Résumé

Problème

Les ressources humaines pour la santé (RHS) au Soudan étaient limitées à cause des pénuries et de la mauvaise répartition des agents de santé, d'une mauvaise gestion, de la fragmentation du service, d'une fidélisation médiocre des agents de santé dans les régions rurales et d'un système d'information sur la santé peu efficace.

Approche

Un processus de «coordination et facilitation national» a été mis en place afin de: renforcer l'observatoire RHS national, fournir une plateforme de coopération pour les acteurs clés, catalyser le soutien des politiques et la planification des RHS, harmoniser la mobilisation des ressources, renforcer les structures de gestion des RHS, créer de nouvelles institutions de formation et élever le niveau de formation des agents de santé communautaires.

Environnement local

Le gouvernement national du Soudan a sanctionné la gouvernance étatique du système de santé, mais de nombreux États manquaient de programmes et de politiques RHS cohérents. La rareté des institutions de formation a limité la production de RHS et le déploiement adéquat et équitable des agents de santé dans les zones rurales.

Changements significatifs

Le processus de coordination et de facilitation du pays a favorisé la création d'un système d'information RHS solide, ainsi que le développement de moyens techniques et d'outils nécessaires à l'analyse des données et à une action et une prise de décisions participatives et fondées sur les faits.

Leçons tirées

Le succès du processus de coordination et facilitation a été confirmé par le soutien coordonné des acteurs clés, basé sur des preuves solides des défis en RHS et sur la responsabilité partagée dans la planification et la mise en œuvre de réponses à ces défis. Le soutien a entraîné un engagement politique et une mobilisation des ressources pour les RHS. Le fait de promouvoir le leadership et l'ouverture d'institutions de formation devrait faciliter la formation, le déploiement et la fidélisation des agents de santé, qui sont nécessaires pour parvenir à la couverture de santé universelle.

Resumen

Situación

Los recursos humanos para la salud (RHS) en Sudán presentaban limitaciones debido a la escasez y mala distribución del personal sanitario, una gestión incompetente, la fragmentación de los servicios, la pérdida del personal sanitario en las zonas rurales y un sistema insuficiente de información sanitaria.

Enfoque

Se puso en marcha un proceso de «asesoramiento y coordinación nacional» a fin de reforzar el observatorio nacional de RHS, proporcionar una plataforma coordinadora para las partes interesadas, catalizar el apoyo de las políticas y la planificación de los RHS, armonizar la movilización de los recursos, reforzar las estructuras administrativas de los RHS, establecer centros de formación nuevos y mejorar la formación del personal sanitario de la comunidad.

Marco regional

El gobierno nacional de Sudán aprobó la autoridad estatal del sistema sanitario, pero muchos estados carecían de unos planes y estrategias de RHS coherentes. La escasez de instituciones de formación limitó en gran medida la creación de RHS y el despliegue adecuado y equitativo del personal sanitario en las zonas rurales.

Cambios importantes

El proceso de coordinación y asesoramiento nacional impulsó el establecimiento de un sistema de información de RHS sólido y el desarrollo de las capacidades y herramientas técnicas necesarias para el análisis de datos y la toma de decisiones y acciones basadas en pruebas científicas.

Lecciones aprendidas

El éxito del proceso de coordinación y asesoramiento nacional se consolidó gracias al apoyo coordinado de las partes interesadas, asentado sobre las pruebas sólidas de los desafíos en el ámbito de RHS y la responsabilidad compartida en la planificación y puesta en marcha de las respuestas para hacer frente a dichos desafíos. El apoyo tuvo como consecuencias el compromiso político y la movilización de recursos para los RHS. La promoción del liderazgo y la apertura de centros educativos deberían facilitar la formación, el despliegue y conservación del personal sanitario necesario para lograr una cobertura sanitaria universal.

ملخص

المشكلة

كانت الموارد البشرية الصحية في السودان محدودة بسبب أوجه النقص وسوء التوزيع في العاملين الصحيين وسوء الإدارة وتشتت الخدمات وضعف استبقاء العاملين الصحيين في المناطق الريفية وضعف نظام المعلومات الصحية.

الأسلوب

تم تنفيذ عملية "التيسير والتنسيق عبر البلد" لتعزيز المرصد الوطني للموارد البشرية الصحية، وتقديم برنامج تنسيق من أجل أصحاب المصلحة الرئيسيين وتسريع الدعم السياسي وتخطيط الموارد البشرية الصحية، وتنسيق تعبئة الموارد، وتعزيز الهياكل الإدارية للموارد البشرية الصحية، وإقامة مؤسسات تدريب جديدة وزيادة تدريب العاملين الصحيين المجتمعيين.

المواقع المحلية

صدقت الحكومة الوطنية السودانية على تصريف شؤون النظام الصحي على صعيد الولايات، ولكن العديد من الولايات افتقرت إلى الخطط والسياسات المتسقة في مجال الموارد البشرية الصحية. وحالت ندرة مؤسسات التدريب دون إنتاج موارد بشرية صحية ونشر العاملين الصحيين في المناطق الريفية على نحو كاف ومنصف.

التغيّرات ذات الصلة

تطلبت عملية التيسير والتنسيق عبر البلد تأسيس نظام معلومات قوي للموارد البشرية الصحية وتطوير القدرات التقنية والأدوات الضرورية لتحليل البيانات واتخاذ القرارات التشاركية المستندة على البيّنات واتخاذ الإجراءات.

الدروس المستفادة

تم إثبات نجاح عملية التيسير والتنسيق عبر البلد عن طريق الدعم المنسق لأصحاب المصلحة، والذي اعتمد على بيّنات دامغة للتحديات في مجال الموارد البشرية الصحية والمساءلة المشتركة في تخطيط الاستجابات لهذه التحديات وتنفيذها. وأدى الدعم إلى الالتزام السياسي وتعبئة الموارد من أجل الموارد البشرية الصحية. وينبغي على القيادة، التي تم تعزيزها والمؤسسات التعليمية التي تم افتتاحها، تيسير تدريب العاملين الصحيين المطلوبين لتحقيق التغطية الصحية الشاملة، ونشرهم واستبقائهم.

摘要

问题

苏丹的卫生人力资源（HRH）受到卫生工作者短缺且分配不合理、管理不善、服务零散、农村地区留不住卫生工作者以及卫生信息系统薄弱等方面的限制。

方法

苏丹实施“国家协调和促进”进程，以便强化全国HRH观察，为关键利益相关者提供协调平台，促成政策支持和HRH规划，协调资源调动，加强HRH管理结构，建立新的培训机构，扩大社区卫生工作者培训规模。

当地状况

苏丹国家政府鼓励州一级的卫生系统管理，但是许多州缺乏一致的HRH规划和政策。培训机构的缺乏限制了HRH培养以及农村地区卫生工作者充分均衡的部署。

相关变化

国家协调和推动进程促进了强大HRH信息系统的建立、数据分析及基于证据的参与式决策和行动所需技术实力以及工具的发展。

经验教训

利益相关者的协调支持证明了国家协调和推动进程的成功，它建立在HRH挑战的确凿证据之上，并分担应对这些挑战的规划和实施方面的责任。这种支持促成了对HRH的政府承诺和资源调度。提升的领导力和开办的教育机构会促进实现全民医疗保障所需的卫生工作者培养、部署和留系。

Резюме

Проблема

Состояние кадровых ресурсов здравоохранения (КРЗ) в Судане характеризовалось нехваткой и неравномерным распределением работников здравоохранения, плохим управлением, фрагментированным оказанием услуг, слабым удержанием работников здравоохранения в сельских районах и неразвитой информационной системой.

Подход

На уровне страны была реализована программа «координации и содействия», которая ставила целью усилить контроль КРЗ на национальном уровне, обеспечить платформу координации действий ключевых заинтересованных сторон, активизировать поддержку политики и планирования КРЗ, согласовать мобилизацию ресурсов, укрепить управленческие структуры КРЗ, создать новые институты подготовки кадров и расширить масштабы подготовки работников здравоохранения на местах.

Местные условия

Национальное правительство Судана санкционировало управление системой здравоохранения на государственном уровне, однако у многих регионов отсутствовали последовательные планы и политика в области КРЗ. Нехватка учебных заведений ограничивала воспроизводство КРЗ, а также адекватное и справедливое распределение медицинских работников в сельских районах.

Осуществленные перемены

Программа координации и содействия, реализованная на уровне страны, инициировала создание надежной информационной системы КРЗ, а также развитие технических возможностей и инструментов, необходимых для анализа данных и совместного принятия решений и проведения мероприятий на доказательной основе.

Выводы

Успех программы координации и содействия в стране был подкреплен скоординированной поддержкой заинтересованных сторон, основанной на надежных доказательствах по сути проблем в КРЗ и общей ответственности при планировании и осуществлении ответных мер, позволяющих решить эти проблемы. Данная поддержка обеспечила политическую заинтересованность и мобилизацию ресурсов для развития КРЗ. Инициированная программой заинтересованность руководства и созданные учебные заведения должны способствовать профессиональной подготовке, развертыванию на местах и удержанию работников здравоохранения, что необходимо для достижения всеобщего охвата медико-санитарной помощью.

Introduction

For many years, the Sudan – once the largest country in Africa by area – has faced political unrest, civil war and economic hardships. In 2011, the country was divided into two independent nations: the Sudan and South Sudan. As a result of the secession of South Sudan, the government of the Sudan lost oil revenue and donor support. These losses exacerbated the Sudan's slow development and health-system challenges, which included health worker shortages, a frequent mismatch between the skills that health workers had and those that were needed, and the maldistribution, migration and poor productivity and retention of health workers.¹1 Human resources for health country profile – Sudan. Geneva: World Health Organization; 2009. Available from: http://www.who.int/workforcealliance/knowledge/resources/hrh_profile_sudan/en/index.html [accessed 16 September 2013].
http://www.who.int/workforcealliance/kno... These weaknesses not only constrained the delivery of health care but also limited the potential for the Sudan to attain any of the health-related Millennium Development Goals (MDGs) or universal health coverage.²2 Rapid assessment on the effectiveness of the country coordination and facilitation (CCF) process in Sudan, Zimbabwe and Zambia, consolidated report. Geneva: Global Health Workforce Alliance; 2012. Available from: http://www.who.int/workforcealliance/knowledge/resources/ccfresources/en/ [accessed 16 September 2013].
http://www.who.int/workforcealliance/kno... ^,33 Health workers for all and all for health workers: the Kampala Declaration and Agenda for Global Action. Geneva: World Health Organization; 2008. Available from: http://www.who.int/workforcealliance/forum/2_declaration_final.pdf [accessed 11 September 2013].
http://www.who.int/workforcealliance/for... The country lacked effective systems for the collection and analysis of the data on HRH that are needed for evidence-based policy-making and the planning of health services. The governance of the Sudan's HRH was also constrained by a general lack of coordination between the main stakeholders in the health system and beyond. The national leadership – assisted by the World Health Organization (WHO) and the Global Health Workforce Alliance – therefore initiated several interventions that catalysed the involvement of many partners in the improvement of HRH.⁴4 The world health report 2006: working together for health. Geneva: World Health Organization; 2006. Available from: http://www.who.int/whr/2006/en/ [accessed 16 September 2013].
http://www.who.int/whr/2006/en/... ^,55 Report on the Prince Mahidol Award Conference 2011, 2nd Global Forum on Human Resources for Health: reviewing progress, renewing commitments to health workers towards MDGs and beyond. Geneva: Global Health Workforce Alliance; 2011. Available from: http://www.who.int/workforcealliance/forum/2011/en/ [accessed 16 September 2013].
http://www.who.int/workforcealliance/for... A new national HRH observatory became a hub for the collation of information that would be used in evidence-based policy reform and action. The launch of the “country coordination and facilitation” process in the Sudan further enhanced the role of the observatory in engaging the diverse HRH stakeholders.⁶6 Country coordination and facilitation (CCF): principles and process. Geneva: Global Health Workforce Alliance; 2010. Available from: http://www.worldcat.org/title/country-coordination-and-facilitation-ccf-principles-and-process/oclc/710999815 [accessed 16 September 2013].
http://www.worldcat.org/title/country-co... This paper aims both to describe the Sudan's experience with the establishment of a national HRH observatory, the country coordination and facilitation process and the related accountability, and to outline the main lessons learnt.

Local setting and context

The health system of the Sudan follows a devolved mode of governance with three levels: national or federal, state and local government. Health expenditure is generally low and the health financing that does exist is skewed towards cure rather than prevention. There are about 100 000 health workers in the Sudan – 80% employed by the public sector – but approximately 70% of this workforce serves just 30% of the population, and 36% of outreach health facilities were not functioning in 2006 because of HRH shortages.⁷7 National human resources for health strategic plan for Sudan, 2012–16. Khartoum: Ministry of Health; 2012. Available from: http://www.who.int/entity/workforcealliance/countries/Sudan_HRHPlan_2012-16.pdf [accessed 16 September 2013].
http://www.who.int/entity/workforceallia... ^,88 Health sector strategic plan 2012–16. Khartoum: Ministry of Health; 2012. Most health care relates to communicable diseases but the prevalence of many noncommunicable diseases is increasing. In a study conducted in 2010, only one third of the Sudan's facilities for primary health care was found to be providing the full package of primary-health-care services and 14% of the rural population had no access to any health facilities.⁹9 Primary health care facility survey. Khartoum: Ministry of Health; 2010. At the same time, the national health information system was weak in terms of coverage, data quality and capacity for data analysis. With infant and maternal mortality rates of 57 deaths per 1000 live births and 216 deaths per 100 000 live births, respectively, the Sudan is currently not on track to achieve any of the health-related MDGs by 2015.⁸8 Health sector strategic plan 2012–16. Khartoum: Ministry of Health; 2012. The density of physicians, nurses and midwives in the Sudan – 1.23 per 1000 population – falls well short of the minimum threshold – 2.3 per 1000 – recommended by WHO.⁴4 The world health report 2006: working together for health. Geneva: World Health Organization; 2006. Available from: http://www.who.int/whr/2006/en/ [accessed 16 September 2013].
http://www.who.int/whr/2006/en/...

Interventions and progress

A national observatory and information system

The solid vision of the national leadership prompted a paradigm shift that was characterized by a sharp focus on human resource development as a key health system priority. Financial and technical support from the Global Health Workforce Alliance spurred the national leadership and facilitated the design of an HRH information system. In 2006, the new information system enabled a newly established national HRH observatory to conduct its first ever nationwide HRH census. This exercise generated comprehensive HRH data, unveiled the challenges facing the health workforce and provided useful evidence for policy- and decision-making.¹⁰10 Badr E. Human resources for health in Sudan: opportunity for revival. Sudanese J Public Health 2007;2:137. The observatory became the hub for HRH stakeholder coordination and advocacy, developed capacity for data analysis and management and created an HRH research agenda that should produce a knowledge base for guiding future HRH development.¹¹11 Establishing an observatory on human resources for health in Sudan: a report for the World Health Organization (WHO) and the Federal Ministry of Health (FMOH). Khartoum: National HRH Observatory; 2007. To institutionalize the HRH information system, the national observatory introduced a conceptual framework that is based on the WHO workforce lifespan model for HRH (Fig. 1).

Coordination mechanisms

As a result of the Sudan's country coordination and facilitation process – which was introduced by the Global Health Workforce Alliance – the national HRH observatory was able to strengthen and expand its “umbrella” over HRH stakeholders and develop a stakeholder forum.²2 Rapid assessment on the effectiveness of the country coordination and facilitation (CCF) process in Sudan, Zimbabwe and Zambia, consolidated report. Geneva: Global Health Workforce Alliance; 2012. Available from: http://www.who.int/workforcealliance/knowledge/resources/ccfresources/en/ [accessed 16 September 2013].
http://www.who.int/workforcealliance/kno... ^,66 Country coordination and facilitation (CCF): principles and process. Geneva: Global Health Workforce Alliance; 2010. Available from: http://www.worldcat.org/title/country-coordination-and-facilitation-ccf-principles-and-process/oclc/710999815 [accessed 16 September 2013].
http://www.worldcat.org/title/country-co... The stakeholder forum has enabled the formation of collaborative partnerships across sectors, eliminated duplication and fragmentation and encouraged coordinated implementation. It has brought representatives of the Federal Ministry of Health, other ministries and governmental institutions, health worker registration councils, professional associations and nongovernmental and international organizations around the same table. Although representatives of some private-sector institutions have joined the forum, the wider involvement of this expanding sector remains a challenge; further encouragement and regulatory measures may be necessary.

The forum meets once a quarter to discuss HRH issues, with the aim of setting strategic directions, devising solutions, building partnerships for implementation, consolidating the coalition between the federal- and state-level ministries of health, and building a culture of good ethics and accountability.¹²12 Travis P, Egger D, Davies P, Mechbal A. Towards better stewardship: concepts and critical issues: evidence and information for policy. Geneva: World Health Organization; 2002. Available from: http://www.who.int/healthinfo/paper48.pdf [accessed 16 September 2013].
http://www.who.int/healthinfo/paper48.pd... This has resulted in a coherent integrated response to each major HRH issue and in beneficial effects on the production, equitable distribution and retention of health workers.²2 Rapid assessment on the effectiveness of the country coordination and facilitation (CCF) process in Sudan, Zimbabwe and Zambia, consolidated report. Geneva: Global Health Workforce Alliance; 2012. Available from: http://www.who.int/workforcealliance/knowledge/resources/ccfresources/en/ [accessed 16 September 2013].
http://www.who.int/workforcealliance/kno... The forum has also successfully promoted evidence-based policy dialogue and resource mobilization for an HRH action plan.²2 Rapid assessment on the effectiveness of the country coordination and facilitation (CCF) process in Sudan, Zimbabwe and Zambia, consolidated report. Geneva: Global Health Workforce Alliance; 2012. Available from: http://www.who.int/workforcealliance/knowledge/resources/ccfresources/en/ [accessed 16 September 2013].
http://www.who.int/workforcealliance/kno... Some stakeholders initially appeared reluctant to join the forum and share the data that they had collected. An effective communication strategy for stakeholder engagement was therefore implemented, the support of data sharing and use by stakeholder institutions was improved, and the equitable participation of all stakeholders in the governance of the national HRH observatory was promoted through the pursuit of collective decision-making processes.

The coordination and “buy-in” of the stakeholders were achieved and strengthened through an acknowledgement of institutional interests, the offering of capacity-building opportunities, the provision of free and timely access to HRH data, and the granting of greater recognition and visibility to the stakeholders. Table 1 summarizes the major achievements and specific results achieved through the introduction of the national HRH observatory and the country coordination and facilitation process in the Sudan. Improvements in the Sudan's HRH situation were achieved through the collective actions of the well-coordinated stakeholders – supported by the technical contributions of the observatory's secretariat, which rendered the procedures for engagement simple, practical and transparent. The HRH information system and the results of related HRH studies provided solid evidence of the main issues affecting HRH in the Sudan, including the numerical shortages, the skill-mix imbalances, the lack of programmes for the continuing professional development of health workers, and the geographical maldistribution and substantial emigration of health workers.

Government commitment and leadership

To substantiate its commitment, the Sudan's national government upgraded the HRH unit in the Federal Ministry of Health to a general directorate, increased the number of institutions providing health worker training and increased enrolment at all such institutions. These changes resulted in a substantial increase in the production and deployment of health workers. The national government also promoted the stakeholder forum and supported the collective pursuit of HRH-related activities. The President of the Sudan set up a special task force charged with reporting to a meeting of the Federal Cabinet on any bottlenecks in the creation and use of HRH. Presidential directives were issued to make HRH a main priority for the National Council for Health Care Coordination. Much of the progress recently made in HRH in the Sudan can be attributed to such high-level attention.

Accountability of stakeholder forum members

For the development of HRH, members of the stakeholder forum followed an evidence-based approach and assumed specific roles and responsibilities that matched their mandates. They also established accountability norms within the forum to promote the transparent involvement of each stakeholder institution in HRH issues and the pursuit of cooperation and joint action.¹³13 Siddiqi S, Masud TI, Nishtar S, Peters DH, Sabri B, Bile KM et al. Framework for assessing governance of the health system in developing countries: gateway to good governance. Health Policy 2009;90:13–25. doi: http://dx.doi.org/10.1016/j.healthpol.2008.08.005 PMID:18838188
https://doi.org/10.1016/j.healthpol.2008... All members of the forum agreed to report periodically on their contributions to HRH in the Sudan. The accountability process enabled the state and local authorities to demand solutions to any HRH challenges that they encountered.

Lessons learnt

The main lesson learnt from recent Sudanese experience in HRH development (Box 1) is that a great deal of power can be created by combining an evidence-based HRH information system with the promotion and implementation of the country coordination and facilitation process and the institutionalization of a framework for shared accountability. Effective governance was critical for developing an HRH-related strategic policy and designing, funding and implementing a national HRH plan. Effective coordination spearheaded a public-sector commitment to HRH reform that was characterized by high-level involvement and the strategic positioning of HRH issues. The revitalization and decentralization of a large number of training institutions – particularly those for nurses, midwives and allied health professionals – reduced the workforce shortages in underserved rural areas.

Competing interests:

References

Publication Dates

History