Global initiatives on HRH and information systems

The health workforce is increasingly recognized as key for scaling up health interventions for achieving the Millennium Development Goals (Box 1.3) (8). Even with additional funds available in recent years from international, multilateral, bilateral and private sources, such as through poverty reduction strategies and debt

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alleviation programmes, or through newer modalities such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (9), the GAVI Alliance (10) and the United States President’s Emergency Plan for AIDS Relief (11), country capacity to absorb funds and to put them to work can be severely crippled by the crisis in HRH. In many countries there is simply insufficient human capacity at all levels to absorb, deploy and use efficiently the financing for scaling up health services delivery offered by recent initiatives.

A series of high-level forums on the health Millennium Development Goals (12), the HRH strategy report of the

Joint Learning Initiative (13), the WHO flagship publica-tion The world health report 2006: working together for health (4), the resolutions of World Health Assemblies on health workforce development (14), and the launch of the Global Health Workforce Alliance (15), as well as certain regional partnership mechanisms such as the Asia-Pacific Action Alliance on Human Resources for Health (16), were among a cluster of international activities that alerted national, regional and interna-tional policy-makers and stakeholders, including the media, civil society and the general public, to the criti-cal importance of HRH worldwide, especially the HRH crisis in sub-Saharan Africa.

Box 1.1 Defining monitoring and evaluation

Monitoring. The ongoing process of collecting and using standardized information to assess progress towards objectives, resource usage and achievement of outcomes and impacts. It usually involves

assessment against agreed performance indicators and targets. In conjunction with evaluation information, effective monitoring and reporting should provide decision-makers and stakeholders with the knowledge they need to identify whether the implementation and outcomes of a project, programme or policy initiative are unfolding as expected and to manage the initiative on an ongoing basis.

Evaluation. The systematic and objective assessment of an ongoing or completed initiative, its design, implementation and results. The aim is to determine the relevance and fulfilment of objectives, efficiency, effectiveness, impact and sustainability. The development of an evaluation framework entails consideration of a range of matters, including identification of the types of data that could inform an evaluation.

Indicator. A parameter that points to, provides information about or describes a given state. Usually represented by a data element for a specified time, place and other characteristics, it gives value as an instrument used in performance assessment.

Data. Characteristics or information, often numerical, that are collected through observation. Data can be considered as the physical representation of information in a manner suitable for processing, analysis, interpretation and communication.

Sources: Adapted from Deloitte Insight Economics (5) and Organisation for Economic Co-operation and Development (6).

Box 1.2 Toolkit for monitoring health systems strengthening

The ability to plan, monitor and evaluate health systems functioning is essential in order to correctly target investments and assess whether they are having the intended impact. Health systems can be described in many ways. The WHO framework delineates six core building blocks: service delivery, health workforce, financing, information, leadership and governance, and medical products and technologies. Through collaboration between WHO, the World Bank, country health information and systems experts and many other organizations working in this field, a toolkit was developed proposing a limited set of indicators and related measurement strategies covering each of the building blocks. As of mid-2008, the Toolkit for monitoring health systems strengthening was being made available while still in draft form to invite comments from a wide array of potential users.

Source: World Health Organization (7).

Monitoring and evaluation of human resources for health: challenges and opportunities

Raising awareness of the critical role of HRH places the health workforce high on global public health agendas.

Countries, donors, international agencies and other stakeholders are increasingly willing not only to invest in but also to contribute to HRH development overall.

The critical role of human resources in the achieve-ments of health systems objectives is more and more recognized and valued.

At the same time, there is an increased demand for trans-parency and performance measurement. For instance, the Global Fund and GAVI Alliance, which spear-head the principles of performance-based release of donor funding, have recognized the need to channel more of their disease-specific funds towards sustaina-ble, comprehensive health care that is accessible and affordable to all. Other recent international initiatives seeking to accelerate progress towards achieving the health-related Millennium Development Goals, together with all major stakeholders, including the International

Health Partnership (17) and the Global Campaign for the Health Millennium Development Goals (18), empha-size the principles of health systems support to achieve improved health outcomes. Increased opportunities for funding health systems strengthening through primary health care means more opportunities for investing in improving the quality of human resources.

To this end, countries are called upon to provide clear and consistent evidence in their requests for both new and ongoing resources for HRH development.

This is also true for decision-making and allocation of resources from national sources. Ministries of health in many low- and middle-income countries face addi-tional challenges posed by the effects of decentralizing responsibilities for both budget and information sys-tems to district authorities, with often incomplete or inconsistent transfers of authority hampering proper decision-making processes.

Box 1.3 Health-related Millennium Development Goals

In September 2000, at the United Nations Millennium Summit, all countries committed to collectively working towards a series of eight goals and 18 related targets for combating poverty and its determinants and consequences, under a compact known as the Millennium Development Goals. Much investment was subsequently allocated for measuring progress towards the achievement of these targets, including a strong focus on monitoring coverage of prioritized health interventions and population health outcomes.

More recently, attention has been directed to addressing and monitoring the health systems inputs, processes and outputs that impede or facilitate progress.

Goals Related targets

1. Eradicate extreme poverty and hunger Halve, between 1990 and 2015, the proportion of people who suffer from hunger

4. Reduce child mortality Reduce by two thirds, between 1990 and 2015, the under-five mortality rate

5. Improve maternal health Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

6. Combat HIV/AIDS, malaria and other diseases

Have halted by 2015 and begun to reverse the spread of HIV/AIDS

Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

7. Ensure environmental sustainability Halve by 2015 the proportion of people without

sustainable access to safe drinking-water and sanitation 8. Develop a global partnership for

development

In cooperation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries

Source: World Health Organization (8).

The importance of sound empirical evidence for informed policy development, decision-making and the monitoring of progress towards achieving HRH devel-opment and strengthening health systems is widely recognized. Evidence is needed to support countries to make the case for HRH both in national budget allo-cation and in their cooperation with donors. However, knowledge about what works and what does not is still very limited, signalling a need for more evidence and further research. The launch of the Health Metrics Network (19), a partnership aiming to increase the availability and use of timely and accurate health infor-mation by catalysing the joint funding and development of core country health information systems, was a big step forward in improving the information and evidence base, including on HRH (Box 1.4).

However, despite the global initiatives to assist in this core area of health systems strengthening, there is little consistency between countries in how HRH strategies are monitored and evaluated (20), thereby limiting the capacity of stakeholders to rationalize the

allocation of resources. In many countries, the prob-lem partly emanates from the fragmentation of HRH information and the shortages in human, financial and infrastructural resources available to collect, compile and analyse health workforce data (Boxes 1.5–1.7) (21–

24). Moreover, the lack of standard tools, indicators, definitions and systems of classifying health workers has placed further constraints on using HRH informa-tion for evidence-informed decision-making.

Strengthening HRH information and monitoring sys-tems requires a better foundation for policy-making, planning, programming and accountability. A range of tools and resources exists to assist countries in devel-oping a national HRH strategic plan (25–27); technical assistance for developing and costing these plans can be sought, but having the necessary underlying data is a prerequisite. The Kampala Declaration and Agenda for Global Action, adopted by the First Global Forum on Human Resources for Health (28), called upon governments, in cooperation with international organ-izations, civil society, the private sector, professional

Box 1.4 Assessment and strengthening of HRH information systems

Assessment and strengthening of national HRH information systems are integral components of efforts to strengthen the evidence base on the health workforce. An assessment of the capacity of a country’s HRH information system to support decision-making may include consideration of:

ttimeliness of the system;

tvalidity of the information contained within the system;

tconsistency across information sources (to allow for comparisons within and across countries and over time);

tlevel of disaggregation of the information within the system, to allow for in-depth analysis on issues of relevance to HRH strategic planning.

In 2006–2007, in collaboration with the Health Metrics Network (19), assessments of the national health information system were conducted in selected low- and middle-income countries, drawing on a standard assessment and monitoring tool. Using a scaled

questionnaire in relation to four core dimensions of national capacity and contents of the HRH database, results of the self-evaluations showed a score of 6.1 out of a possible 12 in Afghanistan, 6.9 in Eritrea, 5.2 in the Republic of Moldova and 7.5 in Sudan (see graph). Of the four core dimensions, tracking the output of health professions education institutions was ranked lowest in most countries.

1.5

Tracks output of health professions education

Results of an assessment of the HRH information systems in selected countries, 2006–2007

Monitoring and evaluation of human resources for health: challenges and opportunities

associations and other partners, to “create health work-force information systems, to improve research, and to develop capacity for data management in order to institutionalize evidence-based decision making and enhance shared learning”.