KINGDOM OF SWAZILAND MINISTRY OF HEALTHecsahc.org/...Policy_Costing_Report_-_(Swaziland).pdfCosting...

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KINGDOM OF SWAZILAND MINISTRY OF HEALTH

Human Resources for Health Implementation Plan: Operational Planning and Costing

2013-2016

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Executive Summary

Background

The Kingdom of Swaziland faces severe challenges in terms of the numbers of skilled health workers available to provide its population with primary health care (PHC) and specialist care services. These challenges are further compounded by an insufficient capacity to plan for human resources for health (HRH) and manage the resources currently available. The HRH landscape is characterized by unclear policies such as those related to employee benefits and staff management, inefficient processes including those related to recruiting and deployment as well as poor working environments for current staff and limited management and leadership of HRH within the health system. To address these issues and strengthen the Government of the Kingdom of Swaziland’s (GoS) capacity to implement its PHC strategy,the HRHStrategic Plan covering 2012 - 2017 was developed. This strategy was formulated in line with the HRHPolicy (2011) and the National Health Policy and National Health Sector Strategic Plan (2009).

The HRH Strategic Plan addresses three pillars or focal areas: the planningof HRH, the developmentof HRH pre-service and in-service education, and the management of HRH as it relates to personnel performance and work environment.With the goal of operationalizing the focal areas and clarifying the their financial outlays, the Human Resources Alliance for Africa program (HRAA), led by the East, Central, and Southern Africa Health Community (ECSA), was requested to develop and cost an HRH Implementation Plan. The implementation plan, covering the period of 2013-2016, was completed by HRAA. The costing assignment was carried out under HRAA as well by Abt Associates, Inc.and is described in this report. It is anticipated that the data and analysis presented in this report will be used to ensure that the resources required to support the implementation plan are requested in the upcoming budget cycle, commencing 1st April 1, 2014.

Costing Approach

The costing process, which took place from May to August, 2013, used an Abt Associates costing tool, the Costing of Operational Plan Reforms for Human Resources for Health (HRH-COPRTM). A costing team, composed of representatives from the Ministry of Health (MOH), GoS, and Abt Associates, followed a six-step process to carry out the costing activity:

Step 1: Define activities.Across the three strategic focal areas of the HRH Strategic Plan, the implementation planning process yielded prioritized strategies for implementation over the period of 2013-2016. For each strategy, activities were clearly defined and assigned estimated timelines, along with the Ministry, department, or individual responsible for carrying out the activity.

Step 2: Determine inputs.The unit cost (price) of the inputs required to carry out each activity was identified.

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Step 3: Determine targets.The targets for each activity were defined. For most activities, target-setting included determining ‘how many’ and ‘how often’ an activity is to be done.

Step 4: Determine cost scenarios.Using the objective of each proposed intervention, multiple scenarios were identified that would accomplish the objective at different cost levels. Such scenario analyses allow for policy-makers to determine the intervention most appropriate to the situation and to the budget.

Step 5: Determine budget templates. The fifth step combines all of the final data and scenarios into a budget template that summarizes the costing estimates in a manner that supports resource mobilization and strategic business planning.

Step 6: Iteratively refine the strategic reforms and budget figures. Determining budget figures which are accurate and useful for decision-making, and finally for implementation, requires an iterative process.Assumptions are refined and decisions are made based on the desired impact and a realistic view of resources which may be mobilized to support implementation of the reforms.The costing and budgeting presented in this report should not be seen as an ‘end product’, but rather a tool to support the completion of Step Six.

Results

The total cost estimate for implementing the full prioritized list of strategies and activities in the HRH Implementation Plan is approximately SZL30 million. Separated into the three strategic focal areas, planning (SZL 3.1 million) and development (SZL 10.1 million) will cost less than management (SZL 16.8 million). The full amount of SZL 30 million represents a small fraction (2.5% and 3.5%) of the actual MOH budget in 2011/12 and the estimated expenditure in 2013/14. While the MOH is expected to outlay most of that, the Ministry of Education (MOE) willbe responsible for about 21% of the total amount for activities that relate to training. A small amount of resources may also need to be mobilized by the Ministry of Labor and Social Security (MOLSS) and the Ministry of Public Service (MOPS). This would be dependenton how and where the responsibility for implementing certain activities and tasks is assigned. For example, activities such as those related to mobilizing funds for post-graduate education bursariesmight be split between different ministries. It is also worth mentioning that there exists limited capacity within the MoH to singlehandedly carry out all of the activities listed in the plan. If support is required from other ministries, then resource mobilization by other ministries may be requiredin addition to accounting for staff time in those ministries.

It is imperative to note that although the total amount estimated in this report appears to be a small fraction of the MoH budget, it only represents a small amount of what will actually be required to achieve the HRH objectives. The current plan is dominated by consultant and ministry-led assessments and strategy development activities. Significant implementation only occurs in years 2 and 3 (and these for activities that have already been designed at the time of this costing).Eight activities alone are ‘assessments’.It is anticipated that these assessments will result in recommendations that will in turn require resources to implement them. For example, improving the infrastructure of training institutions is addressed by an assessment to determine what the infrastructure needs actually are. Following the assessment (estimated to cost SZL 1.4 million in this report), resources will need to be mobilized to carry

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out these improvements. Anecdotal evidence suggests that It is likely that the infrastructure needs will be significant and the cost to address them will be several orders of magnitude higher than the SZL 1.4 million required for the assessment. Therefore, this plans cost estimates will need to be reviewed on an annual basis, so that each year the budgets and budget request figures can be reviewed and increased as necessary.

Next steps

The next step of the costing process is a validation of the activities, unit costs, and total cost estimates contained within this report. Following this, a clarification of roles and points of contact within partner ministries and organizations will be integral to the process, especially the inclusion of finance officers in ministries or organizations responsible for any element of resource mobilization required for implementing the plan. Once the cost estimates and other criteria described in this report have been reviewed by the stakeholders, there will likely be a need to revisit and revalidate the prioritization results. In particular, the costing team has noted the a number of assessments without specific follow-on activities included in the prioritized strategies of the implementation plan. Finally, a Monitoring and Evaluation (M&E) plan will be necessary to track the progress of activity implementation. The analysis presented in this report should not be considered a final document.Rather it should support the ongoing development of an implementation plan that serves a living document. It is anticipated that over time the activities and budgets contained here will be refined and updated.

Conclusions

In its present form, the HRH strategic plan is dominated by reviews and assessments with a limited number of implementationactivities in years two and three. The recommendations of these reviews and assessments are likely to have substantial costs.In particular, the cost of renovating training facilities and staff accommodations alone could reasonably be several orders of magnitude larger than the total cost of the HRH policy given here. This document should be considered a first iteration of the costing exercise to be validated as a next step and revisited each year on a rolling basis, taking in to account changes in the political and economic environment.

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Table of Contents

Executive Summary ....................................................................................................................................... 2

Table of Figures and Tables........................................................................................................................... 7

Acronyms ...................................................................................................................................................... 8

Acknowledgements ....................................................................................................................................... 9

Section 1 Introduction ................................................................................................................................ 10

1.1 Background ....................................................................................................................................... 10

1.2 Stakeholder Engagement .................................................................................................................. 13

Section 2 Methodology ............................................................................................................................... 14

2.1 Purpose of the HRH-COPRTM ............................................................................................................. 14

2.2 The HRH-COPRTM Process .................................................................................................................. 14

2.3 Data collection .................................................................................................................................. 16

2.4 Limitations ......................................................................................................................................... 17

Operational planning .......................................................................................................................... 17

Costing ................................................................................................................................................ 18

Key Assumptions ................................................................................................................................. 18

Section 3 Results and Analysis .................................................................................................................... 19

3.1 Distribution of Costs by Strategic Focus Area ................................................................................... 20

3.2 Distribution of Costs by Year ............................................................................................................. 21

Three Year Summary of HRH Strategy Implementation Costs ........................................................... 21

Three Year “Snapshot” of Costs by Cost Category .............................................................................. 22

3.3 Distribution of Costs by Ministry ...................................................................................................... 25

3.4 Three Year Cost Summary by Activity ............................................................................................... 27

Strategic Focus 1: Human Resources for Health Planning .................................................................. 27

Strategic Focus 2: Human Resources for Health Development .......................................................... 32

Strategic Focus 3: Human Resources for Health Management .......................................................... 38

Section 4 Recommended Finalization Process ........................................................................................... 46

4.2 Confirmation of responsibilities ........................................................................................................ 46

4.3 Re-check of priorities by stakeholders .............................................................................................. 46

4.5 Monitoring and Evaluation ............................................................................................................... 48

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Section 5 Conclusion ................................................................................................................................... 49

Appendices .................................................................................................................................................. 50

Appendix 1: Costing Team and Key Informants .................................................................................. 50

Appendix 2: Detailed Activity Outline (As Presented In Excel File) ..................................................... 51

Appendix 3: Key Results of the HRH Plan’s Strategic Focal Areas ...................................................... 73

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Table of Figures and Tables

Figure 1: HRH Policy Prioritization Results .................................................................................................. 12 Figure 2: The Six-step HRH-COPR™ Process, Illustrated by Establishment of Regional Health Officers for HRH ............................................................................................................................................................. 15 Figure 3: Three year HRH strategy costs by Strategic Focus ....................................................................... 20 Figure 4: Three Year “Snapshot” Of Total Costs for the GOS HRH Implementation Plan .......................... 22 Figure 5: Year Total Costs by Cost Category for Year 1 ............................................................................... 23 Figure 6: Year Total Costs by Cost Category for Year 2 ............................................................................... 24 Figure 7: Year Total Costs by Cost Category for Year 3 ............................................................................... 24 Figure 8: Year Total Costs by Cost Category for Year 1-3 ........................................................................... 25 Figure 9: Total Costs of HRH Policy for Three Years 1-3 by Ministry (SZL) ................................................. 26 Figure 10: Next Steps in HRH Operational Plan Implementation ............................................................... 46

Table 1: HRH Policy Summary Costs by Strategic Pillar (SZL) ...................................................................... 20 Table 2: Government Estimates on Health Sectors (SZL) ........................................................................... 22 Table 3: Strengthen the organizational structure, functions, and enhance capacity for HRH planning, management and development (SZL) ......................................................................................................... 28 Table 4: Revive the HRIS through the Creation of HRH Databases and Increase Capacity for Data Analysis, Interpretation and Reporting (SZL) ............................................................................................................. 30 Table 5: Strengthen the Coordination and Management of Pre-Service Training (SZL)............................. 33 Table 6: Strengthen the Coordination, Quality and Training Plan of In-Service Trainings (SZL)................. 35 Table 7: Improve Physical, Organizational and Operational Capacity of Training Institutions (SZL) .......... 37 Table 8: Strengthen Recruitment and Deployment Procedures (SZL) ........................................................ 39 Table 9: Improve Staff Retention by Improving Scholarship Program Follow-Ups, Job Satisfaction, Working and Living Conditions (SZL) ........................................................................................................... 41 Table 10: Work Hand in Hand with MOPS to Implement the New Performance Management System (SZL) ............................................................................................................................................................. 44 Table 11: Implement the Supportive Supervision and Mentoring Framework (SZL) ................................. 44 Table 12: Summary of estimated recurrent expenditure by economic sector 2013/14 [E'000] ................ 47 Table 13: Summary of estimated capital expenditure by economic sector 2013/14 [E'000] .................... 48

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Acronyms

CSC Civil Service Commission ECSA GoS

East, Central, and Southern Africa Health Community Government of the Kingdom of Swaziland

HRAA Human Resources Alliance for Africa HRH Human Resources for Health HRH-COPRTM Costing of Operational Plan Reforms for Human Resources for Health MF Mentoring Framework MOE Ministry of Education MOH Ministry of Health MOLSS Ministry of Labor and Social Security MOPS Ministry of Public Service PHC Primary Health Care PMS Performance Management System SANU South African Nazarene University SS Supportive Supervision

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Acknowledgements

The costing and report writing team, consisting of Elaine Baruwa, Lorraine Ross and Matt Kukla were supported by the in-country costing team including ThokoMalaza, Wendy Shongwe, DuduNdzinisa and ZwelakheNhleko. Jordan Tuchman kindly reviewed the report and provided useful comments. In-country support was provided by Sibusiso Sibandze, Gloria Dlamini, and Sizakele Hlatshwayo.

A large number of people kindly gave their time and attention to the costing team. Without them, no report would be possible: Mandla Dlamini, Maxwell Masuku, Mzwandile Kunene, Dumisani Shongwe, Simon Zwane, ThembisileKhumalo, NonhlanhlaSukati, NyamileManana, Lomakhosi Dlamini-Vilakati, Zanele Simelane, NomathembaHlope, MumlyMusi, Peterson Dlamini, Phindile Tsabedze, Sibongile Mhlanga, FuthiNkambule, Musa Dlamini and Felton Mhlongo.

Finally, we are grateful to PEPFAR/Swaziland for providing the funding for this work and Grace Masuku of the PEPFAR/Swaziland team for her support throughout the costing process.

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Section 1 Introduction

The Kingdom of Swaziland faces severe challenges in terms of the numbers of skilled health workers available to implement its primary health care strategy. These challenges are further compounded by an insufficient capacity to plan for human resources for health (HRH) and manage the resources currently available. The HRHlandscape is currently characterized by unclear policies including those related to employee benefits and staff management, inefficient processes including those related to recruiting and deployment as well as poor working environments for current staff and limited management and leadership of HRHwithin the health system. To address these issues and strengthen Government of Swaziland (GoS) capacity to implement its primary health care (PHC) strategy,the HRH strategic plan covering (2012 - 2017) has been developed. This strategy was developed to implement the HRH policy (2011) which in turn was formulated in line with the national health policy and national health sector strategic plan (2009).

1.1 Background

The strategic plan of the HRHpolicy addresses three pillars or strategic focal areas; the planningof HRH, the developmentof HRHpre-service and in-service education and finally the management of HRHas it relates to personnel performanceand work environment. Although a fourth strategic pillar focusing on HRHfinancing is described in the plan, this pillar is not addressed by this report directly. Rather it is anticipated that by operationalizing and costing the strategic plan and developing a clear understanding of financial resources required to implement it,the GOS’s capacity toexplore HRHfinancing options successfully will have been strengthened.

Given the broad range of challenges to HRHplanning, development and management, the HRHpolicy is extensive in its approach. However,due to the prevailing lack of financial and management resources faced by the MOH,it was necessary to engage in some form of prioritization in order to initiate a manageable and feasible implementation process. A prioritization exercise was carried out by HRAA prior to the work described in this report. The operational planning and costing conducted in this report is based upon the initial prioritization process results which were provided to the costing team in the document entitled “Human Resource for Health Implementation Plan (2013-2016, Zero Draft)”1 referred to henceforth as the HRHIP. A summary of these results is shown in Figure 1.

It can be seen in Figure 1 that the prioritization process focused on strategies under each of the three strategic focal areas. The specificity with which activities are described in the HRHIP varies substantially. Some activities are specific whereas others are broadly described, thereby requiring more definition around the activities that would be carried out to implement each strategy. Similarly stakeholders were listed but their specific roles were not clearly defined – e.g. whether or not they were responsible for financial resourcing and/or implementing. In addition, targets and milestones were not always

1 This document was provided to the costing team to serve as the list of prioritized strategies and activities to be costed.

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provided.This meant that the originally planned costing exercise had to be combined with an operational planning exercise in order to define activities, targets, responsibilities and timelines - all of which are necessary for a costing exercise to be carried out.

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Figure 1: HRHPolicy Prioritization Results

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1.2 Stakeholder Engagement

Given that the breadth of activities required for MOH to carry out the strategic plan ranges from the provision of education bursaries through to improved working environment and infrastructure, it is important to note that several stakeholders will be required to implement and finance some of the activities to support the HRHstrategic plan. Many of these stakeholders have already been engaged during the prioritization process and include the following:

• Ministry ofPublic Service • Ministry of Education • Ministry of Labor and Social Security • Ministry of Finance • Civil Service Commission • University of Swaziland • South African Nazarene University • Professional Bodies (e.g. Swaziland Medical and Dental Council, Swaziland Nursing Council)

As well as several departments that in the Ministry of Health itself that include the following:

• Strategic Information • Training • Regional Health Offices • Statistics

Following the analysis contained in this report, it will be critical for the HRH Planning Group of the MOH to circle back to these stakeholders to validate the information within this report including activity descriptions, required input, and unit costs. It will also be important to allow the stakeholders to revisit and verify their opinions on the prioritization of activities, which may change upon receipt of the estimated costs and other criteria discussed in the conclusions of this report (including political feasibility and the anticipated economic climate.)

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Section 2Methodology

The objective of this report is to provide detail on the strategies and activities contained in the HRH implementation plan support the operationalization of that plan and the mobilization of resources to support the plan's implementation. The detail includes specific information on activities, inputs, unit costs, responsibilities and timing of prioritized activities. The costing team used the HRH-COPRTM, a costing tool designed by Abt Associates, Inc. to achieve this.

2.1 Purpose of the HRH-COPRTM

The purpose of the HRH-COPRTMis to provide the MoH with a template for estimating the costs of a set of prioritized strategies and activities in order to support decision-making forcarrying outthe HRH implementation plan.

Specifically, the HRH-COPRTMobjectives are to:

1) Develop operational priority reforms by determining concrete implementation activities.

2) Quantify the resources that will be required to implement the activities.

3) Provide a time-bound (a three-year period, with separate budgets for each year) and incremental (reflects all required activities, regardless of whether they currently have funding) budgeting template that combines quantity and cost datato estimate the additional financial resources needed to implement the prioritized activities.

4) Determine the cost of potential scenarios for implementation of activities to guide decision-makers in identifying strategies which will provide the most impact for their investment

2.2 The HRH-COPRTMProcess

Implementation of the HRH-COPRTM involves a six-step process that begins with further defining the reforms and activities determined to be priorities through the completion of the HRH-SPATM.

Step 1: Define activity

For each of the eight strategic areas and activities prioritized, it was critical to discuss the objective of each intervention and to describe the manner in which the reform would be carried out with the stakeholders responsible for and affected by the activity.

Step 2: Determine inputs

Having clearly defined the activities, the next step involves determining the unit cost (price) of the inputs required to carry out each activity. For example, for a training activity like the training of new HRH officers for regional health offices (RHOs) described in Figure 2, the unit costs of venue, tea breaks, meals, lodging, participant per diems, and other materials need to be ascertained. For some activities,in

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order to understand the new resources needed, we had to determine the proposed increase over what was already in place.

Figure 2: The Six-step HRH-COPR™ Process, Illustrated by Establishment of Regional Health Officers for HRH

Step 3: Determine targets

Having clearly defined the inputs required to implement an activity, the next step is to determine the targets for the activity. For most activities, target setting includes determining ‘how many’ and ‘how often’ an activity is to be done. In the example in Figure 2, the target may be all four of Swaziland’s RHOs or there may be a decision to have a single officer cover two of the smaller, less densely populated regions if appropriate. Therefore the salary of the new officers would be a recurrent cost year after year but the training and recruitment costs would be incurred only in one year – the year that the officers are recruited.

Step 4: Determine cost scenarios

Understanding the objective of the activity is critical for understanding its potential scope. By reminding ourselves that improved planning of HRH is the objective of the policy/activity in Figure 2, we may be able to define several possible scenarios. In the example shown in Figure 2, we can see that there are at least two possible scenarios, one in which there is one officer per RHO and one in which one or two officers cover more than one RHO. Given that the current HRH management and planning process is being strengthening and there may be an increase in the future responsibilities of RHO HRH officers it may be appropriate to recruit one officer per RHO now. However, given that many activities and milestones have to occur before those future responsibilities are actualized and current funding is limited, it may be more prudent to recruit fewer offices now and plan for more in the future.Such

Step 6: Review and refineChoose a scenario, iteratively refine the activity and budget template

Step 5: Develop budget templateConstruct a budget template that captures the range of scenario costs for the activity

Step 4: Determine cost scenariosScenario 1: One officer per RHO Scenario 2: One officer covering two RHOs

Step 3: Determine targets Number of Regional Health Offices?

Step 2: Determine inputs Number and salary grade of officers? Office infrastructure and training required?

Step 1: Define activityWhat is the activity’s objective and how will it be operationalized?

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scenario analyses allow for policy-makers to determine the intervention most appropriate to the situation (fulfilling the objective) and to the budget.

Step 5: Determine budget templates

The fifth step combines all of the final data and scenarios into a budget template that summarizes the costing estimates in a manner that supports resource mobilization (where scenarios are discussed in terms of what is feasible versus what options are theoretically available) and strategic business planning.The budget template is designed to serve as a critical tool for the MOH in refining and revising strategic HRH reforms.

Step 6: Iteratively refine the strategic reforms and budget figures

Determining budget figures that are accurate and useful for decision-making and ultimately implementation requires an iterative process of refining assumptions and decision-making based upon desired impact and a realistic view of the resources which may be mobilized to support implementation of the reforms.Since multiple scenarios can be developed for any given activity or intervention area, early iterations do not produce a final ‘total cost’ number. Instead, the objective of the scenarios is to provide a range of estimates that can serve as a basisfor making decisions about the scale of activities being considered. Decisions between activities are often more straightforward to make after assessing their cost implications. However, it may only be possible to make decisions after a lengthier process of consultation and resource mobilization. Thus the costing and budgeting presented in this report should not be seen as an ‘end product’. Rather, this report is a significant preparatory step in the process of determining the cost of operationalizing reform strategies.The HRH-COPRTM costing tool may be used throughout the entire iterative process contained in Step 6, until final decisions are made and resources are mobilized.

2.3 Data collection

The implementation of the six-steps of the HRH-COPRTM in the Kingdom of Swaziland was led by Abt Associates, Inc. under HRAA, with support from a team appointed by the MOH and HRAA (a complete list of team members is included in Appendix 1).

The costing team, with input from outside stakeholders, defined the objective of each activity and how it might be operationalized.Further information on the resources required to implement each activity was obtained from a range of sources.The names of representatives that the budgeting and costing team met with are listed in Appendix 1.Representatives from the human resources, financing, planning, and information technology departments within the MOH provided information on costs currently supported by the MOH.Additionally, the team met with staff from the relevant ministries also anticipated to participate in the implementation of the strategy.

From each stakeholder, the costing team obtained information or estimates on:

1. How the activity has been done in the past, and whether this model might be appropriate for future activities. If past implementation was seen as needing modification, or if the activity had not been done in the past, stakeholders were asked how it might best be done in the future. The costing team sought

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specific information- for example, if a consultant was thought to be needed, the team asked how many days would be required, what type of consultant, etc.

2. Unit costs were derived from past budgets, estimates, or experience. The costing team also identified additional sources for unit costs if program managers were unable to provide estimates.

3. Data required to set targets was collected where needed. Few activities in the implementation plan required target information and those that do, in many cases, still require further definition. For example it is unclear how many managers and supervisors will be required to be trained on the new performance management system (PMS) because the PMS is yet to be piloted and therefore assumptions had to be made to estimate the costs of rolling out the PMS at the MOH. These assumptions will need to be refined upon completion of the pilot PMS by Ministry of Public Service (MOPS). Assumptions such as these are clearly noted in the detailed activity tables contained in the appendices of this report.

2.4 Limitations

It is important to note that there remains a large amount of work to be done to support the implementation of the HRH plan by the MOH. A large number of activities require further consideration and more detailed planning in order for them to be implemented. At present, it is unclear where in the MOH responsibility for the clarification and follow-on process may lie. Nonetheless, this report provides as much information and detail as is currently available; furthermore, it clearly identifies activities that will require more definition prior to implementation.

It should also be noted that there are several activities contained in the implementation plan that have not been costed by this analysis. The reason for this is that these activities had already been initiated at the time of data collection for this report. Therefore, they had already been included in budgets and resources had been mobilized for their implementation. As such, there was no need to address them further. Nevertheless,these activitiesare included in the report tablesto provide a complete picture, but it is clearly notedthat they have already been costed.

Operational planning

Although costing the implementation plan was the primary scope of work for the costing team, it was observed that several of the activities in the implementation plan required further definition in order for them to be implemented. Therefore, the costing team included operational planning as part of its scope owing to the need to have more operational detail in order to be able to identify resources required for implementation. It was also necessary to have enough detail with regards to the timelines for each activity to be able to estimate annual budgets for implementation of the plan.

Due to the need to further define activities within the implementation plan for them to be appropriately costed, some activities in the operational plan in this report will contain additional sub-activities. For example, an activity from the HRH implementation plan may have read “hire an HRH officer”, while the costing report’soperational plan must clearly state all of the steps required for such a hire to occur. This

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would include understanding how the advertising for the position would be carried out, whether additional training would be required for new hires, and whether or not physical resources (e.g. furniture and computers) are currently available for new employees or would need to be procured. It would also be critical to know the responsibilities around such a hire and who is charged with carrying those responsibilities out (e.g. MOH, MOPS, or the Civil Service Commission [CSC]).

Costing

Much of the information required for costing a strategy should be collected when completing the operational plan for the strategy. For example, suppose an activity states that an assessment must be conducted. The operational plan should indicate whether a consultant or MOH employee may be able to carry out an assessment as well as the time period over which the assessment may occur.Rates for local consultants, salary grades for MOH employees, and estimates of the anticipated number of work days required would also be needed to estimate the cost of completing such an assessment.

Key Assumptions

Because comprehensive data was not always available for activities, the costing team made several assumptions for both the unit cost and quantity of resources in order to budget for activities and their broader strategies. Key assumptions were as follows:

(1) Recruitment: Assumptions were made on the unit costs of recruiting, hiring and training new employees.

(2) Source of activity lead and length of trips: Many activities required one or more individuals to collect data, compile needs assessments, hold meetings or workshops, or conduct work that would allow for activities to be implemented. The costing team made assumptions on whether such work would be led/done by an existing government official, a consultant, or a newly trained employee. Moreover, assumptions were made on the scope of work required – notably the length of trips and the number of individuals needed.

(3) Meeting, workshop, and production costs:To determine the scope of work for implementing each activity, train individuals, or build consensus through discussion, several meetings or training sessions were included in the costing plan. Assumptions were made about how many documents were needed and how much they would cost, the number of days for each meeting and workshop, as well as the number of participants.

(4) Scenarios: Several scenarios were included in the costing report which provides options for the Swaziland government as they implement the HRH strategic plan.Generally these scenarios covered (a) the decision to hire a consultant, train a new employee, or utilize a government employee and (b) the decision to develop new systems (i.e. a WIZN) or build upon existing ones.In the report for all tables summarizing total costs the costing team assumed that the lowest cost scenario would be chosen. However, the discussion of detailed costs by strategy and sub-strategy show the cost of each scenario.

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Section 3 Results andAnalysis

The following section presents costs for the 2013 to 2016 HRH implementation plan resulting from the data collection and costing process described above.It first provides a snapshot of the implementation plan’s total cost bystrategic focus area and then by year.As some of the financial responsibility for the HRH policy implementation lies with ministries in addition to the MOH, costs are also presented by ministry. The three-year costs are then presented and broken down by spending category and government department.Finally, a cost summary and timeline is presented for each activity grouped by strategy and strategic areas in Table 3 to

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Table 10.These tables also indicate activities that have already been costed.There are only a few activities where scenario analysis is necessary and the multiple costing scenarios that may be possible are also shown. The lowest cost scenarios were used when deriving total activity and strategy costs in an effort to provide conservative cost estimates.

3.1 Distribution of Costs by Strategic Focus Area

The HRH implementation plan, as it is costed in this report, consists of three pillars: HRH Planning, HRH Development, and HRH Management (see Figure 1 to review a summary of the plan). Total costs over three years for the HRH strategic plan can be seen in Figure 3,with SZL 3.07 million required for HRH Planning, SZL 10.05million for HRH Development, and an additional SZL 16.85 million for HRH Management.

Figure 3: Three year HRH strategy costs by Strategic Focus

The HRH Management pillar requires just over half of all the estimated resources needed. Improving staff retention by improving scholarship programs, job satisfaction, working and living conditions accounts for nearly half of the resources required for this pillar (SZL 7.4m). Detailed breakdowns of the costs for each pillar are provided in the next sections of the report but a summary of the sub-strategies is presented in Table 1.

Table 1: HRH Policy Summary Costs by Strategic Pillar(SZL)

Strategic Pillar 1: HRH Planning

Strategic Pillar 2: HRH Development

Strategic Pillar 3: HRH Management

1. HRH PlanningSZL 3,076,411

10%

2. HRH Development

SZL 10,059,23234%

3. HRH Management

SZL 16,852,35156%

Cost by Activity (SZL)

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Strategy 1.1: SZL 1,246,130









SZL 3,076,411.00 SZL 10,059,232.00 SZL 16,852,351.00

3.2 Distribution of Costs by Year

Three Year Summary of HRH Strategy ImplementationCosts

Figure 4 below shows the HRH implementation plan’s total cost per year (2013 – 2017).The costs are shown in terms of the year of the plan in which activities will be implemented, year 1, 2, or 3. The actual fiscal year for year 1 is anticipated by to 1 April 2014 to 31st March 2015. Again, the total cost of implementing the prioritized activities of the HRH implementation plan is approximately SZL 30 million for the three-year period. Approximately 31 percent of this total spending is scheduled to occur in 2014-2015 (year one of implementation), while 79 percent of the plan’s total costs occur by 2016 (end of year 2 of implementation). An in-depth assessment for what is included in these yearly costs and why costs vary by year can be found in Figures 5-7 below.

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Figure 4:Three Year “Snapshot” Of Total Costs for theGOSHRHImplementation Plan

To put the costs in Figure 4 in perspective, Table 2 presents the MOH budget figures from 2011 to 2016 including actuals for 2011-12 and estimates for the remaining years. The MOH received SZL 872 million in 2011 and is estimated to have a budget of SZL 1.1 billion in 2012/13,an increase of 27%. As such, the cost of implementing the activities costed in this analysis would represent 2% or 3% of the MOH budgetdepending on the final budget outlay.

Table 2: Government Estimates on Health Sectors (SZL)

Ministry of Health 2011/12 Actual 2012/13 Estimate

2013/14 Estimate

2014/15 Estimate 2015/16 Estimate

Health Expenditure 871,856,176 1,106,048,750 1,240,208,616 1,306,292,249 1,361,362,215 Anticipated year-on-year increase

+27% 235,000,000

% required for HRH Policy activities 3.4% 2.7%

Three Year “Snapshot” ofCosts byCost Category

The three-year HRH implementation plan is further broken down by cost category (see Figures 5 through 8.) The first three graphs indicate total costs per category for each respective year, while the fourth graph summarizes these cost categories across years 2013 to 2016.Cost categories are as follows: consultants, stakeholder meetings, training workshops, salaries, infrastructure, and reports and supplies. The costing exercise aimed to collect data and provide estimationsfor the HRH plan’s eventual

9,188,508

14,565,974

6,233,513

-

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

16,000,000

Year 1 Year 2 Year 3

HRH Strategy Total Costs (SZL 29,987,995 )

23

implementation and thus mobilization of resources. As such, the list of cost categories does not includeHRH recurrent costs (the major proportion of which is likely to be staff salaries).This exclusion explains why consultants and meeting costs represent a significant portion of total costs in all three years, whereas salaries and infrastructure make up a small fraction of these costs. To illustrate, consider the provision of bursaries proposed as an activity to improve the development of HRH capacity. Various assessments in the operational plan are scheduled in order to determine the number of bursaries needed. While the cost of the assessments are included in the analysis,since the number of bursaries is not yet known no costs are included for the bursaries themselves.These costs will need to be included in future costing iterations when these assessments and their recommendations are available. At that point, the cost of providing bursaries will be represented as a recurrent cost as bursaries will need to be paid for every year.

During year one shown in Figure 5, consultants and stakeholder meetings account for 96 percent of total costs; the remaining 4 percent include infrastructure, reports, and supplies.In other words, this could be viewed as aninitiation period where consultants will gather data independently and from stakeholders as well as build assessments on the feasibility of broader HRH reform goals.

Figure 5: Year Total Costs by Cost Category for Year 1

During year two, shown in Figure 6,stakeholder meetings will account for less: 19 percent of total costs. However, consultants will initiate training workshops after gathering data from the first year: so these two categories will make up 39 (consultancies) and 7(training workshops) percent of total costs for year 2, respectively. Implementation of projects will begin, representing 26 percent of year 2 costs. Similarly, new employees will be hired and trained, while short term infrastructure projects – such as developing health information systems and scaling up health facilities – will be initiated.These still only account for 3 and 4 percent of total costs in year two.

Salaries0.3%

Reports & Supplies2.2%

Infrastructure1.2%

Stakeholder Meetings

52.9%

Training Workshops

0.0%

Consultants43.4%

Implementation0.0%

Costs by Category2013/2014

24

Figure 6:Year Total Costs by Cost Category for Year 2

In year three, consultants will continue to represent a significant portion of total costs (39 percent), as shown in Figure 7. However, salaries and implementation of activities will account for an increasing share of costs (8 and 40 percent) as employees begin full time work and are trained to independently implement HRH reforms.Training workshops (3 percent) and stakeholder meetings (10 percent) together account for a small percent of year 3 costs.

Figure 7: Year Total Costs by Cost Category for Year 3

Salaries3%

Reports & Supplies2%

Infrastructure4%


19%

Training Workshops

7%

Consultants39%

Implementation26%

Costs by Category2014/2015

Salaries8% Reports & Supplies

0%

Infrastructure0%


10%

Training Workshops

3%

Consultants39%

Implementation40%Costs by Category

2015/2016

25

The final graph, Figure 8, summarizes costs from year 2013 through 2016.Consultant fees, stakeholder meetings, and training workshops will – as explained above – account for nearly 90 percent of total costs during the initial HRH reform phase.However, as reforms are implemented in subsequent years and processes become internally sustainable, these numbers should be reversed and implementation costs, salaries, infrastructure, education, training, and other capacity building projects should make up the bulk of costs.

Figure 8: Year Total Costs by Cost Category for Year 1-3

We note in the Finalization Process section of this report that the estimated figures in this report do not account for the results of the many assessments, reviews, and strategy development activities proposed in the plan. Each of these activities will result in recommendations that in turn will require resources. To that end, it is likely that the overall resources levels required will increase over the implementation period and therefore the distribution by category is also likely to change from the distributions discussed here.

3.3 Distribution of Costs by Ministry

The HRH Strategic Plan will need to be implemented and financed by multiple stakeholders, including the MOH, Ministry of Education (MOE), Ministry of Public Service (MOPS), and the Ministry of Labor andSocial Security (MOL). It is critical that the MOH ensure strong coordination across stakeholders in order for implementation to be successful.Figure 9 illustrates the financing responsibilities ofvarious stakeholders in the HRH implementation plan. While the MOH has theprimary responsibility for coordinating, implementing and financing the majority of the prioritized HRH strategy (41 percent of total costs),the MOE and MOLSS also play a large role in strategic planning. Thefinancing roles played by MOPS and MOLSS still need to be clearly defined, particularly as they relate to the implementation of

Salaries3%

Reports & Supplies2%

Infrastructure3%


29%

Training Workshops

11%

Consultants48%

Implementation4%

Costs by Category2013-2016

26

the PMS and training bursaries.For the time being, they are labeled as MOH/MOPS and MOH/MOL costs and account for 32 and 6 percent respectively of the plans costs over three years. The MOE’s financial responsibility is significant at 21 percent of the total costs. These costs relate to pre-service training, which is considered a priority activity in the GOS’s strategy for addressing the inadequate number of HRH workers in Swaziland. The specific activities that each ministry supports are listed in the next section.

Figure 9:Total Costs of HRH Policy for Three Years 1-3 by Ministry (SZL)

MOESZL 6,314,483

21%

MOHSZL 12,356,860

41%

MOH/MOLSZL 1,895,169

6%

MOH/MOPSSZL 9,421,482

32%

Cost By Ministry

27

3.4 Three Year Cost Summary byActivity

This section of the report summarizes the costs, responsibilities and proposed timelines for each activity under each strategy for each of the three strategic focus areas.

Strategic Focus 1: Human Resources forHealth Planning

The three key elements of the HR planning process are forecasting labor demand, analyzing present labor supply, and balancing projected labor demand and supply. Activities in this focus area are expected to strengthen the availability and use of HRH data.

Strategy 1.1: Strengthenthe organizational structure, functions, and enhance capacity for HRH planning, management and development

As can be seen from Table 3 many of the activities in the strategy are already underway. The only remaining activity is the establishment of HRH manager positions at all regional health offices. Table 3shows that approximately SZL 1.2 million is required to recruit the HRH officers for each regional health office with the objective of moving HRH planning closer to the health service delivery point (decentralization) in order to make HRH planning more responsive to local needs. The costs included in this estimate do not include the recurrent costs (e.g. the salaries of these officers) going forward as these would be captured in the regular, annual HRH staff budget estimates.

28

Table 3: Strengthen the organizational structure, functions, and enhance capacity for HRH planning, management and development(SZL)

Activity # Activity Name 2013/2014 2014/2015 2015/2016

1 HUMAN RESOURCES FOR HEALTH PLANNING 1 1 Strengthen the Organizational Structure, Functions, and Enhance Capacity for HRH Planning, Management and Development 1 1 1 Redefine the HR Department structure and functions at MoH to lead

and coordinate HRH planning, development and management responsibilities

X - - -

1 1 2 Create positions within the revised new structure and recruit new qualified staff in the HRH planning, development, and management at National, Regional, and Facility Levels

X - - -

1 1 3 Establish HR Manager positions at all Regional Health Offices and deploy qualified and competent staff to fill up newly created positions

29,500 1,216,630 -

1 1 4 Employ an HRH Specialist on short term assignment to provide Technical Assistance (TA) in HRH Planning, Development and management

X - - -

1 1 5 Develop and mainstream systems, tools and processes for Health Workforce planning, development and management at national, regional and facility levels

X - - -

1 1 6 Provide short and long term training for HR staff at National, Regional and Facility levels in HRH Planning, Development and Management

X - - -

1 1 7 Orient managers at Regional Health Offices and facilities on HRH tools including Performance Appraisal Systems, Supervision and Mentoring Systems

X - - -

1 1 8 Review procedures for assignment of MOPS staff in the MoH HR Department to reduce inter-ministerial staff turnover, ensure management continuity and deployment of qualified and experienced staff

X - - -

Annual Total 29,500 1,216,630 - Strategic Area Total over Years 1-3: 1,246,130

29

Strategy 1.2 Revive the HRIS through the Creation of HRH Databases and Increase Capacity for Data Analysis, Interpretation and Reporting

Table 4 shows the activities totaling SZL 1.8 million that have been prioritized for improving the availability of relevant data for planning HRH. Many of these activities have already been initiated and their costs are not included here. An important next step for finalizing the operational plan will be deciding between using existing HRH workforce classifications obtained from a recent/on-going CHAI activity or implementing a new study using the WHO’s Workload Indicators of Staffing Need (WISN) methodology because there is a large cost differential between the two.As discussed above and shown in bold below, SZL 1.8 million only includes the lower cost workshop rather than the creation of a WISN. Two thirds of the cost of this activity can be attributed to the significant level of consultant time required to collect and analyze the data.

It should also be noted that activity 1.2.8, the procurement of appropriate HRIS infrastructure and software is based on the costing team’s assumptions and data collection (mainly computers and cables). However, the stakeholders interviewed acknowledge that there is the possibility that additional materials will be required and therefore additional resources so this item will need to be updated when additional data are made available.

30

Table 4: Revive the HRIS throughthe Creation ofHRH Databases and Increase Capacity for Data Analysis, Interpretation and Reporting(SZL)


1 HUMAN RESOURCES FOR HEALTH PLANNING 1 2 Revive the HRIS through the creation of HRH Databases and Increase Capacity for Data Analysis, Interpretation and Reporting 1 2 1 Clean data to finalize the HRIS database - government employees

will need to be used. 682,093 - -

1 2 2 Develop electronic databases to generate information for HRH planning

X - - -

1 2 3 Develop tools for HRH data collection based on the technically proven World Health Organization (WHO) models for data collection

X - - -

1 2 4 Use the HRH databases to develop a robust Human Resources Information System (HRIS) that is compatible and can interface with other Human Resources Information Systems at MOPS, CSC, Ministry of Finance, MoL&SS, Training Institutions, Professional Bodies, Regional Health Offices

X - - -

1 2 5 Develop a system for classifying health workforce onto the HRIS based on the WHO coding system which will disaggregate health professionals into their various health specialties and sub-categories

Scenario 1: Redo WISN* 6,301,293 - -

Scenario 2: Have a workshop to generate buy in for the CHAI version and use the information from that study.

923,592 - -

1 2 6 Develop a core set of HRH Indicators which will be used to monitor progress on HRH management and development.

X - - -

1 2 7 Harmonize all HRIS systems within all key institutions involved in HRH (Y2 - Y3)

X - - -

1 2 8 Procure appropriate HRIS (ICT) infrastructure and software for use as a platform for the HRIS and roll out HRIS to all Regional Health Offices and Facilities

224,597 - -

31


1 2 9 Build capacity at national, regional and facility levels on collection, analysis, interpretation and systematic reporting of HRH Monitoring and Evaluation (M&E) Products

X - - -

1 2 10 Create a platform through the Wider Human Resources Technical Working Group (HRHTWG) for disseminating Trends Reports on critical Health Workforce Issues generated from HRIS

X - - -

1 2 11 Identify critical numbers of posts that should be in place in order to ensure a critical mass of competent health workers at all levels of the health system

Included in CHAI WISN or Activity 1.2.5 Scenario 1

- - -

Annual Total 1,830,282 Strategic Area Total over Years 1-3*: 1,830,282

*Not including Scenario 1 for activity 1.2.5

32

Strategic Focus 2: Human Resources for Health Development

It is essential that there is a scale up of educational programs that ensure the availability of multi-disciplinary teams capable of delivering high quality care. To do this requires a strengthening of pre-service, postgraduate and in-service education. The responsibility for each of these (beyond projecting need) may frequently lie with ministries other than the MOH. For example, pre-service training activities may need to be implemented by theMoE but given the different mechanisms that may be used to fund the training; items like scholarships may be funded by the MoE or the MoH. Similarly, in-service training is supposed to be funded primarily by MoH but there are management functions that require training that could be provided by MOPS. Until more detail is available (and there are several assessments proposed in the operational plan that will provide such detail), it is not possible to estimate the level of resources required or which ministry will ultimately be responsible for mobilizing those resources.

Strategy 2.1 Strengthen the Coordination and Management of Pre-Service Training

Activities around improving the availability of HRH workers by strengthening pre-service training appear to be largely limited to assessment and strategy design. As shown in Table 5 these activities will cost approximately SZL3.1 million over three years. Activities 2.1.1 and 2.1.2 include scenarios, and, in line with selecting the least costly scenario, the costing team chose to achieve these activities through in-house rather than through an external consultant. However an important assumption should be noted here: specifically, this scenario assumes that ministry staff can be identified who will have both the specific skills and time commitment available to carry out these activities. This assumption needs validation.During the re-checking of priorities (discussed in the Section4Recommended Finalization Processsection later in this report) it may be worth stakeholders reviewing the activities suggested in the HRH policy to see if any may be immediately implementable because three years with no planned implementation is not acceptable. Alternatively, the assessments and the pre-service training funding mechanism development should be prioritized for year 1 so that some level of implementation can begin due to the long time span required to witness anyimpact from the proposed activities.

Several activities in the strategy, starting with activity the pre-service activities in strategy 2.1 will require the coordination of a large number of stakeholders. Consequently, a high level of resources is required for meetings and coordination. On the one hand, approaches for having meetings efficiently should be explored to bring down costs. But on the hand, the value of providing resources for coordination should not be underestimated. Achieving consensus with stakeholders present in person and identifying/equipping a person to be responsible for following up with stakeholders across institutions to ensure that responsibilities are carried out is often the difference between initiatives that succeed and those that fail.

33

Table 5: Strengthen the Coordination and Management of Pre-Service Training (SZL)


2 HUMAN RESOURCES FOR HEALTH DEVELOPMENT 2 1 Strengthen the coordination and management of pre-service training 2 1 1 Conduct health workforce training needs assessment

including projections and develop a master plan on pre-service training for the health sector

Scenario 1: In-house assessment

280,714 -

Scenario 2: Assessment conducted by consultants*

469,464 -

2 1 2 Develop a comprehensive health sector pre-service training strategy

Scenario 1: In-house production of strategy

- 198,587 -

Scenario 2: Consultant produce the strategy*

- 315,663 -

2 1 3 Establish a Higher Education Forum to strengthen the link between MOE, MOH, MOLSC and other key stakeholders for pre-service education

565,822 565,822 565,822

2 1 4 Develop a pre-service training quality assurance system

- 540,184 -

2 1 5 Assess alternatives and develop sustainable funding mechanisms for pre-service training institutes

373,997

Annual Total 846,537 1,678,591 565,822 Strategic Area Total over Years 1-3*: 3,090,950

*Not including Scenario 2 for activity 2.1.1 or Scenario 2 for activity 2.1.2

34

Strategy 2.2 Strengthen the Coordination, Quality and Training Plan of In-Service Trainings

Table 6 shows the estimated cost of improving in-service training to be approximately SZL 3.3 million over three years. Activity 2.2.1 offers a scenario for reviewing the coordination mechanisms for in-service training and only included a consultant in the costing process. During data collection the skills audit was highlighted as a necessary activity, because at the current time, staff appear to be able to request training based upon their interest rather than upon specificneeds assessment or based on service delivery needs.This discrepancy has apparently resulted in an inefficient use of resources currently being allocated and used for in-service training. Once an appropriate system for identifying needs is in place, it may be found that more or less resources are required to provide adequate levels of in-service training across the health-related public service. Activities 2.2.4 (the development of a skills audit) and 2.2.5 (the development of a comprehensive training plan) are proposed and should result in an appropriate system for identifying in-service training needs.

35

Table 6: Strengthen the Coordination, Quality and Training Plan of In-Service Trainings (SZL)


2 HUMAN RESOURCES FOR HEALTH DEVELOPMENT 2 2 Strengthen the Coordination, Quality and Training Plan of In-Service Trainings (SZL)

2 2 1 Review the coordination mechanisms and composition of responsible agencies for in-service training

Scenario 1: Consultant Only 314,965 - -

Scenario 2: Consultant + Internal Employee* 494,873 85,000 85,000

2 2 2 Develop in-service training strategy for the health sector which guides standardization of trainings 1,028,318 - -

2 2 3

Asses the capacity of professional councils to lead continued education program and provide the necessary capacity support to their members: 1) Build the capacity of SMDC to fully represent the other professional cadres in registration and continuing medical education programs and 2) establish a web based continuing nursing education program

X - - -

2 2 4 Develop a skills audit guideline and tools and conduct a regular skills audit for MOH staff on a yearly basis. - 658,801 -

2 2 5 Develop a comprehensive training plan and calendar based on skills audit result and established staffing norms - 656,810 -

2 2 6 Develop in-service training database in order to facilitate coordination for short term trainings provided by development partners and governments agencies

- 634,310 -

2 2 7 Review the possibility of using an outside accreditation agency for in-service training - 77,547 -

Annual Total 1,343,282 2,027,469 - Strategic Area Total over Years 1-3: 3,370,751

*Not including Scenario 2 for activity 2.2.1

36

Strategy 2.3 Improve Physical, Organizational and Operational Capacity of Training Institutions

The HRH policy highlights that the physical and organizational/operational capacity of schools is not compatible with the increasing demand for HRH particularly in terms of classrooms, offices, laboratory, hostels, equipment, pedagogical tools and lecturers etc.Of the SZL 3.5 million estimated for the activities prioritized for addressing this situation, nearly this entire amount is to be used for assessments. In this case, this may be appropriate as the capital expenditure to address these gaps may need to be capital expenditure on the part of the MOE. However it will be important for the MOH to coordinate and support the MOE to ensure that the relevant infrastructure, facilities and equipment for medical education are prioritized in any capital expenditure proposed by MOE. It may be worth considering the financing of a joint working group between the two ministries to ensure that assessments conducted by the MOH are turned into implementable, financed capital projects by the MOE. The actually cost of implementing the recommendations from these assessments could be substantial and would need to be added to this plan as soon as the data are available.

37

Table 7: Improve Physical, Organizational and Operational Capacity of Training Institutions (SZL)


2 HUMAN RESOURCES FOR HEALTH PLANNING 2 3 Improve Physical, Organization and Operational Capacity of Training Institutions

2 3 1

Undertake a comprehensive capacity assessment of training institutes and health facilities where practical attachments for students are held covering physical infrastructure, organizational and operational capacity (infrastructure, teaching/learning materials, equipment, human resources, curriculum

1,470,105 - -

2 3 2

Undertake a comprehensive capacity assessment of training institutes and health facilities where practical attachments for students are held covering physical infrastructure, organizational and operational capacity (infrastructure, teaching/learning materials, equipment, human resources, curriculum

373,003 - -

2 3 3 Assess factors contributing to poor attraction and retention of Tutors/Lecturers and Teachers in the Training Institutes

- 537,158 -

2 3 4 Develop a Staff Attrition and Retention Strategy and Action Plan for Lecturers/Tutors/Teachers in Training Institutes

- 268,382 -

2 3 5 Assess, Develop and Implement a Continuous Education Plan for Lecturers and Support Staff in all Training Institutes

- 948,882 -

Annual Total 1,843,108 1,754,422

Strategic Area Total over Years 1-3: 3,597,531

38

Strategic Focus 3: Human Resources forHealth Management

Personnel management for the health sector is regulated by the Ministry of Public Services (MOPS) who is responsible for all public servants but carried out by MOH who manages HRH staff day to day and the Civil Service Commission (CSC) which is responsible for recruitments, promotions retirements etc. Other ministries also play a role in HRH management (e.g. the MOF manages payroll).

Strategy 3.1 Strengthen Recruitment and Deployment Procedures

Several activities are already underway to improve perceived slowness of recruitment and appointment processes that are believed to encourage locally trained staff to leave the country rather than wait for the process to be completed.In Table 7, the two main activities that remain outstanding total SZL 1.5 millionand are reviews of the current processes. The costing team notes that sequencing here does not seem optimal – to have some activities being implemented while reviews are still to be conducted for activities that appear to be closely linked is not appropriate. The two reviews are substantially different in costs because a bill has already been drafted for activity 3.1.1, so this activity may need only a minimal updating depending upon the outcome of the bill’s hearing. It was conservatively assumed that the bill would not pass and a consultant would only be required to assess alternatives. But it should be noted that at least two other ministries have been able to get the legal permission required to set up their own commissions so there is an existing precedent.

39

Table 8: Strengthen Recruitment and Deployment Procedures (SZL)


3 HUMAN RESOURCES FOR HEALTH MANAGEMENT 3 1 Strengthen Recruitment and Deployment Procedures

3 1 1

Engage MOPS and CSC to review and revise recruitment and deployment procedures to reduce cumbersome process and improve effectiveness in recruitment, deployment, transfers, grading of posts, etc.

- - -

Scenario 1: The bill passes - consultant to set up the commission* 1,201,133 - -

Scenario 2: The bill does not pass - consultant to do an assessment of alternatives 410,431 - -

3 1 2

Involve CSC and MOPS in the recruitment of donor supported posts and contracts and define process and timelines to create posts for absorption into government system; Produce a quarterly report of all staff on contract which shows their contract start date and end date so that they are monitored on a monthly basis to allow for preparation of their absorption at the end of their contract

X - - -

3 1 3 Review the current MOH structure to incorporate career progression and succession planning, especially within the health facility 678,912 - -

3 1 4

Engage in policy dialogue with MOPS, CSC, Ministry of Finance and Ministry of Economic Planning through presentation of the staffing norms and staff requirements to implement the Essential Package of Care so that they continue prioritizing the health sector

X - - -

3 1 5 Develop a contingency plan that will address the challenges associated with over dependence on expatriate health workers in the long term - - 514,756

Annual Total 1,089,344 514,756 Strategic Area Total over Years 1-3*: 1,604,100 *Not including Scenario 1 in Activity 3.1.1

40

Strategy 3.2Improve Staff Retention by Improving Scholarship Program Follow-Ups, Job Satisfaction, Working and Living Conditions

Approximately SZL 7.4 million is estimated to be needed to implement the outstanding prioritized activities to improve staff retention. Again, it should be noted that most of prioritized activities are focused on review and assessments.Therefore it is likely that this strategy will need to be revisited by Year 2 to ensure that resources needs are estimated in time for budget inclusion so that the recommendations or operational planning that result from these assessments can be implemented.

It is important to note that for activity 3.2.2 it is likely that legal issues will have to be addressed to make the enforcement of a bonding process feasible. That is, there must be a way to ‘punish’ those who fail to fulfill their commitment which raises the issue of political feasibility that should be considered before resources are used to design a bonding process.

Activity 3.2.8 is an unlikely activity to find in an HRH strategy. Medical equipment is usually considered to be a service delivery or supplies and commodities responsibility. Therefore, coordination with the appropriate unit within the MoH is important to ensure that there is no overlap of responsibilities or that there is effective collaboration in carrying out the activity.

41

Table 9: Improve Staff Retention by Improving Scholarship Program Follow-Ups, Job Satisfaction, Working and Living Conditions (SZL)


3 HUMAN RESOURCES FOR HEALTH MANAGEMENT 3 2 Improve Staff Retention by Improving Scholarship Program Follow-ups, Job Satisfaction, Working and Living Conditions

3 2 1

Assess the existing retention schemes and the situation of internal and external migration, particularly targeting medical officers (find out from the country’s diaspora and from those who come back, especially from the medical officers, what conditions might bring them back to the country) and develop retention strategy addressing the needs of all health personnel-

X 1,157,930 - -

3 2 2 Enforce bonding arrangement with medical students and other cadres pre-service training program to ensure their commitment for service in government after graduation

- 1,521,171 -

3 2 3

Work with South Africa Medical Council and other relevant bodies to control the registration of Swazi Medical Officers graduating from SA Universities: Establish a bilateral agreement to ensure that registrations will only take place if only official support letter is provided by Swaziland MOH.

Costed in 3.2.2 -

-

-

3 2 4 Under the director of health services establish medical officers internship program that oversees its establishment and implementation

-

238,912

-

3 2 5 Work with South African Universities on drafting guideline for the program, including selection of internship sites, selection and assignment of tutors/preceptors, working modalities, rotations

-

432,034

-

3 2 6 Prepare the necessary logistic, including housing, transport, allowances for the interns and preceptors X

-

-

-

3 2 7 Review and incorporate the occupational health and safety structure in the wellness program: Create post and assign occupational safety and health officer at MOH and each region.

-

-

349,031

3 2 8 Develop maintenance and replacement plan for medical equipment and train staff on replacement and maintenance

-

- 1,590,442

3 2 9 Develop policy and guidelines to regulate donated equipment X -

-

742,718

42


3 2 10 Hire private security firms to provide security services in clinics X -

699,315

-

3 2 11 Work with relevant Government body to identify suitable accommodation, or other solutions, including building staff accommodations where required

X -

699,315

-

Annual Total 1,157,930 3,590,748 2,692,191 Strategic Area Total over Years 1-3*:

43

Strategy 3.3 Work Hand in Hand with MOPS to Implement the New Performance Management System

Roughly SZL 4.7 million will be needed to develop and implement the new performance management system. The zero draft HRH strategic implementation plan originally had the implementation of the government wide PMS being rolled out at the same time as MOH’s new Supportive Supervision and Mentoring Framework (SS/MF). However during the course of data collection, informants from both the MOPS and the MOH felt that rolling out the two programs at the same time would be unduly burdensome for the staff to manage as well as for staff being trained. Furthermore, at the time of report writing the MOPS was yet to initiate the pilot for the PMS, which is anticipated to take approximately a year.This implies that the roll out of the PMS in the MOH could not begin until at year 2 at the earliest. This may delay the SS/MF roll unnecessarily.

More definition is required around the roll out of the PMS. The current cost estimates are taken from the projected budget figures for the pilot. However the pilot is being rolled out in the MOPS and MOF first. The cost of rolling out the PMS for the MOH is likely to be much higher than for either of these ministries given the large geographic reach and the higher number of MoH employees.

44

Table 10: Work Hand in Hand with MOPS to Implement the New Performance Management System (SZL)


3 HUMAN RESOURCES FOR HEALTH MANAGEMENT 3 3 Work hand in hand with MOPS to Implement the New Performance Management System (PMS)

3 3 1 Tailored performance management plan and MoH Strategic Plan to incorporate the specific skills and responsibilities of MoH job descriptions

529,887 - -

3 3 2 Assess and develop clear reporting lines and structures within departments and units 518,637 - -

3 3 3 Roll out the PMS to MoH, Regional Health Offices and Health facilities - 1,250,000 -

3 3 4 Collaborate with MOPS to develop and implement a continuous Monitoring and Evaluation System for the PMS - 2,470,744 -

Annual Total 1,048,525 3,720,744 Strategic Area Total over Years 1-3: 4,769,269

Strategy 3.4 Implement the Supportive Supervision and Mentoring Framework

The supportive supervision and mentoring framework is a draft that was still under review at the time of report writing. The framework is a substantial document and a thorough costing of it is a task beyond the scope of this analysis. Therefore the costs shown in Table 11, or roughly SZL 3 million, should be considered as rough estimates only that assume a roll out similar to the M&E of the PMS in Activity 3.3.4.

Table 11: Implement the Supportive Supervision and Mentoring Framework (SZL)


3 HUMAN RESOURCES FOR HEALTH MANAGEMENT 3 4 Implement the Supportive Supervision and Mentoring Framework

3 4 1 Assess SS&MF plan and develop an implementation plan that integrates the roll out of SS&MF with the already existing PMS, as to not create too many parallel reporting structures

- 577,370 -

3 4 2 Roll Out SS&MF to MoH, Regional Health Offices and Health facilities - - 2,470,744

Annual Total 577,370 2,470,744 Strategic Area Total over Years 1-3: 3,048,114

45

46

Section 4 Recommended Finalization Process

As previously mentioned, this analysis should not be considered a final document but rather serve as support toward the development of an implementation plan that remains a living document. It is anticipated that over time, the activities contained here will be refined and budgets updated year on year. Furthermore, other priorities may arise that may need to be considered over the original timeline. However without resources, this plan will be a good idea and nothing more.The costing team considers the following steps to be critical for ensuring that the plan continues to move forward.

Figure 10: Next Steps in HRH Operational Plan Implementation

4.1 Validation of activities and costs

The costing team did a large amount of activity definition during the course of this analysis in order to develop a detailed operational plan. Due to time and resource limitations, the resulting activities described and costed in this report have yet to be validated by the stakeholders who contributed to their development. This validation should be a top priority. It is recommended that one-on-one meetings with the same stakeholders (listed in appendix 1, page 50) be conducted to validate activities and ‘eyeball’ unit and total cost for reasonableness.Few finance officers were available for interview during the data collection period and the validation process would be an ideal time to present draft estimates to them for validation and refining where necessary.

4.2 Confirmation of responsibilities

The MOH will be the coordinator and technical lead for implementing the HRH strategy.As the plan moves from prioritization to implementation, it will be necessary to identify points of contact within the appropriate units of each partner ministry. These points of contact should be a team and include both a technical person as well as a finance officer from the respective ministry. The technical person would coordinate with MOH and track implementation progress while the finance officer will ensure that any budget resources that are necessary are actually included in that ministry’s annual budget request.The activity tables shown in this report should have specific names and units rather than ministry names in the operational plan.

4.3 Re-check of priorities by stakeholders

The costing team did a large amount of activity definition during the course of this analysis in order to develop a detailed operational plan. These activities have not been shared with the broad range of stakeholders that participated in the prioritization process. It is important that the MOH continues to engage these stakeholders.Criteria such as economic environment and political feasibility should be

Validate activities and

cost estimates

Confirm responsibilities

Revise activities and budgets as

needed

Revisit priorities M&E planning Track progress

Revisit and revise activities

and budgets

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considered alongside costs and the criteria originally used in the prioritization activity: relevance, complementarity, potential impact, feasibility and logical sequencing.

There are a number of reasons for reviewing the prioritization of strategies and activities now that more detailed information is available on how that might be operationalized and what resources are required to implement them.

Political feasibility

Several activities proposed in the operational plan upon discussing with stakeholders were identified as possibly being politically infeasible. One reason for this would be the high level of political will that may be necessary to implement activities that require actual changes in the country’s law. An example of this type of activity would be the proposal to enforce bonding arrangement with medical students and other cadres’ pre-service training program to ensure their commitment for service in government after graduation. Punitive measures would have to be enforced for breaking such a bond and these would likely require a law to be passed. The feasibility of passing such a law then depends upon more than the priorities of the HRH strategic plan stakeholders – it depends upon the priorities of the country’s lawmakers. Other examples would include activities related to recruitment and career progression, which are currently the province of the CSC. Changing this responsibility may require an act of parliament – a possibility since the MOE has managed to take control of its recruitment process with the set up a “commission” outside of the CSC.

Current costs and future resources

As perTable 12 and Table 13,health (13%) is GOS’s second highest category of projected recurrent expenditure after education (22%)and fifth highest in terms of projected capital expenditures (6%).Therefore,the MOH needs to carefully consider how it requests more resources for the next fiscal year. As previously noted, the MOH expects to spend 27% more in 2013 than it actually spent in 2012. This is a significant increase in expected expenditure for a single year and it may be challenging for MoH to expend these funds completely (assuming 100% of the funding request is actually provided by GoS). In this context, a request for a further increase in resources following a failure to expend previous year’s allocated resources is unlikely to be looked upon favorably by the Ministry of Finance.Information regarding MOH’s expenditure for 2012/13 was not available during report writing.

Table 12: Summary of estimated recurrent expenditure by economic sector 2013/14 [E'000]

Sector Recurrent expenditure (in thousand Emalangeni) % Education 2,170,867 22% Health 1,240,209 13% Defense 805,478 8% Police 658,609 7% Others 4,830,894 50% TOTAL 9,706,057 100%

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Table 13: Summary of estimated capital expenditure by economic sector 2013/14 [E'000]

Sector Capital expenditure (in thousand Emalangeni) % General Public Services 787,023 35% Transport and Communication 462,379 20% Housing and Community Amenities 260,305 11% Public Order, Safety and Defense 167,763 7% Health 146,580 6% Others 455,821 20% TOTAL 2,279,871 100%

Within the MoH, approximately SZL 333 million was spent on personnel costs in 2012. This represents 38% of the health budget (SZL 871 million). The total cost of this plan as estimated in this report represents 3-4% of what MoH spent on health in 2012.While this seems to be a small amount, it should be noted that it represents only a small amount of what will actually be required to achieve the HRH objectives. The current implementation plan is dominated by consultant or ministry-led assessments or strategy development activities as well as workshops to review the results of the assessments and strategy development activities. There are eight activities that are ‘assessments’ alone in addition to several ‘reviews’.It is anticipated that all of these assessments will result in recommendations that will in turn require additional resources to implement them.

For example, improving the infrastructure of training institutions is addressed by an assessment to determine what the infrastructure needs are. Following the assessment (estimated to cost SZL 1.4 million in this report), resources will need to be mobilized to carry out these improvements. It is likely that the infrastructure needs will be severe and the cost to address them will be several orders of magnitude higher than the SZL 1.4 million required for the assessment.

Therefore, these costs estimates will need to be reviewed on an annual basis so that each year, the budget request figures can be reviewed and adjusted as necessary.

4.5 Monitoring and Evaluation

Once an agreed upon operational plan draft has been approved by stakeholders, it will be necessary to create a monitoring and evaluation (M&E) plan. The MOH and the points of contact in each partner ministry should develop an M&E plan and its indicators. Some useful indicators that should be integral to the plan would include whether or not activities related to the HRH plan have been included in the annual plans of these ministries and have been included in their budgets.Other indicators for the plan should be developed to track progress in line with the key results from the zero draft HRH implementation, listed in appendix 3, page 73.

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Section 5 Conclusion

The total cost estimate for implementing the prioritized list of strategies and activities in the HRH Implementation Plan is approximately SZL 30million. This amount represents a small fraction (2.5% and 3.5%) of actual MOH budget in 2011/13 and 2012/13. While the MOH will be responsible for most of that, the MOE is currently responsible for about 21% of the total amount. In its present form the operational plan is dominated by reviews and assessments. The recommendations of these reviews and assessments are likely to have substantial costs, in particular the cost of renovating training facilities and staff accommodations alone could reasonably be several orders of magnitude larger than the total cost of the HRH policy given here. This document should be considered a first iteration of the costing exercise that should be validated as a next step and then repeated each year on a rolling basis, taking in to account changes in the political and economic environment.

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Appendices

Appendix 1: Costing Team and Key Informants

Costing Team:

Name Organization Division/Position Elaine Baruwa Abt Associates Health Economist Lorraine Ross AbtAssociates Costing Analyst

Matt Kukla Abt Associates Health Economist ThokoMalaza MOH Human Resource Officer Wendy Shongwe MOPS/MOH SMA DuduNdzinisa MOPS SMA ZwelakheNhleko Ministry of Agriculture Planning Officer

Key Informants:

Name Organization Division/Position Mandla Dlamini MoH Training Officer Musa Dlamini MoH Finance Officer Peterson Dlamini MoE Chief Inspector - Tertiary LomakhosiDlamini-Vilakati MoPS SMA NomathembaHlope MoL Principal Secretary ThembisileKhumalo MoH Chief Nursing Officer Mzwandile Kunene MoH/WB/EU Financial Management Specialist Maxwell Masuku MoPS Director – Management Services Sibongile Mhlanga MoH Wellness Coordinator Felton Mhlongo MoPS Under Secretary MumlyMusi MoPS Under-secretary, In-service

Training FuthiNkambule MoH Senior Planning Officer NyamileNyamile MoPS Assistant Director MSD Dumisani Shongwe MoH/WB/EU Project Coordinator NonhlanhlaSukati University of Swaziland Associate Professor Zanele Simelane MoH Director of Strategic Information Phindile Tsabedze HRAA Finance Officer Simon Zwane MoH Director of Health Services

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Appendix 2: Detailed Activity Outline (As Presented In Excel File)

Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 1: HRH Planning Strategy 1.1: Strengthen the organization structure, functions of HRH planning, management and develop and enhance capacity for HRH planning, management and development across the sector. 1.1.1 MOH/MOPS Redefine the HR Department structure and

functions at MoH to lead and coordinate HRH planning, development and management responsibilities

Already budgeted, no costing needed

1.1.2 MOH/MOPS Create positions within the revised new structure and recruit new qualified staff in the HRH planning, development, and management at National, Regional, and Facility Levels


1.1.3 MOH/MOPS Establish HR Manager positions at all Regional Health Offices and deploy qualified and competent staff to fill up newly created positions

Assumptions: 1. Recruitment will be done in Y1 and hiring in Y2 2. One HR Manager for each of the 4 regions

1.1.4 MOH Employ an HRH Specialist on short term assignment to provide Technical Assistance (TA) in HRH Planning, Development and management


1.1.5 MOH Develop and mainstream systems, tools and processes for Health Workforce planning, development and management at national, regional and facility levels


1.1.6 MOH Provide short and long term training for HR staff at National, Regional and Facility levels in HRH Planning, Development and Management


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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 1: HRH Planning Strategy 1.1: Strengthen the organization structure, functions of HRH planning, management and develop and enhance capacity for HRH planning, management and development across the sector. 1.1.7 MOH Orient managers at Regional Health Offices

and facilities onHRH tools including Performance Appraisal Systems, Supervision and Mentoring Systems


1.1.8 MOPS Review procedures for assignment of MOPS staff in the MoH HR Department to reduce inter-ministerial staff turnover, ensure management continuity and deployment of qualified and experienced staff


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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 1: HRH Planning Strategy 1.2: Revive the Human Resources Information System through the creation of HRH database and capacity for data analysis, interpretation and reporting. 1.2.1 MOH

Clean data to finalize the HRIS database - government employees will need to be used.

NOTES: Since version 1.0 of the HRIS has been designed and is close to operational, the activity - as originally written - is not needed. However, there will be a need for government employees to clean the data and finalize the database. As such, it has been assumed that this activity will have one regional consultant for three visits and a total of 40 days. The consultant will work with a team of two local government employees who will be used as data cleaners (60 days). All inputs were completely assumed and not based on a clear understanding of the amount of work that will be needed to actually clean the HRIS.

1.2.2 MOH Develop electronic databases to generate information for HRH planning

Already budgeted. No costing needed.

1.2.3 MOH Develop tools for HRH data collection based on the technically proven World Health Organization (WHO) models for data collection


1.2.4 MOH Use the HRH databases to develop a robust Human Resources Information System (HRIS) that is compatible and can interface with other Human Resources Information Systems at MOPS, CSC, Ministry of Finance, MoL&SS, Training Institutions, Professional Bodies, Regional Health Offices.


1.2.5 MOH Develop a system for classifying health workforce onto the HRIS based on the WHO coding system which will disaggregate health professionals into their various health specialties and sub-categories

NOTES: Abt has come to understand, there was a WISN done by CHAI that would inform this exercise. However, it seems as though the MoH was not happy with the combined methodology of CHAI's WISN. As such, there are two scenarios in this activity. Assumptions made:

(1) Redo a WISN. (2) Have a workshop to generate buy-in for the CHAI version and use the information from that study to inform

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 1: HRH Planning Strategy 1.2: Revive the Human Resources Information System through the creation of HRH database and capacity for data analysis, interpretation and reporting.

1. Cost for consensus meeting, # of participants, # of meetings needed 2. Daily cost per consultant, # of consultants, # of consulting days, # of trips 3. Scenario 2 assumption – information collected by CHAIs will be usable for this activity

this activity.

1.2.6 MOH Develop a core set of HRH Indicators which will be used to monitor progress on HRH management and development.


1.2.7 MOH Harmonize all HRIS systems within all key institutions involved in HRH


1.2.8 MOH Procure appropriate HRIS (ICT) infrastructure and software for use as a platform for the HRIS and roll out HRIS to all Regional Health Offices and Facilities

NOTES: This activity will needan IT assessment of 4 Regional Health Administrators, 6 Administrators at Health Centers, and 4 Administrators at Hospitals. We do not know what the outcome of the assessments will be.Therefore, this iteration of the budget does not have reliable costs for implementation. Assumptions: 1.Since there has not been an assessment, the number of computers and amount of cable needed for this activity are complete assumptions. These numbers will need to be revisited after the assessment is completed. 2. Consultant can both write report and set up the computers needed. 3. If cables that are needed will be laid underground. Price of contractor has not been costed.

1.2.9 MOH Build capacity at national, regional and facility levels on collection, analysis, interpretation and systematic reporting of HRH Monitoring and Evaluation (M&E) Products.


1.2.10 MOH Create a platform through the Wider Human Resources Technical Working Group


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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 1: HRH Planning Strategy 1.2: Revive the Human Resources Information System through the creation of HRH database and capacity for data analysis, interpretation and reporting.

(HRHTWG) for disseminating Trends Reports on critical Health Workforce Issues generated from HRIS

1.2.11 MOH Identify critical numbers of posts that should be in place in order to ensure a critical mass of competent health workers at all levels of the health system

NOTE: The MoH should be able to glean the information required for this activity from the WISN exercise done by CHAI. If CHAI's version of WISN is not accepted, than the cost of doing a WISN and therefore the cost of this exercise is captured in in the costing of activity 1.2.5 Scenario 1. Since we do not know the recommended outcome of WISN, we can not price the number of new positions it will recommend creating. We can only price the cost of the assessment.

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 2: HRH Development Strategy 2.1: Strengthen the coordination and management of pre-service training 2.1.1 MOH/MOE

Conduct health workforce training needs assessment, including projections and develop a master plan on pre-service training for the health sector

1. WISN and Skills Audit are done before this exercise, and the information generated will inform this activity. 2. Scenario 1: Government provides in house transportation 3. Scenario 2: cost per day of consultant, # of consultants, # of consulting days, travel costs 4. Both Scenarios:# of meetings, number of participants at meetings, number of meals, production costs

(1) This assessment is done in-house (2) This assessment is done by consultants

2.1.2 MOH/MOE Develop a comprehensive health sector pre-service training strategy

1. Execute immediately after activity 2.1.1 is completed 2. Scenario 2: Cost per day of consultant, # of consulting days, # of consultants,travel costs, use same consultants as 2.1.1 3. Workshop cost, # of participants, # of days, production cost of report

(1) Strategy is written in-house (2) Strategy is written by consultants

2.1.3 MOH/MOE Establish a Higher Education Forum to strengthen the link between MOE, MOH, MOLSC and other key stakeholders for pre-service education

1. Someone in the MOE/MOH will take responsibility for organizing and convening this forum. 2.Cost for HEF research is represented by costing an international consultant for 30 days of LOE and two trips. However, we cannot be sure that this amount of funding will be sufficient. When the forum convenes they should assess what kind of studies they would like to conduct and then modify budget requests for future years. 3. Meeting Workshop (price of venue, travel costs, food & drinks, allowances for participants) 4.# of participants at each forum, # meeting per year

2.1.4 MOH/MOE Develop a pre-service training quality assurance system

NOTE: Ministry of Education is also working on this initiative. Consultant should coordinate closely with MoE to make sure that the SOW is not redundant. A good contact is Perterson Dlamini, Chief Inspector – Tertiary at MoE Assumptions: 1. Cost per day of consultant, # of consultants, travel

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 2: HRH Development Strategy 2.1: Strengthen the coordination and management of pre-service training

costs 2. Cost of validation workshop w/ SA & Kenya, # of participants

2.1.5 MOH/MOL Assess alternatives and develop sustainable funding mechanisms for pre-service training institutes

NOTE: There have been initiatives to develop alternative sustainable funding mechanisms by both the MoL and the MoE. As such, the consultant should meet with the aforementioned departments before beginning assessment. This could become an assessment of the effectiveness of the current initiatives that are being put together by MoL and MoE. Assumptions: 1. Cost per day of consultant? # days? travel costs? Production cost of report.

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 2: HRH Development Strategy 2.2: Strengthen the coordination, quality and training plan of in-service trainings 2.2.1 MOH Review the coordination mechanisms and

composition of responsible agencies for in-service training

Note: Most of section 2.2 should be done by the same consultant. Scenario 1 isperformed by a consultant who will work with an identified individual within the MoH team and this person will lead activity 2.2.5 and 2.2.6. Scenario 2: On the recommendation of the Chief In-Service Training officer,we propose the hiring of a new employee who would be responsible for the database management in activity in 2.2.5 and 2.2.6. Assumptions: 1.Cost per day of consultant? # days, travel costs, production cost of report. 2. If scenario 2, cost per day of second individual (local?) 3. Assessment needs to address the scope and design needs of the online database (2.2.6) as it is assumed that it will be one of the tools in helping to improve in-service coordination.

(1) Consultant Only (2) Consultant plus hire a new employee

2.2.2 MOH Develop in-service training strategy for the health sector which guides standardization of trainings

1. # of consultants, # of consulting days, Travel costs, 2. Workshop costs, # of participants, # of days, production cost of report, # of workshops?

2.2.3 MOH Asses the capacity of professional councils to lead continued education program and provide the necessary capacity support to their members:1)Build the capacity of SMDC to fully represent the other professional cadres in registration and continuing medical education programs and 2) establish a web based continuing nursing education program


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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 2: HRH Development Strategy 2.2: Strengthen the coordination, quality and training plan of in-service trainings 2.2.4 MOH Develop a skills audit guideline and tools and

conduct a regular skills audit for MOH staff on a yearly basis

NOTE: In FY 2013/14 MoPS is conducting a government wide skills audit with the WHO. Once this initial skills audit is completed, this activity should be conducted. Initial workshop / meeting to plan and develop audit tool, should do in partnership with the MoPS staff. Chief Training Officer said this audit could be conducted every two years. Part of the SOW of consultant should be assessing the recurring cost of conducting a skills audit every two years. Assumptions: 1. Cost per day of consultant? # of consultants? # of consulting days? Travel costs? 2. Production cost of audit tool? Printing or developing the software/database? Production cost of the yearly report? 3. Workshop costs (building, # of participants, food, drinks, materials, # of workshops) 4. If there is a new hire for activity 2.2.1, that employee will also be responsible for coordination the delivery and collection of the skills audit.

2.2.5 MOH Develop a comprehensive training plan and calendar based on skills audit result and established staffing norms

NOTE: The training plan and calendar will be loaded onto a multi-user website. The costs of creating the database and website are in activity 2.2.6.This is more to coordinate current trainings that are being given by health partners. It is assumed that the Kingdom of Swaziland will not be adding its own trainings. Assumptions: 1. Cost per day of consultant, # of consultants, # of consultant days, Travel costs. 2. Meeting cost (to develop & schedule training plans), number of participants. 3. This activity will be gathering information and coordinating current training based on skills audit, not

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 2: HRH Development Strategy 2.2: Strengthen the coordination, quality and training plan of in-service trainings

offering new trainings. If the MoH would like new trainings they will need to be priced and added to this budget. 4. Grade and salary of permanent position; training costs - preferably use same individual as 2.2.1 and 2.2.4

2.2.6 MOH Develop in-service training database in order to facilitate coordination for short term trainings provided by development partners and governments agencies

NOTES: It is not clear yet what the price of creating the database. Therefore, once the consultant, training department employee, and Zanela (HMIS department) decide what is needed for the online database the costs will need to be included in the year 2 budgets. Assumptions 1. Cost per day of consultant, # of consultant days, travel costs 2. Cost of workshop, # workshops 3. If a database will need to be created it’s not costed. Also, will most likely need a computer engineer, and software. 4. Training costs for users of database? We’re assuming juts a 1 day training in each region. If any special equipment is needed it the training sessions it is not yet included in budget 5. The new employee hired in 2.2.1 will be responsible for this database. If the new employee is not hired, then another employee should be given a raise for the increase in responsibility. This has not been costed.

2.2.7 MOH

Review the possibility of using an outside accreditation agency for in-service training

NOTE: After speaking with The Chief Training Officer, he is concerned that using an outside accreditation agency for in-service training may be too costly and not time effective. Instead, he it was suggests a forum be created at a university that is given an honorarium to meet once aquarter. This Forum would review in-service training curricula and make sure that it met required standards and was Swazi specific.

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 2: HRH Development Strategy 2.2: Strengthen the coordination, quality and training plan of in-service trainings

1.Only the review has been costed, not any scenarios for implementation. The review should offer different options and the costs associate for those options. Once an option is chosen it should be incorporated into the budget.

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 2: HRH development Strategy 2.3: Improve physical, organizational and operational capacity of training institutions 2.3.1 MOE Undertake a comprehensive capacity

assessment of training institutes and health facilities where practical attachments for students are held covering physical infrastructure, organizational and operational capacity (infrastructure, teaching/learning materials, equipment, human resources, curriculum)

NOTE: This activity is the assessment; 2.3.1 is the writing of the costed implementation plan. However, there is NO IMPLEMENTATIONincluded in this iteration of the budget. The TOR for the consultant should include producing a COSTED capacity enhancement implementation plan. The budget from that implementation plan should be included in this document for FY2 and FY3. Assumptions: 1.Cost per day of consultant, travel costs, # of consulting days 2. # of meeting, # of participants 3. Production cost of the assessment

2.3.2 MOE Develop a Capacity Enhancement Implementation Plan (CEIP) based on results of capacity assessment

NOTE: This activity is the writing of the costed implementation plan. Activity 2.3.1 is the assessment to inform this report. However there is NO IMPLEMENTATION included in this iteration of budget.. The TOR for the consultant should include producing a COSTED capacity enhancement implementation plan. The budget from that implementation plan should be included in this document for FY2 and FY3. Assumptions: 1. Cost per day of consultant, travel costs, # of consulting days 2. Cost per workshop / meeting? # of meetings?

2.3.3 MOE Assess factors contributing to poor attraction and retention of Tutors/Lecturers and Teachers in the Training Institutes

NOTE: This activity is the assessment; 2.3.4 is the writing of the costed implementation plan. However, there is NO IMPLEMENTATION included in this iteration of budget. The TOR for the consultant should include producing a COSTED capacity enhancement implementation plan. The budget from that implementation plan should be included in this

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 2: HRH development Strategy 2.3: Improve physical, organizational and operational capacity of training institutions

document for FY3. 1. Days of consultant, travel costs 3. Production cost of the assessment 4. Workshop to roll-out assessment and finalize recommendations

2.3.4 MOE Develop a Staff Attrition and Retention Strategy and Action Plan for Lecturers/Tutors/Teachers in Training Institutes

NOTE: This activity is the writing of the costed action plan. Activity 2.3.3 is the assessment to inform this report. However there is NO IMPLEMENTATION included in this iteration of budget. The TOR for the consultant should include producing a COSTED capacity enhancement implementation plan. The budget from that implementation plan should be included in this document for FY3. 1. Cost per day of consultant, # of days, # of regional consultants, travel costs 2. Meeting/ workshop costs, production costs for assessment and final recommendation

2.3.5 MOE Assess, Develop and Implement a Continuous Education Plan for Lecturers and Support Staff in all Training institutes

NOTE: In the current iteration of the budget we are only costing the assessment and development of a continuous education plan for health educators. The TOR for the consultant should include producing a COSTED continuing education plan. The budget from the implementing that education plan should be included in this document for FY3. 1. Price/days of consultant 3. Meeting /workshop costs, production costs for assessment recommendations.

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 3: HRH management Strategy 3.1: Strengthen recruitment and deployment procedures 3.1.1 MOH/MOPS

Engage MOPS and CSC to review and revise recruitment and deployment procedures to reduce cumbersome process and improve effectiveness in recruitment, deployment, transfers, grading of posts, etc.

NOTE:The judges and teachers (Ministry of Corrections, MoE) have their own review and hiring commission. The commissioners received an allowance, it seems to work well. MoH was interested in doing something similar. ECSA has assisted the MoH draft a bill that is hoped to be passed before the parliament dissolves. MAY NOT BE POLITICALLY FEASABLE Assumptions: 1. Days/Price of consultant, International/Local consultant, travel costs 2. # of meeting needed, production costs of new hiring procedure manuals 3. Training costs for HR Staff on new recruitment procedures

(1) The bill passes - consultant to set up the commission (2) The bill does not pass - consultant to do an assessment of alternative possibilities.

3.1.2 MOH/MOPS Involve CSC and MOPS in the recruitment of donor supported posts and contracts and define process and timelines to create posts for absorption into government system;Produce a quarterly report of all staff on contract which shows their contract start date and end date so that they are monitored on a monthly basis to allow for preparation of their absorption at the end of their contract


3.1.3 MOH/MOPS Review the current MOH structure to incorporate career progression and succession planning, especially within the health facility

NOTE:Work with MoPS, as this is a very sensitive initiative. MoPS will be doing a fully civil service review in 2015/2016. This should be done before so that we can leverage/influence the exercise and make sure the MoH needs are considered. MAY NOT BE POLITICAL FEASABLE Assumptions:

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 3: HRH management Strategy 3.1: Strengthen recruitment and deployment procedures

1. Cost per day of consultant, # of days, # of regional consultants, travel costs 2. Cost of developing assessment / questionnaire?(data entry, production, extra travel & time costs) 3. Meeting costs w/ MoH&MoPS (# participants, location, travel)? # of meetings?

3.1.4 MOH/MOPS Engage in policy dialogue with MOPS, CSC, Ministry of Finance and Ministry of Economic Planning through presentation of the staffing norms and staff requirements to implement the Essential Package of Care so that they continue prioritizing the health sector


3.1.5 MOH/MOPS Develop a contingency plan that will address the challenges associated with over dependence on expatriate health workers in the long term

1. Cost per day of consultant? # of days? # of regional consultants? Travel costs? (If needed - same as 3.1.3?) 2. Cost of developing assessment / questionnaire?(data entry, production, extra travel & time costs) 3. Cost of focus group meetings (# of participants, location, travel costs, food, etc)? # of meetings? 4. Production cost of report?

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 3: HRH management Strategy 3.2: Improve staff retention by improving scholarships program follow ups, job satisfaction, working and living conditions 3.2.1 MOH Assess the existing retention schemes and

the situation of internal and external migration, particularly targeting medical officers (find out from the country’s diaspora and from those who come back, especially from the medical officers, what conditions might bring them back to the country) and develop retention strategy addressing the needs of all health personnel-

1. Cost per day of consultant, # of days,travel costs 2. Cost of developing assessment / questionnaire?(data entry, production, extra travel & time costs) 3. Cost of focus group meetings (# of participants, location, travel costs, food, etc), # of meetings 4. Production cost of report

3.2.2 MOH/MOL Enforce bonding arrangement with medical students and other cadres pre-service training program to ensure their commitment for service in government after graduation

It is unclear what enforcement tools the MoH and MoL have at their disposal. In this activity a consultant will review current enforcement of the bonding arrangement and suggest other actions the MoH and MoL can take in order to institute more or better execute bonding arrangements. This activity also incorporates activity 3.2.3. MAY NOT BE POLITICALLY FEASIBLE 1. Cost per day of consultant, # of days, 2. Cost of focus group meetings w/ lead agency and students? (# of participants, location, travel costs, food, etc)? # of meetings

3.2.3 MOH/MOL Work with South Africa Medical Council and other relevant bodies to control the registration of Swazi Medical Officers graduating from SA Universities: Establish a bilateral agreement to ensure that registrations will only take place if only official support letter is provided by Swaziland MOH.

This activity will be included in the ToR for the consultant that works on activity 3.2.2

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 3: HRH management Strategy 3.2: Improve staff retention by improving scholarships program follow ups, job satisfaction, working and living conditions 3.2.4 MOH Under the director of health services

establish medical officers internship program that oversees its establishment and implementation

NOTE: Per a meeting that HRAA had with the Director of Health Services there is already a draft framework for how they would like program to be run. However, the framework is not ready to be shared. There is already an internship program happening at the Mbabane Government Hospital. They have a cohort of six students. DHS would like a local/regional consultant to help implement and guide the program. This activity prices 80 days for a local consultant to help run the program.

3.2.5 MOH Work with South African Universities on drafting guideline for the program, including selection of internship sites, selection and assignment of tutors/preceptors, working modalities, rotations

NOTE: The same consultant from activity 3.2.4 will have 40 days to add for this aspect of their TOR. Assumptions: 1. Cost per day of consultant? # of days? # of regional consultants? Travel costs? (Use consultants from 3.2.4) 2. Cost of meeting /workshop with SA Universities (# of participants, location, administrative odds & ends)? 3. There is local capacity to perform this TOR

3.2.6 MOH Prepare the necessary logistic, including housing, transport, allowances for the interns and preceptors

THIS ACTIVITY IS NOT COSTED NOTE: Though we attempted many different times to receive the draft framework for the internship program, we never received any information. As such we cannot price the logistics of the program. It is recommended that part of the TOR of the consultant in 3.2.4 & 3.2.5 is to put together a COSTED implementation plan for the internship program. Then incorporate the costs into this budget.

3.2.7 MOH Review and incorporate the occupational health and safety structure in the wellness program: Create post and assign occupational safety and health officer at MOH and each region

NOTE: The wellness officer proposed this position to be a redeployment - recommended government level is C4. It is assumed that only one redeployment will be needed in year three, and that already existing employees will be used regionally.

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 3: HRH management Strategy 3.2: Improve staff retention by improving scholarships program follow ups, job satisfaction, working and living conditions

(This activity is for the health and wellbeing of the health workers not the general program)

1. Days/Price of consultant 2. Salary range for the occupational safety and health officer.

3.2.8 MOH Develop maintenance and replacement plan for medical equipment and train staff on replacement and maintenance

NOTE: Hire and train someone who is able to maintain the medical equipment. First, there needs to be an inventory of medical equipment, and the amount wasted because broken equipment cannot be fixed. The outcome of this study will help to advocate for the importance of hiring someone for this position. Expected level would be E4. Assumptions: 1. That there are qualified mechanical engineers in Swaziland 2. Cost / Number of meeting w/ key stakeholders

3.2.9 MOH Develop policy and guidelines to regulate donated equipment

NOTE: Since we do not know the current situation, we cannot price the implementation of the recommendations for the consultant. Part of the TOR of the consultant should be producing costed recommendations on how to regulate government equipment. The costs will then need to be incorporated into the budget. 1. Cost per consultant day?# of consults?# of consulting days? travel costs? 2. Cost of meeting w/ key stakeholders to determine adequate regulations / policies? 3. Cost of producing report?

3.2.10 MOH Hire private security firms to provide security services in clinics

NO IMPLMENTATION In order for this activity to be costed, we need to know how many clinics, and what kind of security they need. As such we are including an assessment below to both identify and price the security needs for clinics in the Kingdom of Swaziland. This assessment will be in year

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 3: HRH management Strategy 3.2: Improve staff retention by improving scholarships program follow ups, job satisfaction, working and living conditions

two, as the implementation of this activity is scheduled for Year 3. When the costs for implementation are identified they need to be added to this budget.

3.2.11 MOH Work with relevant Government body to identify suitable accommodation, or other solutions, including building staff accommodations where required

NO IMPLMENTATION In order for this to be costed, we need to know how many institutional houses are currently needed. How many are available? And of those that are available how many (or percentage) are livable? At this point, we have estimation that 10% are livable (Appraisal of selected health facilities in Swaziland, 2010). However we do not know how many institutional houses are needed, and how many there are in total. A more comprehensive study needs to be done before this can be costed. Therefore we included costs of an assessment and report.

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 3: HRH management Strategy 3.3: Work Hand in Hand with MOPS to implement the New Performance Management System (PMS) 3.3.1 MOH/MOPS Tailored performance management plan and

MoH Strategic Plan to incorporate the specific skills and responsibilities of MoH job descriptions

NOTE: MOPS is piloting a new PMS in year 1, it is recommended that MOH roll out the new PMS in year 2. In order for the MoH to be prepared for the roll out it must first have (a) Clear job descriptions (this activity), (b) Strategic Plan, (c) Budget, (d) Clear Reporting Lines - Activity 3.3.2. All of these must be done in Year 1. We do not have accurate estimates for how much it will actually cost to roll out the new PMS. When MOPS has more accurate information on how much rolling out the PMS will be, include the costs in Year 2. Assumptions: 1. Days/Price of consultant 2. Meeting costs 3. Production costs for new job descriptions

3.3.2 MOH/MOPS Assess and develop clear reporting lines and structures within departments and units

NOTE: It is assumed that the consultant used with this activity would be the same consultant from activity 3.3.1. They would need to coordinate well will MOPS in order to make sure that the recommended reporting lines have MOPS buy-in and are incorporated into the PMS roll-out. Assumptions: 1. Days/Price of consultant, travel costs 3. Meeting costs 4. Production costs for new reporting lines and structures (organograms)

3.3.3 MOH/MOPS Roll out the PMS to MoH, Regional Health Offices and Health facilities

NOTE: The costing team only received the figure of SZL1.25 million in relation to the cost of the PMS roll out. However,the number is the rough estimate of what it will cost to roll-out the PMS in three ministries that are much smaller then the MOH. As such, we do not think this is a realistic number, as it is not based on

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Activity Responsibility Activity Name Assumptions/notes Scenarios Strategic focus 3: HRH management Strategy 3.3: Work Hand in Hand with MOPS to implement the New Performance Management System (PMS)

any actual data. Once MOPS has a better understanding of the costs that will go into the roll out of the PMS, the MOH will need to cost the PMS roll out and enter a more realistic figures into the budget.

3.3.4 MOH/MOPS Collaborate with MOPS to develop and implement a continuous Monitoring and Evaluation System for the PMS

This will involve both the development of the M&E for the PMS (assuming that one is not already developed) as well as the roll out of the M&E system. At the time of the initial costing exercise there is not a clear understanding of what the PMS will entail, as such pricing the M&E for the PMS is not based on solid information. This activity will need to be costed when more information is available on the PMS.

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Strategic focus 3: HRH management Strategy 3.4: Implement the Supportive Supervision and Mentoring Framework 3.4.1 MOH/MOPS Assess SS&MF plan and develop an

implementation plan that integrates the roll out of SS&MF with the already existing PMS, as to not create too many parallel reporting structures

NOTE: This activity prices the assessment that will develop the implementation plan for the SS&MF. Assumptions: 1. Days/Price of consultant 2. Meeting costs, # of meeting, # of participants 3. Production costs

3.4.2 MOH/MOPS Roll Out SS&MF to MoH, Regional Health Offices and Health facilities

NOTE: As we do not have the recommendations from the assessment at the time of the initial budgeting exercise, the costs represented are highly variable. We recommend that the assessment includes a costs along with its recommendations and that those costs are then added into a later iteration of this budget. Assumptions: 1. Days/Price of consultant 2. Meeting costs, # of meeting, # of participants 3. Production costs

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Appendix 3:Key Results of the HRH Plan’s Strategic Focal Areas

The following are the key results anticipated from the HRH plan’s focal areas as per the “Human Resource for Health Implementation Plan (2013-2016, Zero Draft” document.

Strategic Focus Strategic Objective Key Results 1. HRH Planning Management 1.1 An effectively coordinated and resourced HRH

management system realized by 2017 Enhanced leadership and coordination capacity of HRH department at MOH

1.2 A system for HRH planning established and functional across the sector by 2017

Improved evidence base, strategic intelligence and understanding of the labour market dynamics

2. HRH Development 2.1 Adequate, qualified and competent human resources available in the health sector by 2017

Improved pre-service training to meet the evidence based demand of the health sector

2.2 Adequate, qualified and competent human resources available in the health sector by 2017

Improved in-service and continuous education program linked to staff and heath sector need

2.3 Improve Physical, Organizational and Operational Capacity of Training Institutions

Improved pre-service training to meet the evidence based demand of the health sector

3. HRH Management 3.1 Strengthen recruitment and deployment procedures Effective recruitment and deployment system that ensure equitable and need based distribution of health work force in place

3.2 Improve staff retention by improving scholarships program follow ups, job satisfaction, working and living conditions

Improved work environment and retention of health personnel

3.3 Work Hand in Hand with MOPS to Implement the New Performance Management System (PMS)

Improved oversight of health sector staff

3.4 Implement the Supportive Supervision and Mentoring Framework

Improved oversight of health sector staff

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