Health Workforce Development Plan 2006-2015 Mid Term Review
29th Sept 2011
Goal and Purpose
The main purpose of themidterm review was to highlight achievements in the implementation of the Health Workforce Development Plan and to identify priority areas that need to be addressed to achieve the RGC strategic goals for health development in the next five years. Priority attention was given to the capacity of the MOH to guide, monitor and regulate the production and deployment of skilled health personnel through sound governance and quality management.
Process of the Review
The review was facilitated by two external consultants who worked closely with MOH counterparts and stakeholders under the overall guidance and leadership of the Human Resource for Health Committee, established by the Minister of Health and chaired by the Secretary of State for Health. The interactive process of the review was designed to promote national ownership of the issues identified and commitment to implementation of the review recommendations.
The sources of information reviewed by the Committee included desk reviews, routine database data, monitoring reports, quarterly reports, published studies, baseline and periodic review evaluations, commissioned pieces and internal Government reviews. In-depth interviews with stakeholders at national and sub-national level were held as required and circumstances permitted. No primary data other than the stakeholder interviews was collected.
Progress 2006-2010
The Health Workforce Development Plan 2006-2015 (HWDP) , is the second national plan for the health workforce preceding the formulation of the Health Strategic Plan 2008-2015. Below is a summary of areas where progress has been achieved and areas which require further attention and intensified efforts and investments.
The review notes significant progress in the formulation of policy and development of programs which affect thehealth workforce during 2006-2011:
Key policies include, the formulation of policy outlining support and vision for the development of the health workforce: National Strategic Development Plan 2006-2013, the Serving the People Better Policy 2006, Regulations for Private Practice 2007 and Fast Track Initiative Road Map for Reducing Maternal and Newborn Mortality 2010-2015.
In the Health Professional Education sector specific legislation was developed to further regulate quality: Sub decree 21 outlining required quality standards for all health professional education institutions and the Sub decree for Professors, giving a recognized career pathway for faculty. Health Professional Education has expanded with four new private Universities, one of which has gained financial viability. The University of Health Science (UHS) has become a Public Administrative Enterprise and taken over the management of the Technical School of Medical Care (TSMC) which has enabled the use of teaching fees for academic reward. Across all institutions, there has been a rationalization of health education programmes with the cessation of secondary programmes and the establishment of associate degree programmes for nurses and midwives, with a substantial increase in production numbers for midwives and the resumption of Xray and Laboratory Technician programmes.
The Royal Government of Cambodia (RGC) has made seven MoH salary increases, including 20% annual increases of base pay which the Government are committed to repeating until 2013. This goes somewhat further in achieving a living wage. The Personnel Dept has increased the accuracy of their data reporting with an easy to use Data Management Tool Access based database which is decentralised to all Provincial offices and used for planning at Central and Provincial levels. A Projection Tool is also used to bring the planning information inline with the Health Coverage Plan staffing standards, compensation data, attrition rates and health facility deployment. This has assisted planning so that now the Dept has been able to increase their annual Council of Minister staffing allocation to 1400 (from 850) and they can track staff deployment accurately, last year achieving a primary midwife in every health centre.
The Council of Administrative Reform (CAR) has designed, the Personnel Dept has implemented and the Development Partners have funded the Performance Management and Accountability System (PMAS) and the Priority Operating Cost (POC) incentive scheme, all of which are hoped to have lessons for wider performance management gain for all health staff. A full evaluation is scheduled for late 2011. Ministry of Health (MoH) and development partners continue to monitor SOAs which have introduced rural level incentives in about 20% of the health system. Personnel Dept has also maintained a recruitment and transfer policy which limits recruitment and transfers to Phnom Penh, enabling an intensification of resources in the Provinces.
The HWDP 2006-2015 recommendations concerning the strengthening of the management system for human resource for health were only partly achieved. The current review noted that inter-departmental and inter-Ministerial coordination, monitoring and implementation, require further attention, and that a High Level oversight Working Group on Human Resource Development , recommended in the plan has not been established to date. Priority areas that need urgent action include the introduction of Health Professional Registration and Licensing, the up scaling of the public sector workforce against population growth and the development of policy regarding private sector regulation.
This mid term review revisits the recommendations of the HWDP 2006-2015 and focuses on the need to build institutional capacity and infrastructure to cope with the complex situation. The recommendations of this mid term review are around building a system that promotes good governance and evidence based decision making, with strategic focus on the development of the quality of the health workforce and their availability. The recommendations of this mid term review, for the next 3-4yrs (2011-2015), are as follows:
Strategic Priority 1: Human Resource for Health Related Governance:
It is recommended that urgent attention is given to the further development of mechanisms and processes to regulate and ensure quality and adequacy of the health workforce. The emergence of the private sector is a major development that needs to be addressed properly. This development was anticipated in the previous review but gained momentum in the last 5 years. The significant growth of the private sector contribution could be expected to yield benefits if it is properly understood and regulated.
High level governance and leadership is required to improve the situation for human resources for health. The following next steps are recommended:
Short Term:
The HRH Committee, chaired by the Secretary of State for Health, formed for the HWDP mid term review, continues to give the focus and profile for the issues raised
Dedicated time slot for HRH governance issues to become prominent in the National planning processes such as the JAPR, MidYear reviews of the AOP, Taskforce 4, Health Congress and the TWGH
Medium Term:
Integrate the timing of the HWDP with the HSP process in future, with both concluding in 2015. These MTR recommendations, particularly the longer term ones should be used to strengthen the HRH component in the next HSP
Annual Reports on HRH production (student intake, enrolment, graduation), recruitment, deployment and staff developmentto be produced by HRD and Personnel respectively
Biannual meetings for key public and private sector health workers to gain understanding and reach consensus for mutual benefit.
Strategic Priority 2: Improve the Technical Skills and Competence of the Health Workforce
Unless the quality of all public and private sector education institutions improves, there will be an over production of low quality staff, a time bomb, leading to unemployment, community dissatisfaction and low quality health service delivery which cannot be rectified through in-service training.
Cambodia needs to educate and train enough qualified Health Professionals with technical and managerial skills, appropriate in quantity and quality for the health service of Cambodia by:
An increased focus on pre-service education which in turn requires the re-direction of strategic attention (from in-service to pre-service), a formalised governance framework to oversee the accreditation of institutions, quality standards and curricula and processes such as the National Exam.
The following diagram shows the current reporting relationships. Without the Ministry of Health as a regulator, the private institutions have no technical accountability to health and in this absence; some of them are reported to be already producing some health professionals without any clinical practice.
Diagram to Illustrate Reporting Relationships for the Management of Health Professional Institutions
In terms of strategic recommendations:
Short Term:
2.1 Establish an institutional body to oversee and ensure the quality of health professional education.
Health Professional Education Committeeis needed to support this regulatory function (such as sub decree 21 enforcement) and to establish strategy and policy for health professional education. HRD Dept should be the secretariat and the Secretary of State of Basic Education the Chair
2.2 Ensure quality benchmarks for all health professionals, with a focus on the following options:
The National Examination should be established from 2012 initially for Doctors, Dentists, Pharmacists and degree Nurses and eventually for all professions
The National Examination should eventually be the national licensing and registration examination with the Health Professional Councils establishing clinical standards
2.3 Strengthen health professional education
Health Workforce Development Plan 2006-2015 Mid Term Review
29th Sept 2011
Goal and Purpose
The main purpose of themidterm review was to highlight achievements in the implementation of the Health Workforce Development Plan and to identify priority areas that need to be addressed to achieve the RGC strategic goals for health development in the next five years. Priority attention was given to the capacity of the MOH to guide, monitor and regulate the production and deployment of skilled health personnel through sound governance and quality management.
Process of the Review
The review was facilitated by two external consultants who worked closely with MOH counterparts and stakeholders under the overall guidance and leadership of the Human Resource for Health Committee, established by the Minister of Health and chaired by the Secretary of State for Health. The interactive process of the review was designed to promote national ownership of the issues identified and commitment to implementation of the review recommendations.
The sources of information reviewed by the Committee included desk reviews, routine database data, monitoring reports, quarterly reports, published studies, baseline and periodic review evaluations, commissioned pieces and internal Government reviews. In-depth interviews with stakeholders at national and sub-national level were held as required and circumstances permitted. No primary data other than the stakeholder interviews was collected.
Progress 2006-2010
The Health Workforce Development Plan 2006-2015 (HWDP) , is the second national plan for the health workforce preceding the formulation of the Health Strategic Plan 2008-2015. Below is a summary of areas where progress has been achieved and areas which require further attention and intensified efforts and investments.
The review notes significant progress in the formulation of policy and development of programs which affect thehealth workforce during 2006-2011:
Key policies include, the formulation of policy outlining support and vision for the development of the health workforce: National Strategic Development Plan 2006-2013, the Serving the People Better Policy 2006, Regulations for Private Practice 2007 and Fast Track Initiative Road Map for Reducing Maternal and Newborn Mortality 2010-2015.
In the Health Professional Education sector specific legislation was developed to further regulate quality: Sub decree 21 outlining required quality standards for all health professional education institutions and the Sub decree for Professors, giving a recognized career pathway for faculty. Health Professional Education has expanded with four new private Universities, one of which has gained financial viability. The University of Health Science (UHS) has become a Public Administrative Enterprise and taken over the management of the Technical School of Medical Care (TSMC) which has enabled the use of teaching fees for academic reward. Across all institutions, there has been a rationalization of health education programmes with the cessation of secondary programmes and the establishment of associate degree programmes for nurses and midwives, with a substantial increase in production numbers for midwives and the resumption of Xray and Laboratory Technician programmes.
The Royal Government of Cambodia (RGC) has made seven MoH salary increases, including 20% annual increases of base pay which the Government are committed to repeating until 2013. This goes somewhat further in achieving a living wage. The Personnel Dept has increased the accuracy of their data reporting with an easy to use Data Management Tool Access based database which is decentralised to all Provincial offices and used for planning at Central and Provincial levels. A Projection Tool is also used to bring the planning information inline with the Health Coverage Plan staffing standards, compensation data, attrition rates and health facility deployment. This has assisted planning so that now the Dept has been able to increase their annual Council of Minister staffing allocation to 1400 (from 850) and they can track staff deployment accurately, last year achieving a primary midwife in every health centre.
The Council of Administrative Reform (CAR) has designed, the Personnel Dept has implemented and the Development Partners have funded the Performance Management and Accountability System (PMAS) and the Priority Operating Cost (POC) incentive scheme, all of which are hoped to have lessons for wider performance management gain for all health staff. A full evaluation is scheduled for late 2011. Ministry of Health (MoH) and development partners continue to monitor SOAs which have introduced rural level incentives in about 20% of the health system. Personnel Dept has also maintained a recruitment and transfer policy which limits recruitment and transfers to Phnom Penh, enabling an intensification of resources in the Provinces.
The HWDP 2006-2015 recommendations concerning the strengthening of the management system for human resource for health were only partly achieved. The current review noted that inter-departmental and inter-Ministerial coordination, monitoring and implementation, require further attention, and that a High Level oversight Working Group on Human Resource Development , recommended in the plan has not been established to date. Priority areas that need urgent action include the introduction of Health Professional Registration and Licensing, the up scaling of the public sector workforce against population growth and the development of policy regarding private sector regulation.
This mid term review revisits the recommendations of the HWDP 2006-2015 and focuses on the need to build institutional capacity and infrastructure to cope with the complex situation. The recommendations of this mid term review are around building a system that promotes good governance and evidence based decision making, with strategic focus on the development of the quality of the health workforce and their availability. The recommendations of this mid term review, for the next 3-4yrs (2011-2015), are as follows:
Strategic Priority 1: Human Resource for Health Related Governance:
It is recommended that urgent attention is given to the further development of mechanisms and processes to regulate and ensure quality and adequacy of the health workforce. The emergence of the private sector is a major development that needs to be addressed properly. This development was anticipated in the previous review but gained momentum in the last 5 years. The significant growth of the private sector contribution could be expected to yield benefits if it is properly understood and regulated.
High level governance and leadership is required to improve the situation for human resources for health. The following next steps are recommended:
Short Term:
The HRH Committee, chaired by the Secretary of State for Health, formed for the HWDP mid term review, continues to give the focus and profile for the issues raised
Dedicated time slot for HRH governance issues to become prominent in the National planning processes such as the JAPR, MidYear reviews of the AOP, Taskforce 4, Health Congress and the TWGH
Medium Term:
Integrate the timing of the HWDP with the HSP process in future, with both concluding in 2015. These MTR recommendations, particularly the longer term ones should be used to strengthen the HRH component in the next HSP
Annual Reports on HRH production (student intake, enrolment, graduation), recruitment, deployment and staff developmentto be produced by HRD and Personnel respectively
Biannual meetings for key public and private sector health workers to gain understanding and reach consensus for mutual benefit.
Strategic Priority 2: Improve the Technical Skills and Competence of the Health Workforce
Unless the quality of all public and private sector education institutions improves, there will be an over production of low quality staff, a time bomb, leading to unemployment, community dissatisfaction and low quality health service delivery which cannot be rectified through in-service training.
Cambodia needs to educate and train enough qualified Health Professionals with technical and managerial skills, appropriate in quantity and quality for the health service of Cambodia by:
An increased focus on pre-service education which in turn requires the re-direction of strategic attention (from in-service to pre-service), a formalised governance framework to oversee the accreditation of institutions, quality standards and curricula and processes such as the National Exam.
The following diagram shows the current reporting relationships. Without the Ministry of Health as a regulator, the private institutions have no technical accountability to health and in this absence; some of them are reported to be already producing some health professionals without any clinical practice.
Diagram to Illustrate Reporting Relationships for the Management of Health Professional Institutions
In terms of strategic recommendations:
Short Term:
2.1 Establish an institutional body to oversee and ensure the quality of health professional education.
Health Professional Education Committeeis needed to support this regulatory function (such as sub decree 21 enforcement) and to establish strategy and policy for health professional education. HRD Dept should be the secretariat and the Secretary of State of Basic Education the Chair
2.2 Ensure quality benchmarks for all health professionals, with a focus on the following options:
The National Examination should be established from 2012 initially for Doctors, Dentists, Pharmacists and degree Nurses and eventually for all professions
The National Examination should eventually be the national licensing and registration examination with the Health Professional Councils establishing clinical standards
2.3 Strengthen health professional education
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