NATURALEZA DEL MAGNETISMO

Table 24. Baseline and targets for Human Resources for Health

EXPECTED OUTPUTS / OUTCOMES BASELINE 2011 TARGETS 2015 TARGETS 2018

% HF with adequate HR based on the norm

NA 50 TBD

Doctor / population ratio 1 / 16,001 1 / 13,748 1 / 11,993

Nurse / population ratio 1 / 1,291 1 / 1,291 1 / 1,000

Midwife / population ratio 1 / 66,749 1 / 45,000 1 / 25,000 Lab tech / population ratio 1 / 10,626 1 / 10,500 1 / 10,000 % DH/DHU preparing staff census

with iHRIS

The overall objective of Human Resources for Health (HRH) under HSSP III is to ensure availability of an adequate, equitably distributed, quality, motivated, and productive workforce responsive to the country’s changing needs and demands. Three key strategies, based on identified priorities, will be applied to achieve the set objectives, namely:

1. Increasing the quantity, scope, and quality of HRH to adequately respond to the country’s HRH needs;

2. Expanding and strengthening of the capacity of teaching institutions (TI) to augment HRH production;

3. Improving HRH management, ensuring rational deployment, adequate and equitable distribution, and retention of HR staff.

Human resources for health are one of the most important resources for a functional health system. For example, it is documented that reaching 80 percent coverage of skilled attendance at birth requires a threshold of 2.28 qualified medical personnel (doctors, nurses, and midwives) per 1,000 population (WHO’s World Health Report, 2006). It is also well known that there is a direct association between the level of skilled attendance and reduction in maternal mortality ratio. However, availability of quality health workers is an interactive process between factors associated with production, recruitment, deployment, motivation, retention, and appropriate management of exit from the workforce. These issues need to be taken into account when addressing HRH challenges.

5.2.1 Available human resources in Rwanda (2011)

The GOR has made considerable progress in the last five years in the area of HRH. As seen in Table 25, the set targets for health worker: population ratios for doctors and nurses were surpassed. While the ratio for midwives improved—even doubling between 2008 and 2009—the target was not achieved.

Table 25. Progress made in HRH from 2008 to 2011

BASELINE (2008) TARGETS (2010) PROGRESS July 2009–June 2011

1. Ratio medical doctors to population

1 / 33,000 1 / 20,000 1 / 16,001

2. Ratio nurses to population 1 / 1,700 1 / 5,000 1 / 1,291

3. Ratio midwife to population 1 / 100,000 1 / 20,000 1 / 66,749 As of February 2011, there were a total of 661 doctors: 470 Rwandan general practitioners, 133 Rwandan specialists, and 58 expatriate specialists (Rwanda Medical Council). Currently, the doctor : population ratio is estimated at 1 doctor for 16,001 population. The gap to attain the HR norms for doctors was estimated at 930 doctors (HRH Strategic Plan, 2011–2016).

Data of 2009 show a shortage of health workers, especially among (1) medical specialists (with a gap of 685 at district, provincial, and tertiary hospitals), (2) midwives, with a gap of 531 to achieve the norms, (3) biomedical engineers and technicians (in maintenance departments at central and hospital level), with a gap of 10 for engineers (A0) and 160 for technicians (A1); and (4) laboratory technicians, with a gap of 349. However, by December 2011, for most of the health cadres, there was an increase in numbers, thus narrowing the gap (see Table 26). On the other hand, the pharmacists have recently witnessed a worrisome reduction, a situation that is likely due to movement to more lucrative positions in the private sector. The doctors, nurses, and laboratory technicians are insufficient in terms of quantity. The majority of nurses and laboratory technicians are A2, but the required level is A1.

Table 26. Staffing gaps against norms for allied health professionals (2009 & 2011) Total Actual 2009 (District) Total Actual 2011 (District) Norm target Gap to Norm (2009) Gap to Norm (2011) Anesthesiology 90 118 160 70 42 Dental techs 78 66 80 2 14 Hygienists 160 223 540 380 317 Lab techs 931 880 1,280 349 400

Biomedical Engineers (A0) 1 2 10 9 8

Biomedical Technicians (A1) 20 20 180 160 160

Mental Health 50 67 80 30 13 Midwives 49 143 580 531 437 Nutritionists 74 124 540 466 416 Ophthalmologists 28 29 40 12 11 Pharmacists 111 65 80 -31 15 Physical Therapists 58 70 80 22 10 Radiology techs 44 59 80 36 21 Social Workers 766 925 660 -106 -265

Source: District Health Systems Strengthening Tool (DHSST), Dec. 2009 and HRIS 2011

On average there is about 1 nurse for a population of 1,500. There have been three categories of nurses in Rwanda—A2, A1, and A0. A2 level nurses are trained to the secondary school level, A1 nurses possess an advanced certificate in nursing obtained after three years of nursing school, while A0 nurses possess a bachelor’s degree. The overwhelming majority of nurses are A2. Currently, A1 nurses represent less than 10 percent of the total pool of nurses. A2 nurses are relatively evenly spread throughout the country, though there are still disparities between districts, with a number of under-served districts in the South, West, and Northern Provinces.

For the available health workers, the distribution favors urban areas, thereby exacerbating the low staffing levels among health facilities in rural settings. For example, there are virtually no midwifes in health centers and few in district hospitals, as most of them are found in the referral hospitals. Even there, they are still inadequate.

5.2.2 Status and challenges regarding the quantity, scope, and quality of HRH

Over the past years there has been a substantial improvement in numbers, quality, and deployment of staff at health centers and district hospitals. Since 2005, a number of reforms and new initiatives have positively impacted on HRH, ranging from decentralization of the management of human resources to new norms and standards. In light of the above initiatives and reforms, human resource information systems, planning, forecasting, career development, and succession planning capacity will require significant development at all levels, but particularly at decentralized levels. HRH needs at each level will need to be assessed, the A2 nurses and laboratory technicians—cadres that are being phased out—will need to be upgraded to A1, and the staff in the decentralized levels will be trained in health service planning and management.

The MOH HRH strategic plan covering the period 2011–2016 focuses on:  Ensuring a coordinated approach to HRH planning across the sector;

 Increasing the quantity of HRH through increased numbers of trained and equitably distributed staff;

 Increasing the quality of HRH, including improved productivity and performance of health workers;

 Increased capacity to plan, develop, regulate, and manage HRH.

5.2.3 HRH strategies and interventions

Efforts will be made to harmonize the HRH strategic plan and its implementation with the HSSP III, including aligning their end periods.

Norms and standards.

Furthermore, the MOH has developed HRH norms and standards based on workload and aligned to the essential health care package for the various levels of care that will inform the required human resources for the sector. With the new norms and standards, A2 nurses and laboratory technicians are being phased out, which calls for proper planning for upgrading them from A2 to A1 level.

HRH policy

The health sector is developing a guiding HRH Policy that will facilitate and make HR planning relevant and responsive to the HR needs. The role of the HRH Technical Working Group will be crucial in advising the MOH on policy, strategic plans and their implementation.

Training and education

Teaching institutions. Expanding and strengthening the capacity of Teaching Institutions (TI) by providing

pre-service and in-service training

The Faculty of Medicine at the National University of Rwanda (NUR) still remains the only academic

institution that trains physicians both at undergraduate and postgraduate levels. The Faculty consists of three departments: Medicine, Pharmacy, and Clinical Psychology.

Seven post-graduate clinical training programs are available to physicians in Rwanda: Internal Medicine,

Pediatrics, Surgery, Obstetrics & Gynecology, Anesthesia, Ear-Nose-Throat (ENT) Surgery, and Family Medicine and Community Health (FAMCO). Presently the NUR is developing several diploma courses, such as Emergency Medicine, Neonatology, Emergency Obstetrical Care, and Family Medicine and Community Health. During HSSP III, additional specialized programs such as Orthopedic Surgery, Neurosurgery, Neurology, and other subspecialties in Internal Medicine, Pediatrics, and Obstetrics and Gynecology will be initiated. In public health, the National University of Rwanda’s School of Public Health (SPH) provides four master’s degree programs. Another higher learning institution, the Kigali Health Institute (KHI), provides university-level training in ten allied health disciplines with qualifications at undergraduate and post-graduate degrees, as well as post-graduate certificates. Currently, only KHI is training laboratory technicians at A0 level and has a program to upgrade A2 laboratory technicians to A1. Over the period of HSSP III, the training of laboratory technicians and clinical officers will be expanded to increase the production.

For nurse and midwifery training, there are currently five nursing schools (Byumba, Kabgayi, Kibungo,

Nyagatare, and Rwamagana) under the MOH, and responsible for A1 nursing and midwifery education, which is now the minimal acceptable standard for nurses and midwives. This means that most A2 nurses and midwives will need to upgrade to A1. The schools are relatively small and have insufficient teaching capacity to meet the national desired annual enrolment of 250 students. Furthermore, the schools are faced with inadequate laboratory capacity, major lack of equipment and supplies, and inadequate hygiene facilities.

In order to meet the desired HRH norms and standards, substantial efforts are needed to increase the quantity of health professionals. The capacity of TI will be strengthened by increasing the number of TIs; expansion of infrastructure, equipment and staff; and further development and training of teaching staff. At the same time, improving and maintaining quality of the health professionals will receive great emphasis through strengthening of the professional bodies to monitor and evaluate the TIs for quality of training, accreditation, and best practices.

In-service training and mentoring

Furthermore, the Continuing Professional Development (CPD) program will be strengthened and extended to all health professionals. The quality of the training institutions will be further improved by reinforcing international partnerships with external training institutions. The referral hospitals will, in addition to providing specialized care, perform teaching and research functions and provide clinical mentorship to lower levels. Similarly, provincial hospitals will provide clinical mentoring to district hospitals that will in turn provide mentoring to health centers.

Professional regulation

Professional regulatory bodies play an important role in the health system by controlling the practice of health professionals and protecting the public from unsafe practices. Currently there are Medical and Nurses & Midwifery professional councils. Other health professionals are encouraged to establish councils. One of the strategies to scale up the health workforce will be capacity-building for HRH regulation and increasing regional harmonization of professional regulation.

During the implementation of HSSP III, professional bodies in Rwanda will strive to comply with requirements of member states of the East African Community to harmonize professional legal frameworks, education, and practice standards and regulatory tools.

Recruitment and retention

Under the current decentralized system, districts have the mandate to identify and fill existing staff vacancies. However, low human resource management capacity has contributed to delays in recruitment, placement, and promotions. The MOH will provide technical support and supervision to the districts to perform these functions in the short term. During HSSP III, the MOH, in liaison with MINALOC, will promote evidence-based HR planning and advocate for adjustments in budget ceilings to allow for recruitment, deployment, and distribution of required personnel to meet the existing staffing norms. Furthermore, inadequate salaries and limited opportunities for career growth and further training are key factors contributing to HRH attrition, particularly resulting from movement from the public to the private sector. The MOH and the Rwandan health professional councils are in the process of establishing career progression structures that will define career paths for all cadres of professionals, and identifying and operationalizing appropriate staff retention strategies. This will encourage retention and continuing professional development.

In the face of instability and high turnover of staff, especially in the remote areas, Rwanda has adopted performance-based financing to improve motivation and retention. However, the PBF indicators measured are at the facility level, and do not link to employee-level performance goals or evaluations. An individual employee evaluation form exists but is not applied consistently. The use of this form will be revived, and it will be used as a tool for supervisors, alongside HR management standard operating procedures (SOPs) to manage individual employee performance. PBF will continue to be reviewed for further improvements and other forms of incentives, financial and non-financial, will be explored.

Human resource information system

For better planning and management of HR, there is a need for decision makers to have timely and updated information on the state of human resources. To that effect a human resource information system (HRIS) has been installed and the necessary data are being entered. The HRIS will be strengthened by improving data collection, using appropriate software and a user manual, providing advanced training, and monitoring HRIS use. This system will be extended to all institutions nationwide for regular update and usage. The data will be captured, compiled, and analyzed to feed into the national human resource observatory, accessible to all managers for use and informed decisions. (See Section 5.8 for additional information.)