Analysis of Stakeholders in Afghan Human Resources for ...1 GDHR ++ ++ + HR Database Unit has support from MSH and provides timely input. GDHR n eeds Secretariat support – it has

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Ministry of Public Health

General Directorate of Human Resources

Islamic Republic of Afghanistan

Analysis of Stakeholders in Afghan Human Resources for Health (HRH) and Planning and Development for

an Effective National HRH Coordination Forum

December 2010

Prepared by the General Directorate of Human Resources, with support from WHO Afghanistan and the Global Health Workforce

Alliance (GHWA)

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Contents ABBREVIATIONS ................................................................................................................................ 3

1. Background ............................................................................................................................... 4

2. Objectives .................................................................................................................................. 5

3. Stakeholder Analysis .................................................................................................................. 6

4. Conclusions from Stakeholder Analysis and Recommendations for More Effectively Involving Them: .............................................................................................................................................. 11

5. Stakeholders to be Involved and their Roles............................................................................. 13

5.1 High Level HRH Coordination Forum ................................................................................ 13

5.2 Working groups ................................................................................................................ 14

5.2.1 Workforce Plan......................................................................................................... 14

5.2.2 Professional Councils, Standards, Curricula, Accreditation and Registration .............. 15

5.2.3 Needs Assessment, Capacity Building Plan and Training and Development ............... 15

5.2.4 Coordinated HR Practices ......................................................................................... 16

5.2.5 Adequate Funding and Workforce Financing Arrangements ..................................... 16

5.3 Workforce Planning Workshop ......................................................................................... 16

6. Proposed Terms of Reference for the National Consultative Forum for HRH and Priority Agenda Items ............................................................................................................................................... 20

5.2 Terms of Reference .......................................................................................................... 20

6.2 Priority Agenda Items ....................................................................................................... 21

7. Summary Brief for Senior Policy Makers. ................................................................................. 22

8. References ............................................................................................................................... 23

Attachment A: Afghanistan Ministry of Public Health Experiences in Relation to Stakeholder Coordination in Determining and Implementing Human Resource Strategies. ................................. 24

Attachment B: Action Points from 22 June 2010 Country Coordination Meeting hosted by MoPH and Chaired by WHO. ............................................................................................................................. 35

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ABBREVIATIONS APHI Afghan Public Health Institute AKDN Aga Khan Development Network BPHS Basic Package of Health Services CGHN Consultative Group on Health and Nutrition CHW Community Health Worker CSC Civil Service Commission EPHS Essential Package of Hospital Services EU European Union GD General Directorate GDCM General Directorate of Clinical Medicine GDHR General Directorate of Human Resources GDPP General Directorate of Policy and Planning GIHS Ghazanfar Institute of Health Sciences HNSS Health and Nutrition Sector Strategy HSSP Health System Strengthening Program HR Human Resources HRH Human Resources for Health IAM International Assistance Mission (NGO) ICRC International Committee for Red Cross JICA Japanese International Cooperation Agency KMU Kabul Medical University MACCA Mine Action Coordination Centre for Afghanistan MoE Ministry of Education MoF Ministry of Finance MoHE Ministry of Higher Education MoPH Ministry of Public Health MSH Management Sciences for Health NGO Non Government Organisation O & G Obstetrics and Gynaecology PHO Provincial Health Office PTI Physical Therapy Institute of GIHS, MoPH SCA Swedish Committee of Afghanistan SWaP Sector-Wide arrangement Project TAG Technical Advisory Group TOR Terms of Reference UNFPA United Nations Population Fund USAID US Development Aid Organisation WB World Bank WHO World Health Organisation

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1. Background

The General Directorate of Human Resources (GDHR) in the Afghanistan Ministry of Public

Health has undertaken considerable work collaboratively with stakeholders to develop a

number of HRH planning documents. Major ones comprise:

• The MoPH HR Policy 2008-2013, and associated Strategy and Operational Plan 2008-

2010.

• The MoPH Capacity Building Plan, February 2009.

• The MoPH Workforce Plan 2009-2013 (December 2009), and an associated HRH

Afghanistan Profile (Observatory) developed at the request of WHO (January 2010).

GDHR developed a paper for WHO Afghanistan in May 2010, entitled Afghanistan Ministry

of Public Health Experiences in Relation to Stakeholder Coordination in Determining and

implementing Human Resources Strategies. See Attachment A.

Discussion of this paper occurred at a Country Coordination Meeting chaired by WHO and

hosted by MoPH on 22 June 2010. The action points developed by stakeholders, based on

their discussion at this meeting are at Attachment B. The major actions required can be

grouped as follows:

• To develop a summary brief for policy makers, as most of the essential policies and plan

components are still unfunded.

• To establish a national coordination forum for HRH with a well-defined TOR. This would

build on the existing MoPH Human Resources Taskforce, and the Workforce Planning

Meeting, which both include stakeholders, but the latter includes more inter-sectoral

stakeholders and is at a higher level.

• To review and update the 2009-2013 Workforce Plan (an annual exercise) and combine

it with the updating of the HRH Afghanistan Country Profile. The latter was attempting to

include the private sector, although limited data is available. The two need to be

combined and annually updated.

• To review the MoPH HR Strategy and Plan 2008-2010, align this with the updated

country HRH profile/workforce plan, and from this develop a new comprehensive

evidence-based and costed HRH strategy and plan for the country, clearly specifying

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what is required to be done in the public sector and what in the private, and what

collaboratively.

MoPH was part of the HR Cluster proposal to the Donor Kabul conference in July 2010. The

proposal was based on the Workforce Plan 2009-2013, and proposed 16 projects ranging

from institutional development to training and community projects. Detailed proposals have

been drafted but have not yet gone to donor groups. This initiative has given HR in MoPH a

very high profile.

Analysis of the stakeholders who have been involved to date has been undertaken in

determining membership of planning groups: HR Taskforce, Capacity Building Planning

Steering Committee, and Workforce Planning Workshop and Meeting. However, more

needs to be done in analysing their input, and in how to more effectively involve them and

other stakeholders in the future, in order to move effectively towards implementing these

actions.

2. Objectives

Objectives of this document are:

1. To undertake detailed analysis of stakeholders so as to determine their influence,

and strategies to involve them.

2. To draft a well defined TOR for the national coordination forum for HRH, and priority

agenda items.

3. To draft a summary brief for senior policy makers based on the findings of the

analysis, and the plans for the national coordination forum.

A wider objective, the outcome of which will be provided in a separate document is:

4. To review and update the National HRH Afghanistan Country Profile developed in

November 2009, and combine it with the next annual revision of the 2009-2013

Workforce Plan. (This will be a separate document).

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3. Stakeholder Analysis A summary of stakeholders involved in HRH activities in Afghanistan follows: Figure 1: Afghanistan stakeholders diagram:

Regional and International stakeholders (present inside Afghanistan or not): WHO Country Office and EMRO, MSH & Techserve (USAID); European Union, World Bank, Swedish Committee, Aga Khan Foundation, Cordaid, Health Services Strengthening Program (HSSP) John Hopkins, UNICEF, UNFPA, AusAID; JICA; Holland; International Medical Corps (IMC); International Assistance Mission (IAM); International Committee of Red Cross (ICRC); Handicap International (HI): Serving Emergency Rehabilitation and Vocational Enterprise (SERVE): Save the Children; World Vision International (WVI); Italian Cooperation; BRAC; STEP Health and Development Organisation.

Outside MOH at national and regional level: Kabul Medical University, Loma Linda University (LLU); Student Affairs/MoHE, MoE, Ministry of Women’s Affairs, MoF, Central Statistical Office, Civil Service Commission, AGs, Ministry of Labour and Social Affairs; Medical, nursing and midwifery and other professional associations, Private/Public Partnership. Private hospitals and service providers. Afghanistan Human Rights Commission. Integrity Watch Afghanistan. Health and Grievances Parliamentary Committees. Media. Unions. Afghan National NGOs: Afghan Health and Development Services (AHDS); Agency for Assistance and Development of Afghanistan (AADA); SHUHADA,; NAC; Merlin; HNI; HNTPO: ACTD: Solidarity for Afghan Families (SAF); Badakhshan Development Forum; Mine Action Coordination Centre of Afghanistan (MACCA); Private medical facilities (Cheragh Medical Facilities); Private Health Institutes ( Ibn Sina Balkhi; Nangarhar Science Institute; Abu Alisina, Afzal Asas; Kabul; Maihan; Baran, Farabi).

MOPH related people: Minister, deputies and advisers, GDHR, GDPP (and HMIS), Ghazafar Institute of Health Sciences, Afghan Public Health Institute (APHI), Executive Board, HR Taskforce, Workforce Planning Working Group, Capacity Building Planning Steering Committee (CBPSC), Provincial Health Coordination Committee, Heads of each functional area.

Group planning and operating the HRH consultative activities, mainly GDHR team, but collaborating with GD of Policy and Planning.

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Figure 2: Stakeholder analysis:

Stakeholders have been rated on a scale of 5 regarding their support for HRH activities, and how to involve them in the future:

Scale goes from ++ (very supportive attitude, very confident in assessment, very influential) to + to o to – to – – (not at all) Stakeholder’s name

Attitude

Confidence

Influence

Strategies for involving person/group.

1 GDHR ++ ++ + HR Database Unit has support from MSH and provides timely input. GDHR needs Secretariat support – it has limited time and expertise to follow through on actions and update plans etc. Currently.

2 GDPP (including HMIS, HCF and PPP)

++

++ ++ HMIS works very closely with HR Database team and is heavily involved in planning. DGPP Chairs CBPSC – secretariat is in GDHR. GDPP has Public-Private Partnership Unit and also Health Care Financing area which has worked with GDHR on salary equity. The HRH coordination forum must be at a very high level for these units to give HRH the priority it deserves.

3 GD Curative

o + + Heads of Hospital Reform/EPHS, and Curative and Diagnostic Facilities have been involved in HR planning fora. The Ministry must make HR a high priority for them and others in the GD to give it their time.

4 GD Preventive

o o o Heads of Reproductive Health, Disability and Mental Health have attended HR planning fora. BPHS in a limited way. The Ministry must make HR a high priority for them and others in the GD to give it their time.

5 GD Admin - + - There needs to be better coordination between the Finance Directorate and the Health Care Financing Unit of GDPP, to ensure that HR needs are argued strongly.

6 Minister, Deputy Ministers & Advisers

o + ++ Acting Minister is very committed to the MoPH HR Cluster proposal submitted July 2010. This needs to be used to drive actions. HR Support is one of the building blocks of the MoPH. The current Deputy Minister Administration (who is responsible for GDHR and GIHS) is has limited involvement in HRH issues.

7 Executive Board

- + ++ Decisions at the Board tend to be political and members generally appear to have no interest in the detail of HR. All initiatives must therefore be sold as being a top priority for the Government, so the links with the HR Cluster proposal is essential (which major initiatives are part of anyway).

8 APHI o + + APHI is always involved in training discussions. DG is meant to co-chair the HR Taskforce, but has not made the time to do so for a while. With recent change of DGHR it is expected to be possible to re-establish a better working relationship between GDHR and APHI.

9 GIHS + + o Has a new head, who is finding her feet. She will be keen to be involved if she can see benefit.

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Stakeholder’s name

Attitude

Confidence

Influence


10 Provincial Liaison Directorate

o + o This area is not well linked with other initiatives. Provincial Health Directors need to be sold the idea that they need to be proactive in identifying their staffing and training needs in an objective way.

11 M&E Directorate

o + o Has attended HR planning fora, but is not proactive relating to HR. Needs to be persuaded of importance by Executive.

12 Kabul Medical University

+ ++ ++ Chancellor is strongly involved in and supports Workforce Plan aspects relating to curriculum, accreditation, staff numbers and professional councils. Will be involved in high level discussions.

13 Student Affairs/MoHE

+ ++ ++ As above

14 MoE o + o Are linked through a health education teacher training project in the MoPH Kabul Conference proposal, but are not really engaged. Need to develop relationships.

15 MoWA o o + Are linked through Kabul Conference proposal, but no other involvement. Need to develop a relationship to get their support for need for more female health workers.

16 MoF o + ++ Health Section head provided comment which supported the Workforce Plan draft, but could not attend the planning meeting to finalise it. Health Care Financing Head from MoPH is trying to get MoF on side regarding salary increases. HCF must be supported to put the time into this advocacy.

17 Central Statistical Office

o + o The information they have comes from MoPH, so they are of little relevance.

18 Civil Service Commission

+ + ++ The head of the Policy Unit is a very strong supporter of MoPH and has worked with GDHR on training and policy development. Work is needed to get support at the very top levels for salary changes and staffing numbers.

19 AGs o o o Have had limited interaction. This needs to be increased relating to monitoring of registration and complaints. Disputes relating to civil servants can be dealt with through CSC processes, but regarding service providers and the complex mechanisms of employment, working more closely with AGs is required.

20 Ministry of Labour and Social Affairs.

o o o ??

21 Medical Associations

+ + + These are speciality focused (e.g.O&G) or locality focused (e.g. Herat), and are supportive of a Medical Council. It is essential to work with them to improve standards, regulation, accreditation and disciplining of doctors.

22 Nursing/Midwifery

+ + + The standards and accreditation processes are very good. Strong links need to continue.

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Attitude

Confidence

Influence


Associations 23 Private hospitals and service providers

o o variable

Some private hospitals and service providers are highly regarded, others are not. Through the public-private partnership there are moves to have agreed hospital standards. Noone from the public-private partnerships came to the Workforce Planning meeting, although invited. Training of nurses, midwives and technicians through private facilities has not been accredited. This is urgent. The relationship must be improved.

24 Afghanistan Human Rights Commission

o o o They have agreed to be on the Board of Trustees for the proposed Health Complaints Office, but there is no funding for this. The relationship needs to be fostered so they help advocate for this.

25 Integrity Watch Afghanistan

o o o As above

26 Health and Grievances Parliamentary Committees

o o o They strongly support the formation of a Health Complaints Office, which will reduce their workload. They need to be asked to advocate for this in Parliament.

27 Unions o o o Relationships need to be developed with these embryonic bodies.

28 Media o o o It has not been the practice to use the media to get change. Perhaps strategies need to be developed to use the media to assist advocate for change, possibly through the public-private partnership.

29 USAID (MSH, Techserve and GAVI/Health Sector Strengthening)

++ ++ ++ MSH/Techserve have been actively involved in the CBPSC, and the three in the Workforce Planning meetings. They will be keen to be involved in a high level HR coordination meeting. However, their focus is more on morbidity and mortality reduction rather than institutional development (ID), so work needs to be done to encourage them to see ID as necessary to achieve the former.

30 EU ++ ++ + Has been actively involved in “support to institutional development project” in GDHR – expected to start again in 2011. Also mental health. Heavily involved with GDHR counterparts in all planning.

31 WB 0 + + Due to limited staff in country, WB has had no representative on HR Taskforce or CBPSC, but did come to final Workforce Planning meeting. Do not expect much input but would come to high level coordination meeting.

32 Swedish Committee

++ + o Has been actively involved in Workforce Planning meetings relating to disability.

33 AKDN ++ + + Has been actively involved in HR Taskforce and Workforce

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Attitude

Confidence

Influence


Planning Meetings and Kabul Conference MoPH HR Cluster proposal development, relating to MCH.

34 Cordaid + o o Has been actively involved in Workforce Planning meeting relating to disability.

35 HSSP + + o Has been actively involved in HR Taskforce, CBPSC and Workforce Planning meetings relating to MCH.

36 UNICEF o o - Has not come to HR planning workshops. Need to engage. 37 UNFPA + + + Has provided HR Adviser to work with Reproductive Health

area to plan MCH staffing and training, and has come to Workforce Planning meetings.

38 AusAID + + o Provides an Adviser in GDHR. Supports specific projects such as Medical Council and improving information storage and processing.

39 JICA + + + Concerned about MCH and community services in Kabul urban.

40 Holland o o o Involved in midwifery funding 41 HI, SERVE, MACCA – Rehab Orgs.

+ + + Very concerned about mines, physiotherapy and rehab, together with orthopaedic technicians, together with Swedish Committee.

42 Save the Children

43 World Vision

43 Many local or regional NGOs – main ones :STEP, AHDS, AADA, SHUHADA, NAC, Merlin, HNI, HMTPO; ACTD; SAF; BDF

Provision of BPHS services locally – There are about 53 contracted, some are international organisations, but many operate in just one or two provinces.

44 Private Health Institutes: Ibn Sina Balkhi; Nangarhar Science Institute; Abu Alisina, Afzal, Kabul, Maihan,

Train nurses, midwives, pharmacy technicians and others.

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Attitude

Confidence

Influence


Baran, Farabi 45 WHO Afghanistan and EMRO

+ + o Has provided funding and support for Workshops and Planning documents. Has not in the past come to HR Taskforce or CBPSC meetings – but has come to one Workforce Planning meeting. Focus has been on asking MoPH to undertake WHO processes, rather than joining in on MoPH processes (need to work with them to ensure not two separate processes). WHO would come to high level coordination meetings.

4. Conclusions from Stakeholder Analysis and Recommendations for More Effectively Involving Them:

A key problem for involvement in HR activities within the Ministry has been the diverse number of

fora in which HR is discussed, and the inability of senior people to be involved in a number of fora.

Non-attendance has meant that key input has not been obtained.

Also, the lack of HR staff to undertake the data collection and produce drafts of planning documents

has meant that often key people do not attend meetings, as they have not done what they were

asked to do for the meeting.

The plan to have just one high level HRH coordination forum should overcome this problem, as long

as:

• the Executive Board ensures that the key people from the Ministry attend;

• the key people from international agencies and other Ministries feel it is worth their while

attending as they will get something for their organisations from it, and

• meetings are short and have a clearly defined agenda and brief proposals/reports to

consider and decide on. The agenda needs to relate to just high level decision-making.

There should be five working groups feeding in to the high level HRH Coordination Forum, which will

have lower-level staff inputting. Through these, proposals, reports and recommendations would

feed into the high level coordination forum. The five working groups (as proposed in the paper at

Attachment A where there are more details) would be:

o Workforce Plan

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o Professional Councils, Standards, Accreditation, Curricula and Registration.

o Needs Assessment, Capacity Building Plan and Training and Development.

o Coordinated HR Practices

o Adequate funding and Workforce financing arrangements.

The membership of the high level forum would have to be kept small for it to be effective.

It is proposed that previous mechanisms for consideration of HR are reduced in number, namely:

• The HR Taskforce should no longer exist. GDHR should have a strong management committee of

directors to decide on key issues relating to implementation of HR within MoPH. All the wider

issues would be considered by the HR coordination forum and its working groups.

• HR issues would no longer go to CGHN and TAG for consideration, other than HR policy

documents which would go via GDPP to TAG. Issues that relate just to MoPH would be

considered by GDHR management, and if necessary by the Executive Board. Wider issues would

all be considered through the new Coordination Forum and its working groups.

• The Capacity Building Planning Steering Committee would be continued as a working group of

the new Coordination Forum.

• The planned MoPH/MOHE joint committee would occur as a working group of the new

Coordination Forum.

• The Provincial Health Coordination Committee would be represented by the Deputy Minister for

Health Services, and Private/Public Partnerships by a Private Hospital and Private Training

Institution on the Coordination Forum.

The Executive Board of MoPH would also need to ensure that there is funding for a strong

Secretariat to produce the required analysis and ensure decisions are implemented after meetings.

Also the Board would have to ensure that there is support for funding of the necessary initiatives. If

there continues to be non-funding of initiatives strongly supported by key stakeholders, the key

people from other Ministries , NGOs and International agencies, will see no point in attending

meetings.

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5. Stakeholders to be Involved and their Roles

5.1 High Level HRH Coordination Forum It is proposed that the Forum comprises no more than 20 people. Dr Homayee, GDHR Consultant will be head of the Secretariat for the HRH Coordination Forum and for the Working Groups.

Organisation

Name Title Phone Email

MoPH Dr Suraya Dalil (Chair)

Acting Minister ? [email protected]

Dr Nadira Deputy Minister for Health Care Services

? ?

Dr Ihsanullah “Shahir”

Acting Director General (DG) of GDHR

? [email protected]

Dr Ahmad Jan

Acting DG of GDPP

070207826 [email protected]

Dr Noormal Acting DG of APHI 0700281134 [email protected] Dr Kimia

Azizi Director, GIHS. ? [email protected]

MoHE Prof. Dr Obaidullah

Chancellor of KMU


? DG responsible for Student Affairs?

MoF ? DG responsible for Health

CSC ? DG responsible for

USAID World Bank

Dr Sayed Adviser 0700042585 [email protected]

EU ? Task Manager, Health Section

WHO Dr Peter Graff

Head of Mission, Afghanistan


Private Hospital

To be nominated by Dr Miya, Hospitals Reform Unit in MoPH

Private Training Institutio

IbnSina Balkhi Institute

mailto:[email protected]









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Organisation


n National NGO

Dr Parvez Nayani,

AKDN – head of health training


Medical Association

?

Nursing/Midwifery association

Parliamentary Committee

Health or Grievances Committee representative

5.2 Working groups Dr Homayee, GDHR Consultant (0774606218) ([email protected]) will be head of Secretariat for the Working Groups. The names below are initial proposals which should be added to over time.

5.2.1 Workforce Plan Chair: Dr Ihsanullah “Shahir”.

Organisation


MoPH Dr Hoffiani

Acting Director of HR Administrative Capacity Building.


Mr Sadiq

HR Database Manager 0799340393 [email protected]

Dr Homa Kabiri

Acting Director of Professional Capacity Building

? ?

Dr Arzoie

Adviser to DGPP 0700213298 [email protected]

Dr Salehi

Director of Health Care Financing


Dr Shafi Saadat

Private Sector Coordinator


MoHE Dr Said Najmuddin

Director of Student Affairs


CSC Eng. Director of Policy 0772072388 [email protected]












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Organisation


Kahlil v.af

5.2.2 Professional Councils, Standards, Curricula, Accreditation and Registration Chair: KMU Chancellor

Organisation


MoPH

Dr Acting Director of Professional Capacity Building, DGHR

Dr Hoffiani

Acting Director of Admin Capacity Building, GDHR


Dr Kimia Azizi

Director, GIHS [email protected]

Dr Islam Saeed

Director Training and Development, APHI


Dr Said Najmuddin

Director of Student Affairs


Medical and Nursing Associations

?

5.2.3 Needs Assessment, Capacity Building Plan and Training and Development Chair: Dr Ahmad Jan

Organisation


MoPH Mr Sadiq

HR Training Database Manager, GDHR


Dr Kimia Azizi

Director GIHS [email protected]

Dr ? Acting Director of Professional Capacity Building, GDHR

Dr Islam Saeed

Director Training and Development, APHI


USAID Dr Capacity Building 0706155628 [email protected]













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Organisation


Ghulam Rafiqi

Program Manager, Techserve/MSH

Ms Denise Byrd

Head of Party, HSSP [email protected]

5.2.4 Coordinated HR Practices Chair: Dr Noormal.

Organisation


MoPH Dr Hoffiani

Acting Director of HR Administrative Capacity Building.


Dr Abdul Qadir

Head of BPHS 0799131689 [email protected]

Dr Miya Head, Hospitals Reform Unit


CSC Eng. Kahlil

Director of Policy 0772072388 [email protected]

5.2.5 Adequate Funding and Workforce Financing Arrangements Chair: Dr Salehi.

Organisation


MoPH Dr Salehi

Director of Health Care Financing Directorate


Dr Husnia Sadat

Head of Health Care Financing


Dr Hoffiani

Acting Director of HR Admin Capacity Building


? Representative from GDA MOF ? Head of health unit

5.3 Workforce Planning Workshop Attendees to this workshop will include members from the high level forum and working groups above, as well as from the following who attended (or were invited to) the previous Workforce Plan final meeting. Many of the regional/provincial NGOs and Health Institutes will be emailed the draft













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and asked to comment, as it would be too large and unwieldy a workshop and too expensive for them all to attend.

Organisation


MOPH Dr Akhgar DG Clinical Health 0700289012 Dr Hamrah DG Admin 0700276152 [email protected]

m Dr Habib ur

Rahman Head Provincial Liaison Office


Abdul Khalil Khakzad

DGPA 0799334756 [email protected]

Dr Amina Hashimi Director Curative and Diagnostic Facilities


Dr Sayed Kabir Amiry

Director Central Hospitals


Dr Mashal, Muhammad Taufiq

Director, Preventive and Basic Health Care


Dr Sadia Fayeq Acting Director, Reproductive Health


? Head Mental Health

Dr Razi Khan Head Disability Services


Dr Habib Arwal Head of Community Health Worker Program

Dr Said Yaqoob Azimi

Acting Director of HMIS

Dr Zalmai Deputy Director of GIHS


Dr Wahidi Consultant GDHR 0700061660 [email protected]

? Director of Legislation Enhancing Directorate

MoE MLSA MWA AG US Dr Mubarak Chief of Party –

Techserve/MSH 0799410212 [email protected]



















18

Organisation


Dr Zelaikha Anwari Policy Adviser MSH/GDPP


Swedish Committee

Ms Fiona Gall and Heather Dawson

Disability Adviser 0797070987 and 0706604637

[email protected] [email protected]

WB Tawab [email protected]

AKDN Dr Fatima Gohar Nursing/Midwifery Adviser


WHO Dr Haqmal HR & Gender Officer


Dr Ahmed Rahman Medical Officer 0799330027 [email protected]

Dr Ashfaq Ahmed Health Strengthening Consultant

[email protected]

UNICEF Zohra Mohammad EPI Program Manager


UNFPA Dr Zibulessa Alam\Dr Mohammad Tahir

National Program Officer

070276259 0799322119

[email protected] [email protected]

GAVI/HSS/US

Dr Abdul Wali Ghayur

0799353178 0775577096

[email protected]

HSSP Furmali O799338511 [email protected] Cordaid Ms Spoozhmay

Wardak Program Officer 0772015191 Spoozhmay.wardak@cor

daid.net ICRCC HI SERVE Save the Children

World Vision

BRAC Italian Cooperation

STEP IAM JICA AusAID Loma Linda Uni

Afghan Human Rights Commissi




















19

Organisation


on Integrity Watch Afgahnistan

AHDS AADA SHUHADA

NAC Merlin BRAC HNI HNTPO ACTD SAF BDF MACCA Ibn Sina Bakkhi Institute

Nangarhar Science Institute

Abu Alisina Institute

Afzal Asa Institute

Kabul Health Institute

Maihan Institute

Baran Institute

Farabi Institute

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6. Proposed Terms of Reference for the National Consultative Forum for HRH and Priority Agenda Items

5.2 Terms of Reference Mandate

The Consultative Forum for HRH is a permanent mechanism to advise the Minister of Public Health

and other interested Ministries on all issues relating to development and deployment of human

resources for health in Afghanistan, both in the public and private sector.

Membership

Members will not exceed 20, and will comprise: 6 from MoPH; 2 MoHE, 1 MoF, 1 CSC, 1 USAID, I

WB, 1EU, 1 WHO, I Private Hospital, I private training institution, 1 NGO, 2 Professional Associations

(one medical and one nursing/midwifery), 1 from a Parliamentary Committee.

Goals:

• To advise on HR issues and problems and identify measures for their correction.

• To set HR priorities.

• To ensure the National HRH Profile and Workforce Plan are updated each year, and that

feasible private sector data and planning are included together with the public.

• To assess the Plan and advise on:

o Whether it is adequate to meet national and international goals to which the Afghan

government has committed.

o The adequacy of HR resources proposed to implement the Plan.

o The reasonableness of the timeline for phased implementation.

o Financing mechanisms which are not dependent on donor funding

• To advocate politically for required resources.

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• To ensure monitoring processes are in place to track the implementation of the Plan, and

that this is reported annually.

• To ensure there is a third party evaluation undertaken of HR in the public and private sector

periodically against the objectives and timeline within the Workforce Plan.

Secretariat

A Secretariat of 3 senior and five other skilled full-time staff will be funded, and established within

GDHR to undertake the required research, consultation and preparation of reports and proposals for

the Forum. This group will coordinate the work of the 5 Working Groups, and other HR documents

which need to be considered by the Forum. The Secretariat will provide minutes, and following the

instructions from the Forum, will follow-through on action regarding funding and implementation.

Meetings

These will be each three months and will be chaired by the Minister.

6.2 Priority Agenda Items It will be important for the first meeting to be held as soon as possible to discuss the non-funding of

the Workforce Plan 2009-2013, and the MoPH HR Cluster Proposal for the Donor Conference. The

Forum would be essential in providing support at a high level for the 16 priorities in the HR Cluster

proposal. This will need to feed into the budget cycle for 2011.

When the National HRH Afghanistan Country Profile and Workforce Plan have been updated for

2010, probably by the second meeting, the Forum will be able to assist in advocating for funding for

future initiatives, linking in with funding cycles of donors which occur at different times during the

year. Development funds from many donors are usually available in a staggered way.

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7. Summary Brief for Senior Policy Makers. A short brief follows for provision to heads of the 20 stakeholder organisations who will be invited to be members of the Forum. It has been kept brief to ensure they read it. It summarises the analysis and action proposed to advance HRH.

HUMAN RESOURCES FOR HEALTH COORDINATION FORUM

The Ministry of Public Health, with assistance from WHO, has undertaken some analysis of the

human resources involved in providing health services in both the public and private sectors.

Although resources are improving, there is much more that needs to be done.

In the last year MoPH has produced a 5 year Workforce Plan, and also developed 16 proposals as

part of the HR Cluster proposal for the Donor Conference. Both of these are as yet unfunded.

We have many HR committees, but people are busy and attendance is often not regular and activity

is spasmodic. We have therefore decided to reduce the number of committees and establish a very

high level Forum with 20 members that can help drive the required initiatives, and also advocate for

the required funding.

You have been targeted as an essential person to have on the Forum, which will comprise: 6 from MoPH; 2 MoHE, 1 MoF, 1 CSC, 1 USAID, I WB, 1 EU, 1 WHO, I Private Hospital, I private training institution, 1 NGO, 2 Professional Associations (one medical and one nursing/midwifery), and 1 from a Parliamentary Committee. Under the Forum we will have 5 working Groups which will develop proposals and reports for consideration by the Forum on:

o The Workforce Plan

o Professional Councils, Standards, Accreditation, Curricula and Registration.

o Needs Assessment, Capacity Building Plan and Training and Development.

o Coordinated HR Practices

o Adequate funding and Workforce financing arrangements.

The Forum will meet four times a year, and will have a strong Secretariat provided by the MoPH to

drive the activity, with assistance from WHO.

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8. References 1. MoPH: Human Resources for Health Policy 2008-2012, Strategy and Plan 2008-2010. 2. MoPH: National Health Workforce Plan 1388-1392, including appendices, December 2009. 3. MoPH/WHO: Health Workforce Observatory, Human Resources for Health, Afghanistan Profile,

November 2009. 4. HR Cluster, Ministry of Finance, for Kabul Donor Conference, Bankable Program Number Five,

Human Resources for Health, July 2010. 5. MoPH: Detailed 16 Project proposals (incomplete) for consideration in next stage of donor

conference discussions, 11 August 2010.

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Attachment A: Afghanistan Ministry of Public Health Experiences in Relation to Stakeholder Coordination in

Determining and Implementing Human Resource Strategies.

1. AN ANALYSIS OF THE HUMAN RESOURCES SITUATION

[a] Population, Clients, Health Facilities and Staffing.

The estimated population of Afghanistan is 25.64 million and increasing by 2.3% per year. The number of people using public health facilities has generally doubled in the last two years. The availability of health services has been gradually improving (there are now 18 Central Hospitals, 5 Regional Hospitals, 34 Provincial Hospitals, 56 District Hospitals, 374 Comprehensive Health Centres, 26 Multipurpose Health Centres, 679 Basic Health Centres, and 120 Sub-Centres as well as an increasing number of Health Posts. The quality of health services has improved by 25% in the last 5 years (John Hopkins Report to MoPH Results Conference December 2008).

In October 2009 there were 27,867 staff in the HR database, including civil servants (14859) and donor-funded NGOs and other staff (13008). There is no accurate assessment of health workers in the private sector, however an Afghanistan private providers survey undertaken by USAid, in 5 provinces, and presented to the December 2008 MoPH Results conference, indicated that 75% of providers are private and 25% public .

The population ratio of public health workers per 1000 population is 1.08. Females comprise 28%. There are considerable regional dis-balances: the Southern region has one quarter of the health workers of the Central Region. Western is the next most disadvantaged followed by North Eastern. Most provinces are at least 90% rural. There are only 0.45 health workers per 1000 population in rural areas, compared with 3.2 in urban areas. Doctors are 1:4206; nurses 1:4933. There are 2.2 times more health professionals (1:1365) than management/administration and support staff (1:3065). (HR Observatory January 2010)

There is a need to increase the public health workforce by 11.55% to meet the current population, utilisation needs and strategic priorities, as well as align with standards in the Essential Package of Hospital Services (EPHS), and Basic Package of Health Services (BPHS). The urgent requirements within the 5 year life of the Workforce Plan are to increase civil servants by 8.7%, EPHS by 12%, and BPHS by 18.76%. (Workforce Plan December 2009).

[b] Major MoPH HR Documents

There are seven major HR documents, which have been developed through collaborative mechanisms with key stakeholders:

• National Salary Policy for contracted in and contracted out staff, 2005;

• The MoPH HR Policy 2008-2013, and associated Strategy and Operational Plan 2008-2010;

• MoPH Midwifery and Nursing Policy 2008/2009;

• The MoPH Needs Assessment and Capacity Building Plan, January 2009;

• The National Health Workforce Plan 2009-2013;

• The Human Resources for Health Afghanistan Profile (Observatory) completed at the request of WHO in January 2010; and

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• The MoPH New Pay and Grading System, Job Descriptions and Organogramme 2009.

There is significant overlap in information in these documents. Also stakeholders are often requested to be involved in many different committees. The coordination mechanisms through which these HR documents were developed, together with their strengths and weaknesses, and progress in implementing the plans, will be discussed below.

2. CO-ORDINATION MECHANISMS USED TO DEVELOP HR STRATEGIES

The development of human resource strategies is primarily the responsibility of the General Directorate of Human Resources (GDHR) of the Ministry of Public Health. However, the GD of Policy and Planning (GDPP) has responsibility overall for polices, strategies and plans. The two GDs, therefore, work together on many aspects.

Development has been complex due to differing interests and existing mechanisms within the Ministry for consultation and collaboration. A summary diagram attempting to chart the mechanisms and relationships follows:

Donors and International organisations

MoPH Retreat and Results Conference

Workforce Planning

Workshop

Ministry of Higher

Education

Civil Service Commission

Minister and MoPH

Executive Board

Deputy Minister for Policy &

Planning

Deputy Minister for

Administration

Deputy Minister for

Health Services

Technical Advisory Group and

Consultative Group on Health

and Nutrition HR

TaskforceProvincial

Health Coordination Committee

Capacity Building Planning Steering

Committee

Workforce Planning Working Groups

Reform Implementation

Management Unit

DGPPDGAPHI

DGHR

Provincial Liaison

DirectoratePublic-Private Partnerships

NGO Contractors, BPHS, EPHS

Clinical Specialisation Shura/Council

DGCM

Hospital Community

BoardCommunity Health

Committees

Health worker associations &

unions

(a) Human Resources Taskforce

The Taskforce was established in 2005, then after a dormant period was revitalised in 2008 with revised TORs. The TORs state that it should meet fortnightly to guide, and provide advice and recommendations to the MoPH on all HR issues. Membership comprises representatives from relevant Directorates, and development partners. An annual report is to be circulated to all members as well as the Deputy Ministers and all General Directors by the alternate Chairs (the Director General of Human Resources (DGHR) and DG of the Afghan Public Health Institute (APHI)).

The Taskforce has had very active periods, and then has been inactive when work pressures have intervened. In its most active periods it has had wide membership from donor organisations and international NGOs as well as other Directorates, or has seconded people for specific tasks. For example the HR Taskforce, through a number of working groups, developed the HR Policy and Strategy listed above, together with an Action Plan of key priorities. It was also instrumental in coordinating reproductive HR planning, and nursing and midwifery curriculum development and in-service training.

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It is currently not meeting regularly and it is hard to encourage donor organisations or other Directorates to nominate a representative to come regularly. The reporting has been spasmodic and usually issue based. Rather than reporting to Deputy Ministers and GDs, issues for decision have often been referred directly to the GDHR or to the Consultative Group on Health and Nutrition (CGHN), chaired by the Deputy Minister for Policy and Planning. This group has attendance from a wide range of donors, international agencies, NGOs and high level health workers (depending on the topic of the week). If the issue is approved by the CGHN it is referred to the Technical Advisory Group (TAG) which comprises membership from each key donor/international agency group and key policy positions in MoPH. If approved by TAG the next stage is to present to the Executive Board which includes all senior executives. Going through all these processes can take time, so not all issues follow this route, although this is the advised route for policy development in MoPH.

The HR Policy went through all these consultative processes before being approved by the Executive Board.

A problem with these processes is that some of the key people who need to make some of the decisions cannot communicate fluently in English, yet the HR Taskforce, CGHN and TAG are all held in English. Only the Executive Board is conducted in Dari.

TAG has recommended that the HR Taskforce be re-activated and membership broadened. The issue is how to get the high level people needed to attend these meetings to come regularly. Also there is no funding for a Secretariat for the HR Taskforce, which is why, when there are other priority pressures, the meetings are postponed.

The potential for the HR Taskforce to coordinate and drive all HR initiatives is great. But there must be high level people on it, a strong secretariat, and following processes which allow quicker action than at present.

(b) Capacity Building Planning Steering Committee

This was established as proposed in the Afghanistan National Development Strategy (ANDS) and Health and Nutrition Sector Strategy (HNSS) to: (a) develop a systematic and routine capacity building Needs Assessment (NA) (for training and institutional development), (b) develop the first comprehensive Capacity Building Plan (CBP), and (c) update it each year. The TORs for this were approved by CGHN and members invited comprised each Directorate, major donors and some key NGOs. Unfortunately the same problem was experienced as with the HR Taskforce, it was impossible to obtain representatives from all the key organisations required; people were not prepared to nominate a regular attendee.

Despite this, the chair who was the Director General of Policy and Planning (DGPP) and the Secretariat from the General Directorate of Human Resources (GDHR) completed the task (using a bottom-up approach, interviewing the heads of each Unit, other than hospitals) in early 2009, with the help of the EU and some comment from key donors/ Directorates on request. The report was presented to CGHN and supported, and then the Executive asked GDHR to develop a proposal for funding. This was submitted to the Ministry of Finance (MoF) in early 2009, but no funds provided, and again in 2010, with similar lack of success in obtaining (through MoF) development funding from donors for implementation.

It was planned to update the Plan in 2010 (and some work was undertaken to collect additional data from hospitals) but most Units said, they wanted what was in the 2009 report first. There is still no funding for a Secretariat to undertake this task annually, and the development of an annual NA&CBP will not be sustainable until this occurs. Also, until donors provide funds for the first Plan developed with each operational area, there is little point in undertaking an updated planning exercise.

(c) Provincial Health Coordination Committee, and District/Community Mechanisms

Linkages are strengthened between GDHR and the provinces by the placement of a Provincial HR Officer in each province. However, these officers have variable skills, and in some cases the Administration Manager undertakes the role. The delegate from each Province functions as a member of the Provincial Public Health Management Team (where committees have been

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established). He (or she in rare cases) works closely with the GDHR to implement the MoPH HR policies and strategies at provincial level. A Provincial Health Coordination Committee is held monthly; its TORs primarily relate to coordinating activities.

Following some initial training undertaken in Kabul of most Provincial HR Officers, there have been plans to have a quarterly coordination meeting of all these officers in Kabul – to do more advanced training, sharing of information and collaborative planning. These plans require resourcing. Until this occurs the coordination/combined planning between HR in central offices and the provinces will remain inadequate.

There are District Health Officers, and Community Health Committees which comprised 50% government and 50% community members.

(d) Workforce Planning Working Group, Workforce Planning Workshop and Workforce Planning Meeting

At the MoPH Retreat at the end of 2008 considerable discussion occurred about HR planning that had been undertaken, and priorities. It was agreed that a workforce planning workshop would be held to develop a comprehensive workforce plan for MoPH, to which government, NGOs, donors, other government agencies, and the private sector, would be invited.

GDHR, with assistance from the EU, obtained and analysed available data and developed an incomplete draft to use as a starting point for discussion. GDHR then asked GDPP to form a joint Working Group with them to further develop the draft and plan the workshop. The workshop agenda was planned covering the 6 strategies in the draft, and the costing of the Plan. About 60 delegates were invited from MoPH central Departments, hospitals and Provincial Health Offices, donor groups, key other Ministries and key NGOs. They were invited to help further develop the plan in 6 discussion groups. Attendees at the Workshop were variable – some were excellent – others knew nothing about HR, had not read the draft, and wanted to learn not contribute. However, considerable development occurred, and it was agreed that a further meeting would be held (to discuss an improved near final draft) with key people from the workshop and some intersectoral invitees who had not been able to attend the workshop.

Senior people from the Ministry of Higher Education (MoHE), Kabul Medical University, Civil Service Commission (CSC) and the Ministry of Finance (MoF) were invited to this Meeting. The first three attended, but unfortunately the MoF delegate was called away urgently. Kindly he provided comment after the meeting, so his comment could be included. The select attendees at the meeting were able to reach agreement about the final recommendations of the Plan. The learning from this was that a small high level workshop of about 20 high level attendees is the best approach.

It was agreed that the Workforce Plan would be presented to the MoPH Results Conference and the Retreat (scheduled for late January), so the costs could be included in the 2010 budget. Unfortunately, due to the election and the non-appointment of a Health Minister, the Retreat was delayed to early April, so no funding decisions were made in time for the 2010 budget.

(e) Ad Hoc General Directorate of Human Resources (GDHR) Planning Working Group

When WHO asked GDHR to produce an HR Observatory, it was agreed that much of the data required to go in the WHO format was in the Workforce Plan. However, unfortunately some of the categories were different, so some of the data would had to be re-analysed. GDHR was disappointed not to have been given the format earlier so the two could have been produced together as a combined document. However, there were some excellent additions; some additional data required relating to ratios of health workers, shortfalls in specific provinces, and comparison between urban and rural areas.

In order to produce the document by January 2010, a small team of 5 HR staff with the required skills were seconded to undertake the task. This included the HR Database Manager, the Director of Clinical Specialisation, the Director of Capacity Building and one of his local consultants, and the EU international HR consultant.

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This same group of 5 has had input in many key HR planning processes, through the HR Taskforce, and when policies and plans need to be developed at short notice. They consult with wider stakeholders as required but work as a tight group to produce the required outputs.

3. HUMAN RESOURCES FOR HEALTH PLAN

A presentation was made by GDHR at the late March 2010 Results Conference, entitled “Results Relating to Human Resources Developments”. The HR Policy; Needs Assessment and Capacity Building Plan; and Workforce Plan were discussed. As most issues were included in the Workforce Plan, the presentation focussed on the 5 Strategies in the Plan, their costing, and next stages required:

• Increase the size of the workforce in each major skill category • Targeted training in order to obtain and keep skilled staff • Enhancement of Professional Standards and Accreditation of Curricula • Improved HR Practices • Amalgamation of HR Databases and coordinated analysis • Potential changes to public health service workforce financing arrangements so as to improve

staff conditions and increase efficiency and effectiveness. A presentation was made at the Retreat in early April 2010 entitled “Human Resources and Transparency” (HR was joined with wider anti-corruption activities). A summary from the Health Retreat included the following statements about HR:

1. Objective: To gain funded commitments to implement strategies and plans in human resource development

2. The Results Conference referred issues raised to be further discussed at the Retreat; this included health workforce planning: career planning and staff retention.

3. HR- Agreements:

a. Speed up civil service reforms and system improvements b. Institute a climate of accountability for results and ethical practices c. The HR GD to take lead role during any recruitment process. d. Capacity development and team building for all managing teams. e. Coordination with other ministries like MoHE, etc.

4. Needs further exploration: HR 5.

a. Partners to study existing plans that are ready for funding but so far unfunded. b. Competency based payments through contractual mechanisms c. Hazardous and overtime payments for staff in far flung and insecure areas d. Facilitate hiring staff from neighbouring countries to hard-to-reach areas e. How to attract and retain female health workers in remote areas.

6. Next Steps for MoPH teams: 6 big issues – one is HR

. 4. COLLABORATIVE ACTIVITIES WITH STAKEHOLDERS

Development of HR has required specific collaborative activities with key stakeholders, as follows:

[a] Collaborative Meetings with the Ministry of Higher Education (MoHE)

There is no regular meeting of officials from MoPH and MoHE to specifically discuss HR matters, which is unfortunate (An Inter-Ministerial committee discusses wider issues). GDHR has an ad hoc arrangement with MoHE and the DGHR represents MoPH at such meetings when required. MoPH sends MoHE details of numbers of doctors and nurses required, and MoHE sends MoPH the details of students who want to enrol in courses. There is a Clinical Specialisation Shura/Council which

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meets relating to the entrance examination for the postgraduate doctor specialisation trainings; and the Institute of Health Sciences entrance examination.

Registration of health workers is currently through MoPH, and monitoring of adherence to regulations; this is currently the responsibility of MoPH’s Regulation Enforcing Department. Unfortunately the data on private health workers is not complete, or accurate. It is not updated regularly, so includes health workers who died or left the country (the data on doctors held by the Government Statistical Unit is from this database and therefore greatly overestimates the numbers).

An interim National Testing and Certification Board (NTCB) was established by MoPH a few years ago to assess existing staff who were employed when no accredited programs were in existence. The backlog of assessment and additional training through this system is nearly complete. The NTCB also manages the examination process for doctors applying to undertake specialist training within MoPH hospitals. Due to limited accredited curricula to train specialist doctors, plans are underway to run curriculum development workshops for each speciality (3 have been undertaken by donors with Kabul University), but funds are not yet forthcoming for MoPH to improve the other 17 curricula.

There is a Midwifery Education Accreditation Board (including a MoHE representative) which accredits courses and curricula, and a Midwifery Association which records details of midwives after they have obtained licences for private clinic practice through the MoPH Regulation Enforcing Department. The HR database records details of midwives employed in the public or NGO systems. Donor support has been obtained for midwifery and is expected for the establishment of a Nursing Council. Attempts have been made to encourage all health professional groups to establish Councils with both registration and accreditation roles.

An Afghanistan Medical Council Act was drafted in consultation with some public and private medical associations. The draft TORs for the Council would allow it to address adverse reports on medical practice and clinical training establishments, and to arbitrate, judge and apply sanctions (and refer to the judicial system where required if charging in the courts is more appropriate). Discussions were held at TAG and it was proposed to progress the Medical Council proposal through a joint MoPH/MoHE Committee.

At the end of November 2009, at the high level meeting to discuss the Workforce Plan, the Chancellor of Kabul Medical University and the Director of Student Affairs, MoHE, both strongly supported establishing a joint committee of MoPH and MoHE to discuss common issues. These included: curriculum content, standards, accreditation, establishment of new courses, and selection criteria for students.

The committee would also discuss how to assist health professional groups establish Professional Councils. These Councils would be responsible for establishing standards, registration, accreditation of curricula, and management of professional misconduct. The proposed joint committee would have an overseeing role for these developments. It is hoped the committee could, in time, be responsible for establishing an over-arching Professions Council.

A draft letter, attaching a discussion paper on the background and the proposed role of the committee, together with a draft Act, is with the MoPH Acting Minister for signature.

[b]. Collaborative activities with Civil Service Commission (CSC)

Policy

Informal discussions have been held regularly with the Director of Policy, CSC, to obtain his advice, and also drafts of policy have been given to him for his comment prior to finalisation. He commented on the HR Policy, Strategy and Plan, the Capacity Building Plan, and was involved in the high level meeting in late November 2009 to discuss the Workforce Plan. He congratulated MoPH on the preciseness of its Workforce Plan, and detail of its capacity building required. He said it would be possible within the CSC framework to implement proposals regarding 3 month rotations to get staff to work in remote regions, and to change employment conditions of contractors. He would be pleased to discuss these further and to continue to assist with administrative courses (He has been a guest lecturer at many MoPH courses for HR and executive staff, and has been much appreciated).

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Procedures

An HR Procedures Manual was drafted in 2008 and circulated to all Ministries. Additional procedures are gradually being drafted which give the detail required relating to the new Civil Servants Law (June 2008) and February 2007 Labour Law. As these are made available, GDHR plans to subsume these into its planning documents and training of staff. There are Regulations on Retirement Rights of Civil Servants, and on Regulation of Personal Affairs of Civil Servants.

Counselling, Grievances and Disputes

In the past, mechanisms to resolve disputes have not been clear. As a result individuals have often asked their Members of Parliament to lobby on their behalf with the Health, Nutrition and Sport Committee, or the Grievances and Complaints Committee of the National Assembly of Afghanistan, the CSC Board, or the Minister of Health.

There are now rules in the Civil Employees Law, enacted June 2008, for examining grievances and disputes:

• Complaints concerning refusal to accept an application within justifiable reasons, and discriminatory and inequitable treatment by the Appointment Board of Civil Service, Appointment Committees and HR Directorate of MoPH, shall be dealt with by the Civil Service Appeals Board. If any of the parties are not satisfied with the decision of the Board they can refer the case to court;

• Complaints concerning unjustified prescription of disciplinary measures; illegal instructions or

orders by supervisors; prohibition on access of a civil servant to his/her personal records; unjust and discriminatory treatment at the workplace by the supervisor or colleagues; or other matters which are regarded by law as a violation of a manger/supervisor internally within Ministries, shall be dealt with by a Dispute Settlement Commission of the MoPH (to be established)

• A first appeal stage is for the GDHR to appoint an investigating officer. If the appeal procedures

are inadequate; the Ministry does not investigate, or take a decision (reported to Executive Deputy Minister) within 36 days; or the applicant could be exposed to abuse or indoctrination, the applicant can appeal directly to the CSC.

• A regulation regarding the Dispute Resolution Commission has not yet been drafted by CSC, but

there will be clear requirements about: the skills of the chair; the need for membership to include both required skills and tribal range; the independence of the Commission; the reporting to the Minister; and monitoring by CSC. MoPH has nominated members of the Board and is awaiting agreement by CSC.

Reform Implementation Management Unit: The MoPH Organogramme is meant to be reviewed in September each year by GDHR in collaboration with functional areas, with grading in alignment with CSC guidelines, and then endorsed by the MoPH Executive and the CSC, before being approved by the President. In early 2009, a Reform Implementation Management Unit (RIMU) was established in MoPH, and this Unit undertook a major joint review, with a CSC Pay and Grading Team, to upgrade the structure and positions relating to the new CSC Pay and Grading Guidelines.

[c] Collaboration with Donors

Most public health services away from Central Office (including community-based facilities, district and some provincial hospitals) are provided by NGOs employed by the three major donors (European Union, USAid and World Bank) under contract to MoPH. Civil servants provide staff for the 34 provincial health offices, and for some provincial hospitals. Also a number of specialist hospitals in Kabul are staffed by civil servants. Other central hospitals, and private clinics in provinces, are run by

31

private organisations or individuals. There are Community Health Workers employed as volunteers in the provinces working with the NGOs.

Private health services are provided for a fee by private practitioners. Analysis of this sector is being attempted through the MoPH Private/Public Sector Partnership managed through GDPP.

A National Salary Policy was developed (which relates to contracted-out NGO employees and those contracted-in through the Health Service Strengthening project). This was last updated in 2005. There has been great concern among civil servants that contractors receive much higher salaries and this is unfair. However analysis, after the CSC Pay and Grading had been conducted for MoPH and before the Workforce Plan was completed, showed that implementation by CSC would result in more salary equity between civil servants and NGO-contracted staff. However, doctors are the exception; they will still receive 50% more salary through NGOs than those employed as civil servants. There are also 382 staff paid super-salaries directly by donors, mainly the World Bank and UNICEF.

Various mechanisms were discussed in the Workforce Plan to address these anomalies. Also at the Retreat there was discussion of having a SWaP (sector-wide approach). Through pooling of all salary funds from donors, and phasing out donor-funded super-salaries over time, but still maintaining rewards based on performance, the inequities between CSC and NGO salaries could be reduced.

[d] Collaboration on HR Data

The GDHR Database is excellent, and includes data on all staff in the public health sector (civil servants and contractees). It has been gradually improving since its inception in 2005. It links with the MoPH Health Information System. There is also a Training database into which basic data had been inserted by the end of 2009. All three are on Access.

There are additional collaborations required however to better link data and do more effective workforce planning and review. Currently pay data on civil servants is sent on excel spreadsheets to the Ministry of Finance. No historic data is retained on leave, deployment, vacancies, allowances or pay, as there is no “back-end” to the MoF pay database. Also there is no link to the organogramme or job descriptions. Most provinces have inadequate computers so data is often dictated over the phone or sent by mail. Pay data of most contractee organisations is held by them, and not linked with the MoPH system. Data from MoHE and private training organisations is obtained manually. Considerable work is required to improve data and link it with the HR Database, so that better and quicker analysis can be undertaken.

The CSC also wants additional data collected to link with its “yet to be implemented” HR Database.

(e) Health Complaints Office

The MoPH previously agreed to the establishment of a Health Ombudsman’s (Health Complaints) Office and this is stated in the 2008-2012 Health and Nutrition Sector Strategy (HNSS) and the Afghanistan National Development Strategy (ANDS) 2008.

• A Health Complaints Office (HCO) would be a mechanism through which health service clients, MoPH employees or civil society organizations could take complaints or queries about health service delivery issues. It would report to the Executive Board and National Assembly Health and Petitions and Grievances Committees.

The HCO would be a fully autonomous unit (not part of the organization’s management structure, and thus free from interference or influence) to identify, address, and recommend ways to solve issues, and improve systems and procedures so similar problems do not occur again. It can mediate between the parties.

The HCO would provide an informal option for thinking through issues without being “on the record”. The Office would provide an alternative to formal grievance and complaint processes, and be flexible enough to handle any workplace dispute or health service delivery problem.

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• Draft TORs have been discussed at TAG, membership of a Board of Trustees to oversee it nominated (WHO, Afghanistan Human Rights Commission, and Integrity Watch Afghanistan), and it is awaiting presentation to the Executive Board. However, donor groups approached for funding have not seen it as a priority, and it cannot be established without agreement to 5 year funding due to the need for independence.

At the Provincial level, each health facility is required to have a Health Complaints committee comprising an independent chair and half the membership from the community and half health workers. These mechanisms appear to work well in some cases, but there is no monitoring of issues and outcomes.

Also, there is no process for appeal at Provincial level. Processes for dealing with workplace disputes and health service complaints from district to provincial to central level need to be worked out, and how they will all link together to ensure there are no gaps or duplication. The issue of confidentiality where required needs to be addressed, so there are informal as well as formal mechanisms available.

5. FOLLOW-UP AND EVALUATION.

All HR initiatives follow-up and evaluation are primarily the responsibility of the HR Taskforce.

The HR Policy, Strategy and Plan have 13 key indicators which the Taskforce is meant to oversee monitoring of annually. A Review of strategies and indicators is due at the end of 2010. A major review is due in 2012 in line with the HNSS. Annual Actions Plans are meant to be developed and monitored. The review of major strategies and indicators and the Action Plan have been undertaken in part, on an issue based, but not systematically, due to no resourcing for the Taskforce (hopefully through AusAID).

The Workforce Plan and Observatory (which need to be combined in future) are to be annually updated by the Workforce Planning Committee with another annual Workforce Planning Workshop/Meeting. EU funding enabled the first to occur this year; it is uncertain for next year, and for follow-up of implementation (perhaps AusAID funds).

The Capacity Building Plan annual review and update has been delayed due to no funds.

There is limitation and inaccuracy of data on the private sector, and inconsistency in systematic collaboration with the private sector.

6. FUNDING ISSUES

There are three sources of funding for health services in Afghanistan – Public, Donor and Private.

Public “operational budget” funds through MoF are very limited for HR – just salaries. There is no approved budget for operational costs to run HR services. Funding for each initiative has to be requested individually and funds are not forthcoming.

Donors (WB and USAid) provide some development funds to MoF for distribution (but they are ear-marked by the agencies for BPHS, EPHS and some super-salaries, and “cherry-picked” projects. EU, AusAID, JICA, and others provided external funds for projects, which are limited in time-scale. In the presentation to the Results Conference reference was made to attempts to obtain funding, and obstacles. One issue discussed was that WHO hosted a workshop “HR in Crisis in MoPH” in mid-2009. This laid out the details and needs for funding. Donors were invited, but only one attended. Emails to donors following this workshop resulted in replies saying how important these initiatives were, but they were not a priority for their funding.

Reliable long-term funding is desperately needed for on-going essential activities listed in the major documents discussed above. It is hoped that the follow-on process to the Retreat this year will lead to donors supporting institutional development activities and not “cherry picking” programs.

Funding is required to enable better collaboration with the private sector and local NGOs.

7. RELATIONSHIPS BETWEEN STAKEHOLDERS

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Many donor-funded projects do not have staff embedded in MoPH, so tend to come in for spasmodic meetings. Networking with stakeholder groups is easy with some agencies, and hard for others, due to limited communication opportunities. Collaborative planning, funding and implementation is rare due to different funding cycles and a focus on supporting home country priorities before those of Afghanistan. It is essential to have financing mechanisms which would reduce a program focus by donors. The SWaP approach is the only way to prevent individual countries putting their country policies ahead of MoPH priorities.

Funding is required for coordination activities with the private sector and NGO stakeholders, so they can provide time for collaboration.

8. CO-ORDINATION

There are many different mechanisms at which HR issues can be discussed, and decisions can be made within the BPHS or EPHS program regarding HR which is inconsistent with HR policy. Gradually, as GDHR has been drafting significant and well researched planning documents, other areas of MoPH and outside stakeholders are beginning to recognise the need to work closely with GDHR in HR matters. This has not yet led to them attending HR Taskforce Meetings or being involved in other mechanisms.

Coordination mechanisms are primarily for public health HR. There is a need for a sector-wide coordinating mechanism.

9. ASSESSMENT OF CURRENT MECHANISMS AND SUGGESTIONS FOR CHANGES

Problems:

• Time: Donor organisations frequently do not want to be on committees where they will have to do too much work, so it is essential that there is an adequate Secretariat to do most of the work, so donor attendees can be advisers and decision-makers only.

• Level of Representation: Due to many requests the high level invitees often do not have time to attend, and send lower level inexperienced delegates who have little to offer. It is important to limit the requests and to ensure meetings are chaired at a very high level, to ensure stakeholders make attendance a priority.

• Language: Meetings must be in Dari so relevant representatives can participate.

• Complexity and Number of Processes: It is proposed that the consultation processes be simplified dramatically.

• Limitation of private sector involvement: Most mechanisms are just for the public sector. Efforts have been made to begin the process of better collaboration with health associations and the private sector.

Solutions:

The HR Taskforce should become a sector-wide HRH Coordination Body, with meetings held quarterly and chaired by the Minister. Under this umbrella there would be a strong Secretariat and 5 Working groups, as follows:

(i) The Workforce Plan (amalgamated with Health Workforce Observatory), linked with HR database and data analysis, the HR Policy, Strategy and Operational Plan; and Midwifery/Nursing Policies. Currently this mainly public sector – It needs to be sector wide.

(ii) Professional Councils, Professional Standards and Accreditation of Curricula linked with MoHE and private sector; collaboration needs to continue with health worker associations, and with non-functional unions.

(iii) Needs Assessment, Capacity Building Plan and Training and Development; this needs to be broadening to include private sector capacity building.

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(iv) Coordinated HR Practices of MoPH, donor groups (and the private sector where possible), including organisational structures, job evaluation, grading, job descriptions, and personnel management (recruitment, pay, allowances, staff appraisal, career development, rewards, disciplinary measures, counselling, dispute resolution, termination, pensions, etc.); and

(v) Adequate funding and Workforce financing arrangements: Donors must prioritise funding for implementation of major on-going HR functions. The SWaP approach is the only way to prevent individual countries putting their country policies ahead of MoPH priorities.

Membership of the Taskforce itself would comprise 16 people: All 7 MoPH General Directors, a delegate from EU, UsAiD, WB, WHO, UNICEF, the Private Medical Association, MoHE, CSC and MoF.

The 5 working groups would be held monthly, and their tasks would relate to the TORs already determined for those functions, and the review and evaluation timetables and indicators already established. Membership would comprise experts in those areas who could make decisions on behalf of the relevant organisations.

The Secretariat would have adequate numbers and skills of staff to undertake the required action and present findings and drafts to each of the 5 working groups and the Taskforce itself.

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Attachment B: Action Points from 22 June 2010 Country Coordination Meeting hosted by MoPH and Chaired by WHO.

Action Points of the Country Coordination Meeting- June 22, 2010

1. Review of the national HRH strategy, plan and policies.

2. Assess the present status of data set for human resource at the national level

3. Review recruitment processes

4. Establish national HRH observatory

5. Analyze existing policies on staff retention

6. Conduct study on the accessibility to health workers in remote and rural areas of

Afghanistan

7. Conduct study on paid/unpaid work of , Community Health Worker (CHW )and impact of

their performance

8. Develop retention strategy and plan for each health professional category ( MD, nursing,

etc.)

9. Review the medical specialization program (post graduate)

10. Conduct study on paid/unpaid work of CHW and impact of their performance

11. Develop summary advocacy brief for policy makers (MoPH, MOF, MOHE, CSC, MoL, Private

sector, Tech-Serve, HSSP, NGOs, Public Health Association, donors, WHO)

12. Establish national coordination forum for HRH with the well defined TOR.

13. Complete the data set (profile) for private and other sectors.