Ghana (2009), for example, specifically notes that its “existing anti-corruption

institutions are weak in terms of capacity, coordination and collaboration”, while Zambia’s

Ministry of Health (2010) cites “Weaknesses in the systems for and structures for promoting

transparency, accountability and access to information” as a challenge to effective leadership and

governance.

Even in the presence of legitimate, transparent and accurate practices, a significant concern is

that government health care is perceived as being corrupt. In Uganda, for example, a recent

survey estimated that 43% of Ugandans consider health workers to be corrupt (Uganda Ministry

of Health, 2010). Types of corruption in Ethiopia’s health sector described by respondents to a

World Bank Study (Lindelow et al., 2005) included absenteeism or shirking of duties, theft of

drugs and materials, and illicit charging of patients.

At worst, corruption is confirmed in a country’s government, to the direct detriment of its

citizens. In Zambia, for example, donors suspended financial support to the health sector when

corruption was uncovered in 2009, with significant negative consequences for the performance

of the country’s health care system (Zambia Ministry of Health, 2010). In response, the

Government of Zambia and its Anti-Corruption Commission developed a governance action plan

with donor agencies and other partners, which has since been implemented (Zambia Ministry of


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Health, 2009). Similarly, Uganda has adopted a specific Anti-Corruption Strategy and a broader

Governance and Accountability Action Plan, supported by the World Bank (Uganda Ministry of

Health, 2010). Ethiopia (Plummer, 2012) and Niger (World Bank, 2005) have also partnered

with the World Bank to produce independent overviews of the nature and extent of corruption in

their respective countries. If successful, these strategies may lead to significant improvements in

the health sector performance of these countries.

Areas for Further Study

There is great potential to build on this synthesis in future work. The main limitations of this

review were the availability of information on relevant policies, and the timeframe available to

conduct the review. Related to the latter point, as noted above, expanding the search strategy for

peer-reviewed documents to include names of individual African countries would likely yield

more relevant papers. Similarly, follow-up searches for information on specific policies, once

identified, could produce additional information about them, as could mining the references of

relevant documents. Further, interviews or focus groups with key informants in the selected

countries would likely yield additional insights and relevant documents. Finally, although we

have cited government- and NGO-published reports where applicable, we limited our

consideration of the evidence of policy impacts to the peer-reviewed literature. This excludes the

wealth of important analyses being done by NGOs such as the World Bank and CapacityPlus,

which have great potential to inform the kinds of policies considered here but are seldom

published in academic journals.

Summary

Overall, it is clear that the Ministries of Health in the countries studied have attempted, and

continue to explore, a wide range of HRH policy options aimed at improving maternal and child

health among their respective populations. However, the implementation – and therefore the

success – of these policies seem to be severely constrained by economic, political, social,

geographic and technological factors outside these Ministries’ influence. That said, it is

important to note how little information on what health policies currently exist in these countries

– let alone details about their implementation and impacts – is readily available, or even

obtainable through dedicated searching. Most of the policies had to be analyzed based solely on

secondary information, as copies of the actual policies themselves were not available. This lack

of transparency and accessibility makes an objective assessment of these policies – necessary for

any meaningful improvement on them – virtually impossible.


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6.0 Key Messages

The main limitation of this study, in addition to the lack of country-specific searches, was that

our search criteria might have missed potentially eligible citations and documents since a wide

range of terminology is used to describe policy options for HRH. Further, the majority of the

primary research articles employed a variety of both qualitative and quantitative methods. This

triangulation of methods and results suggests that in this particular field of study, document

analysis and synthesis is not necessarily sufficient to create context-driven conclusions or

recommendations.

That said, several key messages emerged repeatedly and clearly enough to be brought to the

forefront.

1. The planning-implementation gap: A wide range of strategic HRH and broader health

system policy interventions appear to have been implemented to improve the training and

deployment of doctors, nurses, and midwives for maternal and child health in rural Africa.

However, there is a wide apparent discrepancy between the number and scope of policies

and strategies that are proposed and what is evidently implemented, and poor maternal and

child health remains widespread in rural Africa. Further, we often found little evidence of

clear policy direction for those policies that were implemented. This discrepancy between

planning and implementation may be due to any number of economic, social, political,

environmental and technological factors, only some of which are within the sphere of direct

influence of Ministries of Health.

2. Underfunding: None of the eight countries studied in depth have met their health sector

funding commitments made under the Abuja declaration in 2001, and underfunding is the

most frequently cited challenge limiting improvements to the health sector. Increasing

funding allocations to meet this commitment is essential to the health of these countries’

populations.

3. Policy Visibility: There is a need to improve the degree of visibility offered by Ministries of

Health in terms of their various policies. Despite the multi-pronged search strategies

described, due to a lack of archiving of policy information on Ministry of Health websites,

for none of the eight countries studied in depth could we find copies of any of the specific

policies included in our analysis, which was therefore limited to evidence from secondary

sources.

4. Unavailability of Evidence: There is a dearth of peer-reviewed evidence documenting the

implementation and impacts of HRH policies in Africa. This may be partially due to the fact

that the evidence being generated is often self-published by NGOs like the World Bank;

there appears to be almost no such evidence published by governments, even where it exists.

Thus a large portion of important policy evidence is either not published or scattered across


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multiple organizational websites which cannot be systematically searched in a timely

manner, therefore greatly limiting its benefit to inform future policies and practices. In this

context, the potential role of an international organization such as the WHO to facilitate the

more systematic documenting of best practices and sharing of other policy evidence across

countries could have tremendous benefits.

5. Research bias: The peer-reviewed evidence included in the review shows a repeatedly

identified bias towards rural HRH training and deployment research carried out in more

developed countries. This is not only an issue suggesting a lack of research being done

where it is needed most (i.e. countries with HRH crises), but also that the majority of the

studies being done for rural training and deployment are not generalizable to the less

developed world.

6. Innovation: The variety of policy interventions described in the documents reviewed

demonstrates the level of innovation being practiced by African countries in efforts to

improve their maternal and child health. Although some strategies focus on more traditional

professions such as doctors, nurses and midwives, there appears to be increasing attention to

and investment in newer cadres such as clinical officers and community health workers.

Furthermore, we were able to identify more evidence of the success of the latter type of

initiative in improving health outcomes than of the former.

7. Aligning services and competencies: The introduction of several new health care cadres

with important responsibilities warrants regular and systematic analysis of how the various

competencies of all health care providers align with the specific health care services required

by the populations in a given country. In this way, training and deployment policies can be

adjusted on an ongoing basis to keep pace with changing health needs and contexts.

8. Alignment of donor funds: Funds from donor agencies make up a large portion of the

health budgets of African countries, and there is evidence that these are put to numerous

beneficial uses. However, there is also evidence that these funds could be used much more

effectively if their application was more closely aligned with broader national health

priorities to fund evidence-informed interventions.

9. Management, monitoring and evaluation: Although shortages of resources in general are

a chronic and widespread problem, so too is a lack of capacity for effective management of

those resources, and to monitor and evaluate the impacts they have when mobilized.

Investment in building such capacity, such as through an international body like the WHO,

thus has the potential to pay great long-term dividends..


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Appendix 1: Appraisal tool for peer-reviewed literature


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Appendix 2: Evaluation templates for non-peer-reviewed literature

I. R

esea

rch

docu

men

ts

II. N

on

-res

earch

docu

men

ts


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II

I. P

oli

cies


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Appendix 3: Summary of peer-reviewed literature included in the review Citation Country of

focus

Type of

article

Provider of focus

(doctors, nurses,

midwives)

Policy focus

(training

and/or

deployment)

Medical schools in rural areas –

necessity or aberration

Longombe, A. O., 2009

Democratic

Republic of

the Congo

Policy

analysis

Medical students Training and

deployment

Community perspectives on roles and

responsibilities for strengthening

primary health care in rural Ethiopia

Curry et al., 2012

Ethiopia Policy

analysis

Implicitly all Deployment

Human resource development for

health Ethiopia: challenges of

achieving the millennium

development goals

Girma et al., 2007

Ethiopia Policy

description

and analysis

Implicitly all Training and

deployment

Health workforce deployment,

attrition and density in East Wollega

zone, Western Ethiopia

Michael et al , 2010

Ethiopia Retrospective

situational

analysis


Reviewing Ethiopia's health system

Wamai, R. G., 2009

Ethiopia Situational

description

and analysis


deployment

Return on Investment for Essential

obstetric care training in Ghana: do

trained public sector midwives

delivery PAC?

Andersen Clark et al., 2010

Ghana Secondary

analysis of

provider data

Doctors and

midwives

Training

Who will be there when women

deliver?

Anderson et al. , 2007

Ghana Specialist

training

program

evaluation

Medical residents Training

Shaping legal abortion provision in

Ghana: using policy theory to

understand provider-related obstacles

to policy implementation

Aniteye, P. & Mayhew, S., 2013

Ghana Policy

analysis

Obstetricians and

midwives

Training

Ghana postgraduate

obstetrics/gynecology collaborative

residency training program: success

story and model for Africa

Klufio et al., 2003

Ghana Specialist

training

program

evaluation

Medical residents Training

Policy talk: incentives for rural

service among nurses in Ghana

Kwansah et al., 2012

Ghana Nurses Deployment


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Perceived barriers and motivating

factors influencing student midwives’

acceptance of rural postings in Ghana

Lori et al., 2012

Ghana Policy

analysis

Midwives Deployment

Innovative community-based post-

graduate training for obstetrics and

gynecology in West Africa

Marley et al., 1995

Ghana Specialist

training

program

evaluation

Medical obstetric-

gynecology

residents

Training and

deployment

The impact of decentralisation on

sexual and reproductive health

services in Ghana

Mayhew, S. H., 2010

Ghana Policy

analysis


Accelerating reproductive and child

health program impact with

community-based services: the

Navrongo experiment in Ghana

Phillips et al., 2006

Ghana Policy

analysis

Nurses Deployment

Key factors leading to reduced

recruitment and retention of health

professionals in remote areas of

Ghana: a qualitative study and

proposed policy

solutions

Snow et al., 2011

Ghana Policy

analysis

Doctors Deployment

Do higher salaries lower physician

migration?

Okeke, N. E., 2013

Ghana Policy

analysis

Doctors Deployment

Human resources for maternal,

newborn and child health: from

measurement and planning to

performance for improved health

outcomes

Gupta et al., 2011

International

(68 countries)

Cross-country

review

Doctors, nurses,

and midwives

Training and

deployment

Compulsory service programs for

recruitment in remote and rural

areas: do they work?

Frehywot et al., 2010

International;

African

countries:

Ethiopia,

Ghana, Kenya,

Lesotho,

Malawi,

Mozambique,

Namibia,

Nigeria, South

Africa,

Zambia,

Zimbabwe

Policy review

and synthesis

Doctors, nurses,

and other healthcare

workers

Training and

deployment

Reproductive health policies and

programs in eight countries: progress

since Cairo

Hardee et al., 1999

International;

African

countries:

Ghana,

Senegal

Policy

revision and

implementatio

n analysis

Implicitly all


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Evaluated strategies to increase

attraction and retention of health

workers in remote and rural areas

Dolea et al., 2010

International;

African

countries:

South Africa,

Mali, Niger

Policy review

and analysis

Non-specific Deployment

Reduction of maternal and perinatal

mortality in rural and peri-urban

settings: what works?

Kwast, B. E., 1996

International;

African

country:

Nigeria

Policy

description

Midwives Training

The impact of an emergency hiring

plan on the shortage and distribution

of nurses in Kenya: the importance of

information systems

Gross et al., 2010

Kenya Policy

analysis

Nurses Deployment

The health worker recruitment and

deployment process in Kenya: an

emergency hiring program

Adano, U., 2008

Kenya Commentary Implicitly all Deployment

Tackling Malawi's human resources

crisis

Palmer, D., 2006

Malawi Policy

analysis


deployment

The impact of primary health care

services on under-five mortality in

rural Niger

Mgnani et al., 1996

Niger Policy

analysis


Impact of health systems

strengthening on coverage of maternal

health services in Rwanda, 2000-2010:

a systematic review

Bucagu et al., 2012

Rwanda Systematic

literature,

policy, and

DHS review


deployment

How to recruit and retain health

workers in underserved areas: the

Senegalese experience

Zurn et al., 2010

Senegal Policy

description

Doctors, nurses,

midwives and other

healthcare workers

Deployment

Analyzing the implementation of the

rural allowance in hospitals in North

West Province, South Africa

Ditlopo et al., 2011

South Africa Policy

analysis

Doctors, nurses,

and other healthcare

workers

Deployment

Provision of abortion services by

midwives in Limpopo province of

South Africa

Sibuyi, M. C., 2013

South Africa Policy

description

and analysis

Midwives Training and

deployment

Policy implementation and financial

incentives for nurses in South Africa:

a case study on the occupation-specific

dispensation

Ditlopo et al., 2012

South Africa Qualitative

case-study

Nurses Deployment

Achieving effective cervical screening

coverage in South Africa through

South Africa Case-study Nurses Training and

deployment


Page | 67

human resources and health systems

development

Kawonga, M. & Fonn, S., 2008

Cost-effectiveness analysis of human

resources policy interventions to

address the shortage of nurses in rural

South Africa

Lagarde et al., 2012

South Africa Policy

analysis

Nurses Deployment

Effectiveness of health sector reforms

in reducing disparities in utilization of

skilled birth attendants in Tanzania

Kengia et al., 2013

Tanzania Quantitative

cross-sectional

analysis


deployment

The neglects of the global surgical

workforce: experience and evidence

from Uganda

Ozgediz et al., 2008

Uganda Situational

and policy

analysis

Surgeons Training and

deployment

Improving facility-based care for sick

children in Uganda: training is not

enough

Pariyo et al., 2005

Uganda Policy and

program

analysis

Doctors, nurses,

midwives, and

other healthcare

workers

Training

Newborn survival in Uganda: a

decade of change and future

implications

Mbonye et al., 2012

Uganda Policy and

situational

analysis


deployment

Health worker satisfaction and

motivation: an empirical study of

incomes, allowances and working

conditions in Zambia

Gow et al., 2012

Zambia Policy

analysis

Doctors, nurses,

midwives, and

other healthcare

workers

Deployment

Health worker shortages in Zambia:

an assessment of government

responses

Gow et al., 2011

Zambia Policy

analysis


deployment


Page | 68

Appendix 4: List of additional literature reviewed by country

This appendix lists the various documents reviewed for each country that were not cited in the

report.

Ethiopia

Africa Health Workforce Observatory. (2010). Human resources for health country profile:

Ethiopia. Brazzaville, Republic of Congo. Available at: http://www. hrh-observatory.

afro. who. int/images/Document_Centre/Country_profile_Ethiopia. pdf

Anonymous. (2004). Background document for: The National Child Survival Conference. Addis

Ababa, Ethiopia.

Central Statistical Agency. (2011). Ethiopia demographic and health survey 2011. Addis Ababa,

Ethiopia. Available at: http://measuredhs. com/pubs/pdf/FR255/FR255. pdf

Ethiopia Federal Ministy of Health. (2005). National health information system road map 2005 –

2013. Addis Ababa, Ethiopia.

Ethiopia Federal Ministry of Health. (2010). Nursing care practice standards: A reference for

nurses and healthcare managers in Ethiopia. Addis Ababa, Ethiopia.

Ethiopia Federal Ministry of Health. (2010). Health sector development program IV 2010/11 –

2014/15 policy matrix. Addis Ababa, Ethiopia.

Ethiopia Federal Ministry of Health. (2011). National guideline for family planning services in

Ethiopia. Addis Ababa, Ethiopia.

Ethiopia Federal Ministry of Health. (2013). Special bulletin: 15th annual review meeting 2013.

Addis Ababa, Ethiopia. Available at: http://www. moh. gov.

et/English/Resources/Documents/ARM%20Special%20Bulletin(FINAL). pdf

Federal HIV/AIDS Prevention and Control Office. (2010). Strategic plan II for intensifying

multisectoral HIV and AIDS response in Ethiopia 2010/11 – 2014/15. Addis Ababa,

Ethiopia. Available at: http://www. ilo. org/wcmsp5/groups/public/---ed_protect/---

protrav/---ilo_aids/documents/legaldocument/wcms_175221. pdf

Global Health Workforce Alliance. (2008). Country case study: Ethiopia’s human resources for

health program. Geneva, Switzerland: Author. Available at: http://www. who.

int/workforcealliance/knowledge/case_studies/Ethiopia. pdf


Page | 69

Global Health Workforce Alliance. (2010). Scaling up universal access to HIV/AIDS

prevention, treatment, and care: Ethiopiarapid situational analysis. Geneva, Switzerland:

Elzinga, G. , Jerene, D. , Mesfin, G. & Nigussie, S. Available at: http://www. who.

int/workforcealliance/knowledge/publications/Ethiopia_report. pdf

Harmonization for Health in Africa. (2005). An honourable calling? Findings from the first wave

of a cohort study with final year nursing and medical students in Ethiopia. Washington,

DC: Serneels, P. , Lindelow, M. , Garcia-Montalvo, J. , & Barr, A. Available at:

http://www. hha-online. org/hso/hrh/knowledge/doc/321/honourable-calling-findings-

first-wave-cohort-study-final-year-nursing-and-med

Independent Review Team. (2008). Ethiopia health sector development program HSDP III

2005/06 – 2010/11 mid-term review. Addis Ababa, Ethiopia. Available at: http://www.

moh. gov. et/mobile/Resources/Main%20Report%20Final%2012[1]. 07. pdf

World Bank. (2005). For public service of money: Understanding geographical imbalances in

the health workforce. Washington, DC: Serneels, P. , Lindelow, M. , Garcia-Montalvo, J.

, & Barr, A. Available at: http://elibrary. worldbank. org/doi/book/10. 1596/1813-9450-

3686

Ghana

Ghana Ministry of Health. (2007). Integrated maternal and child health campaign 2007: A

golden jubilee gift to Ghana’s children. Accra, Ghana. Available at: http://www. moh-

ghana.

org/UploadFiles/Publications/Maternal%20and%20child%20health%20campaign120506

091815. pdf

Ghana Ministry of Health. (2008). High impact rapid delivery policy briefing paper. Accra,

Ghana. Available at: http://www. moh-ghana.

org/UploadFiles/Publications/HIRD120506090346. pdf

Ghana Ministry of Health. (2008). National consultative meeting on the reduction of maternal

mortality in Ghana: Partnership for action. Accra, Ghana. Available at: http://www.

moh-ghana. org/UploadFiles/Publications/Synthesis%20Report%20-

%20MDG5120427093223. pdf

Ghana Ministry of Health. (2008). Millennium development goal 5 background note: November

summit 2008. Accra, Ghana. Available at: http://www. moh-ghana.

org/UploadFiles/Publications/Background%20Note%20-%20MDG5120427092113. pdf

Ghana Ministry of Health. (2008). November summit 2008 background note: Unseen and

uncounted: neonatal mortality. Accra, Ghana. Available at: http://www. moh-ghana.

org/UploadFiles/Publications/Neonatal_Mortalety120427092556. pdf


Page | 70

Ghana Ministry of Health. (2012). Joint monitoring report 13-14th August, 2012. Accra, Ghana.

Available at: http://www. moh-ghana.

org/UploadFiles/Publications/policy%20brief%20on%20CHPS2130109060128. pdf

Ghana Ministry of Health. (2012). Brief on status of CHPS implementation. Accra, Ghana.

Available at: http://www. moh-ghana.

org/UploadFiles/Publications/policy%20brief%20on%20CHPS2130109060128. pdf

Global Health Workforce Alliance. (2008). Country case study Ghana: Implementing a national

human resources for health plan. Geneva, Switzerland: Author. Available at: http://www.

who. int/workforcealliance/knowledge/case_studies/CS_Ghana_web_en. pdf

Parkes, K. A. (2001). Ghana’s participation program, 1996 – 2000: Reproductive health

advocacy at district, subdistrict, and community levels in the Eastern Region. Accra,

Ghana. Available at: http://www. moh-ghana.

org/UploadFiles/Publications/Reproductive%20Health%20Advocacy%20@%20District,

Subdistrict%20and%20Community%20Level120506092402. pdf

Reproductive and Child Health Department. (2007). Reproductive health strategic plan 2007-

2011. Accra, Ghana. Available at: http://www. moh-ghana.

org/UploadFiles/Publications/GHS_Reproductive_Health_Strategic_Plan_FINAL_22AP

R2012. pdf

World Bank. (2011). Creating incentives to work in Ghana: Results from a qualitative health

worker survey. Washington, DC: Livens, T. Serneels, P, Garabino, S. , Quartey, P. ,

Appiah, E. , Herbst, C. H. , . . . Saleh, K. Available at: http://siteresources. worldbank.

org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-

1095698140167/CreatingIncentivestoWorkinGhana. pdf

Mali

International Finance Corporation. (2010). Etude sur le secteur privé de la santé au

Mali: Rapport (projet). [Project Report: Mali’s Private Health Sector]. Washington, DC:

World Bank.

L’Union technique de la mutualité. Statuts de l’union technique de la mutualité

(UTM). [Mutual Health Organization Network Laws]. Bamako, Mali.

Otchere, S. A. , & Kayo, A. (2007). The challenges of improving emergency obstetric

care in two rural districts in Mali. International Journal of Gynecology and

Obstetrics, 99, 2, 173-182.

République du Mali. (1992). La Constitution. [The Constitution]. Bamako, Mali.


Page | 71

République du Mali. (2009). Fixant les modalités d'application de la loi portant

institution du regime d'assistance medicale. [Laying down detailed rules for the

application of the law in instituting the medical assistance plan]. Bamako, Mali.

République du Mali Ministère de la Santé. (1995). Déclaration de politique

sectorielle de santé et de population. [Health and Population Sector Policy

Statement]. Bamako, Mali.

République du Mali Ministère de la Santé. (1998). Schema directeur du systeme

national d’information sanitaire et sociale. [Blueprint of the National Health and Social

Information System]. Bamako, Mali.

République du Mali Ministère de la Santé. (1998). Plan décennal de developpement

sanitaire et social 1998 -2007. [Decennial Health and Social Development Plan 1998 –

2007]. Bamako, Mali.

République du Mali Ministère de la Santé. (2004). Program de developpement

socio-sanitaire (PRODESS II) “Composante Santé”. [Socio-Health Development

Program 2005 – 2009 (PRODESS II) “Health Components”]. Bamako, Mali.

République du Mali Conseil des Ministres. (2006). Cadre Stratégique pour la

croissance et la réduction de la pauvreté 2007-2011. [Strategic Framework for

Development and the Reduction of Poverty, 2007-2011]. Bamako, Mali.

République du Mali Ministère de la Santé. (2006). Dépenses privées de santé 2003 –

2007. [Private Health Expenditures 2003 - 2007]. Bamako, Mali.

République du Mali Ministère de la Santé. (2006). Evolution des dépenses totales de

santé (en Milliards de FCFA) selon les sources de financement entre 1999 et

2004. [Evolution of Total Health Expenditures (in billions of CFA) by funding source

between 1999 and 2004]. Bamako, Mali.

République du Mali Ministère de la Santé. (2007). Annuaire statistique: 12 hôpitaux

au Mali. [Statistical Yearbook: 12 Hospitals in Mali]. Bamako, Mali.

République du Mali Ministère de la Santé. (2007). Convention d'assistance mutuelle

entre la commune et l'association de santé communautaire. Mutual Assistance

Agreement between the Village and the Community Health Association. Bamako, Mali.

République du Mali Ministère de la Santé. (2007). Organigramme du Ministère de

la santé. [Organization of the Department of Health]. Bamako, Mali.

République du Mali Ministère de la Santé. (2008). Carte sanitaire du Mali: Version

1, TOME II, équipments sanitaires – personnels et établissements privés, année 2007 –

2008. [Mali Health Card: Version 1, VOLUME II, Sanitary Equipment – Personnel and

Private Establishments, Year 2007 – 2008]. Bamako, Mali.


Page | 72

République du Mali Ministère de la Santé. (2008). Dépenses publiques de santé

dans le cadre des dépenses nationales (2002-2008). [Public Health Expenditures related

to National Expenditures (2002 – 2008)]. Bamako, Mali.

République du Mali Ministère de la Santé. (2008). Développement des ressources

humaines pour la santé: Plan de motivation 2009 – 2015. [Health Human Resources

Development: Incentive Plan, 2009 – 2015]. Bamako, Mali.

République du Mali Ministère de la Santé. (2009). Accroître les efforts et les

ressources pour la Santé en vue de l’atteinte des OMD. [Increased Efforts and Health

Resources to Achieve the MDGs]. Bamako, Mali.

République du Mali Ministère de la Santé. (2009). Cadre de dépenses a moyen terme

2009-2011. [Midterm Expenditures Framework 2009 - 2011]. Bamako, Mali.

République du Mali Ministère de la Santé. (2009). Dépenses publiques de santé

selon les niveaux de la pyramide sanitaire (2006-2009) (en milliards de FCFA). [Public

Health Expenditures by Health Pyramid Levels (2006 – 2009) (in billions of CFA)].

Bamako, Mali.

République du Mali Ministère de la Santé. (2009). Développement des ressources humaines pour

la santé: Plan strategique national. [Health human resources development plan :

National strategic plan]. Bamako, Mali.

République du Mali Ministère de la Santé. (2009). Développement des ressources humaines pour

la santé: Plan de recrutement. [Health human resources development plan : Recruitment

plan]. Bamako, Mali. Available at : http://www. who.

int/workforcealliance/countries/Mali_HRHPlan_2009. pdf

République du Mali Ministère de la Santé. (2009). Développement des ressources

humaines pour la santé: politique nationale. [Health Human Resources

Development Plan: National Policy]. Bamako, Mali.

République du Mali Ministère de la Santé. (2009). Plan stratégique nationale de la

santé des adolescents et des jeunes 2009 – 2013. [National Strategic Health Plan for

Youth and Adolescents 2009 - 2013]. Bamako, Mali.

République du Mali Ministère de la Santé. (2009). PRODESS II Prolongé 2009

2011: Composante santé. [Extended PRODESS II 2009 - 2011: Health Component].

Bamako, Mali.

République du Mali Ministère de la Santé. (2009). Standards de services de santé

adaptés aux adolescents et aux jeunes (SSAAJ) du Mali. [Health Service Standards

Adapted for Mali’s Youth and Adolescents (SSAAJ)]. Bamako, Mali.


Page | 73

République du Mali Ministère de la Santé. (2011). Dépenses publiques relativement

aux programs du PRODESS (2005-2011). [Public Expenditure for PRODESS Programs

(2005 – 2011)]. Bamako, Mali.

République du Mali Ministère de la Santé. (2013). Plan stratégique de la santé de la

reproduction 2014-2018. [Strategic plan for reproductive health 2014 – 2018]. Bamako,

Mali.

Université de Bamako Groupe de Recherche en Economie Appliquée et Théorique.

(2003). Le marché du travail au Mali. [Mali’s Labour Market]. Bamako, Mali: Author.

Van Dormael, M. , Dugas, S. , Kone, Y. , Coulibaly, S. , Sy, M. , Marchal, B. , &

Desplats, D. (2008). Appropriate training and retention of community doctors in rural

areas: a case study from Mali. Human Resources for Health, 6:25.

World Health Organization (2013). Country Health Policy Process, by the Countries, for the

Countries: Mali – Situation analysis. Geneva, Switzerland: Author.

Mozambique

Department for International Development. (2008). Mozambique: Taking forward action on

human resources for health (HRH) with DFID/OGAC and other partners. UK, London:

Campbell, J. & Stilweel, B. (A joint publication of DFID, OGAC, PEPFAR, USAID, the

Capacity Project, Integrare. ). Available at: http://blogs. dfid. gov. uk/wp-

content/uploads/2008/11/moz-taking-forward-action-on-hrh-finalreport-30may08. pdf

Instituto de Higiene e Medicina Tropical. (2008). Recursos humanos da saúde em Moçambique:

Ponto de situação. [Human resources for health in Mozambique: Situational analysis].

Lisboa, Portugal.

Liverpool Associates in Tropical Health. (2008). Estimativa de custos do plano nacional de

desenvolvimento dos recursos humanos da saúde de Moçambique. [Cost estimates of the

National Development plan for human resources for health of Mozambique]. Liverpool,

UK: Tyrrell, A.

República de Moçambique: Ministério da Saúde. (2006). Estudo sobre incentivos no Ministério

da Saúde. [Study of incentives in the Ministry of Health]. Maputo, Mozambique.

República de Moçambique: Ministério da Saúde. (2008). Relatorio dos grupos focais dirigidos a

profissionais de saude utentes, nas provincias de Niassa, Nampula, Maputo provincial e

Maputo cidade. [Report on focus group for health professionals and users, in Niassa,

Nampula Maputo Province and Maputo city]. Maputo, Mozambique.

Sidat, M & Conceição, C. (2008). Caracterização dos gestores de recursos humanos do sector de

saúde em Moçambique. [Characterization of managers of human resources of the health

sector in Mozambique].


Page | 74

República de Moçambique: Ministério da Saúde. (2008). Addressing the health workforce crisis

in Mozambique: A call for support. Maputo, Mozambique. Available at: http://blogs.

dfid. gov. uk/wp-content/uploads/2008/11/mozambique-flyer. pdf

United States Agency for International Development. (2004). Human capacity development

(HCD) assessment and strategy development for the health sector in Mozambique.

Washington, DC: Decima, E. , Dreesch, N. , & Kiarie, W. Available at: http://pdf. usaid.

gov/pdf_docs/pnade188. pdf

World Bank. (2004). Primary health care in Mozambique: Service delivery in a complex

hierarchy. Washington, DC: Lindelow, M. , Ward, P. , & Zorzi, N. Available

at:http://siteresources. worldbank. org/AFRICAEXT/Resources/ww11888final201. pdf.

pdf

World Bank. (2005). Recursos humanos da saúde em Moçambique: Ponto de situação. [Human

resources for health in Mozambique: Situational analysis]. Washington, DC: Ferrinho, P.

& Omar, C. Available at: http://www-wds. worldbank.

org/servlet/WDSContentServer/IW3P/IB/2007/02/21/000310607_20070221160442/Rend

ered/PDF/386960PORTUGUE1urces0no19101PUBLIC1. pdf

Niger

All documents reviewed were included and referenced in the final report

Tanzania

Chr. Michelson Institute. (2006). Human resources for health in Tanzania: Challenges, policy

options and knowledge gaps. Bergen, Norway: Maestad, O. Available at: http://www.

cmi. no/publications/publication/?2175=human-resources-for-health-in-tanzania-

challenges

Ifakara Health Institute. (2009). Implementation of integrated management of childhood illness

in Tanzania: Success and challenges. Dar es Salaam, Tanzania: Prosper, H. , Macha, J. ,

& Borghi, J. Available at: http://www. crehs. lshtm. ac.

uk/downloads/publications/Implementation_of_IMCI_in_Tanzania. pdf

Kombo, D. , Mutema, Mwakilasa, Pemba, & Petis-Mshana. (2003). Report on human resources:

Tanzania joint health sector review. Available at: http://www. sti.

ch/fileadmin/user_upload/Pdfs/swap/swap299. pdf

National Institute for Medical Research. (2008). Non-financial incentives and the retention of

health workers in Tanzania. Dar es Salaam, Tanzania: Munga, M. A. & Mbiliny, D. R. (a

joint publication with EQUINET, University of Namibia, University of Limpopo, and

ECSA-HC). Available at: http://www. equinetafrica. org/bibl/docs/DIS61HRmunga. pdf


Page | 75

Touch Foundation. (2006). Investing in Tanzanian Human Resources for Health. New York,

NY: Lowell, B. , Garg, R. , Ramji, S. , Silverman, A. , Tagar, E. , & Ware, I. Available

at: http://www. touchfoundation.

org/uploads/assets/documents/mckinsey_report_july_2006_5nYbVVVS. pdf

United Republic of Tanzania National Audit Office. (2008). A performance audit report on the

management of primary health care: A case study of health centers. Dar es Salaam,

Tanzania. Available at: http://www. tanzania. go. tz/egov_uploads/documents/888_sw.

pdf

United Republic of Tanzania Ministry of Health. (1990). National health policy. Dar es Salaam,

Tanzania. Available at: http://www. tzonline. org/pdf/Nationahealthpolicy. pdf

White Ribbon Alliance for Safe Motherhood in Tanzania. (2006). Is it worth it for Tanzania to

invest in community midwives: Debate forum report. Dar es Salaam, Tanzania: Mlay, R.

Available at: http://www. mobilityandhealth.

org/ed/uploads/WRATZ%20DebateForumCommunityMidwivesTanzaniaReportnopictur

es. pdf

Uganda

Africa Health Workforce Observatory. (2009). Human resources for health country profile:

Ethiopia. Brazzaville, Republic of Congo. Available at: http://www. hrh-observatory.

afro. who. int/images/Document_Centre/uganda_country_profile. pdf?ua=1

African Centre for Global Health and Social Transformation. (2012). Mapping health resource

partner institutions (HRPI): Modeling a sustained approach for strengthening health

governance and stewardship in low-income countries. Kampala, Uganda: Omaswa, F. ,

Eriki, P. , Kadama, P. , Okounzi, S. , Odongo, M. P. , Mukwaya, S. , & Crawford, L.

Bancroft, E. (n. d. ). Uganda health workforce retention study manual. Seattle, WA: Washington

University. (a joint publication with Republic of Uganda Ministry of Health, HRSA, the

Capacity Project, USAID, Makerere University, and Aga Khan University). Available at:

http://courses. washington. edu/thesis/Manual%202/OPEN_FIRST_Study_Manual. pdf

Department for International Development. (2004). Case study 6: Review of health service

delivery in Uganda – general country experience and Northern Uganda. London, UK:

Carlson, C. Available at: http://www. gsdrc. org/docs/open/CC97. pdf

Partnerships for Health Reform. (1999). Priority service provision under decentralization: A

case study of maternal and child health care in Uganda. Bethesda, MD: Mswesigye, F.

Available at: http://www. eldis. org/go/home&id=17733&type=Document


Page | 76

Regional East African Health (REACH) Policy Initiative. (2011). An evidence brief for policy:

Improving access to skilled attendance at delivery. Kampala, Uganda: Nabudere, H. ,

Asiimwe, D. , & Amandua, J. (a joint publication with UNHRO, Makerere University,

SURE, and EVIPNet). Available at: http://www. who.

int/evidence/resources/country_reports/SBAFR11082011. pdf

The Republic of Uganda Ministry of Health. (2009). National health policy: Reducing poverty

through promoting people’s health (draft). Kampala, Uganda. Available at: http://www.

health. go. ug/National_Health. pdf

The Republic of Uganda Ministry of Health (2010). Health sector strategic plan III 2010/11 –

2014/15. Kampala, Uganda. Available at: http://www. health. go.

ug/docs/HSSP_III_2010. pdf

The Republic of Uganda Ministry of Health. (2012). Uganda health system assessment 2011.

Kampala, Uganda. (a joint publication with USAID). Available at: http://health. go.

ug/docs/hsa. pdf

Uganda National Health Research Organisation. (2008). Priority health policy and system

challenges (2008 – 2010). Kampala, Uganda (a joint publication with REACH).

World Bank. (2005). Improving health outcomes for the poor in Uganda. Washington, DC:

Author. Available at: http://documents. worldbank.

org/curated/en/2004/06/5504857/uganda-improving-health-outcomes-poor-uganda-

current-status-implications-health-sector-development

Zambia

Berman, P. , Nwuke, K. , Rannan-Eliya, R. & Mwanza, A. (1995). Zambia: Non-governmental

health care provision. Available at: http://www. hsph. harvard.

edu/ihsg/publications/pdf/No-19. PDF

Centre for Health, Science & Social Research. (2008). Planning and budgeting for primary

health care in Zambia: A policy analysis. Lusaka, Zambia: Ngulube, T. J. , Mdhluli, L. Q.

, & Gondwe, K. (a joint publication with EQUINET). Available at: http://equinetafrica.

org/bibl/docs/DIS29ngulube. pdf

Centre for Health, Science & Social Research. (2008). Human resources for the delivery of

health services in Zambia: External influences and domestic policies and practice.

Lusaka, Zambia: Goma, F. M. Available at: http://www. wemos.

nl/files/Documenten%20Informatief/Bestanden%20voor%20HRH/case_study_report_za

mbia. pdf


Page | 77

Department for International Development. (2000). Zambia country health briefing paper.

London, UK: Lake, S.

United States Agency for International Development. (2005). Human resources crisis in the

Zambian health system: A call for urgent action. Washington, DC: Kombe, G. , Galaty,

D. , Mtonga, V. , & Banda, P. Available at: http://www. eldis.

org/go/home&id=21272&type=Document#. UwYCR0JdXwg

World Health Organization. (1994). Experiences with primary health care in Zambia. Geneva,

Switzerland: Kasonde, J. M. & Martin, J. D. Available at: http://whqlibdoc. who.

int/pha/WHO_PHA_2. pdf

Zambia Ministry of Health. (2008). Health sector performance monitoring framework 2009 –

2010. Lusaka, Zambia.

Zambia Ministry of Health. (2008). First actuarial assessment report on the establishment of a

social health insurance scheme in Zambia. Lusaka, Zambia.

Zambia Ministry of Health. (2008). Health institutions in Zambia (Draft). Lusaka, Zambia

Multi-nation including one or more countries from designated sub-set

African Medical and Research Foundation. (2007). People first: African solutions to the health

worker crisis. Nairobi, Kenya: Hall, S. Available at: http://www. eldis.

org/go/home&id=32809&type=Document#. UwYC00JdXwg

Capacity Project. (2006). Retention of health care workers in low-resource settings: Challenges

and responses. Chapel Hill, NC: Yumkella, F. Available at:http://www. capacityproject.

org/images/stories/files/techbrief_1. pdf

Capacity Project. (2009). Worker retention in human resources for health: Catalyzing and

tracking change. Chapel Hill, NC: Yumkella, F. Available at: http://www. intrahealth.

org/files/media/worker-retention-in-human-resources-for-health-catalyzing-and-tracking-

change/techbrief_15. pdf

Bill and Melinda Gates Foundation. (2010). The Sub-Saharan African medical school study.

Seattle, WA: Author. Available at: http://samss. org/samss. upload/documents/126. pdf

Department for International Development. (2004). Human resource studies in health for poor

and transitional countries. London, UK: Hongoro, C. , McPake, B. , Ssengooba, F. &

Oliveira-Cruz, V. Available at: http://r4d. dfid. gov.

uk/PDF/Outputs/HealthSysDev_KP/06-04_human_resource_studies. pdf


Page | 78

International Council of Nurses. (2008). Guidelines: Incentives for health professionals. Geneva,

Switzerland: Author. Available at: http://www. who.

int/workforcealliance/documents/Incentives_Guidelines%20EN. pdf

Ntiro, S. , Mrema, J. , Ballantyne, P. , Koot, J. , & Pakenham-Walsh, N. (2003). Information and

communication technologies and continuing education in East and Southern Africa.

Report of a conference held in Moshi, Tanzania 8-10 April 2003. Available at:

http://www. iicd. org/files/report17. pdf

ReBuild Consortium. (n. d. ). Understanding deployment policies and systems for staffing rural

areas. Project 4 – Rural posting. London, UK: Martineau, T. , Rutebemberwa, E. ,

Mangwi, R. , Chirwe, Y. , & Raven, J. Available at: http://www. rebuildconsortium.

com/news/documents/Annexe1d-ResearchSummaryProject4. pdf

Regional Network for Equity in Health in Southern Africa. (2003). Health personnel in Southern

Africa: Confronting maldistribution and brain drain. Harare, Zimbabwe: Padarath, A. ,

Chamberlain, C. McCoy, D. , Ntuli, A. , Rowson, M. , & Loewenson, R. (A joint

publication of EQUINET, Health Systems Trust, Medact, IDRC). Available at:

http://www. queensu. ca/samp/migrationresources/braindrain/documents/equinet. pdf

Regional Network for Equity in Health in Southern Africa. (2007). A review of non-financial

incentives for health worker retention in East and Southern Africa. Harare, Zimbabwe:

Dambisya, Y. M. Available at: http://www. equinetafrica.

org/bibl/docs/DIS44HRdambisya. pdf

United Nations Population Fund. (2011). The state of the world’s midwifery 2011. Geneva,

Switzerland: Author. Available at: http://www. unfpa.

org/sowmy/resources/docs/main_report/en_SOWMR_Full. pdf

United States Agency for International Development. (2003). The health sector human resource

crisis in Africa. Washington, DC: Author. Available at: http://pdf. usaid.

gov/pdf_docs/PNACS527. pdf

World Bank. (2003). Increasing clients' power to scale up health services for the poor: the

Bamako Initiative in West Africa. Background paper to the World Development Report.

Washington, DC: Knippenberg, R. , Nafo, F. T. , Osseni, R. , Camara, Y. B. , & El

Abassi, A. Available at: http://www-wds. worldbank.

org/external/default/WDSContentServer/WDSP/IB/2003/10/24/000160016_2003102411

4304/Rendered/PDF/269540Bamako0Increasing0clients0power. pdf

World Health Organization. (2005). Rehabilitating the workforce: the key to scaling up MNCH.

Geneva, Switzerland: Author. Available at: http://www. who. int/hdp/publications/10c.

pdf


Page | 79

World Health Organization. (2006). Improving health services and strengthening health systems:

Adopting and implementing innovative strategies. Geneva, Switzerland: Janovsky, K. ,

Peters, D. , Arur, A. , & Sundaram, S. Available at: http://apps. who.

int/iris/handle/10665/69243

World Health Organization. (2006). Working together for health: The world health report 2006.

Geneva, Switzerland: Author. Available at: http://www. who. int/whr/2006/en/

World Health Organization. (2007). Managing the health Millennium Development Goals – the

challenge of management strengthening: Lessons from three countries. Geneva,

Switzerland: Egger, D. & Ollier, E. Available at: http://www. eldis.

org/go/home&id=35046&type=Document#. UwYEiEJdXwg

World Health Organization. (2007). Counting health workers: Definitions, data, methods and

global results. Geneva, Switzerland: Dal Poz, M. R. , Kinfu, Y. , Drager, S. , &

Kunjumen, T. Available at: http://www. who.int/hrh/documents/

counting_health_workers. pdf

World Health Organization. (2009). Global standards for the initial education of professional

nurses and midwives. Geneva, Switzerland: Author. Available at: http://www. who.

int/hrh/nursing_midwifery/hrh_global_standards_education. pdf

World Health Organization. (2010). Increasing access to health workers in remote and rural

areas through improved retention: Global policy recommendations. Geneva,

Switzerland: Author. Available at: http://whqlibdoc. who.

int/publications/2010/9789241564014_eng. pdf


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Appendix 5: Advisory Group Terms of Reference

TRAINING AND DEPLOYMENT OF HUMAN RESOURCES FOR HEALTH IN

RURAL AFRICA: A SYSTEMATIC REVIEW

ADVISORY GROUP TERMS OF REFERENCE

BACKGROUND: An effective health care system is essential to maintaining and promoting the

health of any country’s population. Critical to that system’s effectiveness are the human

resources for health (HRH) which form its core. While there are a number of different

dimensions to how a country’s HRH are planned and managed, perhaps the most critical are how

HRH are developed and trained, and how they are deployed once ready for practice. Although

HRH planning in general is a challenge in many countries, these two aspects appear particularly

difficult to manage effectively. Perhaps nowhere is this challenge greater than in rural Africa,

with its combination of severe health problems and severe shortages of resources to address

them.

Every country has its own policies and other approaches to planning for the training and

deployment of its HRH, which require regular updating to adapt to new challenges and changing

contexts. However, government efforts to improve and update their respective approaches are

often made in isolation, with little opportunity to learn from the experiences of their counterparts

in other countries who may face similar challenges. While information on different countries’

policies and experiences exists, gathering and reviewing all that information is beyond the time

and resource constraints of many policy makers. The purpose of this project is therefore to

conduct a systematic review of the available grey and peer-reviewed literature on the training

and deployment of HRH for rural Africa.

Achieving progress on the Millennium Development Goals 4 and 5 (Maternal and child health) is

a priority area for many countries in Africa. We will therefore focus on HRH training and

deployment policies related to maternal and child health. Further, although all types of HRH can

potentially impact the achievement of MDGs and health outcomes in general, our search will

focus on doctors, nurses, and midwives and because of their especially critical roles related to

MDGs 4 and 5.

EXPECTED OUTPUT OF THE PROJECT:

Improved understanding of effective policies to support the training and deployment of nurses,

doctors and midwives involved in maternal-child care

PURPOSE OF THE ADVISORY GROUP:

The purpose of the AG will be to ensure that the review is as comprehensive as possible, and that

the appropriate stakeholders are engaged in the development and dissemination of its findings.

Specifically, the AG will a) guide the systematic review of policies related to the deployment and

training of nurses, doctors and midwives in maternal-child care in Africa; b) identify and

facilitate the engagement of key stakeholders in the review process; and c) provide advice and

facilitation related to the dissemination of the synthesis findings.


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MAIN ACTIVITIES:

Provide advice and leadership for the systematic review project including:

Provide feedback on the review process including the search strategy, inclusion criteria,

and framework(s) used for policy analysis;

Identify and facilitate the engagement of additional key stakeholders in the review

process to ensure all relevant policies and related documents are included;

Review the draft final synthesis report and provide feedback; and

Assist in the dissemination of the report and its findings.

MEMBERSHIP

The AG shall consist of the following representatives from various countries and organizations:

Dr. Maina Boucar, Regional Director West Africa Region, USAID ASSIST Project,

University Research Co. LLC, Niger

Dr. Paulo Ferrinho, Director, Instituto de Higiene e Medicina Tropical Universidade

Nova de Lisboa, Portugal

Ms. Allison Annette Foster, Senior Advisor for Quality Improvement, and Lead, Health

Workforce Development, University Research Co. LLC, USA

Mr. Solomon Kagulura, HRH Advisor, World Health Organization, Zambia

Dr. Vic Neufeld, Director, Canadian Coalition for Global Health Research, Canada

Mrs. Jennifer Nyoni, HRH Advisor, WHO Regional Office for Africa, Republic of

Congo

Dr. Francis Omaswa, Executive Director, African Centre for Global Health and Social

Transformation, Uganda

Dr. Judith Shamian, President, International Council of Nurses, Switzerland

Dr. Mohsin Sidat, Dean, Faculty of Medicine, University Eduardo Mondlane,

Mozambique

Ex-Officio:

Dr. Fastone Goma,School of Medicine, University of Zambia

Dr. Gail Tomblin Murphy, WHO/PAHO Collaborating Centre on Health Workforce

Planning and Research, Dalhousie University

GOVERNANCE

• The Advisory Group is an independent entity involved in the oversight of the synthesis project.

• Co-facilitation (Drs. Goma and Tomblin Murphy)

MEETING PROCEDURES

Meetings will be held regularly on a monthly basis between October 2013 and December

2013 via teleconference or Elluminate to complete the report

Additional meetings may be scheduled early in 2014 to finalize the dissemination plan and

the timing will be negotiated with group members

Agendas will be set according to the terms of reference, input from members and issues

arising. Final approval of agendas will be by the Co-Chairs.

Meetings will be conducted by the Co-Chairs, or in his/her absence, by a member designated

by the Co-Chairs.


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Proceedings of meetings will be recorded and distributed to members by email as soon as

possible after the meeting occurs.

TERM

October 2013 to March 2014


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Appendix 6: List of websites searched in scoping for country sub-set

Organization URL

African Centre for Global Health and

Social Transformation www.achest.org

African Health Workforce Observatory www.hrh-observatory.afro.who.int

Bill and Melinda Gates Foundation www.gatesfoundation.org

Education Resources Information Center www.ed.gov

Eldis www.eldis.org

Global Health Workforce Alliance www.who.int/workforcealliance/en

Health Policy Monitor www.hpm.org

Health Professionals for a New Century www.healthprofessionals21.org

HRH Global Resource Centre www.hrhresourcecenter.org

IDRC Development Research Information

Service www.idris.idrc.ca

International Confederation of Midwives www.internationalmidwives.org

International Council of Nurses www.icn.ch

International Federation of Gynecology

and Obstetrics www.figo.org

Medicus Mundi www.medicusmundi.org

Regional East African Community Health

Policy Initiative www.hha-online.org/hso

SUPPORT www.support-collaboration.org

THET Partnership for Global Health www.thet.org

WHO Collaborating Centre for Evidence-

Informed Policy (McMaster University)

www.mcmasterhealthforum.org/

healthsystemsevidence-en

WHO Collaborating Centre UWC www.hrhrforafrica.org.za

WHO Regional Office for Africa www.afro.who.int

World Bank www.worldbank.org/eh/topic/

health/brief/human-resources-health


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Appendix 7: Sources of country-specific statistics

All statistics used in Table 4 came from the profiles of each country produced by WHO, located

at http://www. who. int/gho/countries, with the following exceptions:

Ethiopia

- Density of midwives: African Health Workforce Observatory, 2010a.

Ghana

- HRH density: African Health Workforce Observatory, 2010b.

- Proportion of HRH posts filled: Ghana Ministry of Health, 2007b.

Mali

- HRH density: République du Mali Ministère de la Santé, 2012.

Mozambique

- HRH density by profession: Ferrinho & Omar, 2006.

- Expenditure on health as a proportion of GDP: WHO Global Health Observatory Data

Repository at http://apps.who.int/gho/data.

Niger

- HRH absorption by the public sector: République du Niger: Ministère de la Santé

Publique. (2010b).

Tanzania

- Percentage of doctors and nurses in rural areas: Touch Foundation, 2006.

- Percentage of midwives in rural areas: WHO Global Health Observatory Data

Repository.

- Proportion of HRH posts filled, HRH absorption by the public sector: United Republic of

Tanzania MoHSW, 2008.

Uganda

- Percentage of HRH in rural areas: Uganda Ministry of Health, 2010a.

- Percentage of HRH posts filled: Uganda Ministry of Health, 2013.

- Annual training output: Uganda Ministry of Health, 2010c.

Zambia

- HRH density: AFRO country profile for Zambia at

http://www.afro.who.int/en/zambia/country-health-profile.html.

- Percentage of HRH in rural areas: Data were only available at the provincial level; for

this calculation, Lusaka and Copperbelt provinces were considered urban and the rest

rural (Zambia Ministry of Health, 2005).

http://www.who.int/gho/countries

http://apps.who.int/gho/data

http://www.afro.who.int/en/zambia/country-health-profile.html


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- Percentage of HRH posts filled: Zambia Ministry of Health, 2013.

- Annual HRH training output& HRH absorption by the public sector: Zambia Ministry of

Health, 2010.


Page | 86

References

Abuya, T., Amin, A. Molyneux, S., Akhwale, W., March, V. & Gilson, V. (2010). Importance of

strategic management in the implementation of private medicine retailer programs: case

studies from three districts in Kenya. BMC Health Services Research, 10 (Suppl), 1-11.

Adam, T., Ahmad, S., Bigdeli, M., Ghaffar, A., Rottingen, J. (2011). Trends in Health Policy and

Systems Research over the Past Decade: Still Too Little Capacity in Low-Income

Countries. PLoS ONE 6(11): e27263. doi:10. 1371/journal. pone. 0027263.

Adano, U. (2008). The health worker recruitment and deployment process in Kenya: An

emergency hiring program. Human Resources for Health, 6, 19. doi:10. 1186/1478-4491-

6-19.

African Health Workforce Observatory. (2010a). Human Resources for Health Country Profile:

Ethiopia. Available at:

http://www.unfpa.org/sowmy/resources/docs/library/R045_AHWO_2010_Ethiopia_HRH

Profile.pdf.

African Health Workforce Observatory. (2010b). Human Resources for Health Country Profile:

Ghana. Available at: http://www.hrh-

observatory.afro.who.int/images/document_Centre/ghana_hrh_country_profile_2010. pdf

Ageyi-Baffour, P., Rominski, S., Nakua, E., Gyakobo, M., & Lori, J. R. (2013). Factors that

influence midwifery students in Ghana when deciding where to practice: A discrete

choice experiment. BMC Medical Education, 13(64), doi:10. 1186/1472-6920-13-64.

Anderson, F. W., Mutchnick, I., Kwawukume, E. Y., Danso, K. A., Klufio, C. A., Clinton, Y., . .

. Johnson, T. R. (2007). Who will be there when women deliver? Assuring retention of

obstetric providers. Obstetrics and Gynecology, 110(5), 1012-1016. doi:10. 1097/01.

AOG. 0000287064. 63051. 1c.

Andersen Clark, K. A., Mitchell, E. H., &Aboagye, P. K. (2010). Return on investment for

essential obstetric care training in Ghana: Do trained public sector midwives deliver post-

abortion care? Journal of Midwifery & Women's Health, 55(2), 153-161. doi:10. 1016/j.

jmwh. 2009. 12. 012.

Aniteye, P., & Mayhew, S. H. (2013). Shaping legal abortion provision in Ghana: using policy

theory to understand provider-related obstacles to policy implementation. Health

Research Policy and Systems, 11(23), doi:10. 1186/1478-4505-11-23.

http://www.unfpa.org/sowmy/resources/docs/library/R045_AHWO_2010_Ethiopia_HRHProfile.pdf

http://www.unfpa.org/sowmy/resources/docs/library/R045_AHWO_2010_Ethiopia_HRHProfile.pdf

http://www.hrh-observatory.afro.who.int/images/

http://www.hrh-observatory.afro.who.int/images/


Page | 87

Antwi, J., Ekey, V. Herbst, C. & Haddad, D. (2013). The Stock of Health Workers. In E.

Appiah-Denkyira, C. Herbst, A. Soucat, C. Lemiere& K. Saleh (Eds. ). Towards

Interventions in Human Resources for Health in Ghana: Evidence for Health Workforce

Planning and Results (23-48). Washington, DC: World Bank.

Appiah-Denkyira, E., Micah, A. & Haddad, D. (2013). Ghana’s Agencies and Their Roles

and Responsibilities in HRH, 93-109. In E. Appiah-Denkyira, C. Herbst, A. Soucat, C.

Lemiere& K. Saleh (Eds. ). Towards Interventions in Human Resources for Health in

Ghana: Evidence for Health Workforce Planning and Results (93-109). Washington,

DC: World Bank.

Avocksouma, D. A. (2013). Health Workforce Situation in the African Region. Presentation at

the Fourth Regional Consultation on Health Workforce, Brazzaville, Congo, December

2013.

Beciu, H., Preker, A., Ayettey, S., Lawson, A. &Antwi, J. (2013). Capacity of Health-Training

Institutions. In E. Appiah-Denkyira, C. Herbst, A. Soucat, C. Lemiere& K. Saleh (Eds. ).

Towards Interventions in Human Resources for Health in Ghana: Evidence for Health

Workforce Planning and Results (167-169). Washington, DC: World Bank.

Bhutta, Z. A., Lassi, Z. S., Pariyo, G., Huicho, L. (2010). Global Experience of Community

Health Workers for Delivery of Health Related Millennium Development Goals: A

Systematic Review, Country Case Studies, and Recommendations for Integration into

National Health Systems. Geneva: Global Health Workforce Alliance. Available at

http://www.who.int/workforcealliance/knowledge/resources/chwreport/en/.

Blaauw, D., Erasmus, E., Pagaiya, N., Tangcharoensathein, V., Mullei, K., Mudhune, S., . . .

Lagarde, M. (2010). Policy interventions that attract nurses to rural areas: A multicountry

discrete choice experiment. World Health Organization. Bulletin of the World Health

Organization, 88(5), 350-356.

Briceno-Garmendia, C. M., Dominguez, C., Pushak, N. (2011). Mali's infrastructure : a

continental perspective. Washington: The World Bank.

Bucagu, M., Kagubare, J. M., Basinga, P., Ngabo, F., Timmons, B. K., & Lee, A. C. (2012).

Impact of health systems strengthening on coverage of maternal health services in

Rwanda, 2000-2010: A systematic review. Reproductive Health Matters, 20(39),

Available at: http://www.jstor.org/stable/41714699

Buse, K., Mays, N. & Walt, G. (2005). Making Health Policy. Milton Keynes, UK: Open

University Press.

http://www.who.int/workforcealliance/knowledge/resources/chwreport/en/

http://www.jstor.org/stable/41714699


Page | 88

Buse, K., Mays, N. & Walt, G. (2012). Making Health Policy, 2nd Edition. Milton Keynes, UK:

Open University Press.

Bwalya, B., Jere, E., Johnson, D., Hass, S. (2013). An Evaluation Report of the Zambia Health

Workers Retention Scheme of the Ministry of Health. Zambia Integrated Systems

Strengthening Program (ZISSP), Abt Associates Inc. Bethesda, MD.

Campbell, J. & Settle, D. (2009). Ethiopia: Taking forward action on Human Resources for

Health (HRH) with DFID/OGAC and other partners. Barcelona: ICS Integrare. Available

at:

http://www.who.int/workforcealliance/knowledge/publications/partner/tfa_ethiopia.pdf.

CIHR (2012). Guide to Knowledge Translation Planning at CIHR: Integrated and End-of-Grant

Approaches. Available at: http://www.cihr-irsc.gc.ca/e/documents/kt_lm_ktplan-en.pdf

Couttolenc, B. (2012). Decentralization and Governance in the Ghana Health Sector.

Washington: The World Bank. Available at: https://openknowledge. worldbank.

org/handle/10986/9376

COWI, Goss Gilroy Inc., and EPOS Health Consultants (2007). Joint External Evaluation of the

Health Sector in Tanzania: 1999-2006. Dar es salaam, Tanzania: EPOS Health

Consultants. Available at:

http://www.bmz.de/en/publications/type_of_publication/evaluation/international_joint_ev

aluations/Tansania_Health_SectorReport_07.pdf.

Curry, L. A., Alpern, R., Webster, T. R., Byam, P., Zerihun, A., Tarakeshwar, N., . . . Bradley, E.

H. (2012). Community perspectives on roles and responsibilities for strengthening

primary health care in rural Ethiopia. Global Public Health, 7(9), 961-973.

Ditlopo, P., Blaauw, D., Bidwell, P., & Thomas, S. (2011). Analyzing the implementation of the

rural allowance in hospitals in North West Province, South Africa. Journal of Public

Health Policy, 32(SUPPL. 1), S80; S93.

Ditlopo, P., Blaauw, D., Rispel, L. C., Thomas, S., & Bidwell, P. (2013). Policy implementation

and financial incentives for nurses in South Africa: A case study on the occupation-

specific dispensation. Global Health Action, 6, 138-146.

Dolea, C., Stormont, L., &Braichet, J. (2010). Evaluated strategies to increase attraction and

retention of health workers in remote and rural areas. World Health Organization.

Bulletin of the World Health Organization, 88(5), 379-385.

Dominguez-Torres, C.,Briceno-Garmendia, C. (2011). Mozambique’s infrastructure: a

continental perspective. Washington: The World Bank.

http://www.who.int/workforcealliance/knowledge/publications/partner/tfa_ethiopia.pdf

http://www.cihr-irsc.gc.ca/e/documents/kt_lm_ktplan-en.pdf

http://www.bmz.de/en/publications/type_of_publication/evaluation/international_joint_evaluations/Tansania_Health_SectorReport_07.pdf

http://www.bmz.de/en/publications/type_of_publication/evaluation/international_joint_evaluations/Tansania_Health_SectorReport_07.pdf


Page | 89

Dominguez-Torres, C., Foster, V. (2011). Niger’s infrastructure: a continental perspective.

Washington: The World Bank.

Ebbe, O. (2005). Political Corruption in Africa, In Policing Corruption: International

Perspectives. R. Sarre, K. Dilip K. Das, and H. J. Albrecht (Eds. ), Lanham: Lexington

Books, p. 99-106.

Ethiopia Ministry of Finance and Economic Development. (2010). Growth and Transformation

Plan (GTP) 2010/11-2014/15. Addis Ababa: Author.

Ethiopia Federal Ministry of Health. (2005a). Health Sector Strategic Plan (HSDPIII) 2005/5 –

2009/10. Addis Ababa: Author.

Ethiopia Federal Ministry of Health (2005b). National Strategy for Child Survival in Ethiopia.

Addis Ababa: Author. Available at:

http://www.moh.gov.et/English/Resources/Documents/Child%20Survival%20Policy%20

Strategy.pdf.

Ethiopia Federal Ministry of Health (2007). Health Extension Program in Ethiopia. Addis

Ababa: Author. Available at:

http://www.moh.gov.et/English/Resources/Documents/HEW%20profile%20Final%2008

%2007.pdf.

Ethiopia Federal Ministry of Health (2010). Health Sector Development Program IV 2010/11 –

2014/15. Addis Ababa: Author.

Ethiopia Federal Ministry of Health (2013). HSDP IV Annual Performance Report. Addis

Ababa: Author.

Federal Republic of Ethiopia Ministry of Health. (2006). National Reproductive Health Strategy,

2006-2015. Addis Ababa: Author.

Ferrinho, P., Omar, C. (2006). The Human Resources for Health Situation in Mozambique.

Africa Region Human Development Working Paper Series No. 91. Washington: The

World Bank.

Feysia, B., Herbst, C. H., Lemma, W., Soucat, A., Zhao, F., Kedir, N, Lemiere, C. (2012). The

Health Workforce in Ethiopia: Addressing the remaining challenges. Washington: The

World Bank.

Frehywot, S., Mullan, F., Payne, P. W., & Ross, H. (2010). Compulsory service programs for

recruiting health workers in remote and rural areas: do they work?World Health

Organization. Bulletin of the World Health Organization, 88(5), 364-370.

http://www.moh.gov.et/English/Resources/Documents/Child%20Survival%20Policy%20Strategy.pdf

http://www.moh.gov.et/English/Resources/Documents/Child%20Survival%20Policy%20Strategy.pdf

http://www.moh.gov.et/English/Resources/Documents/HEW%20profile%20Final%2008%2007.pdf

http://www.moh.gov.et/English/Resources/Documents/HEW%20profile%20Final%2008%2007.pdf


Page | 90

Frenk, J., Chen, L., Bhutta, Z., Cohen, J., Crisp, N., Evans, T. et al. (2010). Health professionals

for a new century: transforming education to strengthen health systems in an

interdependent world. The Lancet, 376 (9756), 1923 – 1958.

Garcia, M., Rajmukar, A. S. (2008). Achieving better service delivery through decentralization

in Ethiopia. Washington: The World Bank.

George, G., Quinlan, T., Reardon, C., & Aguilera, J. (2012). Where are we short and who are we

short of? A review of the human resources for health in South Africa. Health SA

Gesondheid, 17(1), 1-7. doi:10. 4102/hsag. v17i1. 622

Ghana Ministry of Health (2002). Under Five’s Child Health Policy: 2007-2015. Accra: Ghana.

Ghana Ministry of Health (2006). The Health Sector Program of Work: 2007-2011. Creating

Wealth through Health. Accra: Author.

Ghana Ministry of Health (2007a). The Ghana Health Sector Annual Program of Work, 2007

Accra: Author.

Ghana Ministry of Health (2007b). The Ghana Health Sector 2008 Program of Work.

Accra: Author.

Ghana Health Service (2007c). Reproductive Health Strategic Plan 2007-2011. Reproductive

and Child Health Department. Accra: Author.

Ghana Ministry of Health (2009a). The Ghana Health Sector 2009 Program of Work. Change

for Better Results: Improving Maternal and Neonatal Health. Accra: Author.

Ghana Ministry of Health (2009b). In-depth Review of the Community-based Health Planning

Services (CHPS) Program. A report of the Annual Health Sector Review 2009. Accra:

Author.

Ghana Ministry of Health (2011). Holistic Assessment of theHealth Sector Program of Work

2011, Ghana. Accra: Author. Available at: http://www.moh-

ghana.org/UploadFiles/Publications/Review%20of%20POW%202011121025073305.pdf

Girma, S., Yohannes, A. G., Kitaw, Y., Ye-Ebiyo, Y., Seyoum, A., Desta, H. &Teklehaimanot,

A. (2007). Human resource development for health in Ethiopia: challenges of achieving

the millennium development goals. Ethiopian Journal of Health Development, 21 (3),

216-231.

http://www.moh-ghana.org/UploadFiles/Publications/Review%20of%20POW%202011121025073305.pdf



Page | 91

Gopalan, S., Mohanty, S. & Das, A. (2011). Challenges and opportunities for policy decisions to

address health equity in developing health systems: case study of the policy processes in

the Indian state of Orissa. International Journal for Equity in Health, 10 (55), 1-11.

Government of Ghana (1994). National Population Policy: At a Glance. Accra: Author.

Government of Ghana (1995). Vision 2020: The First Step 1996-2000. Accra: Author.

Available at: http://www.ndpc.gov.gh/GPRS/Ghana's%20Vision%202020%20-

%20First%20Step.pdf

Government of Ghana Ministry of Health (2001). The Health of the Nation. Reflections on the

First Five Year Health Sector Program of Work, 1997-2001. Accra: Author.

Government of Ghana Ministry of Health (2002). The Second Health Sector 5 Year Program

of Work 2002-2006. Partnerships for Health: Bridging the Inequalities Gap. Accra:

Author.

Gow, J., George, G., Mutinta, G., Mwamba, S., &Ingombe, L. (2011). Health worker shortages

in Zambia: An assessment of government responses. Journal of Public Health Policy,

32(4), 476-488. Retrieved from http://www.jstor.org/stable/41342699.

Gow, J., George, G., Mwamba, S., Ingombe, L., &Mutinta, G. (2012). Health worker satisfaction

and motivation: An empirical study of incomes, allowances and working conditions in

zambia. International Journal of Business and Management, 7(10), 37-48.

Grimshaw J. A guide to knowledge synthesis chapter, Canadian Institutes of Health Research.

2010; Available at: http://www.cihr-irsc.gc.ca/e/41382. html.

Gross, J. M., Riley, P. L., Kiriinya, R., Rakuom, C., Willy, R., Kamenju, A., . . . Rogers, M. F.

(2010). The impact of an emergency hiring plan on the shortage and distribution of nurses

in Kenya: The importance of information systems. World Health Organization. Bulletin

of the World Health Organization, 88(11), 824-830.

Gupta, N., Maliqi, B., Franca, A., Nyonator, F., Pate, M. A., Sanders, D., . . . Daelmans, B.

(2011). Human resources for maternal, newborn and child health: From measurement and

planning to performance for improved health outcomes. Human Resources for Health,

9(16), doi:10. 1186/1478-4491-9-16

Hercot, D., Meessen, B., Ridde, V. & Gilson, L. (2011). Removing user fees for health services

in low-income countries: a multi-country review framework for assessing the process of

policy change. Health Policy and Planning, 26, ii5-ii15.

http://www.ndpc.gov.gh/GPRS/Ghana's%20Vision%202020%20-%20First%20Step.pdf

http://www.ndpc.gov.gh/GPRS/Ghana's%20Vision%202020%20-%20First%20Step.pdf

http://www.jstor.org/stable/41342699

http://www.cihr-irsc.gc.ca/e/41382.%20html


Page | 92

Hogan, M. C., Foreman, K. J., Naghavi, M., Ahn, S. Y., Wang, M., Makela, S. M., Lopez, A. D.,

Lozano, R. & Murray, C. J. L. (2010). Maternal mortality for 181 countries, 1980-2008: a

systematic analysis of progress towards Millennium Development Goal 5. The Lancet, 12

(375), 1609–23.

International Committee of the Red Cross (2013). Mali: Access to health care remains

challenging in the north. Available from

http://www.icrc.org/eng/resources/documents/update/2013/11-28-mali-health-care-in-danger.htm.

Investir en zone franc (IZF) (n. d. ) Le Niger. Available at:

http://www.izf.net/upload/Guide/Niger/Page1 htm

JeuneAfrique (2014). Niger Chronologie. Available at:

http://www.jeuneafrique.com/Chronologie-pays_69_Niger

Joint Learning Initiative (JLI). Human Resources for Health: Overcoming the Crisis. Cambridge,

MA: Harvard University Press; 2004. Available at:

http://www.who.int/hrh/documents/JLi_hrh_report. pdf.

Haazen, D. (2012). Making health financing work for poor people in Tanzania. Washington: The

World Bank.

Hardee, K., Agarwal, K., Luke, N., Wilson, E., Pendzich, M., Farrell, M., & Cross, H. (1999).

Reproductive health policies and programs in eight countries: Progress since cairo.

International Family Planning Perspectives, 25, S2-S9. Retrieved from

http://www.guttmacher.org/pubs/journals/25s0299.html

Kamrul, I. & Ulf, G. (2006). The costs of maternal-newborn illness and mortality. Available at:

http://whqlibdoc.who.int/publications/2006/9241594497_eng.pdf.

Kasonde, J. (2009). Developing a knowledge translation platform for health policy and systems

research in Zambia. Geneva: WHO. Available at http://www.who.int/alliance-

hpsr/projects/zamfohr_etpsnp/en/.

Kasonde, J., Campbell, S. (2012). Creating a Knowledge Translation Platform: nine lessons from

the Zambia Forum for Health Research. Health Research Policy and Systems, 10:31.

Kawonga, M., &Fonn, S. (2008). Achieving effective cervical screening coverage in South

Africa through human resources and health systems development. Reproductive Health

Matters, 16(32), 32-40.

http://www.icrc.org/eng/resources/documents/update/2013/11-28-mali-health-care-in-danger.htm

http://www.jeuneafrique.com/Chronologie-pays_69_Niger

http://www.who.int/hrh/documents/JLi_hrh_report.%20pdf

http://www.guttmacher.org/pubs/journals/25s0299.html

http://whqlibdoc.who.int/publications/2006/9241594497_eng.pdf

http://www.who.int/alliance-hpsr/projects/zamfohr_etpsnp/en/

http://www.who.int/alliance-hpsr/projects/zamfohr_etpsnp/en/

http://www.human-resources-health.com/sfx_links.asp?ui=1478-4491-4-24&bibl=B15


Page | 93

Kengia, J. T., Igarashi, I., &Kawabuchi, K. (2013). Effectiveness of health sector reforms in

reducing disparities in utilization of skilled birth attendants in Tanzania. The Tohoku

Journal of Experimental Medicine, 230(4), 241-253.

Klufio, C. A., Kwawukume, E. Y., Danso, K. A., Sciarra, J. J., & Johnson, T. (2003). Ghana

postgraduate obstetrics/gynecology collaborative residency training program: Success

story and model for Africa. American Journal of Obstetrics and Gynecology, 189(3),

692-696.

Kolstad, J. R. (2011). How to make rural jobs more attractive to health workers: Findings from a

discrete choice experiment in Tanzania. Health Economics, 20(2), 196-211.

Koot, J., & Martineau, T. (2005). Zambian Health Workers Retention Scheme (ZHWRS)

2003–2004. Mid-Term Review. Available at: http://www. hrhresourcecenter.

org/hosted_docs/Zambian_Health_Workers_Retention_Scheme.pdf

Kwansah, J., Dzodzomenyo, M., Mutumba, M., Asabir, K., Koomson, E., Gyakobo, M., . . .

Snow, R. C. (2012). Policy talk: Incentives for rural service among nurses in Ghana.

Health Policy and Planning, 27(8), 669-676. doi:http://dx.doi.org/10.1093/heapol/czs016

Kwast, B. E. (1996). Reduction of maternal and perinatal mortality in rural and peri-urban

settings: What works? European Journal of Obstetrics, Gynecology, and Reproductive

Biology, 69(1), 47-53.

Lagarde, M., Blaauw, D., & Cairns, J. (2012). Cost-effectiveness analysis of human resources

policy interventions to address the shortage of nurses in rural South Africa. Social

Science & Medicine, 75(5), 801-806. doi:

http://dx.doi.org/10.1016/j.socscimed.2012.05.005

Lagarde, M., & Cairns, J. (2012). Modelling human resources policies with Markov models: An

illustration with the South African nursing labour market. Health Care Management

Science, 15(3), 270-282.

Lagarde, M., H. Barroy, & Palmer, N. (2012). Assessing the effects of removing user fees in

Zambia and Niger. Journal of Health Services Research & Policy 17(1): 30-6.

Lamiaux, M., Rouzaud, F. & Woods, W. (2011). Private Health Sector Assessment in Mali. The

Post-Bamako Initiative Reality. Washington, DC: World Bank. Available at:

https://openknowledge.worldbank.org/bitstream/handle/10986/5944/632540REPLACEM

00Box0361512B0PUBLIC0.pdf?sequence=1

Leichter, H. (1979). A comparative approach to policy analysis: Health care policy in four

nations: Cambridge: Cambridge University Press.

http://dx.doi.org/10.1093/heapol/czs016

http://dx.doi.org/10.1016/j.socscimed.2012.05.005

https://openknowledge.worldbank.org/bitstream/handle/10986/5944/632540REPLACEM00Box0361512B0PUBLIC0.pdf?sequence=1

https://openknowledge.worldbank.org/bitstream/handle/10986/5944/632540REPLACEM00Box0361512B0PUBLIC0.pdf?sequence=1


Page | 94

Lincetto, O., Mothebesoane-Anoh, S., Gomez, P. &Munjanja, S. P. (2006). Antenatal care. In

Opportunities for Africa's newborns: Practical data, policy and programmatic support

for newborn care in Africa. J. Lawn & K. Kerber, K. (Eds. ). WHO on behalf of the

Partnership for Maternal and Newborn Child Health: Cape Town.

Lindelow, M., Serneels, P., Lemma, T. (2005). The performance of health workers in Ethiopia -

results from qualitative research. Washington: The World Bank.

Longombe, A. O. (2009). Medical schools in rural areas - necessity or aberration?Rural and

Remote Health, 9(3), 1131.

Lori, J. R., Rominski, S. D., Gyakobo, M., Muriu, E. W., Kweku, N. E., &Agyei-Baffour, P.

(2012). Perceived barriers and motivating factors influencing student midwives '

acceptance of rural postings in Ghana. Human Resources for Health, 10(17), doi:10.

1186/1478-4491-10-17.

Maestad, O. (2006) Human Resources for Health in Tanzania: Challenges, Policy Options and

Knowledge Gaps. Chr. Michelsen Institute. Available at:

http://www.cmi.no/publications/publication/?2175=human-resources-for-health-in-

tanzania-challenges

Magnani, R. J., Rice, J. C., Mock, N. B., Abdoh, A. A., Mercer, D. M., &Tankari, K. (1996). The

impact of primary health care services on under-five mortality in rural niger.

International Journal of Epidemiology, 25(3), 568-577.

Martey, J. O., Elkins, T. E., Wilson, J. B., Adadevoh, S. W., MacVicar, J., &Sciarra, J. J.

(1995). Innovative community-based postgraduate training for obstetrics and gynecology

in West Africa. Obstetrics and Gynecology, 85(6), 1042-1046. doi:10. 1016/0029-

7844(95)00066-Z

Mayhew, S. H. (2003). The impact of decentralisation on sexual and reproductive health services

in Ghana. Reproductive Health Matters, 11 (21), 74-87.

Mbonye, A. K., Sentongo, M., Mukasa, G. K., Byaruhanga, R., Sentumbwe-Mugisa, O.,

Waiswa, P., . . . Uganda Decade of Change and Future Implications Analysis Group.

(2012). Newborn survival in Uganda: A decade of change and future implications. Health

Policy and Planning, 27(3), 104-117.

MehryarKarim A, Admassu K, Schellenberg J, Alemu H, Getachew N, Ameha A et al. (2013).

Effect of Ethiopia’s Health Extension Program on Maternal and Newborn Health Care

Practices in 101 Rural Districts: A Dose-Response Study. PLoS One, 8(6): e65160.

http://www.cmi.no/publications/publication/?2175=human-resources-for-health-in-tanzania-challenges

http://www.cmi.no/publications/publication/?2175=human-resources-for-health-in-tanzania-challenges


Page | 95

Michael, Y. H., Jira, C., Girma, B., &Tushune, K. (2010). Health workforce deployment,

attrition and density in East Wollega zone, Western Ethiopia. Ethiopian Journal of

Health Science, 20(1), 15-23.

Mullan, F., Frehywot, S., Omaswa, F., Buch, E., Chen, C., Greysen, S. et al. (2011). Medical

schools in sub-Saharan Africa. The Lancet, 377 (9771), 1113-1121.

National Reconciliation Council (le Conseil de réconciliationnationale, CRN) (1999). Available

at: http://www.coderural-niger.net/IMG/pdf/Ord_No99-50_tarifs_alienation.pdf

Ngulube, T., Mdhluli, l. &Gondwe, K. (2005). Planning and budgeting for Primary

Health Care in Zambia: A policy analysis. The Centre for Health, Science & Social

Research (CHESSORE), Zambia. Retrieved

fromhttp://equinetafrica.org/bibl/docs/DIS29ngulube.pdf

Nyonator, F. J., Awoonor-Williams, J. K., Phillips, J. F., Jones, T. C. & Miller, R. A. (2005). The

Ghana Community-based Health Planning and Services Initiative for scaling up service

delivery innovation. Health Policy and Planning, 20(1): 25-34.

Okeke, E. N. (2013). Do higher salaries lower physician migration? Health Policy and Planning,

1-12, doi:10. 1093/heapol/czt046.

Organization for Economic Cooperation and Development (2012). Mapping Support for Africa's

Infrastructure Investment. Available at: http://www.oecd.org/daf/inv/investment-

policy/MappingReportWeb.pdf

Ozgediz D, Galukande M, Mabweijano J, Kijambu S, Mijumbi C, Dubowitz, G. et al. (2008).

The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda.

World Journal of Surgery, 32: 1208-1215. DOI 10. 1007/s00268-008-9473-4.

Palmer, D. (2006). Tackling Malawi's human resources crisis. Reproductive Health Matters,

14(27), 27-39.

Pariyo, G. W., Gouws, E., Bryce, J. & Burnham, G. (2006). Improving facility-based care for

sick children in Uganda: training is not enough. Health Policy and Planning,

20(supplement): i58-i68.

Pawson, R., Greenhalgh, T., Harvey, G., &Walshe, K. (2005). Realist review – a new method of

systematic review designed for complex policy interventions. Journal of Health Research

& Policy, 10 (1), 21-34.

http://www.coderural-niger.net/IMG/pdf/Ord_No99-50_tarifs_alienation.pdf

http://equinetafrica.org/bibl/docs/DIS29ngulube.pdf

http://www.oecd.org/daf/inv/investment-policy/MappingReportWeb.pdf

http://www.oecd.org/daf/inv/investment-policy/MappingReportWeb.pdf


Page | 96

Phillips, J. F., Bawah, A. A., &Binka, F. N. (2006). Accelerating reproductive and child health

program impact with community-based services: The Navrongo experiment in Ghana.

World Health Organization. Bulletin of the World Health Organization, 84(12), 949-55.

Picazo, O. F., Zhao, F. (2009). Zambia health sector public expenditure review: accounting for

resources to improve effective service coverage. Washington: The World Bank.

Pirkle, C. M., Dumont, A., Traore, M., Zunzunegui, M. V., & QUARITE group. (2013). Effect

of a facility-based multifaceted intervention on the quality of obstetrical care: A cluster

randomized controlled trial in Mali and Senegal. BMC Pregnancy and Childbirth, 13, 24-

2393-13-24. doi:10. 1186/1471-2393-13-24; 10. 1186/1471-2393-13-24

Plummer, J. (2012). Diagnosing corruption in Ethiopia : perceptions, realities, and the way

forward for key sectors. Washington: The World Bank.

Présidence de la République de Niger. (2012). LePrésident. Available at

http://www.presidence.ne/index.php/le-president

Ranganathan, R., Foster, V. (2012). Uganda’s infrastructure: a continental perspective.

Washington: The World Bank.

Republic of Ghana (2000). Adolescent Reproductive Health Policy. Accra: Author.

Republic of Ghana Ministry of Health (2002). Human Resource Policies and Strategies for the

Health Sector 2002-2006. Accra, Ghana: Author

Republic of Ghana Ministry of Health. (2006).The Health Sector Program of Work: 2007-

2011. Creating Wealth Through Health. Accra: Author. Available at: http://www.moh-

ghana.org/UploadFiles/Publications/5Yr%20POW%20III%20(2007-

2011)120422153555.pdf

Republic of Ghana Ministry of Health (2007a). National Health Policy. Creating Health through

Wealth. Accra: Author. Available at:

http://www.ghanahealthservice.org/summit/apr_2007/docs/Updated%20Final%20Draft%

20of%20Health%20Policy.pdf

Republic of Ghana Ministry of Health (2007b). Human Resource Policies and Strategies for the

Health Sector, 2007-2011. Accra: Author. Available at:

http://www.who.int/workforcealliance/countries/Ghana_HRHPolicyPlan_2007_2011.pdf

http://www.presidence.ne/index.php/le-president

http://www.moh-ghana.org/UploadFiles/Publications/5Yr%20POW%20III%20(2007-2011)120422153555.pdf



http://www.ghanahealthservice.org/summit/apr_2007/docs/Updated%20Final%20Draft%20of%20Health%20Policy.pdf

http://www.ghanahealthservice.org/summit/apr_2007/docs/Updated%20Final%20Draft%20of%20Health%20Policy.pdf

http://www.who.int/workforcealliance/countries/Ghana_HRHPolicyPlan_2007_2011.pdf


Page | 97

Republic of Ghana (2010). Medium-Term National Development Policy Framework: Ghana

shared growth and development agenda, 2010-2013. Available at:

http://eeas.europa.eu/delegations/ghana/documents/eu_ghana/ghana_shared_growth_and_

development_agenda_en.pdf

Republic of Ghana Ministry of Health (2011). Holistic Assessment of the Health Sector

Program of Work. Accra: Author. Available at: http://www.moh-

ghana.org/UploadFiles/Publications/Review%20of%20POW%202011121221102738.pdf

Republic of Ghana Ministry of Health. (2012). Brief on Status of CHPS Implementation. Accra:

Author.

República de Moçambique Ministério da Saúde. (2008). Plano nacional de desenvolvimento dos

recursos humanos da saúde 2008 – 2015. [National human resources for health

development plan 2008 – 2015]. Maputo, Mozambique.

República de Moçambique Ministério da Saúde. (2013). Plano Estratégico do Sector da

SaúdePESS 2014-2019. Maputo: Author.

République du Mali: Ministère de la Santé. (2008a). Plan de Formation: Development of Health

Human Resources 2009-2015. Republic of Mali Ministry of Health (2008a). Health

Human Resources Development: Training Plan 2009 – 2015. Bamako: Author.

République du Mali : Ministère de la Santé. (2008b). Plan Stratégique National pour le

Renforcement du Système de Santé (PSN/RSS) 2009-2015. Bamako: Mali. Bureau

d'impression du gouvernement. Republic of Mali: Ministry of Health. (2008b). National

Strategic Plan to Reinforce the Health System (PSN/RSS) 2009-2015. Bamako: Mali.

Government Printing Office.

République du Mali Ministère de la Santé. (2009a). Program de Développement Sanitaire et

Social (PRODESS) II Prolongé 2009-2011 : composante santé. Bamako: Mali. Bureau

d'impression du gouvernement). Republic of Mali: Ministry of Health. (2009a). Extended

Health and Social Development Program (PRODESS) II 2009-2011: Health

Components. Bamako: Mali. Government Printing Office.

République du Mali Ministère de la Santé. (2009b). Développement des ressources humaines

pour la santé: politique nationale. Bamako: Mali. Bureau d'impression du gouvernement).

Republic of Mali: Ministry of Health. (2009b). Health Human Resources Development

Plan: National Policy. Bamako: Mali. Government Printing Office.

République du Mali Ministère de la Santé. (2012). Plan décennal de développement sanitaire et

social (PDDSS) 2013-2022. Bamako: Author.

http://eeas.europa.eu/delegations/ghana/documents/eu_ghana/ghana_shared_growth_and_development_agenda_en.pdf

http://eeas.europa.eu/delegations/ghana/documents/eu_ghana/ghana_shared_growth_and_development_agenda_en.pdf




Page | 98

République du Mali Ministère de la Santé. (2013). Plan stratégique de la santé de la

reproduction 2014-2018. Bamako: Author.

République du Niger: Ministère de la Santé Publique. (2010a). Proposal by the Republic of Niger

for Health Systems Strengthening Support (HSS) from GAVI. Available from

http://www.gavialliance.org/country/niger/documents/proposals/proposal-for-hss-support--

niger/.

République du Niger: Ministère de la Santé Publique. (2010b). Plan dedéveloppement des

ressources humaines 2011 – 2020 en santé. Niamey: Niger. Government Printing Office.

(Republic of Niger: Ministry of Public Health. (2010b). Health Human Resources

Development Plan 2011 – 2020. Niamey: Niger. Government Printing Office. )

République du Niger : Ministère de la Santé Publique. (2011). Plan de développement sanitaire

(PDS) 2011 – 2015. Niamey: Niger. Government Printing Office. (Republic of Niger :

Ministry of Public Health. (2011). HealthDevelopment Plan 2011 – 2015. Niamey: Niger.

Government Printing Office).

Republic of Uganda (2005). Road Map for Accelerating the Reduction of Maternal and Neonatal

Mortality and Morbidity in Uganda 2006-2015. Kampala: Author.

Republic of Zambia (2006). Vision 2030. A prosperous middle-income nation by 2030. Lusaka:

Author. Available at:

http://www.africaportal.org/sites/default/files/Zambia%20Vision%202030.pdf

Reynolds, J., Wisaijohn, T., Pudpong, N., Watthayu, N., Dalliston, A., Suphanchaimat, R.,

Sawaengdee, K. (2013). A literature review: The role of the private sector in the

production of nurses in India, Kenya, South Africa and Thailand. Human Resources for

Health, 11(14), doi:10. 1186/1478-4491-11-14.

Sabatier, P. & Jenkins-Smith, H. (1993). Policy Change and Learning. Boulder, CO: Westview

Press.

Saleh, K. (2013). The Health Sector in Ghana: A Comprehensive Assessment. Washington, DC:

World Bank. Available at:

https://openknowledge.worldbank.org/bitstream/handle/10986/12297/NonAsciiFileName

0. pdf?sequence=1

Sani, R., Nameoua, B., Yahaya, A., Hassane, I., Adamou, R., Hsia, R. Y., Hoekman, P., Sako,

A., & Habibou, A. (2010). The Impact of Launching Surgery at the District Level in

Niger. World Journal of Surgery, 33, 2063 – 2068. doi: 10. 1007/s00268-009-0160-x

http://www.gavialliance.org/country/niger/documents/proposals/proposal-for-hss-support--niger/

http://www.gavialliance.org/country/niger/documents/proposals/proposal-for-hss-support--niger/

http://www.africaportal.org/sites/default/files/Zambia%20Vision%202030.pdf

https://openknowledge.worldbank.org/bitstream/handle/10986/12297/NonAsciiFileName0.%20pdf?sequence=1

https://openknowledge.worldbank.org/bitstream/handle/10986/12297/NonAsciiFileName0.%20pdf?sequence=1


Page | 99

Sanneving, L. Kulane, A., Iyer, A., &Ahgren, B. (2013). Health system capacity: maternal health

policy implementation in the state of Gujarat, India. Global Health Action, 6, 1-8.

Available at: http://www.globalhealthaction.net/index. php/gha/article/view/19629.

Shkaratan, M. (2012). Tanzania’s infrastructure: a continental perspective. Washington: The

World Bank.

Sibuyi, M. C. (2004). Provision of abortion services by midwives in Limpopo province of South

Africa. African Journal of Reproductive Health, 8(1), 75-78.

Snow, R. C., Asabir, K., Mutumba, M., Koomson, E., Gyan, K., Dzodzomenyo, M., Kwansah, J.

(2011). Key factors leading to reduced recruitment and retention of health professional in

remote areas of Ghana: a qualitative study and proposed policy solutions. Human

Resources for Health, 9(13), doi:10. 1186/1478-4491-9-13

Spector, J. M., Lashoher, A., Agrawal, P., Lemer, C., Dziekan, G., Bahl, R., Gawande, A. A.

(2013). Designing the WHO safe childbirth checklist program to improve quality of care

at childbirth. International Journal of Gynecology and Obstetrics, 122(2), 164-168.

Taegtmeyer, M., Martineau, T., Namwebya, J., Ikahu, A., Ngare, C., Sakwa, J., Lalloo, D. &

Theobald, S. (2011). A qualitative exploration of the human resource policy implications

of voluntary counselling and testing scale-up in Kenya: applying a model for policy

analysis. BMC Public Health, 11(812), 1-10.

The United Republic of Tanzania Ministry of Health and Social Welfare (2003a). Second Health

Sector Strategic Plan (HSSP) July 2003-June 2008. Dar es Salaam: Author.

The United Republic of Tanzania Ministry of Health and Social Welfare (2003b). National

Health Policy (Draft). Dar es Salaam: Author. Available at:

http://apps.who.int/medicinedocs/documents/s18419en/s18419en.pdf

The United Republic of Tanzania Ministry of Health and Social Welfare (2007) Primary Health

Services Development Program 2007 – 2017. Dar es Salaam: Author.

The United Republic of Tanzania Ministry of Health and Social Welfare (2008a). The National

Road Map Strategic Plan To Accelerate Reduction of Maternal, Newborn and Child

Deaths in Tanzania. Dodoma: Author.

The United Republic of Tanzania Ministry of Health and Social Welfare (2008b) Human

Resource for Health Strategic Plan 2008 – 2013. Dar es Salaam: Author.

The United Republic of Tanzania Ministry of Health and Social Welfare (2009) Health Sector

Strategic Plan III July 2009 – June 2015. Dar es Salaam: Author.

http://www.globalhealthaction.net/index.%20php/gha/article/view/19629

http://apps.who.int/medicinedocs/documents/s18419en/s18419en.pdf


Page | 100

The United Republic of Tanzania National Audit Office. (2011). A performance audit on the

monitoring, evaluations and budget allocation for maternal health care activities in

Tanzania. Dar es Salaam, Tanzania. Available at:

http://www.tanzania.go.tz/egov_uploads/documents/777_sw.pdf

The World Bank. (2005). Public expenditure management and financial accountability in Niger.

Washington: Author.

The World Bank. (2009). Mozambique | Data. Washington: Author. Available at

http://data.worldbank.org/country/mozambique.

Transitional Government of Ethiopia (1993). Health Policy. Addis Ababa: Author.

Tomblin Murphy, G. (2007). A framework for collaborative Pan-Canadian health human

resources planning. Appendix: Example of a conceptual model for HHR planning.

Available at: http://www.hc-sc.gc.ca/hcs-sss/pubs/hhrhs/2007-frame-cadre/app-ann-

eng.php.

Uganda Ministry of Education and Sports. (2011). Report on the assessment of the quality of

human resources for health pre-service practicum training. Kampala: Author.

Uganda Ministry of Health (2010a). Health Sector Strategic & Investment Plan 2010/11 –

2014/15. Kampala: Author.

Uganda Ministry of Health (2010b). The Second National Health Policy. Kampala: Author.

Uganda Ministry of Health (2010c). Uganda Human Resources for Health Report Issue 3, May

2010. Kampala: Author.

Uganda Ministry of Health (2013). Midterm Review Report of the Health Sector Strategic and

Investment Plan (HSSIP) 2010/11 - 2014/15. Kampala: Author.

United Nations (2013a). The Millennium Development Goals Report. NewYork: Author.

Available at: http://www. undp.org/content/dam/undp/library/MDG/english/mdg-report-

2013-english.pdf

United Nations (2013b). Improve maternal health, Fact Sheet. Available at:

http://www.un.org/millenniumgoals/pdf/Goal_5_fs.pdf

United Nations Development Program (2013). Human Development Reports, Niger.

Available from http://hdr.undp.org/en/countries/profiles/NER

http://www.tanzania.go.tz/egov_uploads/documents/777_sw.pdf

http://data.worldbank.org/country/mozambique

http://www.hc-sc.gc.ca/hcs-sss/pubs/hhrhs/2007-frame-cadre/app-ann-eng.php

http://www.hc-sc.gc.ca/hcs-sss/pubs/hhrhs/2007-frame-cadre/app-ann-eng.php

http://www.un.org/millenniumgoals/pdf/Goal_5_fs.pdf

http://hdr.undp.org/en/countries/profiles/NER


Page | 101

United Nations Population Fund, United Nations Development Fund for Women, Office of the

Special Adviser on Gender Issues and Advancement of Women (2005). Combating

Gender-Based Violence: A Key to Achieving the MDGs. Retrieved from

http://www.unfpa.org/upload/lib_pub_file/531_filename_combating_gbv_en.pdf

United States Agency for International Development (USAID) (2013). Mali Health Strategy

2014-2018. Available from

http://www.usaid.gov/sites/default/files/documents/1864/USAID-

Mali%20Health%20Strategy%202014-2018.pdf

United Republic of Tanzania (no date). Tanzania Development Vision 2025. Dodoma: Author.

Available at http://www.mof.go.tz/mofdocs/overarch/Vision2025.pdf.

Université de Sherbrooke. (1993). Niger: Chronologiedepuis 1960. Available at:

http://perspective.usherbrooke.ca/bilan/servlet/BMHistoriquePays?codePays=NER&lang

ue=fr

Walt, G. & Gilson, L. (1994). Reforming the health sector in developing countries: the central

role of policy analysis. Health Policy and Planning, 9, 353–370.

World Health Organization (2003). World Health Report 2003: Shaping the Future. Geneva.

Available at:http://www.who.int.proxy.lib.uwo.ca:2048/whr/2003/en/Chapter7-en.pdf

World Health Organization (2005). Make every Mother and Child Count. Geneva: World Health

Organization. Available at: http://www.who.int/whr/2005/whr2005_en.pdf

World Health Organization (2006). Country Cooperation Strategy at a Glance, Niger. Available

at: http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_ner_en.pdf?ua=1

World Health Organization (2009) WHO Country Cooperation Strategy 2010-2015. Geneva:

Author. Available at

http://www.who.int/countryfocus/cooperation_strategy/ccs_tza_en.pdf

World Health Organization. (2011). The Abuja Declaration: Ten Years On. Geneva: WHO.

Available at http://www.who.int/healthsystems/publications/abuja_report_aug_2011.pdf.

World Health Organization (2012). Maternal Mortality, Fact Sheet No. 348. Available at

http://www.who.int/mediacentre/factsheets/fs348/en/

World Health Organization (2013a). Health response to the crisis in Mali. Available at:

http://www. who. int/hac/donorinfo/mali_donor_alert_february2013. pdf

http://www.unfpa.org/upload/lib_pub_file/531_filename_combating_gbv_en.pdf

http://www.mof.go.tz/mofdocs/overarch/Vision2025.pdf

http://www.who.int.proxy.lib.uwo.ca:2048/whr/2003/en/Chapter7-en.pdf

http://www.who.int/whr/2005/whr2005_en.pdf

http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_ner_en.pdf?ua=1

http://www.who.int/healthsystems/publications/abuja_report_aug_2011.pdf

http://www.who.int/mediacentre/factsheets/fs348/en/

http://www.who.int/hac/donorinfo/mali_donor_alert_february2013.pdf

http://www.human-resources-health.com/sfx_links?ui=1478-4491-4-20&bibl=B2


Page | 102

World Health Organization (2013b). Country Profile: Tanzania. Geneva: Author. Available

at http://www.who.int/countries/tza/en/

World Health Organization (2013c). Country Profile: Uganda. Geneva: Author. Available at:

http://www.who.int/countries/uga/en/

World Health Organization (2013d). Country Profile: Zambia. Geneva: Author. Available at:

http://www.who.int/countries/zmb/en/

World Health Organization. (2014). Health workforce situational analysis. Available at:

http://www.afro.who.int/index.php?option=com_content&view=article&id=3128&Itemid

=2854.

World Health Organization Regional Office for Africa (2012). Road Map for Scaling Up the

Human Resources for Health for Improved Health Service Delivery in the African

Region 2012–2025. Luanda: WHO.

Wuehler, S. E., & Coulibaly, M. (2011). Situational analysis of infant and young child nutrition

policies and programmatic activities in Mali. Maternal & Child Nutrition, 7 (Suppl 1),

83-112. doi:10.1111/j.1740-8709.2010.00310. x; 10.1111/j.1740-8709. 010.00310.x

Zambia Ministry of Health (1991). National Health Policies and Strategies. Lusaka: Author.

Zambia Ministry of Health (2005). Human Resources for Health Strategic Plan 2006-2010.

Lusaka: Author. Available at

http://www.who.int/nha/country/zmb/Zambia_NH_Strategic_plan,2006-2010%20.pdf.

Zambia Ministry of Health (2008). Report of the Mid Term Review of the Zambia

National Health Strategic Plan NHSP IV, 2006 – 2010. Lusaka: Author.

Zambia Ministry of Health. (2008). National Health Research Strategic Plan 2008-2011.

Lusaka: Author.

Zambia Ministry of Health (2009). Ministry of Health 2009 Action Plan. Lusaka: Author.

Zambia Ministry of Health (2010a). 2009 Joint Annual Review Report. Lusaka: Author.

Zambia Ministry of Health (2010b). Ministry of Health 2010 Narrative Action Plan. Lusaka:

Author.

http://www.who.int/countries/tza/en/

http://www.who.int/countries/uga/en/

http://www.who.int/countries/zmb/en/

http://www.afro.who.int/index.php?option=com_content&view=article&id=3128&Itemid=2854

http://www.afro.who.int/index.php?option=com_content&view=article&id=3128&Itemid=2854

http://www.who.int/nha/country/zmb/Zambia_NH_Strategic_plan,2006-2010%20.pdf


Page | 103

Zambia Ministry of Health (2010c). Sixth National Development Plan 2011-2015. Lusaka:

Author Available at:

http://siteresources.worldbank.org/INTZAMBIA/Resources/SNDP_Final_Draft__20_01_

2011.pdf

Zambia Ministry of Health (2010d). National Health Strategic Plan 2011-2015. Lusaka: Author.

Available at http://www.zuhwa.com/wp-content/uploads/2012/02/national-health-

strategic-plan-2011-2015.pdf.

Zambia Ministry of Health (2011a). Ministry of Health 2011 Action Plan. Lusaka: Author.

Zambia Ministry of Health (2011b). National Human Resources for Health Strategic Plan 2011

– 2015. Lusaka: Author. Available at

http://www.who.int/workforcealliance/countries/ccf/HRH_plan_zambia2011-2015.pdf.

Zambia Ministry of Health (2012). Human resources for health: a snapshot of Zambia’s Strategic

Plan. Commonwealth Health Partnerships.

Zambia Ministry of Health (2013). MoH Staffing. Lusaka: Author.

Zulu, J., Kinsman, J., Michelo, C. &Hurtig, A. (2013). Developing the national community

health assistant strategy in Zambia: a policy analysis. Health Research Policy and

Systems, 11 (24), 1-13.

Zurn, P., Dal Poz, M. R., Stilwell, B., Adams, O. (2004). Imbalance in the health

workforce. Human Resources for Health, 2 (13). Available at:http://www.human-

resources-health.com/content/2/1/13

http://siteresources.worldbank.org/INTZAMBIA/Resources/SNDP_Final_Draft__20_01_2011.pdf

http://siteresources.worldbank.org/INTZAMBIA/Resources/SNDP_Final_Draft__20_01_2011.pdf

http://www.zuhwa.com/wp-content/uploads/2012/02/national-health-

http://www.zuhwa.com/wp-content/uploads/2012/02/national-health-

http://www.who.int/workforcealliance/countries/ccf/HRH_plan_zambia2011-2015.pdf

http://www.human-/

http://www.human-/


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Synthèse et examen systématique : Politiques sur la formation et le éploiement

de ressources humaines en santé en Afrique rurale

Sommaire

Contexte

Les huit objectifs du Millénaire pour le développement (OMD) lancés en 2000 sont considérés

comme étant un plan directeur international visant à améliorer la santé et le bien-être des

personnes les plus vulnérables du monde. La santé et le bien-être des femmes, des nouveau-nés

et des enfants sont au premier rang d'un grand nombre de discussions sur les politiques et la

planification qui touchent les OMD 4 et 5. À mesure qu'approche l'échéance pour atteindre les

OMD, de nombreux rapports d’avancement, particulièrement les rapports concernant des pays

d'Afrique, montrent qu'il reste des défis à relever pour atteindre les OMD 4 et 5. Cette situation

est en grande partie due à la pénurie de ressources humaines en santé (RHS) qui perdure en

Afrique. La plupart des pays du continent n'ayant pas suffisamment de personnel pour offrir les

soins de santé élémentaires à leur population, particulièrement dans les régions rurales. La

capacité de ces pays de réagir à cette crise est sérieusement limitée par le financement et les

lacunes des infrastructures. La planification efficace et la gestion des rares RHS disponibles,

particulièrement pour ce qui est de la santé des mères et des enfants, sont ainsi de la plus haute

importance pour les gouvernements africains. Afin d'orienter la planification, un examen

systématique des données disponibles sur les politiques en matière de formation et de

déploiement pour médecins, les infirmiers, les infirmières et les sages-femmes pour la santé

maternelle et infantile en Afrique rurale a été effectué.

Méthodologie

La principale question d'orientation était : Que savons-nous sur les politiques visant à appuyer la

formation et le déploiement d'infirmiers et d'infirmières, de sages-femmes et de médecins pour

les soins de santé maternelle et infantile en Afrique rurale? D'autres questions portaient sur ces

points : Que savons-nous actuellement sur (a) l'élaboration, (b) la mise en œuvre et (c) les

impacts de ces politiques?

Une approche à deux volets préconisée par un groupe consultatif international a été utilisée, le

premier étant une étude de la portée des données disponibles pour l'ensemble de l'Afrique sur les

questions examinées. Le second volet est une étude approfondie des politiques d'un sous-groupe

de pays africains : Éthiopie, Ghana, Mali, Mozambique, Niger, Tanzanie, Ouganda et Zambie.

Seules les politiques pour lesquelles il était possible de relever des preuves d'utilisation et de

mise en œuvre ont été retenues pour ce dernier volet. En outre, les interventions ou les

programmes individuels mis en place dans le cadre des plans d'ensemble ont été considérés

comme étant des politiques et analysés en profondeur pour préparer ce sommaire. Seules les

données tirées de recherches publiées dans des revues scientifiques examinées par des pairs ont

été considérées comme constituant la composante « impacts » du cadre de synthèse. Cependant,


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la présence d'autres données dans des sources non examinées par des pairs (p. ex. rapports du

ministère de la Santé) est soulignée lorsque ces données sont disponibles et ont été utilisées pour

donner de l'information sur les autres composantes du cadre de synthèse.

Étant donné le peu de documentation sur les politiques disponible pour analyse, il faut faire

preuve de prudence lorsqu'on tire des conclusions sur la quantité et la qualité des stratégies mises

en place dans les pays africains pour ce qui est de la formation en santé maternelle et infantile et

du déploiement de médecins, d'infirmiers, d'infirmières et de sages-femmes dans les régions

rurales. La question est examinée plus en profondeur dans les sections résultats et discussion où

sont décrits des exemples précis des politiques relevés dans le cadre de l'examen qui, même s'ils

ne correspondent pas aux critères d'inclusion, sont néanmoins prometteurs.

Résultats

Les recherches dans la base de données électronique ont permis de relever 548 articles examinés

par des pairs (122 de ces articles étaient mentionnés deux fois). Les 426 articles uniques restants

ont été ajoutés aux 87 articles relevés par les membres de l'équipe de recherche zambienne et du

groupe consultatif, pour un total de 513 articles à examiner. De ces articles, 37 remplissaient les

critères pour être inclus dans l'étude. Le corpus d'articles final couvre 13 pays et toutes les

régions de l'Afrique sont représentées. Le Ghana est le pays avec la plus haute représentation,

soit 9 articles évalués par des pairs, suivi par l'Afrique du Sud avec 5 articles; 5 autres articles

traitaient de plusieurs pays. Quatre articles provenaient d'Éthiopie, les 10 autres pays étant

représentés dans un à trois articles chacun. Les articles retenus proviennent de 22 revues, surtout

du Bulletin de l'Organisation mondiale de la santé et d'autres revues : Health Policy and

Planning, Reproductive Health Matters et Human Resources for Health. La vaste majorité des

articles examinés par des pairs ont été publiés à partir de 2003, ce qui semble indiquer l'impact

de l'introduction, en 2000, des objectifs du Millénaire pour le développement sur l'établissement

des priorités pour la recherche et les politiques. Ces données montrent également qu'un élan a été

créé et s'accélère pour la recherche qui touche les RHS et les OMD 4 et 5.

La représentation des médecins, des infirmiers, des infirmières et des sages-femmes dans la

documentation est assez équitable. Toutefois, beaucoup des articles sélectionnés mentionnent des

fournisseurs parce qu'ils traitent implicitement de politiques de haut niveau, par exemple les

politiques concernant la santé nationale et les réformes dans le secteur de la santé. Les politiques

portant exclusivement sur la formation et le déploiement sont en minorité, alors que ceux qui

traitent des deux domaines, soit directement, soit comme composants de politiques plus larges,

sont en majorité. Le reste de la documentation traite de politiques qui ne sont pas explicitement

destinées à la poursuite des OMD 4 et 5 dans les régions rurales par la formation ou le

déploiement des fournisseurs de services sélectionnés; ces articles sont toutefois pertinents pour

les OMD 4 et 5 compris ou implicites dans les composantes de politiques générales, comme les

politiques nationales sur la santé infantile. Même si les articles exclus ne remplissent pas tous les

critères d'inclusion, ils illustrent la diversité du travail réalisé en matière de politique concernant

la formation et le déploiement de RHS pour améliorer la santé maternelle et infantile dans les

régions rurales.


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Au moment où cet examen a été réalisé, on observait sur les sites Web des ministères de la Santé

des pays africains appartenant aux trois groupes linguistiques une grande diversité quant aux

fonctions et à l'offre de documents pertinents. Certains sites Web présentent une grande quantité

de documents. Quoique opérationnels, les sites Web d'autres ministères de la santé manquent de

cohérence quant aux documents offerts et à leur accessibilité. Notamment, on constate que les

sites Web du ministère de la santé de plusieurs pays possèdent les bases et la structure

nécessaires pour être pleinement informatifs, mais des liens rompus, des pages avec la

désignation « en construction » et l'absence de documents de politique réduisent la capacité de

ces sites d'informer. Par ailleurs, il a été impossible de trouver les sites Web de certains

ministères.

L'examen des sites Web sélectionnés a révélé un large éventail de documents pertinents et

applicables pour le sous-groupe de pays : lignes directrices et protocoles professionnels,

évaluations indépendantes de politiques, notes et actes de conférences et autres documents

examinés par des pairs. Ces documents ont été utilisés pour éclairer la partie de l'analyse portant

sur le contexte du pays et pour cerner les politiques potentiellement pertinentes pour orienter les

questions spécifiques adressées à notre comité consultatif quant à des renseignements

additionnels.

Notre examen a révélé une pénurie de politiques sur la formation et le déploiement de médecins,

d'infirmiers, d'infirmières ou de sages-femmes en santé maternelle ou infantile en Afrique rurale.

Nous avons cependant pu trouver des politiques qui traitent de chacun de ces facteurs; elles sont

décrites en détail dans le rapport.

Au-delà des titres des diverses politiques et des contextes dans lesquels elles ont été mises en

place, nos recherches ne nous ont permis de trouver que très peu d'information sur la création, la

mise en œuvre ou l'impact de ce travail. Plus particulièrement, nous avons relevé la quasi-

absence de données scientifiques évaluées par des pairs concernant les impacts de ces politiques.

La plupart des documents consultés reconnaissent toutefois que malgré les politiques qui

devaient les régler, les problèmes persistent.

Discussion

En dépit de la stratégie de recherche exhaustive et diversifiée, il n'a été possible de relever qu'un

nombre relativement faible de politiques sur la formation ou le déploiement de médecins,

d'infirmiers, d'infirmières et de sages-femmes en santé maternelle et infantile dans les régions

rurales de ces pays. Les politiques mentionnées reflètent l'information relevée à l'aide des

méthodes et dans les sources décrites ci-dessus et facilement disponible pour inclusion dans

notre analyse. Cela ne doit toutefois pas être interprété comme un manque d'attention ou de suivi

pour ce qui est de régler ces problèmes. Plusieurs pays sont en train de mettre en place des

programmes importants qui s'intéressent à ces enjeux, programmes qui ne correspondaient

toutefois pas exactement aux critères d’inclusion. Deux programmes sur lesquels beaucoup

d'information est disponible – le « Health Extension Program » de l'Éthiopie et le « Essential

Health Intervention Project » de la Tanzanie – sont décrits plus en détail dans le rapport.


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Tout compte fait, il est clair que les ministères de la santé des pays étudiés ont mis à l'essai un

large éventail de propositions de politiques en RHS visant à améliorer la santé maternelle et

infantile au sein de leurs populations respectives, et qu'ils continuent d'examiner les possibilités.

Toutefois, la mise en œuvre – et par conséquent le succès – de ces politiques semble

sérieusement entravée par des facteurs économiques, politiques, sociaux, géographiques et

technologiques sur lesquels les ministères n'ont aucune influence directe. De plus, il est souvent

difficile de voir comment les politiques en place s'inscrivent dans les stratégies nationales plus

vastes. Cela étant dit, il est important de souligner que très peu d'information sur les politiques de

ces pays en matière santé – sans parler de renseignements sur leur mise en œuvre et leurs impacts

– est facile d'accès ou disponible, même à l'aide de recherches dédiées. Les politiques ont dû être

analysées à partir uniquement de sources d'information secondaires, puisque les textes des

politiques n'étaient pas disponibles. L'absence de visibilité et d'accessibilité de l'information rend

virtuellement impossible l'évaluation objective de ces politiques – évaluation nécessaire si on

veut y apporter des améliorations appréciables.

Autres domaines à étudier

Il y a un grand potentiel d'utiliser cette synthèse comme point de départ d'autres travaux. Les

principales limites de cet examen sont le manque d'information sur les politiques pertinentes et

l'échéancier à respecter. En ce qui a trait au premier point, comme nous le mentionnons ci-

dessus, élargir la stratégie de recherche de documents examinés par des tiers pour inclure les

noms de pays d'Afrique permettrait sans doute de trouver des documents plus pertinents. De la

même façon, des recherches de suivi pour trouver de l'information sur des politiques spécifiques,

une fois que ces dernières auront été identifiées, pourraient donner des renseignements

additionnels à leur sujet, tout comme l'exploration des références dans les documents pertinents.

De plus, des entrevues des groupes de consultation avec des informateurs clés dans les pays

sélectionnés apporteraient vraisemblablement des données additionnelles et d'autres documents.

Enfin, même si nous avons cité des rapports publiés par des gouvernements et par des ONG

lorsque c'était applicable, nous avons limité notre étude des preuves des impacts des politiques

aux documents examinés par des pairs. Cela exclut les très nombreuses analyses importantes

réalisées par des ONG comme la Banque mondiale et CapacityPlus, analyses dont il est fort

probable qu'elles offrent un grand potentiel d'information sur les types de politiques étudiées ici,

mais qui sont rarement publiées dans des revues universitaires.

Principaux messages

Compte tenu des méthodes et des limites de l'examen, plusieurs points importants sont ressortis

assez souvent et assez clairement pour être mentionnés.

1. L'écart entre la planification et la mise en œuvre : Une grande variété d'interventions

stratégiques en RHS et dans le domaine plus large des politiques touchant le système de

santé semblent avoir été mises en place pour améliorer la formation et le déploiement, en

Afrique rurale, de médecins, d'infirmiers, d'infirmières et de sages-femmes en santé

maternelle et infantile. On constate cependant une forte incompatibilité entre le nombre et la

portée des politiques et des stratégies proposées et ce qui est mis en place, et la mauvaise


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santé maternelle et infantile est toujours répandue en Afrique rurale. De plus, nous avons

souvent observé l'absence d'orientation claire pour les politiques mises en place. Cette

divergence entre la planification et la mise en œuvre peut être due à de nombreux facteurs

économiques, sociaux, politiques, environnementaux et technologiques, dont seuls certains

sont dans la sphère d'influence directe des ministères de la Santé.

2. Sous-financement : Aucun des huit pays étudiés en profondeur n'a respecté les engagements

qu'il a pris dans la Déclaration d'Abuja de 2001. Le sous-financement est la cause la plus

souvent citée comme obstacle aux améliorations dans le secteur de la santé. Il est essentiel

d'augmenter le financement pour la santé des populations de ces pays.

3. Visibilité des politiques : Il faut améliorer la visibilité des ministères de la Santé en ce qui a

trait à leurs diverses politiques. Malgré les stratégies de recherche à volets multiples décrites

plus haut, à cause de l'absence de politique d'archivage des documents sur les sites Web des

ministères de la Santé, il a été impossible de trouver pour les huit pays étudiés en profondeur

aucune des politiques spécifiques couvertes par notre analyse, laquelle a par conséquent été

limitée aux preuves obtenues de sources secondaires.

4. Indisponibilité de preuves : Il y a pénurie de documents examinés par des pairs traitant de

la mise en œuvre et des impacts des politiques sur les RH en Afrique. Cela est peut-être dû en

partie au fait que les preuves recueillies sont souvent publiées par des ONG comme Banque

mondiale; il semble qu'aucune preuve du genre ne soit publiée par les gouvernements, même

lorsque ces preuves existent. Ainsi, une grande partie de preuves importantes sur les

politiques est ou non publiée ou éparpillée sur les sites Web d'une multitude d'organisations

où il n'est pas possible de faire rapidement des recherches systématiques, ce qui limite

considérablement l'avantage de les utiliser dans l'élaboration de futures politiques et

pratiques. Dans ce contexte, une organisation internationale comme l'OMS pourrait jouer un

rôle important et favoriser la collecte systématique de documents sur les pratiques

exemplaires et le partage d'autres preuves sur les politiques dans les divers pays, ce qui

présenterait des avantages formidables.

5. Parti pris de la recherche : Les documents évalués par des pairs qui ont été inclus dans

l'examen montrent clairement que la recherche sur la formation et le déploiement de RHS

dans les régions rurales est plus souvent effectuée dans les pays plus industrialisés. Non

seulement cette constatation suggère-t-elle l'absence de recherche là où elle est le plus

nécessaire (c.-à-d. dans les pays où sévit une crise des RHS), mais également que la majorité

des études sur la formation et le déploiement des RHS en régions rurales ne sont pas

généralisables dans les pays moins développés.

6. Innovation : La variété des interventions politiques décrites dans les documents examinés

montre le niveau d'innovation pratiqué par les pays africains dans leurs efforts pour améliorer

la santé maternelle et infantile chez eux. Même si certaines stratégies mettent l'accent sur les

professions traditionnelles – médecins, infirmiers, infirmières et sages-femmes – il semble


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que de plus en plus d'attention et de fonds sont consacrés à de nouveaux moyens, par

exemple des médecins cliniques et des travailleurs en santé communautaire. Nous avons

également réussi à trouver plus de preuves que ce dernier type d'initiative améliore plus les

résultats de santé.

7. Harmoniser services et compétences : L'introduction de nouveaux cadres de soins de santé

ayant d'importantes responsabilités justifie l'analyse régulière et systématique de la façon

dont les diverses compétences de tous les fournisseurs de soins de santé répondent aux

besoins spécifiques de services de santé des populations d'un pays en particulier. Ainsi, les

politiques de formation et de déploiement peuvent être adaptées continuellement pour suivre

le rythme des changements et des contextes en matière de santé.

8. Mise en place des fonds des donateurs : Les fonds provenant d'agences donatrices

constituent une grande partie des budgets en santé des pays africains, et il y a des preuves que

ces fonds sont utilisés à de nombreuses fins bénéfiques. Il y a cependant des preuves que ces

fonds pourraient être utilisés beaucoup plus efficacement si leur utilisation concordait de plus

près aux grandes priorités nationales en santé et s'ils finançaient des interventions étayées par

des preuves.

9. Gestion, surveillance et évaluation : Même si, de manière générale, les pénuries de

ressources sont un problème chronique et répandu, il en est de même pour l'absence de

capacité de gérer ces ressources efficacement et de suivre et d'évaluer leurs impacts une fois

qu'elles ont été mobilisées. Un investissement visant à renforcer cette capacité, notamment

par l'entremise d'une organisation internationale comme l'OMS, a donc le potentiel de

générer de grands dividendes à long terme.


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Síntese e revisão sistemática: Políticas sobre formação e distribuição de

RHS na África rural

Resumo executivo

Contexto

Os oito objetivos de desenvolvimento do milénio (ODM) divulgados no ano 2000 são

considerados um anteprojeto internacional que pretendem melhorar a saúde e o bem-estar da

população mais vulnerável do mundo. A saúde e o bem-estar das mulheres, dos recém-nascidos e

das crianças constituem o primeiro plano de muitos debates sobre políticas e planeamento

relacionados com os ODM 4 e 5. À medida que se aproxima a data de concretização dos ODM,

muitos relatórios de situações, principalmente em muitos países africanos, assinalam que

continua a haver desafios em atingir os objetivos 4 e 5. Em grande parte, isso deve-se ao facto de

África estar a passar por uma crise de recursos humanos para a saúde (RHS), em que a maioria

dos países daquele continente carecem de pessoal suficiente para prestar cuidados de saúde

básicos à população, sobretudo nas zonas rurais. A capacidade desses países responderem a essa

crise é duramente afetada por insuficiências em matéria de financiamento e infraestrutura. Um

planeamento e uma gestão eficazes dos escassos RHS disponíveis, principalmente no que se

refere à saúde materno-infantil, são de importância fundamental para os governos africanos. Para

comunicar esse planeamento, efetuou-se uma revisão sistemática das provas disponíveis sobre as

políticas de formação e distribuição de médicos, enfermeiros e parteiras no setor da saúde

materno-infantil na África rural.

Abordagem

A questão essencial que orientou a revisão foi a seguinte: O que se conhece sobre as políticas de

apoio à formação e distribuição de enfermeiros, parteiras e médicos no setor da saúde materno-

infantil na África rural? Outras perguntas complementares: O que se sabe atualmente sobre: (a) o

desenvolvimento; (b) a implementação; e (c) os impactos de tais políticas?

Sob a orientação de um Grupo Consultivo, empregou-se uma abordagem composta por duas

partes: a primeira consistiu numa revisão abrangente das provas disponíveis relacionadas com as

questões e que envolvem toda a África; a segunda consistiu numa síntese mais detalhada das

políticas de um subconjunto de países africanos, entre os quais: Etiópia, Gana, Mali,

Moçambique, Níger, Tanzânia, Uganda e Zâmbia.

Na síntese apenas foram inseridas as políticas para as quais existiam algumas provas de

aplicação/implementação. Além disso, as intervenções ou os programas individuais

implementados como parte dos planos mais amplos foram considerados políticas e analisados

integralmente na revisão. Apenas foram consideradas as provas resultantes da pesquisa publicada

em revistas científicas analisadas pelos pares, a fim de constituírem a componente “impactos” do

quadro de ação. Todavia, é observada a existência de outras provas resultantes de fontes não


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sujeitas a análise pelos pares (p. ex.: os relatórios do Ministério da Saúde), quando disponível,

tendo sido utilizadas para fornecer informação sobre outras componentes do quadro de ação.

Devido à escassez de documentação sobre políticas disponível para análise, deveremos ser

prudentes a tirar conclusões sobre a quantidade e qualidade das estratégias que estão a ser

realizadas nos países africanos relacionadas com a formação e a distribuição de médicos,

enfermeiros e parteiras para o setor da saúde materno-infantil nas zonas rurais. Esta questão é

explorada com mais profundidade nos capítulos “Resultados” e “Debate”, onde se descrevem

exemplos concretos de políticas identificadas durante a revisão que não satisfazem os critérios de

inclusão, mas que mesmo assim são prometedoras.

Resultados

As pesquisas na base de dados eletrónica produziram um total de 548 artigos analisados pelos

pares, dos quais 122 eram duplicações. Os restantes 426 artigos exclusivos foram combinados

com 87 artigos identificados pela equipa de pesquisadores zambianos e pelos membros do Grupo

Consultivo, totalizando 513 para análise. Destes, 37 satisfaziam os critérios de inclusão. O

conjunto definitivo de artigos abrangia 13 países, representando cada região de África. Gana teve

a representação mais alta com 9 artigos analisados pelos pares, seguido pela África do Sul e por

artigos que se aplicavam a várias nações, cada um dos quais com 5. Havia quatro artigos da

Etiópia e os restantes 10 países tinham um a três artigos cada. Os artigos selecionados eram

provenientes de 22 revistas diferentes. Os colaboradores mais frequentes foram o “Boletim da

Organização Mundial de Saúde” (Bulletin of the World Health Organization), “Políticas e

Planeamento para o Setor da Saúde” (Health Policy and Planning), “Temas sobre Saúde

Reprodutiva” (Reproductive Health Matters) e “Recursos Humanos para a Saúde” (Human

Resources for Health). A grande maioria dos artigos analisados pelos pares foram publicados a

partir de 2003, deixando entender qual o impacto que a introdução, em 2000, dos objetivos de

desenvolvimento do milénio exerceu na fixação de prioridades para a pesquisa e políticas. Além

disso, tais dados revelam que a pesquisa relacionada com os RHS e os ODM 4 e 5 está a ganhar

terreno.

A representação específica de médicos, enfermeiros e parteiras nos materiais literários era

razoavelmente equitativa. Todavia, muitos dos artigos selecionados englobavam os prestadores

implicitamente baseados nas políticas de alto nível, designadamente as que se relacionam com as

políticas de saúde nacional e as reformas no setor da saúde. As políticas centradas

exclusivamente na formação e distribuição representavam a minoria, enquanto que aquelas que

levavam em conta ambas as áreas, quer seja diretamente ou como componentes integrados de

políticas mais amplas, representavam a maioria. Os restantes materiais literários relacionavam-se

com políticas que não estavam explicitamente concebidas para abordar os ODM 4 e 5 nas zonas

rurais através da formação e/ou da distribuição dos prestadores selecionados, mas que tinham

aplicabilidade para os ODM 4 e 5 integrados ou inseridos em componentes de um mandato mais

abrangente no plano das políticas, designadamente as políticas nacionais sobre saúde infantil.

Apesar de não englobarem todos os aspetos dos critérios de inclusão, os artigos excluídos

revelaram a diversidade do trabalho que estava a ser realizado em relação ao processo de


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elaboração das políticas, enquanto relacionados com a formação e a distribuição de RHS, a fim

de melhorar a saúde materno-infantil nas zonas rurais.

No momento da revisão, os sítios Web avaliados dos ministérios da saúde dos países africanos

pertencentes aos três grupos linguísticos revelaram uma grande variação quanto à funcionalidade

e disponibilidade dos documentos pertinentes. Alguns sítios Web são muito exaustivos nos

materiais fornecidos. Os outros ministérios da saúde tinham sítios Web operacionais, apesar de

haver incoerências nos documentos fornecidos e na sua acessibilidade. Por exemplo, os

ministérios da saúde de vários países possuíam as bases e a estrutura para terem um sítio Web

totalmente informativo. Todavia, a existência de hiperligações interrompidas, segmentos com a

indicação “em construção” e falta de afixação de documentos sobre políticas contribuíram para

reduzir a sua capacidade de informação. Além disso, alguns sítios Web ministeriais nem sequer

foram localizados.

O âmbito dos sítios Web selecionados produziu uma ampla variedade de materiais literários

pertinentes e aplicáveis para o subconjunto do país: diretrizes profissionais e protocolos,

avaliações independentes de políticas, notas e atas de conferências e materiais literários

complementares analisados pelos pares. Tais documentos foram utilizados para informar o país

sobre a análise contextual e, além disso, para identificar políticas eventualmente pertinentes, a

fim de orientar pedidos específicos de informação complementar ao nosso comité consultivo.

A nossa revisão revelou a escassez de políticas inerentes à formação e distribuição de médicos,

enfermeiros e parteiras do setor da saúde materno-infantil na África rural. Contudo,

identificamos várias políticas que contemplavam cada um daqueles fatores, as quais se

encontram descritas em pormenor na parte principal do relatório.

Para além dos nomes das diversas políticas e dos amplos contextos em que foram desenvolvidas,

a nossa pesquisa revelou a escassez de informação disponível acerca da criação, implementação

ou impacto deste trabalho. Em particular, há uma escassez de provas científicas analisadas pelos

pares que se relacionam com os impactos destas políticas. Contudo, a maior parte dos materiais

literários reconheceu que os problemas continuam a persistir, os quais visavam ser abordados

pelas políticas.

Debate

Apesar da estratégia de pesquisa extensa e multifacetada, relativamente poucas políticas foram

identificadas na formação e/ou distribuição de médicos, enfermeiros e parteiras do setor da saúde

materno-infantil nas zonas rurais desses países. As políticas incluídas refletem a informação que

foi identificada e prontamente disponível para inclusão na nossa análise, utilizando os métodos e

as fontes acima indicados. Todavia, isto não deverá ser interpretado como uma falta de atenção

ou de medidas para abordar tais questões. Vários países estão a implementar diversos programas

importantes, a fim de abordarem os problemas que não satisfaziam os critérios exatos de

inclusão. Dois deles, em relação aos quais havia informação significativa, eram o Programa de


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Extensão de Saúde e o Projeto de Intervenção Essencial na Saúde, da Etiópia e da Tanzânia

respetivamente, os quais são descritos em pormenor na parte principal do relatório.

Em geral, é claro que os ministérios da saúde dos países estudados tentaram, e continuam a

explorar, uma vasta gama de opções para as políticas de RHS que visem melhorar a saúde

materno-infantil entre as respetivas populações. Porém, a implementação – e, por conseguinte, o

êxito – dessas políticas parecem estar duramente limitados por fatores económicos, políticos,

sociais, geográficos e tecnológicos que estão fora da influência direta desses ministérios. Além

disso, o alinhamento das políticas implementadas com estratégias nacionais mais vastas é, muitas

vezes, obscuro. Por isso, é importante observar a existência de pouca informação sobre as

políticas de saúde atualmente existentes nesses países, já para não falar dos pormenores acerca

da sua implementação e impactos, que esteja facilmente disponível e acessível por meio de uma

pesquisa exclusiva. As políticas tinham de ser analisadas unicamente com base em informação

secundária, dado não estarem disponíveis cópias das mesmas. Esta falta de visibilidade e

acessibilidade da informação torna virtualmente impossível uma avaliação objetiva dessas

políticas – necessário para uma melhoria significativa.

Áreas para um estudo complementar

Existe um grande potencial para aproveitar esta síntese em trabalhos futuros. As principais

limitações desta revisão foram a disponibilidade de informação sobre políticas pertinentes e a

margem de tempo disponível para efetuar a revisão. Relativamente ao último ponto, conforme

acima indicado, o alargamento da estratégia de pesquisa para documentos analisados pelos pares,

de forma a incluir os nomes dos países africanos, iria provavelmente produzir documentos mais

pertinentes. Da mesma forma, as pesquisas sequenciais de informação sobre políticas específicas,

uma vez identificadas, poderiam produzir informação complementar, bem como a exploração

das referências de documentos pertinentes. Para além disso, com a realização de entrevistas ou a

criação de grupos-alvo com pessoas-chave nos países selecionados iria provavelmente obter-se

mais conhecimentos profundos e documentos pertinentes. Por fim, apesar de termos citado os

relatórios publicados pelo governo e pelas ONG onde for aplicável, limitámos a apreciação das

provas sobre os impactos das políticas aos materiais literários analisados pelos pares. Isto exclui

a amplitude de análises importantes a realizar pelas ONG, tais como o Banco Mundial e a

CapacityPlus, os quais possuem grande potencial para informar os tipos de políticas aqui

consideradas mas que raramente são publicadas em revistas especializadas.

Mensagens fundamentais

Tendo em conta os métodos e as limitações da revisão, surgiram várias mensagens fundamentais,

de uma forma repetida e clara, que merecem ser levadas para o primeiro plano.

1. Lacuna entre planeamento e implementação: Parece ter sido implementada uma vasta

gama de intervenções estratégicas de RHS e políticas mais alargadas do sistema de saúde, a

fim de melhorar a formação e a distribuição de médicos, enfermeiros e parteiras para o setor

da saúde materno-infantil nas regiões rurais de África. Contudo, existe uma discrepância bem

notória entre o número e o âmbito de políticas e estratégias que são propostas e o que é


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evidentemente implementado, continuando a generalizar-se a escassez no setor da saúde

materno-infantil nas regiões rurais africanas. Além disso, encontramos frequentemente poucas

provas de uma orientação política clara em relação às políticas que foram implementadas.

Esta discrepância entre o planeamento e a implementação poderão dever-se a qualquer

número de fatores económicos, sociais, políticos, ambientais e tecnológicos, em que apenas

alguns estão dentro da esfera de influência direta dos ministérios da saúde.

2. Subfinanciamento: Nenhum dos oito países estudados em pormenor conseguiram satisfazer

os seus compromissos de financiamento no setor da saúde realizados ao abrigo da Declaração

de Abuja em 2001. O subfinanciamento é o desafio mencionado com mais frequência, o qual

impõe limitações para melhorar o setor da saúde. O aumento da distribuição de fundos é

fundamental para a saúde das populações desses países, a fim de se poder responder a esse

compromisso.

3. Visibilidade das políticas: Há uma necessidade de melhorar o grau de visibilidade oferecida

pelos ministérios da saúde a respeito das suas diversas políticas. Apesar das estratégias de

pesquisa multifacetada já indicadas, devido à falta de armazenamento da informação sobre

políticas nos sítios Web do Ministério da Educação, não conseguimos encontrar cópias de

nenhuma das políticas específicas inseridas na nossa análise para nenhum dos oito países

estudados em pormenor. Portanto, esta situação estava limitada às provas de fontes

secundárias.

4. Indisponibilidade de provas: Existe uma escassez de provas analisadas pelos pares, nas

quais se documentem a implementação e os impactos das políticas de RHS em África. Em

parte, isto pode dever-se ao facto de as provas a produzir serem frequentemente auto-

publicadas por ONG, como o Banco Mundial. Parece não haver quase nenhumas provas

publicadas pelos governos. Por conseguinte, uma grande parte das provas importantes

relativas a políticas não está publicada ou encontra-se dispersa nos diversos sítios Web das

organizações, o que não pode ser pesquisado sistematicamente em tempo oportuno. Por

conseguinte, esta situação limita grandemente a sua vantagem de informar as políticas e as

práticas futuras. Neste contexto, poderia ter vantagens impressionantes a eventual presença

de uma organização internacional, como a OMS, para facultar uma documentação mais

sistemática das melhores práticas e intercâmbio de outros documentos sobre políticas entre

países.

5. Tendências da pesquisa: As provas analisadas pelos pares inseridas na revisão revelam uma

tendência repetidamente identificada em relação à pesquisa sobre formação e distribuição de

RHS em zonas rurais, realizada em países mais desenvolvidos. Isto não apenas é um

problema que revela a ausência de pesquisa nos países onde é mais necessária (i.e. países

com crises de RHS), mas também a maioria dos estudos que estão a ser feitos sobre a

formação e distribuição em zonas rurais não é generalizável ao mundo menos desenvolvido.


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6. Inovação: A variedade de intervenções das políticas descritas nos documentos analisados

revela o nível de inovação que está a ser praticado pelos países africanos na tentativa de

melhorar a saúde materno-infantil. Embora algumas estratégias se concentrem em profissões

mais tradicionais como médicos, enfermeiros e parteiras, parece haver uma atenção e um

investimento cada vez maiores para novos elementos de pessoal dos quadros, como diretores

clínicos e trabalhadores de saúde comunitária. Além disso, conseguimos identificar mais

provas de sucesso para melhorar os resultados sobre a saúde em relação ao segundo tipo de

iniciativa do que ao primeiro.

7. Alinhamento de serviços e competências: A introdução de vários novos elementos de

pessoal dos quadros do setor da saúde com responsabilidades importantes garante uma

análise regular e sistemática sobre o modo de as várias competências de todos os prestadores

de cuidados se alinharem com os serviços específicos de assistência à saúde, solicitados pela

populações de um determinado país. Desta forma, as políticas de formação e distribuição

podem ser reguladas numa base permanente, a fim de acompanhar os contextos e as

carências evolutivas em matéria de saúde.

8. Alinhamento dos fundos de dadores: Os fundos provenientes das organizações dadoras

constituem uma grande parte dos orçamentos dos países africanos para a saúde, havendo

provas das inúmeras e vantajosas utilizações. Todavia, também existem provas de que tais

fundos poderiam ser usados de uma forma mais eficaz se a sua aplicação estivesse mais

estreitamente alinhada com prioridades de saúde nacional mais amplas, para financiar

intervenções baseadas em dados comprovados.

9. Gestão, monitoração e avaliação: Apesar da escassez de recursos em geral ser um problema

crónico e generalizado, o mesmo se aplica à falta de capacidade para uma gestão eficaz de

tais recursos e para acompanhar e avaliar os impactos que eles produzem quando são

mobilizados. O investimento na criação de tal capacidade, quer seja através de um organismo

internacional como a OMS, oferece o potencial para proporcionar excelentes dividendos a

longo prazo