HRH coordination mechanisms
This section reports on the coordination mechanisms, their main functions and selected attributes (particularly the wider coordination mechanisms) including leadership and accountability; participation, inclusivity and consensus building; sustainability; and finally, performance.
Multiple coordination mechanisms were identified in all three study countries (see Additional file 1: Table S1). Malawi’s HRH TWG and Sudan’s National Stakeholder Forum have broad stakeholder reach and appeared to be long standing and embedded in the MoH systems. Nepal does not have a fully institutionalised health workforce stakeholder coordination mechanism. However, it has general coordination mechanisms that include health workforce and has ad hoc task-focused mechanisms such as the HRH roadmap working group.
The important attributes of the coordination mechanisms cover leadership and accountability; participation, inclusivity and consensus building; and sustainability.
Leadership and accountability
The TWG in Malawi is led by the MoH and is accountable to the broader Health Sector Working Group and the MoH Senior Management Team, “who decides whether to allocate funds to execute” (MWI 001). The National HRH Committee in Sudan is also led by the Undersecretary for Health and accountable to the President, which gives it power. The interdivisional coordination mechanisms in the MoHP in Nepal report to the Secretary in the MOHP, and the HRH Roadmap TWG was led by the joint-secretary and reported to the Secretary MoHP.
The coordination mechanisms in Sudan had clear Terms of Reference (TOR) and guidance documents which describe the roles and responsibilities of the members, the reporting system, and schedule of meetings, with the HR observatory acting as the secretariat. In Malawi, the HRH TWG and the task forces reportedly had clear TORs. There are clear procedures for MoHP interdivisional meetings in Nepal. These instruments, along with the leadership capabilities of senior management (GLO 001), enhance the legitimacy of the mechanisms.
Leadership capacity was impacted by high staff turnover in Malawi and Sudan (partly through migration). HRH coordination mechanisms should address national rather than donor-driven priorities (GLO 003), but because of frequent changes in leadership in the MoHP (NPL 002, NPL 003 and NPL 005) the TWG in Nepal was driven by a development partner. A participant in Malawi referring to the development of the HRH Strategy described how development partners ‘jumped in’, ‘took the heavy lift’, and how a “team of experts really pushed with the HRH Directorate, and then it came to reality’(MWI 006).
The health workforce leadership needs to continuously engage and initiate dialogue with the Ministry of Finance (MoF) so that there are funds behind the priorities and actions identified . Some respondents identified that these actors are often ‘not at the table until a later stage”, at which time they are reluctant to invest in health or the HW (GLO 007; GLO 006). Others have suggested that even when MoF is involved in these HRH coordination mechanisms, macro-economic and investments decisions are often made outside these mechanisms. Limited fiscal space, and international and domestic pressures to comply with the ‘austerity agenda’ and maintain ‘fiscal stability’ can also sway decisions to make long-term investments in the HW (GLO 006).
Participation, inclusivity and consensus building
The Malawi TWG had wide participation (see Additional file 1: Table S1). In Sudan, the Stakeholder Forum had a similarly wide reach of stakeholders with additional attendance by police and military HRH representatives. Respondents highlighted the challenge of leading and maintaining engagement of such large and diverse groups; this required effective communication and trust building efforts. In Nepal and Malawi, the composition of the working groups depends on the task, but donors and development partners will usually participate if they are contributing funds. In Malawi, participation by some MoH Directorates can be sporadic. At one point Sudan had dedicated staff and budgets to promote stakeholder engagement. In all three cases, monetary incentives were needed to encourage participation.
In Sudan, development partners, including UN agencies, have their own forum for general coordination which is represented in the NHC. In Malawi, development partners are members of the TWG, and one is always the co-chair. In Nepal the composition of the working groups depends on the function, but development partners contributing funds usually participate.
There is rapid expansion of private health worker training in Nepal and Sudan. The for-profit private (health) sector, which lack representative bodies, was absent from the HRH coordination mechanisms. Moreover, in Sudan, the private (health) sector remains unconvinced of the value in sharing data or the benefits of participation. Civil society was also missing from HRH coordination in the study countries.
Tensions and conflicts between stakeholders were reported due to the politicisation of health and healthcare funding and the presence of many powerful actors who believe they have a legitimate HRH governance and gatekeeping remit (GLO 002; GLO 006). These tensions were often intersectoral, such as education and defence (e.g. reluctance of security forces to share information in Sudan) or as a result of political transitions and resultant changes in institutional roles and responsibilities (GLO 001 and GLO 008). However, consensus-building, collective agenda setting, sharing objectives, use of workshops and informal communication helped to foster collective insight and views on the HRH topic, which eased tensions. Several global respondents observed that this process also improved HRH literacy amongst stakeholders and in Sudan ‘…the structures for coordination and the meetings, the culture of frequent meetings, has done a lot to mediate this relationship and to address conflicts.” (SDN001).
Many respondents emphasised the need for a sustained forum for developing and overseeing the long-term strategy for the health workforce. The longevity of the HRH TWG in Malawi, despite high turnover of government staff, was attributed in part to its embeddedness within existing MoH governance structures and the perception by stakeholders that it was “a competent structure” and essential to the coordination of new initiatives: “a donor wouldn’t really commit into a serious undertaking before being convinced that the TWG has reviewed and is happy with the direction” (MWI 005).
In contrast, the functioning of the high-profile Stakeholder Forum in Sudan was affected by the recent political transition in the country. One respondent claimed that “it [Stakeholder Forum] was functioning, though the country was unstable politically and the issues around the revolution make it a bit difficult to have the regular meetings as it is scheduled in the plan.” (SDN 004).
Holding regular face-to-face meetings can be expensive if held in hotels and travel costs are required, though for smaller meetings one respondent (NPL 005) said that paying for a “few cups of tea” was a good investment if it helped bring people together. In Sudan, the Stakeholder Forum had dedicated government funding and commitment, with the majority provided through external partners and donors, though “sometimes [per diems] it’s equal […] maybe to their […] monthly salary. So this is one of the things that really motivate people to attend” (SDN 009). During the pandemic in Malawi, the opportunity to hold virtual meetings meant more people were available, meetings were more frequent and cheaper.
The coordinating mechanisms in Sudan and Malawi and the Road Map working group in Nepal had all supported the development of HRH strategic plans to support the long-term health workforce strategy. The coordinating mechanisms in Sudan and Malawi appeared to meet regularly, though this became difficult in Sudan after the 2019 revolution. Effective HRH coordination mechanisms were reported in Indonesia under the UHC umbrella which shared information and planning processes (GLO 006); and in Mozambique where a strong champion created the coordination mechanism which was supported by an HRH observatory. They gained the interest of stakeholders by demonstrating at the health system annual reviews that “even if the issue is not a workforce issue, if you bring it their attention, and workforce component will be looked at” (GLO 003). Two global respondents compared the challenge of coordinating multiple stakeholders in larger—especially federated—countries with smaller countries where all stakeholders could be “in one room” (GLO 002).
This section reports on findings about the structures of HRH Units, their functions and attributes (leadership/accountability, capacity, support to decentralised HRH units), and performance.
Types and functions of HRH units
All 11 countries in the Southeast Asia region reported in 2019 that they have some form of health workforce unit, compared with eight in 2018 , though in Timor-Leste “it was just a one-person show.” (GLO 001). In the African region, 15 out of 16 countries surveyed: “had a responsible HR unit … but in practice, what had happened was that it was not really functional, many of them were just passing papers in practice” (GLO 003). Below we have listed selected findings relating to the functions of the HRH units (or equivalent). Additional file 1: Table S2 shows that whereas Malawi and Sudan have clear HRH units to oversee health workforce functions, in Nepal there was no single structure to provide this oversight.
HRH strategy: development and implementation
HRH functions need to be coordinated within the MoH (GLO 008). A HRH strategic plan is needed for both stakeholders and within the MoH to guide, coordinate, and align HRH initiatives to longer-term health sector plans and fiscal and budgetary space to ensure long-term investment in the HW . Nevertheless, the findings showed that Malawi was the only study country with a costed plan (2018–2022) currently being implemented, although there was no evidence that “costed annual implementation plans” (, p93) proposed in the plan have been developed or approved and/or funds allocated for activities not budgeted in the health sector strategic plan. The development of the Nepal HRH plan appeared to be very time consuming, often getting stuck at the approval stage with Nepal’s 2020–2030 plan only recently signed off. As a pathfinder country for GHWA, there was some external funding for developing Sudan’s 2012–2016 HRH strategy, but the process was apparently owned by the MoH and national stakeholders. In contrast, according to some respondents, the development of the HRH strategy in Malawi and Nepal was strongly influenced by development partners. Investment and therefore, implementation may be hampered without alignment to the fiscal and budgetary space. Although Nepal’s 2011 HRH strategy was officially approved and aligned to the health budget the funds to implement the planned activities were “frozen” (, p41). Dissatisfaction with the financing and implementation of Malawi’s current strategy was expressed: “you need to have a proper budget, you need to have a proper plan, indicators, whether you meet those things or not, so, there should be that kind of platform” (MWI 006).
One global respondent remarked that in many countries HRH departments do not operate at a strategic level and are mainly focused on routine recruitment and deployment (GLO 001). Sometimes major HRH changes may be taken on by a different department. The ‘employee adjustment process’ to support federalisation in Nepal was not managed by HRH officials, but a focal person of the rank of Chief Specialist was appointed to manage this process (NPL 002).
Workforce planning and HR information
Though workforce planning is often a “self-contained exercise within the health sector carried out in relative isolation from other development processes” (, p359), in Malawi the staffing projections were part of the wider strategic HRH plan. The intelligent usage of HRH data  is needed for workforce planning and other workforce management processes. WHO has supported Health workforce observatories to generate such data. In 2015, 34 member states in the AFRO region had these observatories—including Sudan , yet most countries struggle to get accurate, comprehensive and current data on the workforce and only nine are currently active in the African region . Despite years of donor support, the dedicated HRH information system in Nepal had failed and reliance of the personnel information system (PIS) for civil servants—including health workers—is only of “some limited use for the training and other planning purposes” (NPL 002). Sudan’s donor support to HRH information systems was curtailed by political sanctions. In Malawi, several information systems were in place, but the outputs could not be combined to produce useful information. HRH data sharing is limited in many countries, both within the Ministry of Health, itself and between ministries, such as Finance and Labour; “they don’t talk to each other at all” (GLO 001). However, in Indonesia, HRH data sharing between ministries was spelled out in a memorandum of understanding “being very clear what data is going to be shared, when, by whom, and which platforms and everything … they were very systematic on that” (GLO 006).
Lessons from COVID-19 about existing functions
A report from the South East Asian region suggested that lessons from COVID-19 on surge management and protection of health workers should be integrated into updated national HRH strategies . Respondents described how COVID-19 “exposed and amplified country weaknesses around “numbers of staff, distribution, skills” (GLO 002; GLO 007), as well as data on the impact of the pandemic on the HW, for example absence due to medical and non-medical causes. It demonstrated clearly the importance of valuing, protecting and investing in the HW (GLO 001), . One study highlighted how little evidence was available to healthcare managers and decision-makers in developing workforce strategies to respond to COVID-19 . Dramatic changes in HW policy, regulation, legislation were observed as well as “emergency investments” in HW ‘surge recruitment’, and a flexibility in governance and financing mechanisms that seemed impossible previously, all of which allowed a more effective health workforce response to COVID-19 (GLO 001; GLO 002:GLO 007), . Some respondents observed that some decisions were politically motivated, with governments keen to demonstrate they were doing something (GLO 007). In Malawi, in response to the COVID-19 pandemic and to avail of funding from the Global Fund, recruitment processes that normally take six months were completed “within two weeks or even less than that, and that is without compromising any quality” (MWI 006). While some respondents wondered whether things would default back as and when things get better, some were hopeful that with the improved understanding of HW complexities and the need for coordinated policy responses as a result of the pandemic, these levels of flexibility and responsiveness could be sustained (GLO 001; GLO 002).
Missing HRH functions
In Sudan the HR manual identifies the need for an employee relations unit, and this has been recommended in Nepal . However, in spite of the risk of industrial action generally  and in all study countries some of which was related to COVID-19, there was no evidence of the practice of ‘employee relations’ within MoH structures.
Three important attributes of the HRH Units emerged from the findings: leadership and accountability; capacity of HR unit staff; and support to decentralised units.
Leadership and accountability
The success of Sudan’s HRH Directorate was attributed to the leadership’s clear vision and ability to think “outside the box and how to conduct things not like … routine” (SDN 009). Elsewhere, HRH units may be hampered by unclear mandates and weak coordinating powers  or be positioned low in the organisational hierarchy excluding them from strategic decisions-making . Leadership at levels above the HRH unit was also cited as being important to the creation and functioning of such a unit. Strong support was demonstrated in Sudan, but despite numerous calls for its establishment the Personnel Administration Section in Nepal has not been replaced by dedicated HRH Division—“this is the leadership matter” (NPL 002). Weak leadership at both levels will affect accountability. Lack of ownership where initiatives were driven externally, such as the development of strategic HRH plans, was also found to be associated with lack of accountability.
Capacity of HR unit staff
The global HRH strategy  promotes the need for a professionalised body of HRH scientists and planners and as well as policy-makers who understand and can support HRH at a strategic level. Some respondents reported HRH expertise in selected high-income countries, but a recent study in the South-East Asia region found that only 14% of staff in the HRH units were professionals (e.g. with Master’s Degree in Public Health)  and in the African region only 7% of staff were described as ‘technical’ . In Malawi and Nepal, the HRH functions are staffed by people from “common services” ministries with knowledge of routine personnel administration, but who may be unfamiliar with the complexities of developing and managing a health workforce. One respondent said the perception is the management of public health staff and physicians or nurses was the same as managing agriculture staff, for example. “They look [at] everything as … general.” (NPL 006). A respondent from Malawi observed that generally “people who are thrown to the HR department are those who are incapable, or who has a disciplinary issue or who want to have some calm time, so that they will do their own things. So, that is the debacle and because of those things always you see capacity issues” (MWI 006). Another respondent suggested that in order to have a “mature discussion around the intersectoral nature of the health workforce agenda” it is critical to have policy-makers with ‘literacy’ in health workforce, e.g. able to think about “’terms and conditions of employment’, ‘productivity’ [and] ‘performance’ [and] ‘labour rights’” (GLO 007).
Becoming ‘literate’ about the health workforce also takes time. One respondent at a senior level in Sudan had been working for many years in HRH. However, just when the officer can develop effective and appropriate strategies, they may be transferred: “when they start to pick up things, they also move to the other institution. So that's really quite a big handicap for an institution as specialized as health.” (MWI 003). A review from Nepal in 2013 showed very high turnover of staff working on HR functions, especially those in leadership roles . High turnover of senior managers has continued in Nepal, some of which is associated with political instability. In Sudan, training in health workforce development contributed to improved capacity of the HRH directorates at State and National levels. In the absence of a stable body of HRH professionals, some countries have relied on the use of international consultants with the risk that no expertise remains when the contracts finish . “In Burkina [Faso] they have received support from I think Belgium cooperation to have again an expert to strengthen the HRH unit. And they have done a good job to strengthen HRH information system at the national level. And then when the expat left, nobody was able to manage the system. Then the system died.” (GL 004).
Support to decentralised units
Many countries either have or are moving towards decentralised health systems and management of the health workforce, as in the three study countries. This requires provision of support, including capacity strengthening, to the decentralised HRH units [3, 35]. Support strategies were included in Sudan strategic HRH plan for 2012–2016  and implemented. One respondent reported that all 18 state-level HRH units (staffed with one or more focal persons) are functioning. Strategies to support decentralised HRH units in the federal, provincial, municipal structures were included in Nepal’s HRH Roadmap. Similar support to Malawi’s devolution was anticipated in its HRH strategic plan—the “devolution of the HR function led to a delineation of roles and responsibilities between the line Ministry (MoHP) and the Councils” ([19, p16), but at the time of this study, institutional HRH roles and responsibilities, e.g. of the health service commission and the local government service commission at central and subnational levels had not been fully delineated.
Factors impacting on performance
A range of factors were found to impact on the performance of HRH Units, including: their legitimacy and power linked to positioning within the MoH structure and hierarchy (GLO 001) ; their political capital and engagement of stakeholders at the highest level, “that gives you the power in order to bring different departments on the table” (GLO 001); “funding power” (GLO 002) and their “capacity and policy space to plan, manage, cost and follow up all actors adhering to one HW plan” . To maintain technical autonomy and financial and programmatic independence, availability and use of monitoring and evaluation instruments and HR data are needed to monitor, report on and be accountable for results. This requires the availability and retention of HR literate professionals .