EQUINET in co-operation with ECSA-HC have, with government and researchers in five countries, carried out review and field studies on the implementation of incentives for health worker retention and of their impact on the adequacy and distribution of health workers. A regional meeting was held in February 2009 to review this work and other work on health worker migration and distribution in EQUINET in Windhoek Namibia, locally hosted by the University of Namibia. The recommendations of the meeting are shown below. For further information please contact us at admin [at], using "HCW Retention" in the subject line.

Recommendations from the regional meeting on health worker retention in East and Southern Africa February 27 2009

The EQUINET –ECSA HC regional meeting on health worker retention in east and southern Africa (ESA) was held in Windhoek, Namibia February 25-27 2008 and involved 32 delegates from government, academic and research institutions, health worker organisations, parliament and civil society from 10 ESA countries and from regional organisations including SADC and WHO (see delegate list). In line with the ECSA Regional Health Ministers Conference (RHMC) resolutions 2006-2008, the SADC Resolutions on Health workers, and the ECSA and SADC strategies on health workers, the meeting reviewed evidence from two regional review papers, five country field studies (see reference list), a multi-country participatory research programme and delegate experience to propose areas for policy, guidelines and research on health worker retention, especially in priority health services. ...

The evidence presented reinforced the existing policy understanding of the crisis in human resources for health (HRH) , reflected in inadequate numbers of critical health personnel, high levels of external and internal migration, poor distribution of staff in areas of high health need, low staff morale and some report of health worker abuse within the region. There has, until recently, been inadequate attention given to systems planning and many ministries of health lack information systems and management capacities to plan responses. Fiscal thresholds have diminished state leeway to increase health worker employment in some of the countries. Underlying this, delegates recognized the critical contribution of economic decline and political instability as factors driving out-migration of health workers. The 2005 SADC health ministers meeting identified non availability of skilled health professionals in member states as undermining achievement of key Millennium Development Goal targets.

At the same time opportunities exist in the political and policy recognition of the crisis at national, regional and international level, in the capacities for training in the region, in the availability of significant global and international resources for systems strengthening, and in numerous examples of good practice from within the region. Tapping these opportunities and improving the health worker situation depends fundamentally on improving the economic conditions and political stability of countries in the region.

The country studies presented at the meeting demonstrated that, beyond salaries, the push factors for health worker movement commonly include poor work environments and conditions, poor communication resources at facilities and poor communication within the health system, inadequate management and supportive supervision, heavy workloads and inadequate recognition. HRH policies and a number of non financial incentives (NFIs) were being applied across all countries, but gaps existed with respect to
 Implementation, monitoring and evaluation
 Sector wide vs cadre specific NFIs
 Impact assessment of NFIs
The country studies indicate a need to intensify focus on issues of operationalising and implementing NFIs sector wide, taking the influence and role of other sectors beyond health –including public service, finance, public works, education and housing- into account.
Policy recommendations
The meeting noted that producing and retaining HRH are a priority focus for addressing the health worker crisis, within the context of National Health Strategic plans and strengthened HRH planning, information and management that addresses HRH demand and supply. The meeting proposed a number of policy options for strengthening HRH retention, i.e.

Planning and implementing HRH retention strategies
 Retention packages should preferably be health sector wide, based on needs assessment and intersectoral and stakeholder input; be costed and supported by an HRH monitoring system and an institutional capacity to manage incentives.
 HRH policies should aim to build cohesive and functional health teams, respect health workers rights and responsibilities towards patient and community rights, with clear and comprehensive regulatory frameworks.
 Non financial incentive retention strategies valued by workers across most countries include: career paths; stimulating training and encouraging deployment through investment in services (including “centers of excellence”); providing housing mortgages / loans; rewarding performance and securing health worker health and access to health care. Delegates proposed that these be considered as core retention strategies, applied across all countries, even while further locally relevant strategies are considered.
 Training should be in line with labour market demands and support career guidance programmes, to guide proper selection of training courses
 Retention strategies should be regularly reviewed and stakeholders informed about the progress and impact of incentives.

Financing HRH retention strategies
 Governments must increase budgets for health to meet the Abuja commitment of 15% government spending on health, and encourage donors to pool funds into sector wide incentive schemes for HRH.
 Financing schemes for HRH should be owned by countries, aligned with countries’ needs (through needs assessments), strategies, systems and procedures, and external funder actions harmonized with national plans, with issues of governance and management addressed where external funds are reported through existing local financing systems.
 Sustainability of resources for HRH incentives needs to be addressed in the National Strategic Plan, including provision for transfer of skills and knowledge to local personnel.
 Countries and regional organisations need to enhance coordination at regional and country level to increase effectiveness of development aid, and SADC to adopt a common position / guidelines on externally funded projects based on the five principles of the Paris Declaration on Aid Effectiveness.

On capacity and systems support for HRH retention
Capacity strengthening necessary to implement HRH retention incentives includes:
 training of health workers in use of healthcare management tools (standards, guidelines);
 strengthening institutional capacities for improved governance and delegating more power and authority to and capacitating the district level of health systems;
 developing and/or reviewing HRH /staff development policies to address current issues relating to training, promotion, career paths and other incentives;
 establishing or improving performance management systems with clear-cut rules of performance and independent evaluations;
 Delegates proposed that a network of HR professionals be formed in the region, including HRH management and research personnel, with provision for annual meetings for information and professional exchange.
In addition to retention incentives the meeting reviewed evidence and proposed policy options for strengthening the effective performance of HRH, ie:

Strengthening the Primary Health Care (PHC) orientation of health workers
Noting the policy priority expressed by countries in ESA to strengthen PHC as an approach across the health system as a whole, to mainstream specific programmes within PHC and to strengthen the community, primary and district levels of the health system, delegates proposed that:
 Governments take leadership in the provision, supervision and support of Community Health Workers (CHWs), that HRH strategies include the Community Health Worker cadre, and provide for the resources for their training and functioning.
 Health sectors involve primary care level health workers and community representatives in local health planning.
 Primary level health worker roles in facilitating and managing community programmes / interactions be recognised in health worker performance appraisal incentive and management systems.
 Training modules be developed for HRH on public health planning and management and on communication and facilitation skills; with training integrated into HRH training and induction;
 Incentive schemes address specific non financial incentives for primary level health workers in rural communities, including but not limited to support for housing construction (to stabilize them in these areas) and schooling for children.
• Personnel in other sectors, such as transport, infrastructure, water, be oriented and encouraged to play their role for PHC to be effective.

On task shifting
 Policy dialogue on task shifting needs to be backed by more evidence on current practice and skills needs, to be based on task analysis, to be linked to policies on career path development and to take into account industrial relations implications.

On HRH migration
 The right to move and free movement of labour needs to underpin responses to migration, together with the need to protect health care services. This calls for capacities to negotiate agreements on migration, supported by databases and information on HCW migration and its impact, including on health systems.
 Legally binding bilateral and multilateral agreements should respect the rights of migrating workers and of communities from sending countries, ensure that migrating workers are not paid less than those in receiving countries, and provide for receiving countries to meet costs of losses to the health systems in sending countries, such as through investment in the retention incentives, working conditions and training programmes of sending countries.
 Delegates encouraged SADC to implement its proposals to standardise the systems for qualification, registration, training and the curricula and for this standardisation to be more widely applied within the ESA region.
 Delegates recognised that internal migration within ESA countries is a major factor affecting access to quality health care and encouraged strategies and agreements for management of migration within and beyond the region to explicitly address this issue.

The meeting identified areas and recommended follow up work at regional level to develop guidelines to support health systems responses on HRH:
 Guidelines to support development of, and analysis of data from information systems to support planning, monitoring and evaluation, including indicators on: reasons for why people are leaving; resignations, infrastructure, basic resources; NFI type, target group, funding agent and sustainability, perceived effectiveness of incentives.
 Management and Implementation guidelines for introducing, managing, monitoring and evaluating non financial incentives (including on nature, purpose; beneficiaries and funding of incentives).
 Guidelines to support the sustainability of financing schemes for HRH and the management of external funds for HRH, including in terms of capacity building (e.g training, knowledge transfer, mentoring, under-studying and systems building); remuneration; ethical recruitment and the relevance and appropriateness of technical assistance.

Knowledge gaps
A number of areas were identified as knowledge gaps meriting further audit or research, including the need for:
 Strengthened monitoring and evaluation systems and analysis of -primary data on different dimensions of migration and retention, including numbers of migrating professionals; out-migration to other sectors - with destinations and motivations; migration and return intentions and motivations; remittance flows; training capacities in countries by cadre.
 Evidence to inform understanding of the “stay” factors of health workers who do not move (eg support for own housing) for better integration of these factors in HRH policies and programmes.
 Cost benefit assessment of non-financial incentives, to assess their sustainability and impact on retention; and to further explore career path strategies (including training, promotion and education qualification systems).
 Assessment of the performance of the regional strategy for building centres of excellence, including in terms of investments in capacities and uptake of such centres.
 Assessment of mechanisms for managing external funds, including mechanisms at country level to sustain or take over externally financed programmes, for capacity building for this and options being used to overcome fiscal constraints to expenditure on HRH, such as using local contributions to recruit additional staff.
 Assessment of impacts of migration and the performance of retention incentives on health and health care outcomes.
 Cross country research to map, understand and exchange information on the functioning and shortfalls of the current CHW schemes in different countries.
 A needs and capacity assessment in countries to align any dialogue on task shifting to the reality of what is happening on the ground in services.

Follow up on these issues will be taken up at national and regional level with relevant authorities and institutions. Research should encourage multi-actor teams that involve policy, government and research co-operation from design stage. It was proposed that the regional institutions (ECSA-HC and SADC) set up a regional fund that can be used to carry out small scale country specific research to support HRH planning, policy development and management. The meeting also proposed that EQUINET facilitate a follow up process based on work done to date to develop guidelines for robust research methodologies for the assessment of HRH retention incentives and their impacts, sustainability and costs, to stimulate and support further research.