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The lack of policy champions or entrepreneurs for HRH has been one of the reasons that the commitment of resources required for a major scale-up in production has not occurred. Within many Ministries of Health across Africa, few bureaucrats have the technical acumen to be effective policy champions. Those that do are often constrained by office politics [ 29 , 32 ].

The status of the position of the HRH director widely varies in ministries, and the role is not usually considered a prestigious or high-profile post. The position of a director or office chief is tied to a Principal Secretary PS or Director-General DG , who is usually the second in line under the Minister, and does not want to be viewed as disruptive or antagonistic [ 30 ].

Many donors provide assistance on an annual basis, which renders long-term planning impossible. Aid agencies drive Ministries of Health towards treatment of specific diseases e. Other health issues take precedent due to their urgency and relative ease to solve. While the MDGs did pressure developing countries and the donor community to mobilize towards achieving important targets in global health, the MDGs and the SDGs that have followed suffer from an emphasis on final targets without an adequate focus on intervening or secondary targets that influence primary health outcomes.

Traditionally, maternal mortality has been considered a robust proxy for the strength of a health system, but HRH issues like the production of more health workers were largely absent from the discussion of MDG 5 [ 33 , 34 ].

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The post global development agenda might be another missed opportunity as emerging issues, such as climate change, sanitation, water, and gender-based violence, crowd out the HRH issue. When donors want to address an issue in global health, they often decide that it will be through an alliance independent of the WHO, e. Notwithstanding the successes of these parallel structures, the pattern is clear: once WHO identifies a priority area, there is a tendency to establish a separate structure to work on the problem.

Much of the justification speaks to the rigidity of the WHO system, which in most cases means that donors want to retain absolute control of their resources through these structures [ 35 — 38 ]. Despite these successes, GHWA did not produce an adequate level of resource mobilization from domestic and international sources to address the shortage of health workers in the 37 African crisis countries.

GHWA also might have had the unintended consequence of isolating HRH and limiting the potential linkages to other health issues like maternal and child mortality. The Code was adopted after a protracted period of negotiation in May The guiding principles of the WHO Code include ethical international recruitment of health workers, a focus on the health system in the context of HRH sustainability, fair treatment of migrant health workers, support to developing countries and especially HRH crisis countries, data gathering on HRH migration, and information exchange [ 39 , 40 ]. With the Code came expectations that countries would make adequate investments in their HRH production and retention and would strengthen HRH governance structures.

The Code also called for bilateral and multi-lateral arrangements that recognize the contexts of different countries, e. Brain drain largely overshadowed the broader discussion at the World Health Assembly, which the Code addressed through three principles: 1 the right of a health worker to migrate is a human right; 2 countries are free to accept migrant health labor, but they should not recruit actively for it; and 3 labor-receiving countries have no responsibility to compensate labor-sending countries for their loss of labor [ 39 ].

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  • The final point continues to be particularly contentious among HRH crisis countries. The Code was viewed not as a path to deal with the HRH shortage systematically but rather as an unfair compromise in which the negotiation was a zero-sum game that labor-receiving countries won [ 41 , 42 ]. As a result, the Code was never the comprehensive framework or the disruptive force for HRH mobilization that it was intended to be.

    Within development circles, the issue of relevance became the most severe criticism of a political economy approach. If a change is to occur in the policy agenda, it usually happens due to a disruption in the political or institutional arrangements. This tumult in the status quo might take the form of a regime change, an election result, an emerging idea, or a new technology [ 17 , 18 ].

    This paper offers Ethiopia as an example of how HRH crisis countries might create the disruption needed to overcome the political and structural hurdles for greater health worker coverage. Upon the release of the WHO Report, Ethiopia had among the lowest health worker densities in the world. Ethiopia increased its health worker density including all cadres per population from 0.

    [Full text] Physician distribution and attrition in the public health sector of Et | RMHP

    The Ethiopian example shows that opportunities do exist in overcoming these political economy barriers. In the mids, Ethiopia committed to a long-term 20 plus years strategy to address health service provision. At a very low level of health worker density, Ethiopia recognized that progress in HRH would require decades to improve service coverage.

    In the face of a crowded development agenda, HRH needed to be linked with other development objectives to be prioritized. The Health Sector Development Program HSDP is a multiple-phase plan to improve health service coverage and provision in which HRH planning was explicitly part of all four of its iterations [ 43 , 44 ].

    Ethiopia also introduced a new cadre of health workers, the health officer, to provide basic health services and to manage the expansion of its public health service. In , the Ministry revealed its HRH Strategy , a plan that addressed higher skilled health cadres, in particular medical doctors, whose stock was planned to rise from less than in to 50, trained by Ethiopia is on track to meet this target, which is to be reflected in its number of physicians in [ 43 ].

    As a stepping stone to better service provision, the health workforce was prioritized in achieving better health outcomes. This framing of HRH formed the basis of the political will to sustain the program over many years. The power of the idea that HRH was a crucial element in improved health services disrupted the previous order by changing the priorities within the development agenda.

    The national long-term commitment to HRH resulted in access to resources with domestic stakeholders forced to work within the directive of the HSDP. One of the major obstacles for HRH crisis countries to raise their health worker density is the weak capacity of the government to plan and coordinate effectively. During the process of expanding the health workforce, Ethiopia implemented Business Process Reengineering BPR at all its federal and regional governing departments and units.

    BPR was a program to introduce results-based management to the public sector.

    No health without research

    Despite mixed results, BPR strengthened capacity in the government overall. The Ministry of Health demonstrated its increased capacity in the quality of its strategic planning in health and HRH, its donor coordination, and its management of large sums of ODA. Many national HRH plans suffered from similar problems: over-ambitious targets, disruptions or even abandonment due to leadership changes, little political support, and weak resource mobilization.

    Ethiopia differed in that it wrote its first HRH plan in , a decade before the publication of World Health Report The plan included a thorough costing of all activities; it was monitored rigorously and evaluated independently; and stakeholders, external and internal, considered the plans to be country-owned. The successive HRH plans became an advocacy tool domestically and globally, particularly for donors [ 45 — 48 ]. Ethiopia has had authoritarian governance for the last two decades, and there might be a temptation to argue that authoritarianism might be good for development and HRH specifically.

    Without the pressure from civil society or an electorate in a democratic society, as the argument follows, bureaucrats are free to act and implement effective development policies that might be unpopular in the short-term. Another interpretation of this argument is skeptical that democratic rule can promote good governance in new regimes in Africa [ 49 ]. This argument might seem compelling, but there are reasons to discount it.

    Many HRH crisis countries have authoritarian regimes, and they have failed to achieve any improvement in health worker density. Democratic regimes are likely to have better development outcomes, because mechanisms of accountability encourage politicians and bureaucrats to act on behalf of the common good [ 50 ]. In the case of Ethiopia, there is no way to know if the policy trajectory towards better health outcomes and increased HRH coverage would have been different or not under democratic rule. Ethiopia has received a large amount of ODA in health. While other countries, especially those with generalized HIV epidemics, experienced similar growth in health spending, a significant proportion of the ODA received by Ethiopia was allocated to support HRH production, which was not the case in other HRH crisis countries [ 24 , 47 , 48 ].

    This was a direct result of the strategic health plans adopted and implemented by the Ethiopian government which donors could support and convince their own stakeholders of the potential impact.

    Physician distribution and attrition in the public health sector of Ethiopia

    Even though donors have their own interests and face domestic pressures regarding ODA, they are also open to recipient country initiatives. Despite the inconsistency of annual ODA flows and large off-budget funding in vertical programs, Ethiopia channeled their assistance into increasing health worker density through thoughtful planning and coordination with donors. Its Ministry of Finance and Economic Development designed the Aid Management Platform to harmonize the various streams of ODA, which has become a best practice for donor coordination [ 44 , 47 ].

    This is why support from development partners, whether bilateral or multi-lateral, is increasing. Despite a global recognition of the gravity and urgency of health worker shortage in Africa, little progress has been achieved to improve health worker coverage in many of the African HRH crisis countries generally. Powerful political and institutional incentives push stakeholders at the domestic and international levels not to invest in HRH. The status quo of institutional arrangements needs to be changed for new policy choices to reach the top of the agenda, and ideas have the power to be the earthquake to disrupt the previous rules of the game.

    Good governance and some degree of bureaucratic capacity alone do not ensure a successful HRH plan. We argue that political will, in the form of a long-term commitment to HRH, is essential to mobilize internal and external resources. We also contend that this political commitment to HRH was the product of framing—policy entrepreneurs successfully tied more health workers to better health services for more Ethiopians. Donors play a vital role in the HRH space, but they should not be leading the charge.

    The case of Ethiopia shows that if recipient countries present a reasonable national HRH plan to donors, they are willing to support it through ODA, as long as the donors receive attribution for results that they can present to their legislatures or parliaments. The WHO target of 2.

    Consensus politics is difficult to practice and maintain in any country, and it has been elusive in most of the HRH crisis countries in Africa. Even though Ethiopia has enjoyed initial success, it requires at least another decade to reach the WHO health worker target. While Ethiopia provides an example of a country that is successfully navigating its way past the very same political economy challenges facing other African HRH crisis countries, it is abundantly clear that there remains no quick fix for the HRH shortage.

    The views and opinions expressed in this paper are those of the authors and not necessarily reflect the views and opinions of the United States Agency for International Development; the East, Central and Southern Africa Health Community; or the University of KwaZulu-Natal.