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Strengthening Human Resources for Health (HRH): Year Three Work planI - General InformationProject Title:Strengthening Human Resources for HealthPrime partnerJhpiegosub-partner(s):Management Sciences for Health (MSH),Ethiopian Midwives Association (EMA),Ethiopian Association of Anesthetists (EAA),Open University (OU).Cooperative agreement number:AID-663-A-12-00008Project Start & Completion date:18 May 2012 – 17 May 2017Period of implementation:01 October 2014 – 30 September 2015Submission Date:Resubmitted7 December 2014Name & contact address of the COP:Dr. Damtew Woldemariam DagoyeJhpiego EthiopiaKirkos Subcity, Kebele 02-03House No 693Wollo Sefer/Ethio-China Street near MinaBuildingP.O.Box 2881Code 1250 Addis Ababa1

Strengthening Human Resources for Health (HRH): Year Three Work n College of Nurse-MidwivesAudio VisualBalanced Score CardBusiness Process ReengineeringCommunity Based EducationContinuing Professional DevelopmentCertificate of CompetenceDirectorate of Human Resources Development and AdministrationData Quality AssessmentEthiopian Broadcasting CorporationEthiopian Association of AnesthetistsEffective Teaching SkillsEthiopian Midwives AssociationEmergency Medical TechniciansFood, Medicine and Healthcare Administration and Control AuthorityFederal Ministry of EducationFederal Ministry of HealthFixed Obligation GrantGovernment of EthiopiaGlobal System for Mobile CommunicationsHealth EconomicsHealth Extension WorkerHealth Extension ProgramHigher Education Relevance and Quality AgencyHuman Resources Information SystemHuman ResourcesHuman Resources for HealthHuman Resources ManagementHealth Sector Development ProgramHealth Sciences Education Development CenterIntensive Care UnitIntegrated Community Case ManagementInternal Quality AssuranceInformation TechnologyIntegrated Pharmaceutical Logistic SystemInformation and Communication TechnologyIntegrated Supportive SupervisionIn-service TrainingJob DescriptionLeadership, Management and Governance2

Strengthening Human Resources for Health (HRH): Year Three Work APMTCTPMPPSERHSCRHBSBM-R ternal and Child HealthMaternal and Child Health Integrated ProgramMillennium Development GoalMedical Education Partnership InitiativeMonitoring & EvaluationManagement and Organizational Sustainability ToolMemorandum of UnderstandingManagement Sciences for HealthOpen UniversityOccupational Assessment and Certification AgencyOperation RoomPhilippines Association of Accredited Schools, Colleges and UniversitiesPharmaceuticals Fund and Supply AgencyPrevention of Mother to Child TransmissionPerformance Monitoring PlanPre-service EducationRegional Health Science CollegeRegional Health BureauStandards-Based Management and RecognitionSupply Chain ManagementSouthern Nations, Nationalities and Peoples RegionScope of PracticeTuberculosisTraining of TrainersTerms of ReferenceTechnical Working GroupTechnical and Vocational Education and TrainingUnited States Agency for International DevelopmentUnited Nations Population FundVoluntary Service OverseasWork Climate ImprovementWorld Health OrganizationZonal Health Department3

Strengthening Human Resources for Health (HRH): Year Three Work planII- Back ground1. PROGRAM AREA / PROJECT DESCRIPTION:The Strengthening Human Resources for Health (HRH) project is a five year (2012 – 2017)bilateral cooperative agreement with an overall goal of improving the human resources forhealth status in Ethiopia. Funded by the United States Agency for International Development(USAID) under the “Investing in People” category of the foreign assistance framework, theproject is contributing to the Government of Ethiopia’s (GoEs) efforts to build or strengthenlocal capacity for development of sustained systems for managing human resources forhealth, increasing availability of midwives, anesthetists, health extension workers and otherpriority cadres, improving and monitoring the quality of education, and continuingprofessional development of health care providers, and generating evidence to inform HRHpolicies and practices.A qualified, motivated and competent health workforce is a critical element required toaddress Ethiopia’s high burden of morbidity and mortality resulting from communicablediseases, nutritional disorders, and poor maternal and child health outcomes, and tocontribute towards achievement of key goals in the national Health Sector DevelopmentProgram (HSDP IV), Human Resources for Health (HRH) strategy and health relatedMillennium Development Goals (MDG 4, 5 & 6).However, findings from a 2012 Rapid Situational Assessment of Human Resources forHealth in Ethiopia 1 indicated that there was a critical shortage of health professionals acrosscadres in most regions. Unmet need for midwives and anesthetists stood at 63% and 44%,respectively, with regional variations such as Gambela (93%) and Somali (89%). Althoughthe Federal Ministry of Health (FMOH) has successfully trained and deployed more than34,000 health extension workers (HEWs), the annual attrition rate was approximately 5%. Inaddition, some regions still had a high unmet need for HEWs, including Somali (34%) andTigray (19%).Poor quality pre-service education (PSE) and in-service training, rapid turn-over of skilledhealth care providers, inequitable distribution of the health workforce, underdevelopedregulatory capacity needed to sustain human resources for health quality, and ineffectivemanagement of human resources for health systems further contributed to the HRHchallenges. In addition, inconsistencies in and lack of availability of HRH data were evidentat the FMOH and RHBs. The newly deployed Human Resources Information System (HRIS)was not fully functional and requires additional strengthening and expansion to all levels ofthe health system. Of particular importance is having structure and staff dedicated to HRISand providing training in human resources data collection, processing, data analysis and datafor management decision-making.Though there is an overall critical shortage in the recommended number of qualified healthworkers across cadres, the government has prioritized a focus on the production and retentionof qualified and competent midwives, anesthetists, health extension workers (HEWs), and1Jhpiego 2012. Human Resources for Health: Rapid Situational Assessment of Prioritized Geographic Areas.4

Strengthening Human Resources for Health (HRH): Year Three Work planother essential health cadres such as emergency medical technicians and biomedicaltechnicians with HRH project support.Through program inputs at both the national and regional level, and in collaboration andcoordination with the Federal Ministry of Health (FMOH), Higher Education Relevance andQuality Agency (HERQA), Food, Medicine and Health Care Administration and ControlAuthority (FMHACA), Regional Health Bureaus (RHBs), and other key stakeholders, theHRH project is working to address these challenges by implementing the strategies outlinedbelow.2. OBJECTIVES/PURPOSE:The ultimate goal of the HRH project is to improve health outcomes for all Ethiopians, withemphasis on the reduction of infectious diseases and maternal and newborn morbidity andmortality. The HRH project’s efforts will build upon previous work and processes, andimplement activities organized within the following key results:Result 1: Improved Human Resources for Health ManagementResult 2: Increased Availability of Midwives, Anesthetists, Health Extension Workers(HEW)s and other Essential Health WorkersResult 3: Improved Quality of Training of Health WorkersResult 4: Monitoring & Evaluation, Program Learning and ResearchThe projects goals and objectives will be met through systems aimed at production,deployment and support of high-quality professionals at all levels of health service delivery.The increased quantity and quality of health workers (Result 2 and 3) will be supported by anoverall strengthened health management approach (Result 1). All project approaches will beevidence based and rooted in program learning (Result 4).The following key strategic approaches will be used to guide project implementation:Strengthen the GoE’s human resources management (HRM) system:The GoE has made considerable investments in strategies and processes such as BusinessProcess Re-engineering (BPR), Balanced Score card (BSC) based performance managementsystems, and various participatory planning and management efforts. These investments areaimed at strengthening HRM systems to create a health workforce that is responsive to healthneeds of the communities. The HRH project is building upon existing efforts and providingevidence-based support to prepare a cadre of capable human resource managers. These HRMleaders will be supported to create systems consistent with international standards to recruit,deploy and maintain employees to improve health services.Strengthen HRH policies and practices:The project will support the FMOH to finalize the draft Human Resources (HR) strategicplan, and collaborate with them to disseminate, implement and monitor the guidelines andrecommendations outlined in the final plan. The HRH project will also work closely with theFMoH and RHBs to identify, print and/or photocopy and disseminate the Federal andRegional Proclamations, policy and procedure manuals on HRM. Additionally,5

Strengthening Human Resources for Health (HRH): Year Three Work planmultidisciplinary stakeholder leadership and collaboration is essential for the oversight,strategic guidance, and improved planning of activities related to HRH. To this end, theHRH project will facilitate the establishment of HRH forums at the national and regionallevels. The National forum will meet twice a year and regional forums quarterly, with closelinkages and coordination between regional and national forums.Strengthen legal frameworks and mechanisms for licensure and regulation of healthworkers performance: The GoE, through the Higher Education Relevance and QualityAgency (HERQA) and the Food, Medicine and Healthcare Administration and ControlAuthority (FMHACA), has developed standards for educational accreditation and licensureand will be supported to strengthen legal frameworks and processes for effective andsustainable regulatory systems. The project will work with key stakeholders to buildregulatory processes consistent with policies established by the GoE and internationallyrecognized best practices.Strengthen capacity for improved quality of pre-service educationUniversities and colleges will be supported to improve the quality of pre-service educationthrough various inputs such as strengthening curricula and infrastructure, establishing healthsciences education development center (HSEDC), improving faculty teaching skills,reforming curricula, strengthening assessment policies and strategies, and implementation ofcontinuous internal quality improvement. Clinical practice sites affiliated with the targetschools will also be strengthened in an effort to ensure that students have access to practicethe required competencies prior to graduation.To ensure sustainability, the project will institutionalize these and other quality improvementinitiatives by supporting higher education institutions to establish health sciences educationdevelopment centers.Standardize and institutionalize in-service trainingThe HRH Project will support the FMOH’s initiative to standardize and institutionalize inservice training through development of an in-service training strategy and guideline andprovision of technical, material and financial support to build the capacity of training sitesselected by the government. The project will also support the FMOH to establish andimplement a Continuing Professional Development (CPD) System.Research and Program Learning:To support evidence-based decision-making, the HRH project will conduct relevant,coordinated assessments, research and program learning, and will systematically capture andprocess information and document lessons learned in alignment with the GoE’s HSDP IVand HRH Strategic Plan.Linkage of Project Results to Funding Streams and Health Outcomes:The HRH project was designed to operationalize the Human Resources for Health ActionFramework illustrated in Figure 1 below. It is expected that a competent and motivatedhealth workforce, adequately supported through strengthened health systems and policies,will be equipped and enabled to provide effective, efficient, equitable and quality healthcare6

Strengthening Human Resources for Health (HRH): Year Three Work planservices to the population, reducing burden of infectious diseases (especially HIV,tuberculosis, and malaria) and improving maternal, newborn and child health outcomes.Figure 1. Health Action FrameworkThe table below summarizes assumptions that can be used to guide the process ofdetermining the impact of health system strengthening interventions on service delivery7

Strengthening Human Resources for Health (HRH): Year Three Work planProject InterventionsProject OutcomesIR ONE: Improved Human Resources for Health ManagementBuild technical, management and leadership capacity of HR An increased number ofleaders, managers, supervisors and staff at FMoH, RHB,qualifiedHRandManagement professionalsZHDs and WoHOs through:- HRM capacity assessment and implementation ofavailable to plan, develop,recruit, orient, deploy andcapacity building interventions;support health workers at- In-service training in HRM;national, regional, sub- Postgraduate education in human resourceregional and health facilitymanagement and health economics;- Post-training follow up, mentorship and on-job technical levels across the countrysupportStrengthen HR structures, budgets and staffing levelsTechnical support provided to improve HRM practices at alllevels (development, revisions and updating of jobdescriptions, improved recruitment and deploymentpractices; orientation of new staff and performancemanagement and support)Support the development of policies and systems to supportrecruitment, deployment and retention of health workersTechnical and financial support to develop policies to ensureappropriate qualification of health workers, including,competence & review system, registration and licensureTechnical and financial support to National and RegionalHRH Strategic planning and annual woreda-based planningIncreased number anddistribution of the healthworkforce at district andhealth facilitiesWell managed health systemwith improved healthworkers’ job satisfaction,motivation, productivity andretention. Attrition of healthworkers reduced andequitable distribution ofhealth workers increased.Increased quality of healthworker skills andprofessionalization- Improved planning,implementation and8Proxy Measure of Impact on Service Deliveryand Health Outcomes Increased coverage of MCH, FP/RH, HIV, TBand malaria servicesImproved quality of MCH, FP/RH, HIV, TB andmalaria servicesReduced burden of HIV, TB, and malariaReduced maternal and under-five mortalitylevelsReduced disparities in MCH, FP/RH, HIV, TBand malaria service coverage and outcomesacross social groups

Strengthening Human Resources for Health (HRH): Year Three Work planProject InterventionsProject Outcomesin all regions.Proxy Measure of Impact on Service Deliveryand Health Outcomesperformance monitoringand evaluation for priorityhealth programs in thecountry.- Improved availability ofneeded health workforceIR TWO: Increased Availability of Midwives, Anesthetists, HEWs and other Essential Health WorkersSupport pre-service education of midwives, anesthetists, Increasednumberof Increased coverage of MCH, FP/RH, HIV, TBHEWs, and other essential health workers, includingcompetentmidwives,and malaria services- Evidence-based curriculum development and revisionanesthetists, HEWs, and Improved quality of MCH, FP/RH, HIV, TB andotheressentialhealthmalaria services- Procurement of teaching/learning materialsworkers available to provide Reduced burden of HIV, TB, and malaria- Faculty developmentservices Reduced maternal and under-five mortality- Expanding and strengthening clinical practice siteslevels- Strengthening internal quality assurance systems Reduced disparities in MCH, FP/RH, HIV, TB- Building capacity of professional associationsand malaria service coverage and outcomesacross social groupsIR THREE: Improved Quality of Training of Health WorkersProvide support to improve quality of health workers Increased number of Increased coverage of MCH, FP/RH, HIV, TBeducation through:competent health workersand malaria services- Developing innovative curriculaavailable to provide services Improved quality of MCH, FP/RH, HIV, TB andmalaria services- Strengthening faculty capacity Reduced burden of HIV, TB, and malaria- Developing or strengthening clinical skill learning Reduced maternal and under-five mortalitylaboratorieslevels- Improving educational infrastructure- Strengthening internal quality improvement systems Reduced disparities in MCH, FP/RH, HIV, TBand malaria service coverage and outcomesStrengthening accreditation and regulatory systems, Healthprofessionalacross social groupsincludingeducation regulatory systems- Strengthening accreditation and external quality audits of strengthened resulting inimproved competence that ishigher education institutions and their programs- Developing national licensing to verify initial competence maintained over time9

Strengthening Human Resources for Health (HRH): Year Three Work planProject Interventionsfor new graduatesSupport continuing professional development forpracticing health workers to ensure continued fitness topracticeSupport standardization and institutionalization of In-ServiceTraining (IST) in line with national guidelines.- Support establishment or strengthening of 35 ISTcenters- Develop the capacity of trainers- Develop standard training packagesIR FOUR: Program Learning and Research ConductedSupport the government to conduct operational research andgenerate evidence on priority HRH issues: Midwifery and anesthetists competence levels Health workers motivation, satisfaction and retention Health workers Task Analysis Health workers regulation Effects of HRM interventions on organizationalperformance, provider job satisfaction, and serviceutilization Effects of PSE strengthening interventions on qualityand competence of graduates and service utilizationSupport the government to conduct integrated supportivesupervisionSupport the government to organize annual review meetingsProject OutcomesProxy Measure of Impact on Service Deliveryand Health Outcomes-Competent health workerswith improved technicalcapacity available to provideservicesEvidence-based strengthening of education,practice, regulation and management of HRH. Improved quality of servicesat health facility levelImproved monitoring andquality of health deliverythrough identification of bestpractices and challenges10Increased coverage of MCH, FP/RH, HIV, TBand malaria servicesImproved quality of MCH, FP/RH, HIV, TB andmalaria servicesReduced burden of HIV, TB, and malariaReduced maternal and under-five mortalitylevelsReduced disparities in MCH, FP/RH, HIV, TBand malaria service coverage and outcomesacross social groupsQuality of MCH, HIV, FP/RH, TB, and Malariaservices provided at health facility levelsDecisions made to provide quality MCH, HIV,FP/RH, TB, and Malaria services

Strengthening Human Resources for Health (HRH): Year Three Work plan3. SUMMARY OF SELECTED ACHIEVEMENTS BY RESULT AREAS(A detailed report of Year One (15 May 2012 – 30 Sep 2013) and Year Two, Quarter 1 3 (01 Oct 2013 – 30 June 2014) accomplishments can be found in the attached Annex A)IR One: Improved Human Resources for Health Management1.1 Improved HRM Capacity To ensure that interventions are evidence/need-based and contextually relevant, HumanResources Management (HRM) rapid capacity assessments were conducted at the FederalMinistry of Health (FMOH), FMHACA, 11 Regional Health Bureaus (RHBs), theEthiopian Midwives Association (EMA) and Ethiopian Association of Anesthetists(EAA). Findings identified HRM gaps and challenges, and informed development ofthree-year action plans aimed at improving organizational structure, policy and practicesrelated to HRM. The entire process was participatory ensuring ownership, trust andcommitment for action by the beneficiary institutions. One of the critical gaps identified in the HRM assessments was structural. Subsequently,existing HR structures were reviewed and a total of 1226 new HR and other positionscreated fully funded out of the government budget. Regional health bureaus were also supported to strengthen HR management practices(updating job descriptions, recruitment and orientation, HRIS data collection and entry,etc.). The HRH project provided leadership and governance training for 19 EMA and EAAboard members to strengthen the associations Technical and financial support provided for Woreda-based health sector planning inOromia, Amhara, Harari, SNNPR and Benishangul-Gumuz regions. Supported secondment of 7 staff at FMHACA, HERQA, and FMOH. These staffprovided technical assistance and support to the government stakeholders fordevelopment and review of policy documents and standards, as well as support forimplementation of activities.1.2 Improved Motivation and Retention One of the biggest HRH problems in Ethiopia is low motivation and high turnover ofstaff. To provide evidence for an effective and contextually relevant and feasiblemotivation and retention strategy, a desk review was done; subsequently, a nationalretention study was conducted, sampling 1,356 health workers and 217 managers. Dataanalysis has been completed, and a technical report is current being developed. Findingswill be disseminated and utilized to inform development of staff motivation and retentionstrategies. Employee job satisfaction surveys were also conducted at the FMOH and 9 RegionalHealth Bureaus. In addition, employee exit interviews were conducted in all 11 RegionalHealth Bureaus. Findings will be additional inputs to design motivation and retentionstrategies as well as work climate improvement interventions.1.3 Improved Human Resources for Health Policies and Practices Graduates from technical and vocational education and training programs are required tosit for a licensing exam to verify their competence prior to deployment. This requirement,however, has not been applied to graduates from university study programs. The HRH11

Strengthening Human Resources for Health (HRH): Year Three Work plan project supported development of a policy document making it compulsory for all healthprofessionals to take a standard national licensure exam.An up-to-date scope of practice is an important regulatory mechanism to ensure publicsafety by delineating the limits of what a given cadre is qualified to do. The HRH Projectsupported the development and updating of Scopes of Practice for health workers for 26professional categories.It is not just lack of HR policies and laws that is causing inconsistencies and gaps inHRM practices. It is also a lack of awareness of existing HR policies and laws. Toaddress this gap, the HRH Project supported the FMOH to orient its staff on labor laws,proclamations and civil service codes. An Employee handbook was also developed toguide orientation of new FMOH and RHB staff.HRH planning is critical to forecast and develop evidence-based human resourcerequirements for the health sector. The national HRH Strategic Plan was developed in2008 and remained in draft form. The HRH Project supported the FMOH to review andupdate the HRH Strategic Plan. Ongoing support is being provided towards finalizing theplan.1.4 Enhanced Human Resources for Health ForumsAddressing human resources for health challenges requires coordinated inputs from multiplestakeholders working for synergy. The HRH Project supported the Ministry of Health toestablish a multi-sectoral National HRH Forum that will meet semi-annually. Regional HRHForums are also established in 10 regions, each having agreed to meet quarterly. The forumswill encourage strategic partnership, collaboration, local ownership, transparency,accountability and sustainable solutions for HRH problems. National and regional forumswill also be linked ensuring feedback, experience sharing, coordination and follow-up ofaction items.1.5 Improved management of staff trainingStaff training should be planned and conducted based on a formal process of assessing staffneeds and address the organization’s key priorities and changes in the health sector andpractice. HRM focal persons need enhanced skills to manage staff training. Accordingly, anHRH Management In-service Training Package was developed and endorsed by the FMOH.Subsequently, a Training of Trainers (TOT) was provided to 60 participants from FMOH,federal agencies and hospitals and RHBs. Following the TOT, a total of 364 HR managerswere trained. Technical support was also provided to RHBs to develop in-service trainingplans.Result 2: Increased Availability of Midwives, anesthetists, HEWs and other EssentialHealth Workers Improving maternal and child health outcomes and reducing burden of infectiousdiseases like HIV, TB and malaria requires availability of sufficient number of healthworkers especially midwives, anesthetists and health extension workers. However, thenumber of these cadres is presently low mainly due to limited capacity for production.12

Strengthening Human Resources for Health (HRH): Year Three Work planIncreasing supply and availability of these cadres requires strengthening the capacity ofeducation institutions to increase production while maintaining or increasing quality.Accordingly:- Educational standards were developed and training and mentoring support given formidwifery, anesthesia and HEW schools to guide quality improvement processes.- Educational materials including simulators and clinical equipment to strengthenclinical skills learning labs were distributed to 49 education institutions.- Faculty development courses were conducted for 4,919 instructors and preceptors (asof 30 September 2014) to build their capacity as educators in such areas as EffectiveTeaching Skills, Instructional Design Skills, Simulation-based Healthcare Education,HIV/PMTCT technical updates, etc.The HRH Project also supported review of occupational standards and development/revisionof 13 curricula for 8 cadres (including Midwifery Master’s program, HEW, biomedicaltechnician, emergency medical technician, neonatal Intensive Care Unit (ICU) nurses,Operation Room (OR) nurses).As a result of project inputs in years one and two, we contributed to the graduation of 13,733health workers from public training institutions (6,192 midwives, 423 anesthetists, 3,377rural HEWs level III, 3,169 HEWs level IV, and 572 other essential health workers).The needs for supply of health workers is not limited to clinical providers but also includespublic health professionals who can improve human resource planning and managementcapacity in the context of broader health sector strengthening. Thus, 3 public Universities and1 private Higher Education Institution were supported to design and prepare for provision ofpost-graduate programs in Health Economics and Human Resources for Health Management.The program was launched in July 2014 at Gondar University, with preparations for others tofollow in year three.Result 3: Improved Quality of Training of Health Workers3.1 Improved Quality of PSE of Health WorkersThe Ethiopian Government is doing well in scaling up the quantity of health workereducation. Increasing numbers of health workers without assuring quality of education willnot however translate into improved population health outcomes. Accordingly, the HRHProject supported education institutions and regulatory bodies to improve educational qualityand quality assurance systems.The HRH Project promoted the establishment and strengthening of Health SciencesEducation Development Center (HSEDCs) in all public and private health teachinguniversities and colleges. The HSEDCs will lead educational quality improvement processes,curriculum review, appraisal and development, faculty development and in-service trainingof health workers, review and improvement of assessment, and educational research.Inyear two, through Fixed Obligation Grants (FOGS), 42 HSEDCs were provided with fundingand mentoring to conduct activities related to improving quality of education such as facultydevelopment, internal quality audit and curriculum revision.13

Strengthening Human Resources for Health (HRH): Year Three Work planWe procured educational materials and equipment (buses, skills lab materials, anesthesiamachines, books, computers, and furniture) to strengthen infrastructure for quality educationin 49 health teaching universities and colleges.With regards to educational accreditation and regulation, the HRH Project provided technicaland financial support to the Higher Education Relevance and Quality Assurance Agency(HERQA) and the federal and regional Technical and Vocational Education and Trainingoffices. A national advocacy meeting with the State Minister of Higher Education andMembers of Parliament was held to disseminate lessons learned from a benchmarking to thePhilippines Association of Accredited Schools, Colleges and Universities (PAASCU).In partnership with HERQA and MOH, a strategic document to revitalize quality assurancesystems for education of health professionals was developed. Consequently, educationalstandards that will guide accreditation and quality improvement for the seven major healthprofessions (medicine, h

BSC Balanced Score Card . BPR Business Process Reengineering . . Process Reengineering (BPR), Balanced S- core card (BSC) based performance management systems, and various participatory planning and management efforts. . equitable and quality healthcare : 6 . Strengthening Human Resources for Health (HRH): Year Three Work plan :

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