People deliver eye care: managing human resources
People deliver health. Effective health care needs an efficient and motivated health workforce, which is the totality of individuals who directly or indirectly contribute to the promotion, protection and improvement of the health of the population.
Community eye health is about providing eye health care to the people as close as possible to where they live and as much as possible at a price they can afford. It promotes people-centred care rather than the traditional disease-centred eye care services. In order to provide effective and efficient eye care services, we need an adequate number of well-qualified, well-motivated and equitably distributed eye health workers (EHWs).
The reality today is that in most communities in developing countries, especially in sub-Saharan Africa, there are very few EHWs. Those that are available are overworked, under compensated, unrecognised and very poorly motivated. The managers of district health facilities have no control or input into training, recruitment, compensation or deployment of staff and have limited knowledge or skills in how to motivate the staff working with them. This scenario may have advised the decision to make human resources development one of the main pillars of VISION 2020: The Right to Sight. If the objectives of this global initiative are to be met, then we need to have adequacy in number and quality of well- motivated EHWs at every level of eye care.
Identifying staffing gaps
The first step to achieving staff adequacy is to do a situation analysis and identify staffing gaps. The World Health Organization (WHO) norms for eye care personnel are denominated by the population size, such as number of ophthalmologists per million population. However, this does not translate into personnel in health facilities, especially outside the cities. In many developing countries, where human resources planning is rudimental at best, most of the high level EHWs (ophthalmologists, ophthalmic nurses/assistants, and optometrists) live and work in big towns and cities. For example, Togo has three ophthalmologists per million population (higher than the minimum of two ophthalmologists per million population recommended by WHO for Africa) but over 80 per cent of them live and work in Lomé, the capital city. Hence, gaps based on these norms would not reveal the functional gaps in the districts, where the needs for services are greatest. A more realistic way to identify staffing gaps for achieving VISION 2020 goals is the suggestion of a team concept, based on the staffing needs of a country to provide specific services.
Training, recruitment and deployment
The next step is training, recruitment and equitable deployment of staff. In most countries, these functions are centralised and multisectoral, involving many ministries and government agencies. The EHWs have very limited opportunity to influence this in favour of the regional or district eye care services. However, the manager or coordinator of the National Programme for the Prevention of Blindness (or VISION 2020 committee) can build an ‘Advocacy Alliance’ with professional associations and non-governmental development organisations who are active in the country and able to influence the authorities for an increase in the training and recruitment of EHWs. This is not going to be an easy task. Most countries are going through economic reforms that prescribe significant cuts in public spending and a freeze on staff recruitment in the public sector. However, there is a window of opportunity with the current drive to put human resources for health on the global agenda, especially in Africa. A number of countries are going through health system reforms and it is hoped that this may lead to decentralisation that would give regions and districts better control of staff recruitment, deployment and compensation.
In addition to its advocacy role with government, the Advocacy Alliance could advocate with the heads of pre-service training institutions to make training more relevant to national needs and disease priorities, thus making them more compliant with VISION 2020.
At the district level, in spite of having little influence in the number and quality of EHWs working with him/her, the leadership and managerial skills of the leader of the eye care service is crucial to the performance of the few poorly motivated staff. At a recent workshop in West Africa on human resources development for scaling up cataract surgical rate (CSR), poor motivation of staff was considered the most important factor responsible for low CSR and it was rated higher than supply of consumables and training.1 So, if managers must improve performance in the district, they have to motivate their staff.
In considering motivation, most of us think of financial benefits but the truth is that these have limited and short- lived effect on motivation. Poor salaries are known to demotivate, but the effect of increase in salaries on improved performance lasts less than eight weeks. In a study in Nigeria on the reasons for intention to emigrate, poor remuneration was a distant second to limited opportunities for rapid promotion and it was ranked equal to poor career recognition.2 Sustained motivation and improved performance results from effective people-centred human resources management (HRM) in which there is respect for people, work is valued and career development is given due consideration. Staff are motivated when they:
- are respected as people and their opinions are sought and considered in the decision-making process
- have meaningful work that is recognised and contributes to the overall goals of the organisation, and this includes being given responsibilities and challenges
- have opportunities for career development through training and retraining.
For further ideas on how to improve human resources management, see Box 1.
This issue of the Community Eye Health Journal addresses the different aspects of managing people effectively. An article from ICARE, L.V. Prasad Eye Institute, discusses the importance of establishing clearly defined roles and responsibilities within the eye care team. Helen Roberts’s article provides practical suggestions on how to increase staff motivation. Miriam Cano’s article reflects on managing groups of people representing institutions, based on the experience of establishing a relationship between 12 institutions to form the National VISION 2020 Committee in Paraguay. In conclusion, effective and good quality people-centred eye care services that are required to achieve the goals of VISION 2020 be achieved with people-centred HRM even in the face of restricted staff recruitment, inequitable deployment and low budgetary allocation. Good management depends on a leadership that is committed to the people serving and the people to be served.
Box 1. Seven key actions for improving human resources management
In the context of VISION 2020, the head of the district eye health service, within the limits of his or her authority, can achieve improved performance and better motivated staff through improving the human resources management (HRM) at the facility by seven key actions:
- Designate a senior member of staff to be in charge of HRM to give some decision-making authority to the HRM team.
- Institute responsive supervision of clinical teams, whose work plans are clearly defined and are based on the work plan of the district. The leader of the team takes responsibility for supervision of individual members of the team.
- Develop and implement a performance review system that is not punitive but helps recognise achievements and identify training needs.
- Ensure equity in how the workload is distributed and how people are compensated; these mechanisms should be transparent.
- Track employee data for attrition (or loss of staff), staff turnover and absenteeism.
- Establish a good supplies management system for consumables, in order to ensure timely provisions, so as to provide good quality service that would boost patient satisfaction and staff morale.
- Support career development of staff through training and job challenges. Most training can be organised on-the-job or on-site. When there is opportunity for external training, this should be such that the training contributes directly and immediately to the organisation’s performance. The beneficiaries of this training should be selected in a transparent manner.
1 Workshop on project proposal for the 2nd human resources development for prevention of blindness (HRD II) in West Africa, organised by West African Health Organisation, 22nd – 24th July 2004, Accra, Ghana.
2 Nyoni J. Emigration of health workers from Africa – facts and lessons. Paper presented at the sub-regional forum on human resources for health in West Africa. 4-6 April 2005, Abuja, Nigeria.