Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program (2020) / Chapter Skim
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8 Recommendations
8 Recommendations
Pages 227-250
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From page 227... ...
The charge of this evaluation framed impact from a more vertical perspective. OVERARCHING EVALUATION CONCLUSIONS The HRH Program had many successes with respect to its goal to expand the quantity and quality of the health workforce in Rwanda, with 227
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The HRH Program represented what was, at the time, a relatively uncommon (although not unique) donor-funded approach to strengthening HRH capacity in low- and middle-income countries by focusing on a large investment, at a foundational level, for capacity building in institutions for health professional education.
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Such investments have the greatest potential to yield sustainable results when aligned with long-term systems strengthening strategies and coordinated with concurrent investments from governments and other donors. RECOMMENDATIONS The committee was tasked with making recommendations "to inform future HRH investments that support PLHIV and to advance PEPFAR's mission." The committee's recommendations are therefore framed with the intention of helping to make the balancing act between disease specificity and systems strengthening more achievable, and more measurable, for future investments in HRH.
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Recognizing the inherently complex interactions among many factors, stakeholders, institutions, and sectors when it comes to HRH, these recommendations emphasize the following aspects of an integrated approach to improving HRH through health professional education: • Codesign among relevant stakeholders; • A systems approach with adequate needs assessment and planning time; • Operational planning that emphasizes adaptive management; • Selection of a tailored set of components from models for improv ing health professional education; • A prospective and multifaceted approach to monitoring, evalua tion, and learning; and • In all of the above, an explicit connection from disease-specific ele ments to interrelated broader systems elements. Program Codesign To ensure a robust and feasible programmatic design, an effective approach is to employ a collaborative design process at the level of key decision makers representing funders and government leadership across relevant sectors, while including implementers and beneficiaries (in the case of health professional education, faculty, trainees, the public and private health systems that will employ program graduates, and ultimately, patients)
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, program administrators (e.g., government leadership in relevant sectors and nongovernmental leadership) , implementers (e.g., program managers and health professional education program leaders)
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For complex and long-term initiatives such as the HRH Program, which sought to strengthen HRH through building health professional education, including a process whereby different stakeholders formally articulate their commitments over different time spans can reduce longerterm risk. These risks include the donor's ceasing funding of the program, as occurred with the HRH Program, or the host government's not following through on commitments to recruit and retain the health care workers who have graduated.
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Time Frame Considerations for Strengthening HRH Effective systems strengthening for HRH, especially in relation to faculty production and building university infrastructure, requires decades. Investments in health professional education and training should be expected to take many years to yield effects, given the time required for students to complete training programs, for trainees to make their way as fully qualified health professionals into the service delivery system, and for new or newly upgraded faculty to produce ongoing cohorts of providers.
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. Funding Considerations for Strengthening HRH Because systems strengthening takes decades and the HRH pipeline spans multiple stages -- from recruitment of students to preservice training through specialization and continuing professional development of the workforce, to longer-term issues such as health worker motivation and retention -- designers of HRH programs should articulate and work toward comprehensive long-term goals and outcomes.
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. Systematic Approach in the Context of the Labor Market Although programs and policies that focus on boosting health professional education are key to addressing the health workforce shortage, adopting a labor market lens can both leverage health professional education investments and redress factors that undermine the capacity of the health workforce (Evans et al., 2016; Sousa et al., 2013)
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The experience of the HRH Program points to the need for strong management structures and processes that allow for continuous learning and improvement as a means of moving toward the defined programmatic goals, even in the face of policy pivots such as PEPFAR's shift from its 2.0 to 3.0 strategy, which resulted in a determination to cease funding. Recommendation 3: To maximize the effectiveness of investments in human resources for health, which inherently require change within a complex system, designers of programs to strengthen human resources for health should spend time before implementation to establish a shared vision, proposed mechanisms to achieve that vision, and an operational plan that takes an adaptive management approach.
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As discussed under Recommendation 6, there is a need for HRH programs to include a comprehensive approach to monitoring, evaluation, and learning as an integrated responsibility not only for designated staff but also for other technical and operational staff. Adaptive management is only possible if the people implementing the program are open to critically engaging with and learning from rapidly collected and analyzed data to make programmatic adjustments.
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For adaptive management to succeed in the context of reliance on multiple funding sources, external donors and governments that fund HRH programs need to embrace the approach of expecting well-executed implementation to include clarity of rationale and specificity of design at the outset, and learning-based adjustments as implementation proceeds. Program assessment and accountability mechanisms should be based partly on the process of implementation and on achieving reasonable progress toward goals, in the context of the realities encountered during implementation, rather than basing accountability narrowly on adherence to the original design.
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; • Ensuring faculty have time built into their schedules to commit to additional health professional education development; • Ensuring time and funding are provided to focus on accreditation, research skills, and other elements that are not a direct transfer of teaching skills; • Emphasizing longer-term institutional partnerships; and • Teaching models that require less time from faculty (blended learning)
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WHO, the European Union's ESTHER2 Alliance for Global Health Partnerships, and the United Kingdom's Tropical Health Education Trust have been employing institutional twinning partnerships with African hospitals and other institutions since at least 2009 (European ESTHER Alliance Secretariat/GIP ESTHER, 2018; THET, 2019; WHO, 2019b)
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This could be particularly effective for deans of institutions, or for medical or surgical subspecialists for whom longer-term placements are impractical. Using ratios greater than one to one for the partnering between external and local twins could also be an effective approach to optimize capacity building for health professional education.
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In addition to planning for learning about implementation processes and program outcomes, it would be valuable for future efforts to prospectively plan for analysis that would allow program designers, implementers, and others looking to learn from such programs to understand the costs of program implementation and select, plan for, and carry out assessments of return on investment. Below is a breakdown of monitoring, evaluation, and learning options at different points in a program's time line.
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Designers and program administrators should also conduct a baseline assessment that maps the country's HRH needs to the design of the program, helping to assess how to balance specialized care and primary care, the cadres required to address HIV and to have a broader health impact, and the teaching cadres who can continue building the needed workforce. A baseline assessment also gives the program a starting point for midpoint or endpoint learning.
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. Another suggests that to improve accurate and timely diagnosis, national cancer control plans should include capacity building for general practitioners, and continuing professional development should address "context-specific educational gaps, resource availability, and referral practice guidelines" (Martin et al., 2019)
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, as well as project- or program-specific capacity building. For an HRH program that uses a twinning model, monitoring the twinning process and interactions and adapting recruitment and onboarding based on this evidence could improve implementation and achievement of results.
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Process evaluations provide a good platform to teach other designers what they should consider during the design of HRH programs. A developmental evaluation is particularly well suited to stimulating innovative program design in response to dynamic realities, possible desire for program replication, and complex issues and environments (Patton, 2010)
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2016. Addressing the challenges of health professional education: Opportunities to accelerate progress towards universal health coverage: A special report of the Health Professional Education Advisory Board.
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2017. Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: Recommendations of the Simnovate Global Health Domain Group.
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2016. Health workforce requirements for universal health coverage and the Sus tainable Development Goals.
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2019b. Twinning partnerships for improvement: Tools and resources.
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