1. Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane Universitys School of Public Health Training Resources Group From Health Labor Market Analysis to Results- Based Financing: Insights from a Post-Conflict Country (Côte d'Ivoire) Gilbert Kombe, MD, MPH Senior HIV/AIDS and Infectious Disease Technical Advisor Health Systems 20/20 Project January 14, 2009

2. Discussion Outline Country Context and HRH Background Technical Approach Key Findings Use of Analytical Findings in Developing Key Interventions Take Home Messages

3. Country Context Population: 18,700,000 (2004) GDP per Capita: $1,650 (2006) HIV Prevalence Rate: 4.7% (2005) Like many SS African countries, CI s economy grew from 1960 -1990s Between 1999-2002, military started demanding salary increases which were unmet 2002, CI experienced the first coup d' é tat which brought General Robert Guei to power 2002 witnessed mass exodus of all health workers due to civil unrest In 2004, due to insecurity, health workers fled, relocated or were unable to go to work Public health sector lost one-fifth of medical doctors and one quarter of nurses WHO estimated that 70% of health facilities across the country were not functioning

4. Health Coverage per Inhabitant 199819992000 1PHC per 13,5161PHC per 12,1121PHC per 12,257 1 public hospital per 225, 979 1 public hospital per 237,185 1 public hospital per 230, 983 1 bed per 2,6431 bed per 2,6911 bed per 2,890 Doctor1/9,739, Nurse 1 /2,374, Midwife 1 / 2,081

5. HRH Situation: Per Cent Vacancy Rates By Cadre Cadre 20012004 PostsFilledVacancy(%)PostsFilledVacancy (%) Doctors 16011924.724711752.7 Pharmacists 702268.61132+90 Dental Surgeons 2520 16156.25 Nurses 13003777194930567.9 Midwives 50017365.447319664.3 Special Health Technicians 2272193.521118711.4

6. HRH Expenditures in the Context of Total Health Budget YearTotal Health Budget (USD) Total Cost of Salaries (USD) Salary as % Total Health Budget 1997$206,510,417$73,520,83336% 2000$205,331,015$49,494,74324% 2003$159,714,432$50,859,39832% 2005$148,840,210$52,537,76335%

7. Why Health Systems 20/20 Project Focused on HRH? Modeling exercise for PEPFAR indicated HRH shortage is a common problem in Sub-Saharan Africa HRH was a reflection of social, political, and economic challenges Little was being done to address this issue With increased burden of HIV/AIDS, Malaria and TB, came projected increase in human resource need HRH growth rate in many countries was very slow compared to population growth

8. Why USG cared about HRH in CI What was the impact of HIV/AIDS on HRH shortages? Questions about reaching targets of major initiatives e.g. MDG & PEPFAR Are there staff to run facilities? Investments in drugs and supplies will be wasted HW growing slower than population

9. Typical Dynamics of the Health Labor Market

10. Technical Approach Three interrelated approaches were used. Conducted a comprehensive desktop review of both published and unpublished documents. Conducted key informant interviews with Ministry of Education, Ministry of Health and Population, development partners, and other key stakeholders. Facility surveys of HRH in public and private health facilities (2 phases) In 2005, collected data from 301 public facilities (primary, secondary, tertiary) out of 1,381 across the country (MOH, 2005). In 2006, collected data from 279 facilities (polyclinics, clinics, medical centers/practices, nurse/midwife practices, social medical centers, village enterprises) out of 1,144 (MOH, 2005). Included training institutions.

11. Fundamental Analytical Questions 1.How big was the issue of HRH across the country? 2.How many doctors, nurses, laboratory technicians, social workers did the country have? Were they available? How were they distributed? What proportion of HRH should go to HIV/AIDS, Malaria, TB? 3.How much would it cost to intervene and can the Ivorian government alone address the issue? 4.What were the health system wide effects of the HR crisis?

12. Assessment Limitations Outdated national data from DHR. Data registers did not reflect the existing situation of demand and supply. Data on HRH in the private sector was scarce; no data since 1997. Difficult to make comparisons between past and future HRH growth rates of private providers. Data from training institutions did not indicate where graduates were going.

13. Findings

14. I.Supply of New Graduates The Unite de Formation et de Recherche des Sciences Medicales de lUniversité de Cocody Doctors trained in 2004 (280) and in 2006 (203). Faculty-to student ratio ranged from 1:15 to 1:87. (2006) Institute National de Formation des Agents de Santé (INFAS, laboratory technicians) Nurses/Midwives 2004 (1,545), 2005 (1,818), 2006 (2,176). Instructors 2004 (66FT), 2005 (71), 2006 (71). The Institute Nation de Formation des Agents de Santé 117 (2004) to 160 (2005) and 218 (2006). Faculty-to-student ratio 2004, 2005, and 2006 are 1:117, 1:160, and 1:218, respectively.

15. II. Not All Graduates are Employed by the Public Sector Staff TypeUFR Graduates in 2004 # Hired by the Public Sector Unemployed or Hired in Other Sectors Doctors312117195 Pharmacists963264 Dental Surgeon 261511

16. II.Very High Annual Attrition Rates Among Public Health Workers

17. III. Small HRH Growth Over Time Staff Cadre HR Stock in 2004 Average Annual Number of Graduates (2002-04) 40% Hiring in the Public Sector (2002-04 Average Annual Attrition rate (2003-04) 200520062007 Doctors1,5923361340.09158315741567 Midwives2147142570.09201118871774 Nurses68423131250.07648861595853 Pharmacists200118470.09239276312 Lab Techs46038150.04457454451

18. IV.Distribution of Public Health Workers Skewed Towards Abidjan In 2002, the Lagunes region had 64% of doctors, 48% of nurses, 74% of pharmacists, 48% of lab technicians and 67% of social workers. In 2004, the figures rose, especially among lab technicians (66%) and social workers (77%).

19. V. Private Sector Using a Combination of PT & FT Workers

20. VI.Growth Among Part- and Full-Time Private Physicians

21. VII.HRH Length of Service in Private Sector Facilities Interviewed 279 HW. 33% of HCW worked for over 11 years 27% spent between 6-10 years 18% worked 3-5 years Only 8% spent between 1-2 years

22. Using Health Labor Market Data for Policy Program Planning Development of a 5-year National HRH Policy Emergency hiring of nursing instructors Development of pilot incentive scheme Strengthening human resource information system Strengthening of management of HRH

23. A. Development of a National HRH Policy

24. Key Components of the 5-Year Strategy

25. B. Emergency Hiring and Management Strengthening Hired 35 clinical nursing instructors and mentors for 3 institutions Reduced the faculty-to-student ratio from 1:39 (2007) to 1:28 (2008) Trained 187 central, provincial and district managers in health services management Developing HRIS at the central and provincial levels

26. C. Incentive Scheme Pilot in Ferke District

27. Facts About Ferke District Population (2007): 330,048 HIV/AIDS Prevalence: 16.76% among those tested at facilities Infant Mortality Rate: 127 per 1000 Private Sector Health Facilities: 1 Hospital 2 Health Facilities 3 Dispensaries Public Sector Health Facilities: 1 District Department 2 General Hospitals 1 National Institute of Public Hygiene 4 Urban Health Facilities 6 Rural Health Facilities 8 Rural Dispensaries

28. Elements of the Incentive Scheme MOH, DMO, Unions, USG Implementing Partners Monthly 10% Salary Top-Up for Participating Health Workers Quarterly Pay-for-Performance Bonus for Participating Health Workers Quarterly Performance Bonus To Participating Facilities Based On Targets Met/Exceeded

29. HRH Included in the Pilot Incentive Scheme Participants: District Department (6 facilities): 1 physician; 1 chemist; 1 assistant chemist; 3 nurses 2 General Hospitals: 8 physicians; 2 chemists; 1 assistant chemist; 7 nurses; 3 nurse specialists; 5 midwives; 1 lab tech; 2 orderlies 3 Urban Health Facilities: 3 physicians; 4 nurses; 3 midwives 1 Rural Facility: 1 nurse; 1 midwife Total Salary Top-Up: $24,172/month

30. Take Home Messages HRH issue must be on the national and international agendas and action must be taken now Implementing sustainable solutions requires time and resources to be successful HRH interventions must not be more of the same... we need to implement comprehensive solutions in public and private health sectors e.g. P4P,incentives, focus on increasing productivity There are no one-size-fits-all solutions Outcome-oriented, innovative, learning-oriented and system-linked We must not walk away from HRH issues, we must walk into them Long-term cost of not acting now is very high