HRH2030 - Enhanced Supervision Landscape Analysis Report (2)

2 July, 2019

I read this useful posting by Rachel Duessom (HRH2030 - Enhanced Supervision Landscape Analysis Report) and have been truly excited, since. I am trying to read the whole document (I don’t know how long it will take but it is very interesting).

The opening paragraph of the Executive Summary says, ‘The strength of a health system - and ultimately the health of a population - depends on health worker perrformance. However, insufficient support to build, manage, and optimize human resources for health (HRH) across broader workforce development functions results in insufficient quantity and quality of health workers in low- and middle-income countries (LMICs). This in turn perpetuates health inequities and results in low-quality health services.’

Nothing could be truer. No investment in the HRH capacity and competence to produce consistent quality and safe care can be too much.

I am excited to read the Report because not only is it very true but it reminds me of the summary of a statement released by a Joint BMJ - NMF (Nigerian Medical Forum UK) after its exploratory visits to many health stakeholders including the Minister of Health, the Nigerian Medical Association (NMA) in 1995. After what we saw in the libraries (Health Information centres), hospitals and comments from colleagues working in the Nigeria Health System, we concluded, all those years ago, that ‘No matter how beautiful the buildings in a health facility or how sophisticated the equipment therein, the critical factor to reduce morbidity and mortality is the knowledge, skills and attitude of the health workers’ We added the dictum, ‘No health, no wealth, no health, no development’ (NMF-BMJ Visitation Report. September, 1995). On our return to London from Lagos (there was no Abuja in 1995), colleagues that we shared our experiences with reminded us that the appalling situation was/is not confined to Nigeria, but sadly is replicated all over LMICs.

In 2019, we can read/see that a lot has been achieved whether in malaria control, reduction of avoidable child and maternal deaths, etc, but it is also the case that a lot, lot more needs to be done. The health systems in LMICs cannot be strengthened to deliver on UHC and SDG until the critical value of HRH capacity, capability and attitude is recognised and maximised, and interventions implemented to achieve it.

Politicians and many policy makers focus on building ill-designed structures (that look more like and are arranged more like hotels than hospitals / clinics where the sick is attended to). These structures are costly to build and to maintain, and they are mostly ill equipped and located in inappropriate sites when commissioned as health facilities. They are hardly fit-for-purpose. Their reason is that ‘that is what the public can see and recognise as politician’s legacies'. Little attention is paid HRH: building the quality and quantity of selection, training, certification, posting, supervision, monitoring and inspections, re-training, incentivisation, reward and safety of health workers who are expected to deliver the quality and safe care. The lack or inadequacy of these HRH indicators is the main reason that the health systems in LMICs remain weak inspite of the mind-boggling transformation of science, technology, and knowledge that has changed the world as we use to know it even two decades ago.

More recently, we in Nigeria adopted PACK (Practical Approach to Care Kit) from the Knowledge Translation Unit (KTU) University of Cape Town and BMJ, localised its content completely (line by line) with reference to over 13 existing guidelines and policy documents on the practice of primary health care in Nigeria, including the Standing Order 2015 that is used community health worker cadre only. We produced PACK Nigeria (Adult and Child) Guide for use in the Nigerian PHC. PACK Nigeria guide is only one of the five pillars of the entire PACK programme. The other pillars that must go along with the guide (facility readiness; educational outreach onsite and inservice training per PHC facility; monitoring and supervision; community engagement) are designed to go with the guide and customised training materials, to ‘enhance supervision’ so that the users / providers of care can provide consistently high quality and safe care that is verifiable and transferable. The PACK Nigeria pilot in 2016/2017 showed the effectiveness of the programme, with all the cadres in PHC (community health practitioners, nurses, midwives and medical doctors) working together from one ‘hymn sheet’; increasing diagnostic and treatment accuracy; enhancing rapport and harmony in the multidisciplinary team; and increasing appropriate referral to the next higher cadre or facility. In today’s climate of less and less money for health (less domestic allocations and donor support fatigue) the PACK Nigeria pilot showed that the programme by building the clinical competence of health workers led to less polypharmacy prescriptions and less inappropriate investigation of patients conditions ( request ing only tests recommended by PACK), these have potential for huge economic savings and impact, whilst maintaining or increasing quality.

Joseph Ana.

HIFA profile: Joseph Ana is the Lead Consultant and Trainer at the Africa Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria. In 2015 he won the NMA Award of Excellence for establishing 12-Pillar Clinical Governance, Quality and Safety initiative in Nigeria. He has been the pioneer Chairman of the Nigerian Medical Association (NMA) National Committee on Clinical Governance and Research since 2012. He is also Chairman of the Quality & Performance subcommittee of the Technical Working Group for the implementation of the Nigeria Health Act. He is a pioneer Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. He is particularly interested in strengthening health systems for quality and safety in LMICs. He has written Five books on the 12-Pillar Clinical Governance for LMICs, including a TOOLS for Implementation. He established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria in 2007. Website: Joseph is a member of the HIFA Steering Group and the HIFGA working group on Community Health Workers: jneana AT