1. Human resources
for health
training:
An overview of
training priorities
and approaches
Tana Wuliji
Senior
Associate,nstituto de
Cooperaciόn Social -
Integrare (ISCI)
Tana.wuliji@integrare.es
1
DL4H International
Workshop
London, UK
26 October 2010

2. Overview
• Background
• Post-qualification training priorities
• Training design for performance
• Conceptual framework for approaches to
health worker training
2

3. Background Human resources
for health crisis
3
Health systems
strengthening

4. What is a health system?
4
“All organisations, people
and actions whose primary
intent is to promote, restore
or maintain health”
WHO, 2000

5. Health systems building blocks
5
Service delivery
Health workforce
Information
Medical products,
vaccines and
technologies
Financing
Leadership/
governance
Improved health
Responsiveness
Social and financial risk
protection
Improved efficiency
4 million health worker
shortage in 57 countries
In 60 countries, less than
¼ deaths recorded
Medicines availability 20%
in public sector in 39 LMIC
100 million people
impoverished due to
health spending per year

6. Public health spending
6

7. Private health spending
7

8. 8
Child 1-5 mortality
www.worldmapper.org Data: UNDP, WHO, 2002

9. Health workforce crisis: 57 countries
9

10. Nurses
10
www.worldmapper.org Data: WHO Global
Health Workforce Atlas

11. Midwives
11
www.worldmapper.org Data: WHO Global
Health Workforce Atlas

12. Pharmacists
12
www.worldmapper.org Data: WHO Global
Health Workforce Atlas

13. Physicians
13
www.worldmapper.org Data: WHO Global
Health Workforce Atlas

14. Dentists
14
www.worldmapper.org Data: WHO Global
Health Workforce Atlas

15. Post-
qualification
training
priorities
Training and
performance
15
Health systems
strengthening
perspective

16. Training priorities
16
Service delivery:
Diabetes UK Twinning to train
health workers and trainers
Health workforce:
PEPFAR funded MEPI, NEPI;
PROFAE nursing workforce
Brazil, AMREF nursing
workforce
Information:
Field Epidemiology Training
programs (FETP): Americas,
Africa
Medical products,
vaccines and
technologies:
Supply chain management
training (MSH, JSI)
Financing
Leadership/
governance:
6 month health management
skills program Yale/Liberia
- HR
Managers
-Educators
-Primary
healthcare
workers
-Specialists
Supply chain
management
- Researchers

17. Health systems building blocks
17
Service delivery
Health workforce
Information
Medical products,
vaccines and
technologies
Financing
Leadership/
governance
Improved health
Responsiveness
Social and financial risk
protection
Improved efficiency
Training!
But is training always the
answer?

18. 18
Myth: Training will
result in
improvements in
health worker
performance
Performance
Competence
Training
Work
environment
Job satisfaction
Autonomy
Supervision support
and feedback
Monitoring of
outcomes
Performance is influenced by a
broad set of factors

19. Training design
for performance Interactive and
integrated learning
19
Work-place based
learning
Distance education
and e-learning

20. Workplace based learning
• Health facility management 6 month training program in
Liberia
– Reduced disruption to work, enabled field based learning
for application of learnt skills
• Field Epidemiology Training Program
– Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua,
Dominican republic, Burkina Faso, Ethiopia, Ghana, Kenya,
Nigeria, Rwanda, South Africa, Tanzania
– 80% learning in field, 20% in classroom
• 3 year work-place based post-graduate diploma to build
general level competencies of hospital pharmacists (UK)
20

21. Distance education and e-learning
• University of Western Cape Masters of Public Health
– Health workforce management. 75% distance education.
Face to face learning: 4 visits.
• E-learning: online video programs, online modules, live
videoconferencing and broadcasting, online case
conferencing, web based portfolio systems, online learning
platforms
• 2008 meta-analysis of 201 studies (Cook et al, 2008)
– large and positive effects from e-learning vs non-
intervention
– Mixed/limited positive effects compared to classroom
based training
21
Distance education
produces comparable but
not necessarily superior
effects to classroom
education

22. Interactive and integrated learning
22
Level 1: Interactive and clinically
integrated
Level 2: Interactive classroom activities
and didactic, clinically integrated activities
Level 3: Didactic /classroom
Khan & Coomarasamy, 2006
Improvements in
evidence based
medicine practice
7/8 evaluations: Associated
with improvements in
practice
6/7 RCTs: No significant
differences between groups

23. Conceptual
framework for
approaches to
health worker
training
Broadening the
Distance Education
approach
23
From competence
to performance

24. 24
BEHAVIOUR CHANGE
Performance
As Performance
institutionalisation
Level 4: Results
Eg –Improvements in health outcomes, improved
health service efficiency (mortality, morbidity,
healthcare utilisation)
Level 3: Behaviour
Eg – Improvements in health worker performance
(peer review, observation, patient exit surveys)
Supervision, support
& feedback
Monitoring of
outcomes (audit)
Work environment
Structured
preceptorship
Work-place based &
integrated learning
Peer learning and
review
Competence
COMPETENCE
Level 2: Learning
Eg – Improvements in competence (pre-test vs
post-test, self-assessment)
Feedback
Self-directed learning
Problem based
learning
Simulations and case
based learning
Distributed learning
Engagement
ENGAGEMENT
Level 1: Reaction
Eg – Positive response to training
Interactive
Competency based
Clear learning
objectives
Relevant
assessments
Kirkpatrick’s levels of training
effectiveness
HEALTH WORKER CAPACITY
BUILDING PROCESS GOALS
Enabling factors

25. Broadening the distance education approach
25
Performance
Competence
Training
Work
environment
Job satisfaction
Autonomy
Supervision support
and feedback
Monitoring of
outcomes/audit
= small/moderate
effect on practice
= small/moderate
effect on practice
Distance education supported
by strategies to enable
behaviour change to improve
and institutionalise
performance