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
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 maternalchild 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 peerreviewed 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 nonpeer-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 nonpeer-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
English, French, or Portuguese
Language of publication
1990 – 2013
Years published
Applied (i.e. not theoretical, but some evidence that the
Type of policy initiative
policy has been/continues to be implemented)
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
Country or countries of
focus
Policy focus
Type(s) of providers
Specific clinical focus
Jurisdictional focus
Types of data sources
Any African country whose official languages include
English, French, and/or Portuguese1
Training and/or deployment of providers as it pertains to
rural health
Doctors, nurses, and/or midwives
Maternal-child health: reproductive health, pregnancy, birth,
newborns, childhood disease, and adolescents
International or national (e.g. not provincial or districtspecific)
Policy documents, policy evaluations, professional
protocols/clinical guidelines, literature reviews, peerreviewed 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 nonpeer-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.
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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.
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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.
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 peerreviewed 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
10
9
8
7
6
5
4
3
2
1
0
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
5
4
3
2
1
0
n=32 as some articles mentioned more than one country
2
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
Year of publication is shown in Figure 6, and demonstrates that the vast majority of the peerreviewed 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
8
7
6
5
4
3
2
1
0
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).
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 socioeconomic 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).
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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.
Policy monitoring
and/or evaluations
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Other
Strategic plans
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-deorhs
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/healthworkforce
Zambia
 www.moh.gov.zm/
Policy documents
Country
Professional protocols/
clinical guidelines
Table 3: Information available on selected countries’ Ministry of Health websites
✔
✔
✔
✔
✔
✔
Phase II
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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.
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.
3
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5
Purchasing Power Parity (PPP) international dollars
Doctors, nurses, midwives (headcount) per 1,000 population
6
From HRH training programs, as % of # of established posts
7
Proportion of graduates from health training programs who enter employment with government health services
8
Per 100,000 live births
9
Per 1,000 live births
4
Details on the sources of these statistics are provided in Appendix 7.
Table 4: Country-Specific Contextual Data
A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 20062010 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
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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, nongovernmental 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 publicprivate 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 & BricenoGarmendia, 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 FiveYear 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
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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).
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 publiclyfunded 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 macroeconomic 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 20112015, 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 fiveyear 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,
4
An 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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, sociopolitical 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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
Mandatory public service after graduation
Ethiopia
Differentiated terms and conditions for pay & benefits
New Medical Education Initiative
2011
Nurse anaesthetist program
2010
Accelerated training & increased staffing for midwives
2009
Decentralized medical resident training
2000
Ghana
Deprived Area Incentive Scheme Allowance (DAIA)
2004
Health Staff Vehicle Hire Purchase Scheme
1997
Community-based Health Planning and Services program
1999
(CHPS)
Medicalization of rural areas
Mali
Mozambique No available information on applied policies meeting criteria
Scholarships for rural students
2011
Niger
Mobile health teams
2011
District-level surgery training
2005
No available information on applied policies meeting criteria
Tanzania
Incentives scheme for human resource in hard-to-reach areas
Uganda
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
One-year rural attachment for trainees
1991
Zambia
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 postgraduate 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 –
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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.
Country
Ethiopia
Table 6: Information Availability by Policy
Information Available on…
Policy
Development Implementation Impacts5
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
Mali
Decentralized medical resident
training
Deprived Area Incentive
Scheme Allowance (DAIA)
Health Staff Vehicle Hire
Purchase Scheme
Community-based Health
Planning and Services program
(CHPS)
Medicalization of rural areas
Niger
Scholarships for rural students
Ghana












As noted above, for the purposes of this review, only information published in peer-reviewed scientific
journals was considered as evidence of policy impact.
5
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
Mobile health teams
District-level surgery training
Uganda
Zambia
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
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
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
Ministry of Health, 2013). Although not specific to the mandatory public service policy, a midterm 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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.
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 evidenceinformed 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 redirected 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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).
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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,
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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
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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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II. Non-research documents
I. Research documents
Appendix 2: Evaluation templates for non-peer-reviewed literature
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III. Policies
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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
Democratic
Republic of
the Congo
Policy
analysis
Medical students
Training and
deployment
Ethiopia
Policy
analysis
Implicitly all
Deployment
Ethiopia
Policy
description
and analysis
Implicitly all
Training and
deployment
Ethiopia
Retrospective
situational
analysis
Implicitly all
Deployment
Ethiopia
Situational
description
and analysis
Secondary
analysis of
provider data
Implicitly all
Training and
deployment
Doctors and
midwives
Training
Specialist
training
program
evaluation
Policy
analysis
Medical residents
Training
Obstetricians and
midwives
Training
Specialist
training
program
evaluation
Medical residents
Training
Nurses
Deployment
Longombe, A. O., 2009
Community perspectives on roles and
responsibilities for strengthening
primary health care in rural Ethiopia
Curry et al., 2012
Human resource development for
health Ethiopia: challenges of
achieving the millennium
development goals
Girma et al., 2007
Health workforce deployment,
attrition and density in East Wollega
zone, Western Ethiopia
Michael et al , 2010
Reviewing Ethiopia's health system
Wamai, R. G., 2009
Return on Investment for Essential
obstetric care training in Ghana: do
trained public sector midwives
delivery PAC?
Andersen Clark et al., 2010
Who will be there when women
deliver?
Anderson et al. , 2007
Shaping legal abortion provision in
Ghana: using policy theory to
understand provider-related obstacles
to policy implementation
Aniteye, P. & Mayhew, S., 2013
Ghana postgraduate
obstetrics/gynecology collaborative
residency training program: success
story and model for Africa
Klufio et al., 2003
Policy talk: incentives for rural
service among nurses in Ghana
Ghana
Ghana
Ghana
Ghana
Ghana
Kwansah et al., 2012
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
Perceived barriers and motivating
factors influencing student midwives’
acceptance of rural postings in Ghana
Lori et al., 2012
Innovative community-based postgraduate training for obstetrics and
gynecology in West Africa
Marley et al., 1995
The impact of decentralisation on
sexual and reproductive health
services in Ghana
Mayhew, S. H., 2010
Accelerating reproductive and child
health program impact with
community-based services: the
Navrongo experiment in Ghana
Phillips et al., 2006
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
Do higher salaries lower physician
migration?
Okeke, N. E., 2013
Human resources for maternal,
newborn and child health: from
measurement and planning to
performance for improved health
outcomes
Gupta et al., 2011
Compulsory service programs for
recruitment in remote and rural
areas: do they work?
Frehywot et al., 2010
Reproductive health policies and
programs in eight countries: progress
since Cairo
Hardee et al., 1999
Ghana
Policy
analysis
Midwives
Deployment
Ghana
Specialist
training
program
evaluation
Medical obstetricgynecology
residents
Training and
deployment
Ghana
Policy
analysis
Implicitly all
Deployment
Ghana
Policy
analysis
Nurses
Deployment
Ghana
Policy
analysis
Doctors
Deployment
Ghana
Policy
analysis
Doctors
Deployment
International
(68 countries)
Cross-country
review
Doctors, nurses,
and midwives
Training and
deployment
International;
African
countries:
Ethiopia,
Ghana, Kenya,
Lesotho,
Malawi,
Mozambique,
Namibia,
Nigeria, South
Africa,
Zambia,
Zimbabwe
International;
African
countries:
Ghana,
Senegal
Policy review
and synthesis
Doctors, nurses,
and other healthcare
workers
Training and
deployment
Policy
revision and
implementatio
n analysis
Implicitly all
Page | 65
A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
Evaluated strategies to increase
attraction and retention of health
workers in remote and rural areas
Dolea et al., 2010
Reduction of maternal and perinatal
mortality in rural and peri-urban
settings: what works?
Kwast, B. E., 1996
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
The health worker recruitment and
deployment process in Kenya: an
emergency hiring program
Adano, U., 2008
Tackling Malawi's human resources
crisis
Palmer, D., 2006
The impact of primary health care
services on under-five mortality in
rural Niger
Mgnani et al., 1996
Impact of health systems
strengthening on coverage of maternal
health services in Rwanda, 2000-2010:
a systematic review
Bucagu et al., 2012
How to recruit and retain health
workers in underserved areas: the
Senegalese experience
Zurn et al., 2010
Analyzing the implementation of the
rural allowance in hospitals in North
West Province, South Africa
Ditlopo et al., 2011
Provision of abortion services by
midwives in Limpopo province of
South Africa
Sibuyi, M. C., 2013
Policy implementation and financial
incentives for nurses in South Africa:
a case study on the occupation-specific
dispensation
Ditlopo et al., 2012
Achieving effective cervical screening
coverage in South Africa through
International;
African
countries:
South Africa,
Mali, Niger
International;
African
country:
Nigeria
Policy review
and analysis
Non-specific
Deployment
Policy
description
Midwives
Training
Kenya
Policy
analysis
Nurses
Deployment
Kenya
Commentary
Implicitly all
Deployment
Malawi
Policy
analysis
Implicitly all
Training and
deployment
Niger
Policy
analysis
Implicitly all
Deployment
Rwanda
Systematic
literature,
policy, and
DHS review
Implicitly all
Training and
deployment
Senegal
Policy
description
Doctors, nurses,
midwives and other
healthcare workers
Deployment
South Africa
Policy
analysis
Doctors, nurses,
and other healthcare
workers
Deployment
South Africa
Policy
description
and analysis
Midwives
Training and
deployment
South Africa
Qualitative
case-study
Nurses
Deployment
South Africa
Case-study
Nurses
Training and
deployment
Page | 66
A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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
Effectiveness of health sector reforms
in reducing disparities in utilization of
skilled birth attendants in Tanzania
Kengia et al., 2013
The neglects of the global surgical
workforce: experience and evidence
from Uganda
Ozgediz et al., 2008
Improving facility-based care for sick
children in Uganda: training is not
enough
Pariyo et al., 2005
Newborn survival in Uganda: a
decade of change and future
implications
Mbonye et al., 2012
Health worker satisfaction and
motivation: an empirical study of
incomes, allowances and working
conditions in Zambia
Gow et al., 2012
Health worker shortages in Zambia:
an assessment of government
responses
South Africa
Policy
analysis
Nurses
Deployment
Tanzania
Quantitative
cross-sectional
analysis
Implicitly all
Training and
deployment
Uganda
Situational
and policy
analysis
Surgeons
Training and
deployment
Uganda
Policy and
program
analysis
Doctors, nurses,
midwives, and
other healthcare
workers
Training
Uganda
Policy and
situational
analysis
Implicitly all
Training and
deployment
Zambia
Policy
analysis
Doctors, nurses,
midwives, and
other healthcare
workers
Deployment
Zambia
Policy
analysis
Implicitly all
Training and
deployment
Gow et al., 2011
Page | 67
A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 | 68
A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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-findingsfirst-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. 1596/1813-94503686
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. mohghana.
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 | 69
A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 20072011. 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/2816271095698140167/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.
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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.
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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.
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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/wpcontent/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].
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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-tanzaniachallenges
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
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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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.
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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
African Centre for Global Health and
Social Transformation
African Health Workforce Observatory
URL
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
IDRC Development Research Information
Service
International Confederation of Midwives
www.hrhresourcecenter.org
International Council of Nurses
International Federation of Gynecology
and Obstetrics
Medicus Mundi
Regional East African Community Health
Policy Initiative
SUPPORT
www.icn.ch
THET Partnership for Global Health
www.thet.org
WHO Collaborating Centre for EvidenceInformed 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
www.achest.org
www.hrh-observatory.afro.who.int
www.idris.idrc.ca
www.internationalmidwives.org
www.figo.org
www.medicusmundi.org
www.hha-online.org/hso
www.support-collaboration.org
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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).
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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.
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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 quasiabsence 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 cidessus, 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 maternoinfantil 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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 autopublicadas 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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A Synthesis & Systematic Review: Policies on Training and Deployment of HRH in Rural Africa
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
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