Table 5 Summary of the main health labour market policies in four countries, 2000–2011 ^f

Policies to increase the production of health workers

1. Investment in health training institutions since 2000.

Positive effect: this policy together with policy to grant subsidies to private sector increased the number of trained medico-sanitary workers from 2,285 in 2000 to 3,307 in 2011 (69%).

1. National health training policy in 2009.

Negative effect: lack of coordination among training agencies resulted in inefficiencies, duplication of effort and wastage of resources. Lack of investments in training despite increase in demand; thus, the number of graduates in various cadres, e.g., nurses, has steadily decreased.

1. Revolution of Higher Education (1996).

Positive effect: About 10 new universities were opened and intake increased. The number of medical schools increased 8 times between 1996 and 2012. The number of doctors graduating each year increased from 400 to 1,400. Number of health workers in the public sector increased. Negative effect: increase in unemployment among new graduates, e.g., junior doctors.

1. Reopening of closed public training institutions, increased number of scholarships for in-service training programs, provision of financial retention incentives for teaching staff (within past five years).

Positive: number of graduates increased from 1,101 in 2007 to 2,311 in 2010 (increase of 110%).

2. Reform of the Faculty of Medicine and Biomedical Sciences (FMBS) with the opening of new training branches; creation of 3 new faculties of medicine (2007).

Positive effect: increased number of students in the faculty. Education of a medical officer requires at least 7 years, thus the benefit in terms of more health workers will be effective from 2014.

2. Facilitate rational development of the health workforce through alignment of curricula and training needs, create pre-service scholarships, establish cadre-based colleges, and establish medical training colleges in every county by 2017.

Positive effect: increased enrolment of students in the areas of need. Negative effect: the transition phase as devolution takes effect will bring some confusion in the health system.

2. Sudan Declaration for Allied Health Professionals (2004) to scale up the education of nurses, midwives, and allied health professions.

Positive effect: increased intake in different universities; a bridging programme was adopted to raise educational level of vocationally-trained cadres. Negative effect: universities could not expand the intake of nurses, midwives, and allied health professions to meet the needs, which resulted in the initiation of the Academy of Health Sciences.

2. Training community health workers to improve access of rural population to health services, 2010.

Positive effect: 307 community health workers graduated in 2011 and all have been placed in health posts in rural areas; 290 were enrolled for training in 2012.

3. Institutionalization of competence- based training programs, e.g., e-learning programme for nurses.

Positive effect: increased number of nurses trained in rural areas.

3. Decentralized Health Professional Education (HPE) through Academies of Health Science (in 2005) to ensure that programs are established according to the needs of the state and increase the training capacity of the allied health academy.

Positive effect: increased production of nurses, midwives, and allied health professions and improved skill mix composition of health workers; 6,000 new graduates from nursing, midwifery, and allied health professions recruited within their states.

Policies to address inflows and outflows

1. Performance-based financing approach in Eastern region since 2006. Now extended to other regions (North West, South West, and Littoral).

Positive effect: improvement in quality and quantity of care delivered, more resources collected by involved health centres, and better remuneration of staff.

1. Introduction of hardship and commuter allowances; improve data collection on health worker mobility and retention to curb out migration of health workers within and without the country since 2011. Improve working conditions (since 2009).

Positive effect: decreased migration of nurses. Negative effect: has not been enough to stop exits of medical doctors (50% between 2005 and 2009) and enrolled community nurses (81%).

No national policy to address inflows and outflows.

No national policy to address inflows and outflows.

1. Policies to attract foreign health workers with same conditions as nationals, except that foreign nationals are employed on renewable fixed-term three-year contracts.

Positive effect: The percentage of doctors increased by 30%.

2. Structural adjustment programme (before 2007) resulted in employment freeze of civil servants (with the exception of doctors). Freeze reversed in 2009 with expansion and opening of new facilities and upgrading of existing ones.

Positive effect: a significant reduction in vacancy rates; an increase in staff of 2,793, representing 8.4% growth between 2009 and 2010. Negative effect: the employment freeze resulted in a long-term decline in the number of civil servants including health workers; as a consequence, some cadres, such as nurses, medical laboratory, and dental technologists, have a high proportion of over 45-year-olds.

2. Improve employment conditions for health workers, and introduce in-service training and opportunities for progression within the public sector. More intense implementation since 2003.

Positive effect: decreased migration of nurses, from 99 in 2007 to 44 in 2011.

3. The retirement age of civil servants raised from 55 to 60 years in 2009.

Effect: changed the age profile of public sector health workers, which may result in high rates of unemployment and brain drain among new graduates, who will have difficulty finding a job in the health sector.

3. Public sector incentives to improve wages. Deliberate policy since 2005 to improve salaries for health workers.

Positive effect: decreased migration of nurses from 99 in 2007 to 44 in 2011. Negative effect: vacancy rates not necessarily decreased because staffing requirements keep changing with growing demand for services.

Policies to address maldistribution and inefficiencies

1. Emergency plan for upgrading quantity and quality of workforce (2006–2008).

Positive effect: helped recruit nearly 2,500 health workers in remote areas with severe needs for health workers. Negative effect: donor funding of programme came to an end; health workers have the right to move.

1. Review workforce norms and standards, measure performance of health workforce, establish frameworks to manage and monitor health workers, improve performance standards, strengthen supervision and accountability by 2030.

Positive effect: decreased inequality in the distribution of health workers and improved quality of services. Negative effects: main challenge is lack of functional infrastructure for service delivery, which undermines the performance of health workers.

1. Policy on deployment of medical specialists adopted in 2002. A contract with the Ministry of Health offers specialist training in exchange doctors agreeing to work in states according to health needs.

Negative effect: doctors may not abide by the contract and recipient states may not provide competent training services.

1. Compensation scheme for medical doctors serving in rural areas introduced in 2003 and expanded to other health workers in 2007.

Positive effect: this programme helped increase the number of health workers in rural areas between 2005 and 2010. Limited effect: no reduction in shortages of health workers in remote areas, because of effect of other factors, such as living conditions, safety, infrastructure, and job opportunities.

2. Programme to encourage employment in difficult areas (supported by C2D funding) launched in 2012.

Too early to measure effects.

2. Emergency hiring programme (2006) to provide a 3-year contract for health workers who work in underserved areas, recruit local health workers and provide hardship allowances, housing grants and paid leave.

Positive effect: increased number of health workers in rural areas. Negative effect: disharmonized remuneration.

2. Policy on deployment of medical specialists adopted in 2002: every medical or health graduate is obliged to work one year as national service; handled by the Ministry of Defence, which distributes them throughout the country to address geographical maldistribution.

Negative effect: the new graduates are young and inexperienced.

2. The UN Population Fund introduced a bonding system, in which nursing students in Northern Western Province received a bursary for payment of tuition fees from 2003.

Positive effect: improved staffing and retention of nurses in the province, as students are bonded for a period of 2 years after graduation.

3. Enhance staff motivation with payment of “productivity allowance” (10% of financial resources generated by the facility activities) since 1994.

Positive effect: improved quality of care delivered; Negative effect: no proof of reduced out-migration.

3. Develop a national electronic database for nurses to better match nurses to underserved areas in 2005.

Positive effect: reduced unfilled rural posts and faster recruitment.

3. Grant specialization scholarships for doctors practising in hardship areas. Provide incentive packages to retain doctors.

Positive effect: increased rotation of health workers in underserved areas. Negative effect: sporadic efforts not sustained.

Policies to regulate public and private sectors

1. Subsidies granted to private sector since 2000.

Positive effect: (together with investment in health training institutions) number of trained medico-sanitary workers increased from 2,285 in 2000 to 3,307 in 2011 (69%).

1. Launch distance e-learning through public-private partnership, establish interagency coordinating committee for human resources for health (HRH), form 26-member multi-stakeholder group for HRH

Positive effect: improved harmony in addressing HRH issues. Negative effects: difficult to convince some stakeholders to prioritize the issues raised in the health sector.

1. Directorate of Planning of the Federal Ministry of Health in 2010 adopted a policy towards private sector.

Negative effect: The Ministry of Health has weak regulatory and monitoring tools.

1. Encourage private sector participation in pre-service training.

Positive effect: (together with other policies) number of graduates increased from 1,101 in 2007 to 2,311 in 2010 (increase of 110%).