Analytical summary - Health workforce
There have been some remarkable improvements over the past two years with regard to the employment of medical doctors in health facilities country wide as shown in table 4.1 below. A total of 241 doctors/physicians were identified to be working in the country in 2010 compared to 201 in 2008. Similarly, the doctor to patient ratio increased from 19.7 in 2008 to 23.0 in 2010 reflecting a 3.3% increase.
Nurses form a significant majority of the overall health sector human resource and by such play a very critical role in the day to day management of patients in health facilities. While 2008 Service Availability Mapping (SAM) found a total number of 1778 nurses practicing in the country of which 1531 were Swazi, the 2010 SAM found a total of 1911 nurses practicing in the country 1714 of which were locals.
Due to the bureaucratic recruitment and management procedures, the MOH is committed to setting up a Health Service Commission to perform the functions of recruitment, selection, promotion and development of health professionals, as stated in the HR Policy document. The law required to set this up has been drafted and is currently under discussion.
Deployment of workers is based on existing vacancy and request of health facilities, regions and departments. Currently the Ministry doesn’t have staffing norms and a few cadres have clear career path and scope of practice for health workers. The Ministry is in the process of developing career systems and health workers distribution mechanism.
There have been recent increases in staff numbers and these are due both to filling existing vacancies and to the creation of new establishment posts. There is a “zero growth” policy for government wage spending in Swaziland; however special considerations are made for social sectors including health.
Currently MOH overall vacancy rates ranges from 5% to 18% depending on the stage at which recruitment processes are. Some cadres though such as health education, Laboratory staff, and Pharmaceutical staff may be as high as 35% to 40%.
The recent improvements in pay and working conditions for Swazi public servants have been important in retaining staff in the health services. Salary increment has been consistently applied across the board in the last decade. Other benefits include sick pay, paid holiday, housing, little workplace health care, medical referral outside the country for complicated cases, access to loans and housing loans.
Incentives & Allowances put in place in the last transport and allowances, overtime – applicable to all grades with maximum of 150 hours per month, and on call and standby allowances for selected cadres (medical, nursing, pharmacy and laboratory staff). Non-financial incentives have been widely shown as important as financial for motivating and retaining staff, but in Swaziland these incentives are often missing.
The MOH currently lacks institutional arrangements conducive for human resource planning. Instead this function has been partially fulfilled by the personnel unit. This unit however have largely focused on the day to day management and development of existing staff. There is currently no structure responsible for carrying out the human resource planning functions, hence human resource planning has been haphazardly driven by workload pressures from the various departments with no analysis of medium to long term needs. Although with the support of development partners there is a standing human resource working group its benefits are yet to be fully realized.
Staff Performance Appraisal is currently carried out annually, but is felt to be inadequate to deal with poor quality of health services. Performance appraisals are currently not directly linked to the performance of staff and the achievement of the services they are responsible for. This is often perceived as a bureaucratic form filling exercise related to promotions and redeployment.
A new performance management system was developed in 2006 as part of the national Public Service Reform Project (PSMP). However the performance appraisal has not been fully implemented throughout the civil service as negotiations with staff associations have not yielded any fruits.
There is a Nursing Council (SNC) and a Medical and Dental Council (SMDC) in Swaziland which register newly qualified professionals. The SMDC is currently trying to amend the 1971 Act which allows British and South African doctors automatic registration. The nurses Act of 1965 was reviewed, and a new act enacted by parliament in 2010. The new act better represents consumers which was not the case in the previous one. The current nursing act amends registration process in a way that qualifying exams are mandatory for registration.
One of the key functions of the MOH is to regulate the health sector, enforce good public health practices and ensure provision of high standard of health services in accordance with the Laws of the country. More importantly, it is the responsibility of the MOH to protect public interest in health by safeguarding people from various health hazards and enforcing professional ethics and discipline among health providers. The current situation points to weak MOH’s capacity at both national and regional levels to effectively regulate the health sector, set and maintain ethical and clinical standards of acceptable quality and enforce the health laws.
Quality assurance programmes has been recently initiated by the Ministry and these are yet to make significant impact in healthcare services delivery. The absence of adequate quality control and assurance systems, procedures and capacity to ensure that high standards of care is upheld and maintained, especially considering the large number of private, almost unregulated, providers compromises health outcomes in the sector.
The MOH computerised Human Resources Information System (HRIS) is part of the Ministry’s health information system and was set up in 2006. Despite its limitations the HRIS is expected to generate monthly HR indicators from the database, with vacancy rates and numbers of posts filled, staff losses, length of service in the public sector and staff by nationality. Although currently not utilised to its potential, it can be used to identify vacancies, and human resource planning.
Some of the benefits of the computerised system are tracking recruitment progress, identifying ghost workers, monitoring long-term vacancies, producing a HR indicators report, automatic monthly nursing inventory, rapid retrieval of personal files and sharing data with HR partners.
Once fully developed the HRIS needs more complete data from the private sector and NGOs, disaggregated information by age and nationality, by residence (urban/rural), compatibility with WHO classification of health workforce, data on in-service training, further data on attrition and be networked with regional offices.