HEALTH WORKFORCE

STRATEGIC PLAN
2020–2030
Investing in Skills and Job Creation for Health
SADC Health Workforce Strategic Plan 2020–2030

Southern African Development Community (SADC) Secretariat

Plot 54385 CBD Square
Private/Bag 0095
Gaborone, Botswana
Tel: +267 395 1863
Email: [email protected]
Website: www.sadc.int

©SADC 2021

Information in this report may be reproduced, used, and shared, but with full acknowledgement.

Citation: SADC, SADC Health Workforce Strategic Plan 2020-2030, Gaborone, Botswana, 2021

About SADC

The Southern African Development Community is an organisation founded and maintained by countries
in Southern Africa that aims to further socio-economic, political, and security cooperation among its
Member States and foster regional integration, in order to achieve peace, stability, and wealth. The
Member States are: Angola, Botswana, Union of the Comoros, Democratic Republic of the Congo,
Eswatini, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa,
United Republic of Tanzania, Zambia, and Zimbabwe.
HEALTH WORKFORCE
STRATEGIC PLAN
2020–2030
Investing in Skills and Job Creation for Health

November 2020

United Nations
MPTF Office
iv
v
TABLE OF CONTENT
TABLE OF CONTENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
ABBREVIATIONS AND ACRONYMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
LIST OF TABLES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
LIST OF FIGURES.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
ACKNOWLEDGEMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
EXECUTIVE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
CHAPTER 1: INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2 Global and Regional Health Workforce Context. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Recommendations of the Commission on Health Employment and Economic Growth
(HEEG) and the SADC Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.4 Approach to the Health Workforce Strategic Plan Development .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CHAPTER 2: SITUATION ANALYSIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.1 Population and Socio-Economic Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1.1 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.2 Socio-economic background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.3 Economics of COVID–19 Pandemic in SADC Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.4 Overview of Health Status and Health Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.5 Health Workforce Situation across the SADC Member States.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.5.1 Health Workforce Stock in the SADC Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.5.2 Health Workforce Needs and Supply Gaps.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.5.3 Health Workforce Leadership, Governance and Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.5.4 Education and Training Efforts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.5.5 Absorption, Distribution and Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.5.6 Human Resources Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.4.7 Gender .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.5.7 Accreditation and Regulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.5.8 Monitoring, Evaluation, and Information Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.5.9 The Impact of COVID–19 Pandemic on Health Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.6 Framework for the SADC Health Workforce Resource Pool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
CHAPTER 3: STRATEGIC DIRECTIONS FOR THE HEALTH WORKFORCE IN THE SADC
REGION.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.1 Introduction.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

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 3.2 Theory of Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.3 Strategic Directions and Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.1 Strategic Direction (SD) 1: Investment in health workforce jobs and decent employment. . . . . . 31
3.3.2 Strategic Direction (SD) 2: Harmonisation of Education, Training and Development.. . . . . . . . . . . . . 32
3.3.3 Strategic Direction (SD) 3: Develop and adopt best practices in strategic HRH
Leadership and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.3.4 Strategic Direction (SD) 4: Enhanced Health Workforce Governance and Regulation.. . . . . . . . . . 33
3.3.5 Strategic Direction (SD) 5: Develop Reliable Data, Monitoring and Evaluation Systems . . . . . . . 34
CHAPTER 4: IMPLEMENTATION ARRANGEMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.1 Implementation Mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.2 Role of the SADC HRH Technical Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.3 Role of the SADC Secretariat.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.4 Implementation Plan .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
4.5 .Implementation Framework for a SADC Recruitment Pool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
CHAPTER 5: COSTING OF IMPLEMENTATION PLAN AND INVESTMENT CASE. . . . . . . . . . . . . . . . . . . . . . . . . 45
5.1 Methodology for costing the implementation plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.2 Limitations of the costing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.3 Estimated cost of operationalising the Strategic Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.4 Financial space potential for health workforce investments in the SADC region.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.5 The Health Workforce Investment Case for the SADC Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
CHAPTER 6: MONITORING AND EVALUATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.1 Introduction.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
6.2 Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
6.3 Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
6.4 Mechanism for collaboration and Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
6.5 Key Performance Indicators and Targets.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
6.6 Overview of Potential Risks and Mitigation Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
ANNEXURES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Annex 1: Economic Feasibility Analysis.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Annex 2: Estimated cost of implementing the strategic plan by type of resource needs at the level.. . . 69
Annex 3: Reporting Framework Tool by Member States to the SADC Secretariat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

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ABBREVIATIONS AND ACRONYMS

AFRO Africa Region Office

AU African Union

CCP Commonwealth Code of Practice

CPI Consumer Price Index

COVID-19 Coronavirus Disease

CPD Continuing Professional Development

CSO Civil Society Organization

DRC Democratic Republic of Congo

ELS Employment & Labour and Social Partners

FBO Faith-Based Organization

GDP Gross Domestic Product

GGHE General Government Health Expenditure

GHED Global Health Expenditure Database

GSHRH Global Strategy on Human Resources for Health

HEEG UN High-Level Commission on Health Employment and Economic Growth

HesDA Health Service Development and Analysis

HMIS Health Management Information Systems

HR Human Resources

HRH Human Resources for Health

HRIS Human Resources Information Systems

HO Health Occupation

HWSC Health Worker Safety Charter

ICT Information and Communication Technology

ILO International Labour Organization

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KPI Key Performance Indicator

M&E Monitoring and Evaluation

NGO Non-Governmental Organization

NHO Non-Health Occupation

NHWA National Health Workforce Account

OECD Organization for Economic Co-operation and Development

OSH Occupational Safety and Health

PHC Primary Health Care

RC Regional Committee

SADC Southern African Development Community

SDG Sustainable Development Goals

SD Strategic Direction

TWG Technical Working Group

UEMOA Member States of the West-African Economic and Monetary Union

UHC Universal Health Coverage

UN United Nations

UNAIDS Joint United Nations Programme on HIV and AIDS

USD US Dollars

WDI World Development Indicators

WEO World Economic Outlook

WFO World Food Organization

WHO World Health Organization

WISN Workload Indicators of Staffing Need

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LIST OF TABLES

Table 1: Gross Domestic Product in SADC at Current Market Prices, (US $ million), 2008–2018.. . . . . . . . 10

Table 2: Unemployment, youth (% ages 15–24) (%) in SADC, 2008–2017. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Table 3: Life Expectancy in the SADC Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Table 4: Maternal mortality ratio (deaths per 100,000 live births) in SADC, 2010–2015. . . . . . . . . . . . . . . . . . . . . . . . . 13

Table 5: Selected Health Workforce Stock and Densities in the SADC Member States – 2018 – a. . . . . 16

Table 6: Selected Health Workforce Stock and Densities in the SADC Member States – 2018 – b. . . . . 17

Table 7: Selected Health Workforce Stock and Densities in the SADC Member States – 2018 – c.. . . . . 18

Table 8: SADC Needs and Supply gaps for Doctors, Nurses and Midwives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Table 9: Key actions to implement Recruitment Pool mechanism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Table 10: Estimated cost of implementing the Strategic Plan .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Table 11: Estimated Financial Space and Economic feasibility analysis – SADC Region
(Million US Dollars). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Table 12: Monitoring and Evaluation Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Table 13: Summary of key Risks and Mitigation measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

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LIST OF FIGURES

Figure 1: SADC mid-year population, 2018. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Figure 2: GDP Growth rate for the SADC Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Figure 3: SADC UHC Service Coverage Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Figure 4: Health Worker COVID–19 infections in SADC region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Figure 5: Theory of Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Figure 6: Health pathway to economic growth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Figure 7: Ratio of Non-Health Occupation (NHO) workers to Health Occupation (HO) workers,
by income group, 2015. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Figure 8: Economic feasibility analysis – Botswana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Figure 9: Economic feasibility analysis – Comoros. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Figure 10: Economic feasibility analysis – Eswatini. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Figure 11: Economic feasibility analysis – Leshoto.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Figure 12: Economic feasibility analysis – Malawi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Figure 13: Economic feasibility analysis – Namibia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Figure 14: Economic feasibility analysis – Seychelles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Figure 15: Economic feasibility analysis – Zimbabwe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

xi
ACKNOWLEDGEMENTS

The development of this SADC Health Workforce Strategic Plan Strategic Plan, 2020–2030 was a
SADC Secretariat-led collaboration of Member States, supported by the WHO Botswana Country
Office, WHO AFRO, ILO, and the generous financial contribution of the joint ILO–OECD–WHO Working
for Health Multi-Partner Trust Fund. The oversight provided by Dr Willy Amisi was critical in ensuring
that this work is grounded in the context of SADC Member States current and projected future health
workforce priorities. The contribution and engagement of SADC Member States representatives’ HRH
Consultative Forum, as well as an ILO-led tripartite technical workshop for the SADC region, was inval-
uable to the process and highly appreciated. The leadership and coordination from Dr. Josephine
Namboze, WHO Representative to Botswana, is highly appreciated. The technical guidance and inputs
of Mr Paul Marsden and Mr James Avoka Asamani, Dr. Juliet Bataringaya and Dr. Madidimalo Tebogo
and administrative support from Joel Motswagole of WHO is highly acknowledged, as well as the ILO
team of Ms Christiane Wiskow, Mr Simphiwe Mabhele, Mr Sipho Ndlovu, and Dr. Maren Hopfe including
the contribution of consultants Ms Maritza Titus, Dr. Percy Mahlathi and Mr. James Nyamosi.

xii
EXECUTIVE SUMMARY

SADC Member States have made significant progress towards the attainment of their key health indica-
tors over the last decade, however, the biggest challenge for ensuring equitable access to health for all
is the persistent shortage and availability of skilled health and social care workers across the region, and
the sub-optimal utilization and efficiency of the existing workforce. SADC Member States’ total popula-
tion of 345.2 million as of 2018 is estimated to be growing at an average rate of 2.5% annually, placing
extra demands on the health systems. Additionally, fewer people are attracted to health and social
care professions due to low wages, long working hours, violence and harassment at the workplace
and occupational safety and health risks. Access into employment plays a significant role, with some
Member States reporting challenges regarding the available fiscal space for government to employ
and absorb the additional health workers that are needed to fill the already existing workforce gaps, in
particular, new graduates. A new dynamic introduced by the coronavirus pandemic (COVID–19) is its
devastating health and economic impact, with lower and middle-income countries (LMIC), and those
experiencing fragility, violence, and conflict (FCV), affected the most. This has highlighted the need for
countries to develop robust health systems, strengthen primary health care capacity, and build public
health preparedness and response capability. The occupational health, safety, and protection of the
workforce, especially those directly exposed who are working in high-risk settings has been brought
into sharp focus, as health systems globally were affected by high levels of health and social care worker
infection rates, and deaths.

The COVID–19 pandemic, whilst its impact has not been fully evaluated, is cause for concern for the
SADC region. As the numbers of COVID–19 cases and deaths in the WHO Africa Region has continued
to show a downward trend, SADC must factor in its long-term effects. It is the health and care workers
that face a substantially higher risk due to excessive exposure to COVID–19. This also has major psy-
cho-social impact on individual health workers as fear of taking the disease to their families is realistic.

The UN High-level Commission on Health Employment and Economic Growth emphasises the impor-
tance of the health and care sector in providing growing opportunities for employment and the econ-
omy, particularly by empowering women and young people with skills, jobs and economic participation.
Although existing training capacity within the SADC region could potentially meet almost 66% of this
need in aggregate terms, given the prevailing trends in HRH underinvestment, reduced budgets and
cost containment across the region, only around 33% of the needed numbers may be funded positions
by 2030.

The perennial challenge is that health workforce gaps across the region are generally determined based
on existing staff establishments and/or funded posts. These approaches to workforce planning mis-
represent the true picture for SADC member states when measured against their need-based projec-
tions for delivering universal health coverage (UHC) and meeting their 2030 SDG targets. This strat-
egy advances a practice where its application serves as a mechanism to challenge traditional views
on health workforce gaps, determining demand and investment needed, and how governments can
unlock additional domestic and other resources. This situation necessitates a regional response and
comprehensive strategy to address the key human resources challenges across SADC.

xiii
Among the main objectives of SADC, the achievement of economic development, growth, enhance-
ment of the standard and quality of life of the peoples of Southern Africa. This envisages actions
through regional integration and harmonisation of development approaches. To achieve these objec-
tives in the health sector requires a strategic leadership that utilises a multisectoral framework to build
and resource comprehensive plans for effective health workforce planning, development, and manage-
ment. However, without accurate, current data for human resource policies, planning and management
meaningful development in the region is difficult. Thus, the need for a regional health workforce strategic
plan.

In developing this strategic plan, two critical engagements took place in Johannesburg, South Africa:
(i) the SADC human resources for health technical consultations from 26–29 August 2019, and (ii) the
tripartite technical workshop for the SADC region organised by ILO on 10–12 September 2019. Both
engagements were highly participatory with Member States represented at senior leadership of the
HRH divisions of the Ministries of Health Ministries of Labour and Employment and employers’ and
workers’ representatives who had converged on the need to: align the SADC HRH strategy with the
SADC Employment and Labour Policy Framework (2020–2030); enhance collaboration and social dia-
logue between all relevant stakeholders at national and regional level; strengthen coordination mech-
anisms among governments, workers, employers and other relevant stakeholders to promote decent
work in the health sector; and ensure a strategic plan that guides and compliments individual Member
States’ policies and strategic plans on the health workforce.

The SADC Health Workforce Strategic Plan, 2020–2030 presents five (5) evidence-based strategic
directions to inform member states’ health workforce policy, planning and implementation:

1. Invest in health worker jobs and decent work.

2. Harmonise Education, Training and Development.

3. Establish best practices in strategic HRH Leadership and Management.

4. Enhance Health Workforce Governance and Regulation.

5. Develop and Use Reliable Data, Monitoring and Evaluation Systems.

The following are the key milestones targeted to be achieved by both the SADC Secretariat and Member
States during the plan period:

xiv
 2021–2025 MILESTONES 2026–2030 MILESTONES

SD 1: Investment, Jobs & Decent Work SD 1: Investment, Jobs & Decent Work
1.2 By 2023 Member States will commence 1.1 By 2030 Member States will have
expansion by at least 40% of the fiscal improved the density of health workers
space to enable increase investments in from the current SADC median of 1.02 to
skilled health workforce 4.45 per 1,000 population
1.3 By 2023 Member States will be contin-
uously protecting health workers from SD 2: Education, Training & Development
occupational hazards and risks 2.1 By 2026 Member States will have harmo-
1.4 By 2023 Member States will be contin- nised training and development
uously improving the working conditions 2.2 By 2027 Member States will be conduct-
and remuneration of health workers ing specialist health professions training in
1.5 By 2025 Member States will have devel- line with current and emerging population
oped and implemented strategies to health needs
mainstream gender equality in the health 2.3 By 2027 Member States will have poli-
sector workforce improving the working cies that promote access to education
conditions and remuneration of health opportunities in health based on princi-
workers ples of equality and affordability, inclusive
of youth and women
SD 2: Education, Training & Development
2.4 By 2025 regional training centres of excel- SD 3: Leadership & Management
lence will have been designated 3.2 By 2026 Member States will have strength-
2.5 By 2025 SADC Secretariat will have ini- ened their capacity in health labour mar-
tiated the health workforce development ket analysis, HRH planning, development,
scheme and management
3.4 By 2027 Member States will have insti-
SD 3: Leadership & Management tutionalised social dialogue mechanisms
3.1 By 2023 Member States will champion the among governments, workers, employers
mainstreaming of health workforce issues and other relevant stakeholders
in all health policies and interventions
3.3 By 2024 SADC will have established a SD 4: Governance & Regulation
mechanism for peer-to-peer support and 4.2 By 2027 SADC Secretariat will have devel-
accountability mechanism oped a framework with strict compliance
criteria for mutual and reciprocal recogni-
SD 4: Governance & Regulation tion of health professions education and
4.1 By 2021 Member States will enforce the qualification
upholding of professional standards and 4.3 By 2026 Member States will be promot-
safeguard public safety ing exchange programmes between
the Member States especially for skills
SD 5: Data, Monitoring & Evaluation transfer
5.1 By 2021 Member States will have HRIS 4.4 By 2026 Member States will have cre-
with ability to generate information to ated multi-sectoral collaboration/partner-
track end-to-end health workforce life ships (PPP) to facilitate sharing of HRH
cycle (production – active stock – exit) resources
5.2 By 2023 Member States will have a health
workforce registry to track health work- SD 5: Data, Monitoring & Evaluation
force stock, distribution, flows, exits, 5.5 By 2026 Member States will have inte-
demand and supply grated health worker safety indicators
5.3 By 2021 Member States will have improved with health information system
multi-sectoral dialogue for improved man-
agement of the health workforce
5.4 By 2022 Member States will have insti-
tutionalised national health workforce
accounts (NHWA) and reporting annually

xv
The overall estimated cost of implementing the strategic plan is roughly US$15.7 million over the
10-year period. Of this amount, about 35% (US$5.6 million) would be needed at both the SADC sec-
retariat and Member States to generate evidence, facilitate policy dialogue, and mobilize resources
to increase investments substantially to approximately expand health workforce employment by 40%
over the 10-year period (strategic direction 1). This cost, however, excludes the cost of training and
remuneration for health workers at the Members States which a country-by-country analysis is highly
recommended as part of the investment case development at the level of Member States.

It is envisaged that multisectoral policy advice and technical guidance may be required in some instances
during the development of Member States’ national health workforce policies and strategies – in par-
ticular, to focus on adopting investment planning for employment creation and decent work, inter alia
through their decent work country programmes and regional decent work programmes; drawing on the
collaborative multi-sectoral approaches and strategies to expand and transform the health and social
care workforce that are guided by the ILO–OECD–WHO Working for Health programme and its 5-year
Action Plan on health employment and growth: 2017–2021.

xvi
CHAPTER
01
INTRODUCTION

1.1 Background
The Southern Africa Development Community (SADC) adopted a Protocol on Health in 1999 which
followed the SADC Health Policy Framework in 1998 setting out a framework “to attain an acceptable
standard of health for all citizens by promoting, coordinating and supporting the individual and collective
efforts of Member States” (SADC, 1999). The Protocol is based on the principles of:

• Equality of Member States.

• Co-ordination, sharing and support.

• Health for All through Primary Health Care (PHC).

• Health Care for All through better access.

• Promoting equity to achieve better health.

Various efforts guided by the principles enshrined in the Protocol provided an enormous impetus for
accelerating progress towards the attainment of key health targets in tandem with global efforts during
the era of the Millennium Development Goals (MDGs) (International Council for Local Environmental
Initiatives, 2015). Efforts are continuing to maintain the momentum of progress across the SADC
Members States. For instance, healthy life expectancy has improved from an average of 52 years in
2008 to 60 years in 2018 across the SADC Member States (SADC, 2018). Also, data from the UNAIDS
Global HIV & AIDS statistics show that the number of new HIV infections have declined from an average
of 1,202,759 in 2008 to 820,689 in 2018 (UNAIDS, 2019).

These among other gains made in health status indicators have provided optimism and impetus for
the attainment of the health-related targets of the Sustainable Development Goals (SDGs) which were
adopted by United Nations Member States in 2015 (UNDP, 2016).

In operationalizing aspects of the SADC Protocol on Health (SADC, 1999), SADC in 2006 developed a
Human Resources Strategic Plan (2007–2019) with an ultimate goal “to ensure adequate production,
recruitment and retention of the required Human Resource for Health in the region by 2019”. The stra-
tegic plan guided complementation of individual Member States policies and strategic plans on the
health workforce; and promoted close cooperation and collaboration for enhanced capacity to design
and implement health programmes to respond to the dynamic and changing population health needs.

2
As the horizon of the SADC HRH Strategic (2007–2019) ended in 2019, and in light of global develop-
ments, including the WHO Global Strategy on Human Resources for Health and the UN High-Level
Commission on Health Employment and Economic Growth (HEEG) (World Health Organisation, 2016a),
a review of the SADC Human Resources for Health (HRH) Strategic Plan became necessary. At the
SADC Health Ministers’ Meeting in March 2018, the revival of the SADC Human Resources for Health
Technical Committee was approved and tasked with leading the development of the HRH strategy for
the SADC region based on current HRH situation and taking into account the recommendations of the
HEEG Commission. This document is a result of extensive consultation and dialogue with the technical
and social partners of SADC Member States, and review of relevant evidence relating to the health
workforce.

1.2 Global and Regional Health Workforce Context

The Astana Declaration on Primary Health Care global leaders calls on countries to scale up efforts
towards the attainment of Universal Health Coverage (UHC) and the SDGs through a renewed Primary
Health Care (PHC) focus (World Health Organisation, 2018). It centres on the pivotal role of respon-
sive and resilient health systems underpinned by adequate, motivated and equitably distributed health
workforce. It has been recognised that the health workforce contribution to the SDGs goes beyond
the attainment of optimal health (SDG 3), being intricately connected to SDGs 4 (quality education), 5
(gender equality), and 8 (decent work and economic growth).

The World Health Assembly (WHA) in 2016 also adopted the Global Strategy on Human Resources for
Health: Workforce 2030 (GSHRH) (World Health Organisation, 2016b) which aims at ensuring equitable
access to qualified health workforce towards achieving UHC and SDGs. Its specific objectives are to:

a. Optimize the performance, quality, and impact of the health workforce to accelerate progress
towards UHC and SDG

b. Align investment in HRH with the current and future needs of the population and health systems
to maximize job creation and economic growth

c. Strengthen the capacity of institutions at regional and national levels for effective public policy
stewardship, leadership, and governance on HRH

d. Strengthen data, evidence, and knowledge for cost-effective policy decisions.

The GSHRH also implores countries to “build planning capacity to develop or improve HRH policy and
strategies that quantify health workforce needs, demands and supply under different future scenarios
in order to manage health workforce labour markets and devise effective and efficient policies that
respond to today’s population needs while anticipating tomorrow’s expectations” (p.25). Thus, countries
and regional bodies such SADC are urged to ensure that their plans are continually updated to address:

3
 a. The estimated number, category, and qualification of health workers required to meet public
health and population health needs;

b. The capacity to produce a sufficient, and adequately distributed health workforce (education
and effective regulatory policies); and

c. The government and labour market capacity to attract, recruit, deploy and retain health workers
(economic and fiscal capacity, and workforce deployment, remuneration, and retention through
financial and non-financial strategies).

The UN High Commission on Health Employment and Economic Growth (HEEG) provides a wealth of
evidence for the health workforce investments that are needed to meet a projected needs-based short-
age of 6.1 million in the Africa region.1 In the context of the Africa Region, the Regional Committee (RC)
of the World Health Organisation (WHO) adopted a roadmap for scaling up health workforce interven-
tions in the Region (2012–2025) and also approved a regional implementation framework of the global
strategy on HRH in 2018. These global and regional initiatives have provided blueprints for evidence-in-
formed health workforce policy and investment in the context of SADC.

1.3 Recommendations of the Commission on Health Employment

and Economic Growth (HEEG) and the SADC Context
The report of the UN High Commission on Health Employment and Economic Growth (HEEG) demon-
strated that investing in the health workforce yielded a nine (9) fold return on investment (World Health
Organisation, 2016a). It also demonstrated that half of the global economic growth over the last decade
resulted from improvements in health, noting that for every added year of life expectancy, the economic
growth rate is boosted by 4%. While this sector is an important driver of economic growth, it is esti-
mated that globally, about 40 million health workers would be needed, primarily in upper-middle- and
high-income countries (Liu, et al., 2017). It is however projected that the growth in jobs will take place
alongside a potential shortfall of 18 million health workers if universal health coverage is to be achieved
and sustained by 2030 (World Health Organisation, 2016b).

Against this background, the high-level commission made ten (10) recommendations (see box 1) and
proposed these five immediate actions:

1. Encouraging commitments; fostering intersectoral engagement and develop an implementation plan

2. Galvanizing accountability, commitment, and advocacy

3. Advancing health market labour data, analysis and tracking in all countries

4. Accelerating investment in transformative education, skills, and job creation

5. Establishing an international platform for health worker mobility

1
Health workforce needs, demand and shortage to 2030, an overview of forecasted trends in the global labour market,
Cometto, Scheffler, et al, in ‘Health Employment and Economic Growth: an evidence base, Buchan, Dhillon and Campbell,
WHO, 2017

4
Box 1: Recommendations of UN High-Level Commission on HEEG

1. Job Creation: Stimulate investments in creating decent health sector jobs, particularly for
women and youth, with the right skills, in the right numbers and the right places.
2. Gender and Women’s Rights: Maximize women’s economic participation and foster their
empowerment through institutionalizing their leadership, addressing gender biases and inequi-
ties in education and the health labour market, and tackling gender concerns in health reform
processes.
3. Education, Training and Skills: Scale-up transformative, high-quality education and lifelong
learning so that all health workers have skills that match the health needs of populations and
can work to their full potential.
4. Health Service Delivery and Organization: Reform service models concentrated on hospital
care and focus instead on prevention and the efficient provision of high-quality, affordable,
integrated, community-based, people-centred primary and ambulatory care, paying special
attention to underserved areas.
5. Technology: Harness the power of cost-effective information and communication technologies
to enhance health education, people-centred health services and health information systems.
6. Crises and Humanitarian Settings: Ensure investment in the International Health Regulations
core capacities, including skills development of national and international health workers in
humanitarian settings and public health emergencies, both acute and protracted. Ensure the
protection and security of all health workers and health facilities in all settings.
7. Financing and Fiscal Space: Raise adequate funding from domestic and international
sources, public and private where appropriate, and consider broad-based health financing
reform where needed, to invest in the right skills, decent working conditions and an appropriate
number of health workers.
8. Partnership and Cooperation: Promote intersectoral collaboration at national, regional and
international levels; engage civil society, unions and other health workers’ organizations and the
private sector; and align international cooperation to support investments in the health work-
force, as part of national health and education strategies and plans.
9. International Migration: Advance international recognition of health workers’ qualifications to
optimize skills use, increase the benefits from and reduce the negative effects of health worker
migration, and safeguard migrants’ rights.
10. Data, Information and Accountability: Undertake robust research and analysis of health
labour markets, using harmonized metrics and methodologies, to strengthen the evidence,
accountability and action.

To accelerate global action on the recommendations of the Commission on HEEG, particularly to avert
the potential shortage of 18 million health workers by 2030, ILO, OECD and WHO jointly established the
Working for Health programme to support the expansion and transformation of the global health and
social service workforce in order to accelerate progress towards universal health coverage and global
health security. Guided by the Commission’s recommendations and the Five-Year Action Plan for Health
Employment and Inclusive Growth (2017–2021), the Working for Health programme will coordinate,
enhance and extend the policy advice, technical assistance and capacity support that the ILO, OECD
and WHO will provide to their constituents and partners (World Health Organisation, 2016a).

5
In November 2017, the South African Ministry of Health, as the incumbent SADC chair, took the initiative
to propose to the SADC Health Ministers’ meeting to develop a SADC action plan on health employ-
ment and economic growth. This was inspired by the Member States of the West-African Economic
and Monetary Union (UEMOA) that has developed a UEMOA action plan which was endorsed by an
inter-ministerial meeting in March 2017. The SADC health ministers noted that by taking immediate
action and making strategic investments across the SADC region, Member States could potentially
avert serious health workforce shortfalls to better position health systems to achieve the health-SDGs
as well as create much-needed jobs to address youth unemployment and enhance women’s labour
participation.

The SADC Health Ministers’ Meeting considered that in light of global developments, including the WHO
Global Strategy on Human Resources for Health and the Commission HEEG, the existing SADC Human
Resources for Health Strategic Plan and its Business Plan needed to be updated. They approved
the revival of the SADC Human Resources for Health Technical Committee and considered that a
sub-committee of the SADC HRH technical committee should develop a costed SADC five-year action
plan to implement the outcomes of the Commission HEEG, and that the action plan should be guided
by principles of collaboration and partnership.

Furthermore, the meeting of the SADC Ministers of Employment & Labour and Social Partners (ELS)
held their meeting in Cape Town on 2nd March 2018. Ministers agreed to include an item titled ‘Health
employment and economic growth’ under the section on issues for noting as one of the inter-sectoral
issues of priority to the Employment and Labour Sector.

SADC HRH technical committee needs to build a framework for translating the Global Strategy on
Human Resources for Health and the recommendations of the Commission HEEG to the regional
context. Recognising this, SADC aims to attain an acceptable standard of health for all citizens and to
reach specific targets within the objective of “Health for All” by 2030. Therefore, the Framework should
support accelerating progress towards achieving the population health objectives of Health 2020 and
the longer-term health goals for the Member States in the SADC region. The Framework should help
build sustainable transformed and effective health workforce within strengthened health systems and
supports Global Strategy objectives.

Lastly, the Framework should provide vital support to the SADC Member States by identifying policy
options and guidance on investment. It is within this context that ILO, OECD and WHO should provide
technical support to capacitate the development of broader strategic objectives and policy options for
the SADC region. The SADC Member States will then, based on their context, develop, review, and
prioritise actions from the broader strategic objectives and policy options that are set out in the regional
health workforce strategic plan.

6
1.4 Approach to the Health Workforce Strategic Plan Development
The consultative process and methodology were applied to engage the Member States and social
partners. A mixed-method approach was used to ensure robust qualitative and quantitative data were
obtained to inform a comprehensive sub-regional strategy. Member States were requested to complete
a rapid self-evaluation of their level of readiness using thematic areas adopted from an HRH Effort
Index Tool (Fort, et al., 2017). The tool covers 50 items distributed over seven recognized HRH dimen-
sions: (1) Leadership and Advocacy, (2) Policy and Governance, (3) Finance, (4) Education and Training,
(5) Recruitment, Distribution, and Retention, (6) Human Resources Management, and (7) Monitoring,
Evaluation, and Information Systems. Also, quantitative data on the health workforce production, den-
sities, staffing establishments/norms and spending was submitted to SADC by nine (9) Member States
and which guided technical consultations from 26–29 August 2019 in Johannesburg, South Africa, and
supplemented with additional data drawn from the WHO National Health Workforce Accounts (NHWA)
platform.

During the technical consultative meeting, Member States presented the outcomes of the various HRH
self-evaluations and were then further supported to complete Health Service Development and Analysis
(HesDA) Model (Asamani et al. 2018) using their country data. Each Member State in attendance pre-
sented their health workforce forecasts, projected supply, labour market gaps, including economic
feasibility analysis and there were extensive discussions on the policy priority of their own countries as
well as the implications for the broader SADC sub-region. The outcome of this technical consultation,
which was facilitated by WHO and ILO, was presented to a tripartite technical workshop for the SADC
region in Johannesburg on 10–12 September 2019 for consideration.

The recommendations from the ILO tripartite technical workshop for the SADC region were incorpo-
rated and a draft SADC HRH Strategy Framework was developed, supported by a team of consultants,
with technical backstopping from experts in WHO and ILO and coordinated by the SADC Secretariat.
The draft HRH Strategy Framework was reviewed by technical experts of the SADC and taken note of
by the SADC Ministers of Health on 7th November 2019 in Dar Es Salaam, Tanzania. Feedback from the
SADC Ministers informed further analysis and refinement of the framework into this HRH Strategic Plan
2020–2030, which was endorsed by the Member States on 15 November 2020 during the meeting of
SADC Ministers in charge of Health and HIV/AIDS in Maputo, Mozambique and further endorsed by the
SADC Ministers of Labour and Employment.

7
CHAPTER
02
SITUATION ANALYSIS

2.1 Population and Socio-Economic Background

2.1.1 Population

The SADC Member States is estimated to have a total population of 345.2 million as of 2018 which
grows at an average rate of 2.5% annually. The Democratic Republic of Congo (DRC) has the larg-
est share of the SADC population with approximately 27%, followed by South Africa and Tanzania at
16.7% and 15.7% respectively. Seven Member States (namely Seychelles, Namibia, Mauritius, Lesotho,
Eswatini, Comoros and Botswana) together constitute slightly less than 3% of the SADC population (see
figure 1). Thus, the principle of sharing and interdependence as espoused in the various SADC proto-
cols is essential to benefit from the economic dividends of the population (SADC, 2018).

Share of SADC Mid-Year Population (%) – 2018

Figure 1: SADC mid-year population, 2018

Source: SADC selected economic and social indicators, 2018

2.2 Socio-economic background

Together, the SADC sub-region has a Gross Domestic Product (GDP) of US$721.3 billion in 2018 which
has grown by nearly 42% from US$508.7 billion in 2008. The sub-region’s GDP is growing at a declining
rate – an average of 1.8% in 2018 which is an average 6.4% decline in annual economic growth rate
since 2008 (see table 1 for GDP of SADC Members States and figure 2 for the trend of aggregate GDP
growth rate). As evident from figure 2, the effects of global economic downturn adversely impacted
the economic growth in the sub-region. However, the anticipated economic downturn resulting from
COVID–19 may further hamper economic growth.

9
Table 1: Gross Domestic Product in SADC at Current Market Prices, (US $ million), 2008–2018
SADC
Member 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
States
Angola 88 539 70 415 83 799 111 943 128 138 136 725 145 668 116 164 101 124 122 121 107 970
Botswana 10 945 10 267 12 787 15 438 14 420 14 902 16 251 14 421 15 662 17 486 18 596
Comoros 524 531 906 1 022 1 016 1 116 1 148 988 1 021 1 082 1 241
DRC 19 144 16 004 21 567 25 841 29 308 32 686 35 909 37 918 37 135 37 981 47 228
Eswatini 3 279 3 612 4 436 4 821 4 830 4 587 4 440 4 023 3 815 4 440 4 362
Lesotho 1 867 1 886 2 384 2 787 2 727 2 553 2 616 2 463 2 305 2 592 2 519
Madagascar 9 413 8 544 9 983 11 552 11 579 12 424 12 523 10 371 11 805 13 177 13 904
Malawi 5 322 6 185 6 960 8 003 5 721 5 290 5 918 6 431 5 310 6 348 7 197
Mauritius 9 984 9 135 10 002 11 517 11 669 12 122 12 804 11 671 12 127 13 146 14 129
Mozambique 11 557 11 242 10 456 13 135 15 343 16 123 17 327 15 457 10 902 12 647 14 428
Namibia 8 346 8 954 10 911 12 602 13 032 12 659 12 848 11 725 11 293 13 579 14 446
Seychelles 969 849 970 1 019 1 060 1 328 1 343 1 377 1 428 1 503 1 589
South Africa 287 100 297 217 375 298 416 878 396 811 366 837 351 047 317 638 296 333 349 630 368 398
Tanzania 27 389 28 574 31 704 34 452 39 643 45 668 49 969 47 522 49 763 53 281 57 347
Zambia 17 909 15 329 20 266 23 461 25 528 28 076 27 163 21 274 21 031 25 590 25 177
Zimbabwe 6 451 8 157 12 042 14 102 17 115 19 091 19 495 19 963 20 549 22 041 22 790
SADC region 508 737 496 902 614 470 708 572 717 940 712 186 716 470 639 406 601 602 696 643 721 321

Source: SADC Selected Economic and Social Indicators, 2018

Figure 2: GDP Growth rate for the SADC Region

Source: SADC Selected Economic and Social Indicators, 2018

Youth unemployment in the sub-region varies significantly with figures of less than 10% recorded for
countries such as DRC, Madagascar, Malawi and Tanzania in contrast to countries as high as 57% such
as South Africa (57.4%), Eswatini (54.8%), Mozambique (42.7%) and Namibia (45.5%) (SADC, 2018).

10
Table 2: Unemployment, youth (% ages 15–24) (%) in SADC, 2008–2017
SADC
Member 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
States

Angola 33.7 28.1 22.8 16.9 17.0 17.0 17.0 16.9 18.0 19.1
Botswana 32.5 32.6 35.3 35.3 35.4 35.6 35.4 35.3 35.7 35.7
Comoros 9.9 9.9 9.9 9.9 9.9 9.9 9.9 9.9 9.9 10.0
DRC 7.3 7.3 7.3 7.3 7.3 7.3 7.3 7.3 7.3 7.3
Eswatini 53.0 53.1 53.1 53.1 53.3 53.4 53.5 53.5 54.1 54.8
Lesotho 47.7 46.2 36.3 38.9 32.9 34.5 34.9 38.0 39.0 38.5
Madagascar 5.5 5.9 6.4 3.8 1.0 1.5 2.0 3.0 3.0 3.0
Malawi 9.6 9.2 8.9 8.6 8.2 7.8 7.9 7.8 7.9 8.0
Mauritius 18.9 21.8 23.2 22.1 24.4 23.4 24.6 26.0 23.6 23.3
Mozambique 38.5 38.5 38.5 38.5 38.6 39.8 43.2 43.2 43.0 42.7
Namibia 46.1 46.6 45.3 42.6 34.3 40.8 38.7 40.1 45.2 45.5
Seychelles N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
South Africa 45.6 48.4 51.2 50.3 51.7 51.4 51.3 50.1 53.4 57.4
Tanzania 6.9 4.9 5.9 7.1 6.5 5.8 3.7 3.7 3.8 3.9
Zambia 15.5 20.9 26.8 20.1 15.3 15.3 15.3 15.2 15.3 15.4
Zimbabwe 7.9 8.2 8.4 8.5 11.5 11.5 11.4 11.4 11.4 11.4

Source: SADC Selected Economic and Social Indicators, 2018

2.3 Economics of COVID–19 Pandemic in SADC Region

At the beginning of 2020, the SADC region reported its first case of the COVID–19 infection. The dis-
ease has since spread rapidly across many countries in the region, impacting severely on their econ-
omies and health systems. The impact of COVID–19 is changing the economic landscape around
the world including SADC region. The SADC regional economy, which was forecasted to recover in
2020 according to the October 2019 WEO has seen significant downward revision due to the adverse
impact of COVID–19. Resultantly, SADC regional 2020 economic growth initially forecasted at 3.3 per
cent in October 2019, has been revised downwards to a contraction of about 3 per cent. Disruptions
of economic activity and the elevated expenditures by Governments coupled with economic pack-
ages in response to the pandemic is expected to affect economic growth of SADC Member States.
Consequently, scale deficit is forecasted to widen to 5.7 per cent of GDP in 2020 compared to the
previous estimate of 3.0 per cent of GDP. Additionally, debt levels are forecasted to increase beyond the
regional threshold of 60 per cent of GDP to 69.8 per cent of GDP in 2020.2

Economic sectors that have been severely impacted by COVID–19 include the tourism and leisure,
aviation and maritime, automotive, construction and real estate, manufacturing, education and the oil
industry. There were initial concerns that the COVID–19 pandemic would also disrupt the global food
processing and retail business. However, these have remained stable. The food processing and retail
business largely benefited from the announcement by WHO and World Food Programme that, it is
highly unlikely that people can contract COVID–19 from food or food packaging.

2
https://www.sadc.int/files/6915/8758/8533/BULLETIN_2-SADC_Response_to_COVID19_ENGLISH.pdf

11
SADC Member States have instituted several socio-economic policies and measures to minimize the
impact of COVID–19 to the economy. These policies and measures include suspension of non-essen-
tial economic activities; increased spending in health sector and in social safety nets; accommodative
tax measures; economic stimulus packages, accommodative monetary policies and establishment of
emergency/solidarity funds. These policies and measures have far-reaching implications on Member
States including availability to invest in health workforce post the pandemic (SADC, 2020).

2.4 Overview of Health Status and Health Systems

Many African countries made significant progress towards the attainment of key health indicators over
the last decade. For instance, 43 countries in Africa observed much more significant declines in child
mortality during the 2000–2013 period than during the 1990–2000 period. Also, the continent recorded
a massive decline in under-five mortality rate by nearly 56% between 1990 and 2012; infant mortality
declined by 40% (UNICEF, 2018).

In the context of the SADC region, in the last decade from 2008 to 2018, the average life expectancy
improved by about 8 years, from 52.4 years in 2008 to 61 years in 2018. This represents an average
improvement of 16% across the SADC Members States. However, wide variations have also been
observed in the accrued improvements in life expectancy. The largest gains were recorded in Zimbabwe
(30%), Botswana (29), Democratic Republic of Congo (26%), Angola (24%) and Malawi (23%); and on
the other hand, other Member States such as Namibia, Lesotho and Madagascar recorded less than a
percentage point improvement in life expectancy over the last decade (see table 3).

Table 3: Life Expectancy in the SADC Region

Percent
SADC
change
Member 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
since
States
2008
Angola 49.9 48.2 48.4 48.6 48.7 48.9 60.3 61.2 61.5 61.7 62.0 24%
Botswana 52.8 53.2 53.3 68.0 68.0 68.0 68.0 68.0 69.0 67.0 68.0 29%
Comoros 66.2 66.5 66.8 67.1 67.4 67.6 67.9 68.1 68.3 68.5 68.7 4%
DRC 47.6 47.8 48.1 48.4 48.7 56.0 56.0 59.1 59.1 59.1 60.0 26%
Eswatini 45.2 45.1 45.1 45.2 45.3 45.5 45.6 45.7 45.8 61.2 58.0 28%
Lesotho 46.1 46.9 47.6 42.5 43.1 43.6 44.0 45.0 45.5 45.7 46.3 0%
Madagascar 65.9 66.2 66.5 66.7 66.9 64.7 65.2 65.5 65.7 65.8 66.0 0%
Malawi 47.6 51.7 52.5 53.4 54.3 55.1 56.0 56.8 57.6 58.4 58.6 23%
Mauritius 73.2 73.3 73.7 73.9 74.1 74.2 74.4 74.4 74.6 74.5 75.0 2%
Mozambique 51.3 51.7 52.1 52.4 52.8 53.1 53.5 53.8 54.1 53.7 55.0 7%
Namibia 61.1 61.7 62.2 56.9 56.9 56.9 56.9 57.5 59.0 60.0 60.2 -1%
Seychelles 72.9 72.9 73.2 72.6 74.2 73.1 73.2 74.2 74.0 74.0 74.0 2%
South Africa 56.0 57.4 58.9 59.9 61.2 61.8 62.5 62.8 63.2 63.9 64.2 15%
Tanzania 54.0 54.0 55.0 55.0 61.8 61.8 61.8 61.8 61.8 61.8 61.8 14%
Zambia 51.3 51.2 51.2 52.7 52.8 53.0 53.2 53.3 53.7 54.9 54.6 6%
Zimbabwe 47.2 48.6 50.0 51.4 60.7 60.7 60.7 60.7 60.7 59.7 61.4 30%
SADC Total 52.4 52.9 53.5 54.0 55.9 57.8 59.0 60.0 60.2 60.4 61.0 16%

Source: SADC selected economic and social indicators, 2018

12
Other population health indicators such maternal mortality also recorded some improvements from an
average of 443 per 100,000 live births in 2008 to 367 per 100,000 live births in 2017. This represents
14% reduction in maternal mortality over the last decade (see table 4). However, in some Member States
(example Malawi and Zimbabwe), no or just marginal improvements were recorded as compared to
Botswana (24%) and Tanzania (23%) where the most gains were made in the SADC region. Related
health indicators such skilled birth attendance rate, infant mortality and crude death rate per 1,000 peo-
ple all recorded aggregate improvements over last decade but significant disparities are inherent across
Member States owing to varying degrees of service coverage.

Table 4: Maternal mortality ratio (deaths per 100,000 live births) in SADC, 2010–2015
Percent
SADC Member reduction
2010 2011 2012 2013 2014 2015
States between 2010
and 2015
Angola 561.0 546.0 526.0 509.0 493.0 477.0 15%
Botswana 169.0 159.0 153.0 139.0 134.0 129.0 24%
Comoros 388.0 376.0 365.0 354.0 344.0 335.0 14%
DRC 794.0 777.0 771.0 746.0 717.0 693.0 13%
Eswatini 436.0 418.0 400.0 413.0 400.0 389.0 11%
Lesotho 587.0 555.0 549.0 532.0 513.0 487.0 17%
Madagascar 436.0 420.0 402.0 384.0 369.0 353.0 19%
Malawi 629.0 618.0 624.0 636.0 638.0 634.0 -1%
Mauritius 59.0 51.0 54.0 54.0 54.0 53.0 10%
Mozambique 619.0 596.0 563.0 528.0 506.0 489.0 21%
Namibia 319.0 315.0 299.0 283.0 273.0 265.0 17%
Seychelles N/A N/A N/A N/A N/A N/A N/A
South Africa 154.0 154.0 152.0 145.0 140.0 138.0 10%
Tanzania 514.0 483.0 464.0 438.0 418.0 398.0 23%
Zambia 262.0 251.0 243.0 237.0 231.0 224.0 15%
Zimbabwe 446.0 409.0 379.0 369.0 401.0 443.0 1%
SADC Region 424.9 408.5 396.3 384.5 375.4 367.1 14%

Source: Adapted from SADC selected economic and social indicators, 2018

Universal Health Coverage (SDG 3 target 3.8), generally defined as all persons receiving the health
services that they require, ranging from health promotion through prevention, curative, to rehabilitative
and palliative care which is effective and of good quality; delivered to the population without impos-
ing the risk of catastrophic financial expenditure to people at the point of care (WHO, 2015). Globally,
UHC is monitored using a defined index based on tracer indicators across four dimensions: reproduc-
tive, maternal, new-born and child health; infectious disease; non-communicable diseases; and service
capacity and access (WHO and World Bank, 2015, 2019).

In the 2019 monitoring report, the UHC index for the SADC Member States ranged from as low as 28%
in Madagascar to as high as 71% in Seychelles, the average being 48%. Thus, on average, only 48% of
the population in the SADC region can reliably obtain the services they need which are of good quality
and without pushing them into poverty. About 33% of SADC Member States are below the regional
average whereas 67% of Member States are above the regional average. Thus, it is evident that there
are still some gains to be realised for Member States to achieve UHC by 2030.

13
 UHC Service Coverage index, 2019

Figure 3: SADC UHC Service Coverage Index

Source: WHO/World Bank 2019 UHC Monitoring report

2.5 Health Workforce Situation across the SADC Member States

The Africa Region of the WHO which has 47 countries including all the SADC Member States has
recorded a 13% increase in the numbers of nurses, doctors and midwives between 2005 and 2015.
However, the Region continues to face a critical shortage of health workers as just 11 (23%) of the coun-
tries had at least 2.3 doctors, nurses and midwives per 1000 population by the end of 2015.

Globally, the Region bears about 25% of the disease burden but with less than 5% of the global health
workforce (World Health Organisation, 2016a). It is estimated that this current shortage of health workers
may not be significantly bridged if much-concerted efforts to tackle underinvestment in the workforce
are not made. Africa’s shortage of health workers is projected to be around 6.1 million by 2030 – includ-
ing 1.1 million physicians, 2.8 million nurses and midwives, and 2.2 million of other cadres (Cometto et
al, 2017). Whereas some 3.1 million health workers are projected to be produced, absorption capacity
(economic demand) could limit employment to only 2.4 million, leaving around 700,000 health workers
who are trained and “needed” but unemployed/underemployed by 2030, because governments may
not have the funding required to absorb and deploy them. This raises the issue of “paradoxical surplus”,
which occurs where health workers are trained and needed but governments lack the fiscal capacity to
absorb them into the service delivery structures (Asamani, et al., 2019). The following sections explore
this phenomenon and its contributory factors in the context of the SADC region, and sets out the evi-
dence base for a set of proposed strategy and policy interventions to address these challenges.

14
2.5.1 Health Workforce Stock in the SADC Region

Based on data obtained from the WHO/AFRO Survey 2018, it is estimated that the SADC region has
about 689,342 doctors, nurses, midwives and associates. Across the Member States, there are wide
variations in the density of medical doctors, dentists, midwives, and nurses, ranging from 0.9 to 120 per
10,000 population (see table 5). The average density of medical doctors, dentists, midwives, and nurses
per 10,000 population is about 19.3 as compared to the global threshold of 45 per 10,000 deemed
necessary to make sustainable progress towards universal health coverage (UHC) by 2030.

Considerable uncertainty is inherent in the aforesaid estimates given that the quality of the is not satis-
factory. Nonetheless, the data is similar to those reported in various regional and global reports and in
some cases was supplied by the Member States. The data, despite its quality concerns with a result-
ing imprecise estimate, is indicative of several challenges for example unequal production capacities,
unharmonized conditions of employment including remuneration, poorly managed migration of health
personnel and less than optimal funding of the health systems in Member States.

15
Table 5: Selected Health Workforce Stock and Densities in the SADC Member States – 2018 – a
Grand Total
Total No. Total No. No. of No. Nurses,
No. No. No. No. Density:
Member Doctors, Nurses, Pharmacists, Midwives,
Dentists & Medical Nurses & Midwives & Year Population Per 10,000 Data Source
State Associates Doctors
Dentist &
Associates Associates
Midwives & Technicians Pharmacists,
Population
Associates Associates & Associates Dentists and
Doctors

Angola 856 6593 7449 46082 1438 47520 2302 2018 57271 32 866 000,00 17.4 WHO/AFRO

Botswana 94 853 947 6935 n.a. 6935 487 2018 8369 2 352 000,00 35.6 WHO/AFRO

Comoros 32 220 252 747 487 1234 55 2018 1541 16 426 000,00 0.9 WHO/AFRO

DRC 404 31546 31950 103785 3642 107427 1687 2018 141064 89 561 000,00 15.8 WHO/AFRO

Eswatini 74 278 352 2204 14 2218 281 2018 2851 1 160 000,00 24.6 WHO/AFRO

Lesotho 159 998 1157 8245 496 8741 398 2018 10296 2 142 000,00 48.1 WHO/AFRO

Madagascar 556 5230 5786 4560 3164 7724 329 2018 13839 27 691 000,00 5.0 WHO/AFRO

Malawi 112 2760 2872 6025 n.a. 6025 387 2018 9284 19 130 000,00 4.9 WHO/AFRO

Mauritius 466 2395 2861 4419 567 4986 748 2018 8595 1 270 000,00 67.7 WHO/AFRO

Mozambique 545 2180 2725 7961 5820 13781 2310 2018 18816 31 255 000,00 6.0 WHO/AFRO

Namibia 289 1445 1734 12956 n.a. 12956 907 2018 15597 2 541 000,00 61.2 WHO/AFRO

Seychelles 152 240 392 645 4 649 135 2018 1176 98 000,00 120.0 WHO/AFRO

South Africa 6816 43503 50319 287458 n.a. 287458 16195 2018 353972 59 309 000,00 59.7 WHO/AFRO

Tanzania 682 2885 3567 31940 n.a. 31940 1845 2018 37352 59 734 000,00 6.3 WHO/AFRO

Zambia 455 2026 2481 14516 3432 17948 1708 2018 22137 18 384 000,00 12.0 WHO/AFRO

Zimbabwe 347 1959 2306 25835 854 26689 776 2018 29771 14 863 000,00 20.0 WHO/AFRO

SADC
12039 105111 117150 564313 19918 584231 30550 2018 731931 378 782 000 19.3
Region

16
Table 6: Selected Health Workforce Stock and Densities in the SADC Member States – 2018 – b

Health care
Medical
Environmental Medical assistants Medical Medical and
Community Health imaging and
and occupational assistants Paramedical Dieticians and and other and dental pathology
Member State health service therapeutic Year Data Source
health & hygiene – clinical practitioners nutritionists personal prosthetic laboratory
workers managers equipment
workers officers care technicians technicians
operators
workers

Angola 657 1 680 134 56 n.a. n.a. 328 75 98 789 2018 WHO/AFRO

Botswana 99 n.a. n.a. 58 n.a. 1 622 n.a. n.a. 460 78 2018 WHO/AFRO

Comoros 389 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 8 498 2018 WHO/AFRO

DRC 167 n.a. n.a. n.a. 535 n.a. 2 651 n.a. 2 934 338 2018 WHO/AFRO

Eswatini 187 6 324 28 29 n.a. 927 195 n.a. 370 47 2018 WHO/AFRO

Lesotho 144 14 508 71 4 29 849 110 10 205 41 2018 WHO/AFRO

Madagascar 15 35 000 n.a. n.a. 414 311 411 52 306 214 2018 WHO/AFRO

Malawi 35 10 016 2 804 98 25 178 178 n.a. 542 44 2018 WHO/AFRO

Mauritius 48 180 9 24 n.a. 1 153 315 12 291 213 2018 WHO/AFRO

Mozambique n.a. 2 205 n.a. n.a. n.a. n.a. 2 466 29 1 951 206 2018 WHO/AFRO

Namibia 218 2 292 21 1 053 33 n.a. 313 470 510 303 2018 WHO/AFRO

Seychelles 69 n.a. n.a. 36 5 258 0 11 54 3 2018 WHO/AFRO

South Africa 3 585 54 180 577 n.a. n.a. n.a. n.a. n.a. n.a. 8 072 2018 WHO/AFRO

Tanzania 578 n.a. 9 250 1 963 148 25 803 633 73 4 361 681 2018 WHO/AFRO

Zambia 2 016 1 262 2 617 n.a. 404 n.a. n.a. n.a. 1 602 602 2018 WHO/AFRO

Zimbabwe 1 644 2 143 76 1 094 n.a. 2 115 327 10 648 412 2018 WHO/AFRO

SADC
Region

17
Table 7: Selected Health Workforce Stock and Densities in the SADC Member States – 2018 – c
Other
Traditional
health Other sci-
Physiotherapists Other health and com-
Member Optometrists manage- ence profes- Social
and physiother- service plementary Year Data Source
State and opticians ment and sionals and workers
apy assistants providers medicine
support technicians
practitioners
workers

Angola 56 1 156 28 324 n.a. 468 n.a. 16 380 2018 WHO/AFRO

Botswana 1 38 n.a. 20 n.a. n.a. n.a. 2018 WHO/AFRO

Comoros n.a. n.a. 44 115 161 n.a. n.a. 2018 WHO/AFRO

DRC n.a. 395 74 310 1 608 n.a. n.a. n.a. 2018 WHO/AFRO

Eswatini 12 29 1 215 85 84 n.a. 7 2018 WHO/AFRO

Lesotho 8 22 2 130 58 416 n.a. 6 097 2018 WHO/AFRO

Madagascar 56 99 6 355 n.a. n.a. n.a. 602 2018 WHO/AFRO

Malawi 13 52 n.a. n.a. n.a. n.a. n.a. 2018 WHO/AFRO

Mauritius n.a. 64 3 295 n.a. 274 n.a. 5 2018 WHO/AFRO

Mozambique 147 377 26 735 n.a. 5 726 n.a. n.a. 2018 WHO/AFRO

Namibia 147 233 2 157 n.a. 1 739 509 8 2018 WHO/AFRO

Seychelles 25 33 n.a. 31 4 n.a. n.a. 2018 WHO/AFRO

South Africa n.a. 11 975 n.a. 15 266 8 415 n.a. n.a. 2018 WHO/AFRO

Tanzania 213 103 n.a. 3 630 3 028 n.a. 15 200 2018 WHO/AFRO

Zambia 61 606 17 801 n.a. n.a. n.a. n.a. 2018 WHO/AFRO

Zimbabwe n.a. 459 9 502 1 122 368 n.a. 5 2018 WHO/AFRO

SADC
Region

18
2.5.2 Health Workforce Needs and Supply Gaps

Using the trend of the density of doctors, nurses and midwives (which are based on data availability), a
linear extension was conducted to provide a rough estimate of the future supply of doctors, nurses and
midwives if current levels of production continue. The observed trend in the SADC region was consist-
ent with the overall trend of 13% increase between 2005 and 2015 in the African Region.

As shown in table 5a, it is estimated that in 2018 the SADC region had about 689,342 doctors, nurses,
midwives and associates which may reach 728,698 by 2020 and 975,791 by 2030 as a result of scale-up
programmes in health workforce production. However, there are expected cross-country variations in
the level of production in that some countries are likely to train more than the projected numbers while
others may train less.

Using the HWF SDG-index which is a threshold density of 4.45 doctors, nurses and midwives per 1,000
population established in the Global Strategy on Human Resource for Health by WHO as the minimum
requirement towards UHC, it is estimated that the SADC region collectively required at least 1.6 million
doctors, nurses and midwives by 2020, which it is estimated to increase to at least 2 million by 2030.

Compared with the potential supply, SADC will, by 2020, supply only 51% of its needs. It has the
potential to improve its supply capacity to 56% by 2024 and 66% by 2030. Although existing training
capacity could potentially meet almost 66% of need (in aggregate terms), given the prevailing trends
in HRH investments, reduced budgets, and cost containment across the region, those that are likely
to be employed from the supply be around 33% of the number needed by 2030 using the SDG-index
benchmark.

Table 8: SADC Needs and Supply gaps for Doctors, Nurses and Midwives
2020 2024 2030
SADC Member
States Minimum Estimated Workforce Minimum Estimated Workforce Minimum Estimated Workforce
Need Supply Ratio Need Supply Ratio Need Supply Ratio
Angola 136,599 59,240 43% 151,054 70,999 47% 172,454 93,153 54%
Botswana 13,213 8,761 66% 14,052 11,086 79% 15,321 15,782 103%
Comoros 4,933 1,587 32% 5,395 1,891 35% 6,077 2,460 40%
DRC 429,300 144,380 34% 469,312 155,834 33% 531,130 174,741 33%
Eswatini 6,473 2,714 42% 6,690 3,209 48% 7,040 4,125 59%
Lesotho 11,510 10,590 92% 12,196 12,520 103% 13,073 16,096 123%
Madagascar 115,840 14,085 12% 126,612 16,653 13% 142,560 21,410 15%
Malawi 82,937 9,552 12% 91,334 11,294 12% 103,815 14,519 14%
Mauritius 7,074 8,004 113% 7,113 9,411 132% 7,181 11,999 167%
Mozambique 130,824 17,001 13% 143,880 19,289 13% 162,926 23,311 14%
Namibia 14,038 15,659 112% 14,553 18,514 127% 15,462 23,801 154%
Seychelles 3,142 947 30% 3,333 1,074 32% 3,588 1,298 36%
South Africa 264,388 343,704 130% 280,061 370,681 132% 303,403 415,167 137%
Tanzania 250,679 40,308 16% 276,771 54,000 20% 313,985 83,734 27%
Zambia 79,299 21,276 27% 87,426 24,139 28% 99,765 29,172 29%
Zimbabwe 68,575 30,890 45% 73,796 35,913 49% 81,687 45,021 55%

SADC Total 1,618,825 728,698 51% 1,763,579 816,508 56% 1,979,469 975,791 66%

19
The foregoing presents an emerging challenge where in some SADC Member States where there are
inadequate funded positions to absorb trained health workforce even though there are substantial
normative staffing gaps – the paradox of surplus health workers within a country with a critical need-
based shortage. In the self-assessment and consultative process, Member States indicated that in
some instances, trained health workers have remained unemployed for periods between one and three
years before being absorbed. This also raises an additional concern of how to keep the practical skills
of health professionals up to date when they remain unemployed for such a considerable period.

During the technical consultations, most Member States indicated that delayed and limited absorp-
tion of newly trained health workers had become pressing policy issues in their context, which was
mainly attributed to limited post establishments (funded positions) as a result of budgetary constraints
and sometimes restrictive and outdated staffing norms/standards. Some countries were mitigating this
delay by offering internships to new graduates and would employ as and when vacancies and funding
become available. The participants of the ILO tripartite technical workshop for the SADC region pointed
towards the general mismatch between demand for and supply of health workers (ILO, 2019). To com-
pensate for workforce gaps, sometimes excessive overtimes are used which may at the same time con-
stitute a constraint for job creation in the health sector. The foregoing therefore calls for country-specific
robust labour market analysis and investment cases for enhanced policy and social dialogue to priori-
tise health workforce employment across the sector as a whole, including the NGO and private sectors.

2.5.3 Health Workforce Leadership, Governance and Policy

This section covers the areas of leadership, advocacy, policy, and governance. The leadership and
advocacy dimension covered five items which include human resources for health (HRH) prominence
within respective Ministries of Health; political support for HRH; the influence of HRH leaders or cham-
pions; strength of an HRH observatory, stakeholder or technical working group and media coverage
for HRH.

Strengthening leadership and governance capacity entails improving policy dialogue and establishing
clear mechanisms for coordination between line ministries, the private sector and other stakeholders
(Afriyie et al., 2019). The WHO Regional Roadmap for scaling up human resources for health in Africa
(WHO, 2012) identifies weak governance and leadership for HRH as a priority area for intervention.
A well-functioning health system with equitably distributed healthcare infrastructure underpinned by
transparent and accountable leadership and governance has been shown to influence staff motivation
and acceptance of postings to district and sub-district levels (Lehmann et al., 2008). Appropriate and
sustained leadership skills have been linked to increasing staff productivity and retention (Asamani et
al., 2016).

20
During technical consultations, SADC Member States who responded to the self-assessment indi-
cated an HRH prominence in their respective Ministries of Health where a permanent HRH office or
post within the Ministry of Health develops and monitors HRH policies and strategies. However, some
Member States indicated challenges with high mobility of HRH leaders within the public service (i.e.
frequent changes to administrative leadership) which has an adverse impact on continuity and capac-
ity. It was also gathered that Member States make use of Technical Working Groups / Observatory /
HRH Committees (however named) as a mechanism for stakeholder coordination and policy dialogue.
However, while some countries mentioned that these bodies are vibrant, have sub-committees and
have regular meetings, others indicated that these bodies may have the inadequate capacity and not
optimally institutionalised. Additionally, countries had various degrees of engagement with other sectors
including non-governmental organisations.

A recent analysis by the WHO Regional Office Africa demonstrated that by 2014, only 14 out of 47 coun-
tries (about 30%) in the Africa Region had comprehensive and costed HRH plans in place, the majority
had some drafts many of which remained for long (Afriyie et al., 2019). Consistent with this finding, a
considerable number of SADC Most Member States during the consultations indicated that they had
no current, comprehensive and costed HRH strategic plans in place. In most SADC Member States,
the plans were either in draft form or processes were being initiated to develop/review the HRH plan.
Member States indicated that while their HRH strategy is informed by analysis of country-level data, the
implementation of these plans is often constrained due to limited funding available.

2.5.4 Education and Training Efforts

Over the last decade, there has been 4% to 13% scale-up in the training of health workers which is sim-
ilar to the overall African average. Indeed, all Member States who participated in the technical consul-
tation indicated that there have been efforts to scale-up their supply pipelines through the training and
deployment of health workers, which has led to improvements in health workforce density. Two-thirds of
Member States who responded indicated the existence of a comprehensive approach to health work-
force education through existing training plans which are gender-responsive in terms of equal access
to training.

In terms of quality of health workforce training, Member States indicated the availability of quality cur-
ricula that align with national health priorities, but inadequate faculty, infrastructure, equipment, and
practice sites tend to pose a challenge in translating the curricula into an acquired skill for the students/
trainees. Across the Member States, various regulatory bodies conduct monitoring exercises to ensure
quality assurance standards related to training are met. Nevertheless, Member States indicated and
registered concern regarding the variations in the quality of training; and requirements for professional
recognition / registration for similar health worker categories across the SADC region. Some regulatory
bodies, under the auspices of SADC, have therefore begun to work towards harmonizing their regula-
tory frameworks for the licensing of health professionals.

21
Owing to inadequate faculty as well as limited capacity to train adequate health workers, especially for
the highly skilled and specialized medical professionals, some Member States (especially small popula-
tion countries) rely on training abroad (from which some of the trainees do not return upon completion
of their studies) and also in recruiting health workers from other countries. None or extremely limited
information was immediately available on training slots (theoretical capacity) per programme by country
as well as graduation and certification rates. However, in one-third of SADC Member States, it was
indicated that student drop-out rates were low, between 3% and 6% - the most cited reasons for the
drop-outs was lack of financial resources.

To mitigate cases of extreme financial barrier to health workforce training, it was gathered that most
governments of SADC Member States allocate some funding for both pre-service and in-service edu-
cation, including Continuing Professional Development (CPD). Member states further asserted that the
allocation of funding is based on training needs assessments to identify training gaps. These are,
however, mostly focused on clinical areas while managerial and administrative related training appears
neglected.

2.5.5 Absorption, Distribution and Retention

Member States self-reported based on their country contexts, issues and challenges relating to how the
analysis of shortages and labour market dynamics are undertaken; absorption of pre-service education
graduates; effectiveness (and transparency) of health workforce recruitment strategies; effectiveness of
health worker deployment and distribution strategies and the effectiveness of health worker retention
strategies.

Seventy-seven per cent (77%) of Member States indicated that their national recruitment and distribu-
tion of the health workforce is based on HRH planning and is linked to public service statutes. However,
most Member States underscored significant financial constraints in rapidly employing / absorbing
health workers soon after graduation, an observation that corroborates empirical analysis in the pre-
vious section. Member States believed that their recruitment processes are transparent albeit linked
to the broader public service policies and procedures which has inherent layers of bureaucracies that
inhibit the speed of recruitment.

Globally, equity in the distribution of health workers is a lingering thorny issue which is influenced by
political decisions, wages/salaries, social living conditions and individual health worker factors, among
others. In the context of Africa, it was previously estimated that 29-53% of all health workers are not
equitably distributed whilst over 90% of pharmacists, 86% of medical specialists, 63% of general physi-
cians and 51% of nurses/midwives work mainly in urban areas (WHO/AFRO, 2006). During the technical
consultations for this strategic plan, Member States acknowledged worrying levels of inequities in health
workforce distribution, especially in underserved areas. In addition, 55% of SADC Member States indi-
cated a need for evidence-based deployment and distribution strategies in their respective countries.
Only a few countries have used evidence-based tools such as Workload Indicators of Staffing Need
(WISN) as a guideline for the equitable redistribution and deployment of health workers.

22
All Member States indicated that retention and staff turnover in underserved and hard to reach areas
remains a problem, and while countries have some form of rural and remote incentive scheme, there is
a need for the strategy to be reviewed. Further emphasis was placed on the migration of higher-skilled
health professionals to other countries and the private sector which continues to deplete the existing
workforce stock.

2.5.6 Human Resources Management

The dimension for Human Resources Management includes: human resources management (HRM)
leadership capacity and availability; existence and availability of human resource manuals/guidelines; per-
formance management practices; performance evaluation and results; career development; health
workforce occupational safety and health (OSH) strategy; non-discrimination, equal opportunity, and
gender equality in the workplace and enabling health workforce performance and productivity.

All Member States indicated the existence and availability of human resource functions, processes,
manuals and/or guidelines, albeit linked principally to public service rules and regulations. However,
most countries expressed concerns over the insufficient numbers of HRM leaders across the sector
and inadequate capacity and training of HRM practitioners and managers, especially at sub-national
and district levels. Most countries indicated that issues with performance management and health
worker productivity levels were regarded as suboptimal and associated measures, rewards and sanc-
tions were applied ineffectively. In terms of career development, some Member States indicated a need
to develop and strengthen career pathways for various professional cadres. Additionally, some coun-
tries indicated that career development is based on merit, health facility needs and individual healthcare
workers’ preferences.

All Member States indicated the existence of a national occupational health and safety (OSH) strategy
that covers the broader public service, under the responsibility of the Ministries of Labour. However,
there are few OHS programmes and strategies that are specific to the unique context and operational
environment of the health sector. This is an area requiring attention is given to the emerging occupa-
tional health and safety risks of COVID–19 International Health Regulations (IHR), international labour
standards, such as the Occupational Safety and Health Convention, 1981(No. 155), and the Violence
and Harassment Convention, 2019 (No. 190), and related public health emergency measures.

2.4.7 Gender

Member States indicated that they aim to ensure equitable and fair practices with respect to the gender
of the health workers. Nevertheless, gender disparities in the health workforce remain an issue for many
countries. A key theme of the SADC health workforce strategic plan will be to guide member states to
identify, address and eliminate gender inequities, notably as they relate to participation, occupational
segregation by gender, leadership, decent and safe work including bias and discrimination in the work-
force, as well as the working environment, and gender pay gaps. A first step in addressing this is by
mainstreaming gender equality, equity, rights, protection and economic participation throughout this
strategic plan. In some instances, where pervasive gender gaps exist an explicit gender analysis may be
necessary to inform the needed policy measures to achieve gender balance – with measurable targets
and indicators.

23
Additionally, to advocate member states to collate and use workforce profile data disaggregated by
gender/sex and other aspects of personal identity (i.e. ethnicity, language) in all policy, decision mak-
ing and reporting processes. Proposed investment in the health workforce should be cognizant of the
need to promote gender-responsive policy across and opportunities for gender transformative change.
Including, but not limited to key areas, such as: equal pay and the recognition of unpaid and underpaid
work in the health and social sector; decent work – with respect to the work environment, safety and
protection; equal access and opportunities in training, education recruitment and promotion; and elim-
inating harassment, violence, and sex discrimination in the workplace, all of which have an important
gender component.

2.5.7 Accreditation and Regulation

All Member States indicated the existence of professional councils that regulate licensing and cer-
tification. These professional bodies also ensure that health worker classifications and their related
scopes of practice are recognized and defined. Most Member States who responded indicated that
health workers need to demonstrate CPD credits to ensure certification and re-licensure and that this
is done through the various professional bodies in their countries. However, countries indicated a need
to strengthen this process or a specific coordination programme to be developed to ensure that the
criteria are applied to all health workers consistently.

Member States also expressed concerns about lack of uniformity and inconsistencies in the standards
of training health professionals and requirement for professional licensing across and between member
states. It was noted that efforts to establish a harmonized health professions regulatory mechanism are
being initiated by SADC, which is timely and hopefully will be expanded to cover all health professions.
This is an important initiative by SADC which will be used as a foundation for the regional recruitment
pool.

2.5.8 Monitoring, Evaluation, and Information Systems

Some Member States indicated various degrees of efforts aimed at improving the availability and use
of health workforce data, information, and evidence. The main challenge in this area has been weak
technical capacity and lack of or poorly implemented Human Resources Information Systems (HRIS).
Unfortunately, there no comprehensive data on the sector as a whole; incomplete data; limited integra-
tion and interoperability of data sets. Many countries indicated that monitoring and evaluation relating
to the health workforce is not fully institutionalised. In line with the various World Health Assembly res-
olutions to strengthen health workforce data and evidence, most Member States were at various initial
stages of implementing National Health Workforce Accounts (NHWA).

24
2.5.9 The Impact of COVID–19 Pandemic on Health Workers

Health workers face several occupational risks in their daily work. These include, for example, risks asso-
ciated with biological, chemical, physical, ergonomic, and psychosocial hazards thus increasing the risk
of occupational disease and injury on them, patients, quality of care and the overall resilience of health
systems at risk. The COVID–19 pandemic exacerbated these risks and highlighted the need for strong
occupational safety and health measures and policies in addition to infection prevention and control
measures. At the beginning of 2020, the SADC region reported its first case of the COVID–19 disease.
The pandemic has since spread rapidly across many countries in the region, impacting severely on
their economies, health systems, and society. As of 1 September 2020, accumulative total of 1 056 448
COVID–19 cases was reported in the region of which 860 927 (82%) have recovered from the disease.
The SADC region has the highest number of registered cases 66% (701,146) in Africa. South Africa has
registered more than half, 59% (628,259) of all reported confirmed cases in the region. Furthermore,
there is an increase in infections among health workers. About 27,736 health worker infections have
been reported in 14 countries in SADC region since the beginning of the outbreak. Overall, South Africa
has been the most affected, with 25,841 of its health workers infected as of 2nd September 2020.

Although the impact of COVID–19 on health workers has not been fully evaluated, is cause for con-
cern for the SADC region. It is the frontline healthcare workers that face a substantially higher risk of
infection and death due to excessive COVID–19 exposure (Shaukat et al, 2020). The pandemic has also
highlighted the extent to which protecting health workers is key to ensuring patient safety as well as a
functioning health system and a functioning society (WHO, 2020). This therefore emphasizes the critical
need to ensure they have access to personal protective equipment, the latest infection prevention and
control protocols, regular testing, and ultimately are prioritized as a key group for accessing COVID–19
therapeutics, treatments and vaccines through the Access to COVID–19 Tools (ACT) Accelerator and
COVAX initiatives when initial supplies are readily available. Their high risk of exposure causes consid-
erable mental stress, resulting in high levels of anxiety and post-traumatic stress disorders with nurses
being the most affected (Chersich et al, 2020). Other envisaged implications include increased workload
leading to potential burnout, declined enrollment in health training programmes, among others. Figure
4 shows the number of health workers infected in the SADC region.3

Figure 4: Health Worker COVID–19 infections in SADC region

Source: WHO COVID–19 External Situation Report 27
3
Source: WHO COVID–19 External Situation Report 27

25
In September 2020, WHO released Health Worker Safety Charter that provides guidelines on how to
ensure that health workers have the safe working conditions, the training, the pay and the respect they
deserve. The Charter calls on governments and other actors providing health services at local levels
to take five actions to better protect health workers. These include steps to protect health workers
from violence; to improve their mental health; to protect them from physical and biological hazards; to
advance national programmes for health worker safety, and to connect health worker safety policies to
existing patient safety policies.4 In light of the above emerging implications of COVID–19 on the health
workforce, it is recommended that SADC prioritizes a rapid assessment on the impact of COVID–19 on
health workers by mid-2021 and adopt additional interventions to address the impact of COVID–19 on
the health workforce in the region.

2.6 Framework for the SADC Health Workforce Resource Pool

Rationale for a SADC Resource pool: Whilst Member States of SADC continues to train a significant
number of health professionals, the challenge of excessive health workforce migration is also a chal-
lenge where some health workers seek employment in better resourced health systems outside their
countries of origin. However, despite the importance of health worker migration, estimates remain
imprecise, hampered by poor administrative data collection (Azose, 2019). Also, some Member States
do not have adequate domestic capacity to train certain cadres of health workers at graduate and post-
graduate level especially medical specialists (SADC 2019). They thus depend on external recruitment
to fill critical health workforce gaps health service delivery. This has led to a decision by SADC Member
States to develop a mechanism for a health workforce pool where countries that cannot produce locally
can recruit from others. It is envisaged to be applicable for both specialist and non-specialist health
professionals.

There are existing guiding protocols which relate to the recruitment of health personnel e.g.
Commonwealth Code of Practice for the International Recruitment of Health Workers (2003), Kampala
Declaration (2008), and the WHO Code of Practice on the International Recruitment of Health Personnel
(2010). The WHO Code was influenced by the uncontrolled health personnel migration experiences of
developing countries and provides a backdrop for a SADC regional framework on intercountry recruit-
ment. Relevant international labour standards on labour migration also apply, including the Migration
for Employment Convention (Revised), 1949 (No. 97) and Migration for Employment Recommendation
(Revised), 1949 (No. 86); the Migrant Workers (Supplementary Provisions) Convention, 1975 (No. 143)
and Migrant Workers Recommendation, 1975 (No. 151); the Private Employment Agencies Convention,
1997 (No. 181), and the Maternity Protection Convention, 2000 (No. 183).

The Africa Health Strategy 2007 – 2015 identified, inter alia, the following workforce related challenges
as contributing to the efforts to reduce the disease burden being undermined: a shortage of appropri-
ately trained and motivated health workers, capacity of the private sector including non-governmental
organisations not fully mobilised; lack of intersectoral action and coordination; and gaps in governance
and effective leadership of the health sector. These factors will play a role in the applicability and rele-
vance of the envisaged SADC health workforce recruitment pool.

4
Source: WHO’s Health Worker Safety Charter, September 2020

26
A likelihood exists that the establishment of a regional recruitment tool may have an impact on health
worker migration patterns. There is no existing evidence which points to any SADC country having
developed a monitoring system for health worker migration (Mahlathi & Dlamini, 2015). This therefore
necessitates that the SADC Secretariat becomes the best placed organisational unit to develop, man-
age, and monitor a regional recruitment pool. Whilst implementation and actual activity will be at coun-
try level, the integrity of the system will be the responsibility of the SADC Secretariat.

Guiding Principles: Whilst the AU Protocol to the Treaty Establishing the African Economic Community
Relating to Free Movement of Persons, Right of Residence and Right of Residence objective is to facili-
tate the progressive implementation of free movement of persons, there is currently inhibitions regarding
the ability of health workers to cross borders in search of work. The establishment of a regional health
workforce recruitment pool will be guided by the following principles.

a. The SADC Secretariat is the custodian of the recruitment pool

b. In operationalising the recruitment pool, consideration is given to the WHO Code international
labour standards and similar policy instruments that impact on SADC
c. The pool is established based on voluntary structured cooperation between two or more
countries
d. The recruitment pool is developed and organised based on the underlying SADC and national
legal frameworks, diplomatic and policy instruments
e. It allows for wide participation by various stakeholders e.g. health agencies, health care provid-
ers, education institutions, research institutions, regulatory / statutory bodies, or other relevant
health sector actors
f. Each Member State must establish / strengthen and maintain an updated database of laws and
regulations relating to the recruitment of health personnel including migration
g. Each SADC Member State must submit to the SADC Secretariat data relating to its health
needs that justify the need to recruit from other Member States

Success Factors: This framework is an overarching mechanism, and its principles take precedence.
Bilateral or multilateral arrangements predating this mechanism must be reviewed and harmonised
with this framework. Voluntary bi- or multilateral cooperation agreements can help address the health
workforce challenges that often force patients to travel outside their countries to find appropriate care
(Kroezen et al, 2017).
Accreditation: relates to the recognition of education and training which leads to the accreditation of
the health practitioner qualifications.
Diplomatic: relates to political relations between countries and within the region that create an
enabling environment for cooperation to thrive.
Economic: relates to intercountry trade and economic relations that impact on health goods and
services which in turn have considerable financial implications in areas like specialist
care.
Legislative: relates to the institutional frameworks including legislative requirements of registered
practitioners including policies on employment of non-resident health practitioners.
Social: encompasses several factors including organisational culture, language and socio-
cultural practices that impact on communication and health seeking behaviours of
the population.
Leadership: relates to the way the national health system and relevant organizational divisions are
led influences staff attitudes and can act as either an attraction or repellent to health
professionals, thus affecting the stability of the health workforce.

27
CHAPTER
03
STRATEGIC DIRECTIONS FOR THE
HEALTH WORKFORCE IN THE SADC
REGION

3.1 Introduction
SADC Member States have experienced a shortfall and continued underinvestment in the number,
availability, and quality of their human resources for health. The causes for these have ranged from
interrelated factors such as limitations in the coordination, integration and use of workforce planning
and projection models to inform the delivery of essential services, and limited strategic management
and development of the workforce; all of which contribute to persistent imbalances in skills mix, urban
versus rural deployment, distribution, retention, and the effective utilisation of the workforce across
member countries. These issues are further exacerbated by the impact of unregulated and uncoordi-
nated health worker mobility and external migration – both between member states and beyond the
SADC region. Against this background, and building on the previous SADC HRH Strategy with the view
to deliver on the SADC region’s collective future health and developmental priorities, and related SDG
targets, this consolidated, evidence-based and costed SADC Health Workforce Strategic Plan provides
the basis to implement investment to impact on health, skills, jobs and economic growth.

3.2 Theory of Change

SADC Health Workforce Strategic Plan’s overarching goal is to enable investments by Member States
in health workforce development and decent employment as a catalyst to achieving universal
health coverage. The achievement of this goal will be driven by interventions informed by a theory of
change (TOC) anchored on three (3) key strategic catalysts namely accountability and data; partner-
ship and dialogue; and learning and decision making. Figure 5 depicts interrelationship of facets of
this Theory of Change. Below is operational description of these catalysts drawn from the recommen-
dations of the Commission on Health Employment and Economic Growth (HEEG).

• Accountability and Data: Through the SADC Human Resources for Health Technical Committee,
initiate and adopt a mechanism to inform evidence-based policy and decisions related to invest-
ments and efficient management of health workforce. Accountability would be achieved through
robust data, research, and analysis of health labour markets, using harmonized metrics and meth-
odologies to strengthen the evidence, accountability and action.

29
• Partnership and Dialogue: Denotes collaboration and dialogue with various sectors and stake-
holders at national, regional, and international levels to support investments in the health work-
force. For example, Member States are expected to institute a mechanism to enhance collab-
oration between ministries of health and labour to create an investment case for health worker
skills, education, and jobs. Additionally, through enhanced collaboration between health sciences
faculties in the region – including the designation of regional training centres of excellence where
dedicated slots for specialised trainings will be reserved for Member States without such training
capacity, standardised competency frameworks and professional regulatory mechanisms across
the region among other interventions.

• Learning and Decision-making: This implies creating a policy and social dialogue platform under
the SADC Human Resources for Health Technical Committee, where health workforce managers
and social partners have the opportunity to shape the agenda, make collective decisions, and
address key challenges by implementing priority workforce actions and interventions. This mul-
ti-stakeholder consultative and learning platform will also serve as a peer-to-peer support network
and a key accountability mechanism for the strategy’s implementation.

Figure 5: Theory of Change

3.3 Strategic Directions and Interventions

The SADC Health Workforce Strategic Plan 2020-2030 has five (5) strategic directions (SDs) namely
(1) Invest in health worker jobs and decent employment, (2) Harmonise Education, Training and
Development, (3) Establish best practices in strategic HRH Leadership and Management, (4) Enhance
Health Workforce Governance and Regulation, and (5) Develop and Use Reliable Data, Monitoring and
Evaluation Systems. Each strategic direction has a set of interventions that will inform resource alloca-
tion to actualize the plan. An implementation framework (chapter 4) details the steps, with timelines, that
need to be taken by SADC Member States and partners.

30
3.3.1 Strategic Direction (SD) 1: Investment in health workforce jobs and
decent employment

Employment and decent work in the health sector are fundamental for ensuring the effective function-
ing of resilient health systems; a prerequisite for addressing health workforce shortages and achieving
equity in access to high-quality health services for all. This should include the planning, production and
absorption of trained health workers and new graduates. Of equal importance is ensuring that these
health workers are attracted, deployed, appropriately supported, enabled, retained, and adequately
protected in community and facility settings where the need is greatest. It is equally important that
the financing of HRH programmes and interventions for increasing jobs and skills are driven through
significant investments that guarantee health, economic and developmental impact, and sustainability.
The objective is to ensure adequate budget allocations by the Ministries of Finance and appropriate
investments by Ministries of Health, labour, education, and other social sectors in programmes that
will ensure the sustainability of HRH availability and investment to catalyse creation of decent jobs and
improving skills, aligned to the country’s National Human Resource for Health Strategy. This is premised
on astute utilisation of existing resources through efficient investment in HRH. The following are key
interventions to drive investments in health workforce jobs and decent employment.

SD1.1 Develop health workforce investment plans based on robust evidence that quantify
health workforce needs, demands and supply that respond to the population’s needs
and economic realities.

SD1.2 Expanding the fiscal space for the health sector to enable increase investments in skilled
health workforce, decent employment, and retention of health workers in line with the
national health workforce investment plan.

SD1.3 Develop occupational health and safety policies and programmes that protect health
workers from occupational hazards and risks in accordance with national legislation and
backed by effective enforcement mechanisms in line with the relevant international labour
standards, as well as the ILO–WHO Joint Global Framework for National Occupational
Health Programmes for Health Workers.

SD1.4 Improve the working conditions and remuneration of health workers including competi-
tive and gender-equitable salaries, guided by a SADC reference remuneration package,
to improve retention and reduce turnover.

SD1.5 Mainstream gender equality in strategies and approaches to the health sector work-
force. This includes strengthening policies and strategies to promote and ensure equal
opportunities, participation and treatment of women and men, including equal remuner-
ation for work of equal value, and the development of gender-responsive legislation, pol-
icies, and measures for a health sector workplace free from violence and harassment.

31
3.3.2 Strategic Direction (SD) 2: Harmonisation of Education, Training and
Development

Quality education, training and continuing development are key ingredients of a functional health sys-
tem. Member states should develop effective policies, aimed at facilitating the transition from educa-
tion and training to work, with emphasis on the effective integration of young people into the health
workforce. Ongoing improvements to ensure that the health workforce obtains and applies the relevant
competencies and skills to meet current and future needs will assist in the provision of quality health
care and services. It is, therefore, essential to develop and continuously improve the quality of educa-
tion and training programmes to produce and enhance the future skills base and competencies of the
workforce. The Member States will prioritise the following interventions for harmonisation of education,
training, and development:

SD2.1 Harmonised accreditation of training programmes and health training institutions.

SD2.2 Scale-up the training of specialist health professionals in line with current and emerging
population health needs in all Members States.

SD2.3 Ensure access to education opportunities in health based on principles of equality and
affordability, inclusive of youth and women.

SD2.4 Strengthen cooperation and collaboration between health sciences faculties in the
region – including the designation of regional training centres of excellence where ded-
icated slots for specialised trainings will be reserved for Member States without such
training capacity.

SD2.5 Establish a SADC health workforce development scheme that will provide or facilitate
the acquisition of competitive scholarships and research grants for health workforce
research.

3.3.3 Strategic Direction (SD) 3: Develop and adopt best practices in

strategic HRH Leadership and Management

A major reason for the prolonged and persistent health workforce shortages and underinvestment
across the Member States is the lack of evidence-based planning, policy, and decision-making capa-
bility. To drive reforms and investment in the health workforce, a critical mass of enabled, competent,
and skilled HRH managers, analysts and planners are needed to ensure that the Member States have
the capacity for strategic human resource management, planning and development. This is to enable
informed and evidence-based policy choices that translate into actionable implementation and invest-
ment plans for the health workforce. Efforts in this strategic direction are aimed at ensuring the develop-
ment of systems and tools for improved systemic HRH leadership and management; as well as improv-
ing the capability and capacity of HR practitioners in planning, resourcing, developing, and managing
the health workforce. Priority Interventions under this strategic direction include:

SD3.1 Establish (for Member States that do not currently have) HRH Departments/Directorates
in MOH/Service delivery agencies to champion the mainstreaming of health workforce
issues in all health policies and interventions at all levels of the health system.

32
 SD3.2 Strengthen Member States capacity in health labour market analysis, HRH planning,
development, and management through the application of evidence-based tools.

SD3.3 Institute a health workforce leadership capacity development training for HRH managers
within the region.

SD3.4 Institute an annual SADC forum of health workforce managers and social partners dia-
logue to discuss progress and challenges in the implementation of priority interventions
and also serve as peer-to-peer support and accountability mechanism.

SD3.5 Enhance collaboration and social dialogue between all relevant stakeholders and
strengthen, at the national and regional level, coordination mechanisms among govern-
ments, workers, employers and other relevant stakeholders to promote decent work in
the health sector.

3.3.4 Strategic Direction (SD) 4: Enhanced Health Workforce Governance

and Regulation

Most health practitioner classifications are regulated. Thus, the way that the health professions are gov-
erned and regulated provides a major reflection on the influence they wield beyond formal structures.
Profession-specific governance systems are partly where practitioners derive the associated profes-
sional authority through licensure and being guided by Codes of Ethics. The leadership of health work-
ers must be immersed in improving governance systems and mechanisms in line with societal expec-
tations and the application of best practices. SADC Member States have a responsibility to establish
and enable regulatory mechanisms that provide oversight of all aspects of HRH, especially education,
training, practice, and migration. The attainment of this strategic direction will be hinged on enabling
health worker leaders to address the contextual challenges of evolving health priorities and systems by
ensuring fair regulatory environments, development of competencies in policy development, manage-
ment, and evidence generation. Member States will implement the following priority interventions to
enhance health workforce governance and regulation:

SD4.1 Establish (for Member States that do not currently have) health workforce regulatory
bodies for all health professions to uphold professional standards and safeguard public
safety.

SD4.2 Develop a SADC framework with compliance criteria for mutual and reciprocal recog-
nition of health professions education and qualification through the adoption of minimum
curricula content and harmonisation of regulatory mechanisms.

SD4.3 Strengthen the health workforce governance structures through sharing of good prac-
tice and relevant WHO guidelines.

SD4.4 Institute mechanism to foster multisectoral collaboration and cooperation between the
public and private sector to create synergies by sharing HRH resources.

33
3.3.5 Strategic Direction (SD) 5: Develop Reliable Data, Monitoring and
Evaluation Systems

Member States continue to experience challenges with data collection, analysis, use, monitoring and
evaluation. This is ascribed to a variety of factors including limited ICT, data inoperability capacity and reli-
ance on manual systems. There are also challenges posed by the lack of advanced Human Resources
Information Systems (HRIS) including systems that are inadequate to cater to their information require-
ments and demands. The SADC Member States should aim to apply robust evidence and data for
guiding health workforce policy, planning and investment. In addition, they must regularly monitor and
report on key HRH indicators and metrics across the region. This strategic direction seeks to guide the
development of Human Resource Information Systems and capabilities across member states, with
appropriate tools and guidelines for the efficient management of the health workforce. Member States
will strengthen data, monitoring and evaluations systems through the following interventions:

SD5.1 Develop and/or strengthen human resource information system that is scalable and
interoperable with routine health information systems.

SD5.2 Strengthen the implementation of National Health Workforce Accounts (NHWA) and
Human Resources Observatories to improve data availability, quality and use for policy
and decision making.

SD5.3 Improve multi-sectoral dialogue for improved management of the health workforce
through the NHWA and HRH Observatories.

SD5.4 Develop the competencies of HRH staff through reliable tools and guidelines for moni-
toring and reporting on standard key HRH indicators and scorecards (country-specific
and regional) across SADC member states.

SD5.5 Develop integrated metrics of health worker safety indicators and integrate with health
information system.

34
CHAPTER
04
IMPLEMENTATION ARRANGEMENTS

The combined efforts of the Member States are required to adapt and implement this SADC Health
Workforce Strategic Plan within their respective HRH, health, and broader national development strat-
egies. The SADC secretariat will provide the accountability platform and mechanism for coordinating,
monitoring, and reporting on the implementation of the strategy across member states.

4.1 Implementation Mechanism

The strategic plan implementation process should adopt a consultative multisectoral approach, involv-
ing different stakeholders including non-state actors (CSOs, FBOs/NGOs, private sector, development
and Implementing partners), and state actors (government Ministries, Departments and Agencies) at the
Member State level. The Health Workforce Strategic Plan will be implemented through member states’
work plans, which set out and operationalise more detailed activities for priority interventions. Several
structures and stakeholders will be key for ensuring accountability and implementation of the strategic
plan. Collaboration between member states in terms of operationalising and implementing the strategic
plan will be carried out through the SADC Human Resources for Health Technical Committee, with the
SADC Secretariat playing and overall coordination role.

Political level: The SADC Ministers of Health will provide overall high-level policy guidance to inform
the implementation of the strategic plan. This is expected to be particularly important because of the
need to engage inter-sectoral collaboration with health and other key partners sectors/ministries such
as education, labour, social welfare, finance, and foreign affairs, among others. The Ministers in charge
of Health provide policy guidance, leadership, and accountability for implementation at Member State
level.

Operational and technical level: The SADC Secretariat, through the SADC HRH Technical Committee
will coordinate the implementation of the strategic plan. The Secretariat will also be responsible for
implementing integrated interventions such as formulation of the regional protocol on health worker
resource pool, and coordination of monitoring and evaluation activities. The Secretariat will provide reg-
ular progress reports and plans to the Ministers for decision-making and approval.

4.2 Role of the SADC HRH Technical Committee

The SADC HRH Technical Committee (SADC HRH Managers’ Forum) will be the implementation arm of
the SADC Secretariat for the purposes of operationalising this strategic plan. The Technical Committee
has a key role in operationalizing the strategy and mobilizing resources and technical support as well as
facilitate information sharing, mutual support, and multisectoral coordination between partners imple-
menting HRH initiatives at a national level and between member states. The SADC Secretariat will
ensure coordination and accountability for implementation through member states and will expedite the
ratification of regional-specific protocols, development of enforcement mechanisms and appropriate
institutional framework to facilitate implementation of the strategic plan.

36
The key responsibilities of the HRH Managers’ Forum are provision of guidance and technical support.
These are listed below:

• Act as a key link between Member States and the SADC Secretariat.

• Set a regional agenda for adoption and implementation of the workforce strategic plan.

• Monitor and evaluate the implementation of the strategic plan.

• Advise on operations research to identify evidence-based policy options.

• Promote the sharing of best practices across member states.

• Advance technical cooperation between countries on areas such as health workforce education
especially curricula, regulation of the health professions, advice on evidence-based deployment
and retention strategies.

• Promote gender mainstreaming in all aspects of health workforce including promotion of intersec-
toral collaboration at both regional and country level.

• Support Member States with training on health workforce modelling, planning, costing of national
strategies on human resources for health and conducting health labour market analyses.

4.3 Role of the SADC Secretariat

The SADC Secretariat will develop a technical assistance (TA) plan to guide support to Member States
requiring additional expertise to implement certain interventions. Its key responsibilities are advocacy
and promotion of compliance by member states. These are highlighted below:

• Facilitate annual reporting by countries utilising a minimum set of core indicators of human
resources for health, for monitoring and accountability for the Regional Strategy.

• Support Member States to establish and strengthen the quality and completeness of national
health workforce data.

• Develop a SADC multilateral framework on health workforce mobility (or health workforce pool) as a
mechanism for ethical cross-country recruitment of trained health workers within the SADC region.

• Adapt, integrate, and link the monitoring of targets in the Regional Strategy to the accountability
framework of the UN Sustainable Development Goals.

• Present recommendations for regional action to be taken by Member States and relevant
stakeholders.

• Promote the role of multisectoral partnerships at country level by encouraging regular formal engage-
ment with sectors like education, social welfare, treasury, labour, donors whilst at regional level this
would include for example bodies like WHO, International Labour Organisation, and others.

37
Member State (MS) level: The Ministries or Departments of Health will coordinate with key sectors
including the labour, employment, education and other social sectors on the implementation of this
strategic plan, with a specific focus on securing domestic and donor resources and investments for
its implementation; with an emphasis on mobilizing additional funds to drive investments in skills, edu-
cation and jobs, and to empower the economic participation of women and youth in employment and
decent work in the health sector. Through its HRH Technical Committee, the SADC Secretariat will work
closely with Member States including designated institutions or centres of excellence, as well as with
regional and international partners to coordinate the integration country-specific strategies and policy
interventions into their national health workforce strategies and implementation plans. Through the
guidance of the SADC HRH Technical Committee, member states will ensure that the regional health
workforce initiatives are integrated into their health plans, monitor implementation of programmes at MS
level and provide feedback to the SADC Secretariat. To ensure wider collaboration and engagement
on the plan, Member States should seek to establish and/or further strengthen existing multisectoral
and multi-stakeholder HRH coordination mechanisms and platforms, including regional or country-level
HRH Observatories.

4.4 Implementation Plan

The following is provided as a basic implementation framework that aligns country to the SADC Health
Workforce Strategic Plan and can be adapted at country level. It is acknowledged that a Member State
may have additional strategic goals/objectives than expressed in the SADC Strategic Plan.

However, these should as much as possible link and relate to the broad strategic objectives as espoused
by the Strategic Plan. It should be noted that the key to a successful implementation of this strategic
includes the Ministries of Health possessing staff that has the appropriate knowledge and skills in the
various fields to enable its operationalization.

Since many of the interventions expressed under each Strategic Direction are essentially part of a
process, it is expected that Member States will ensure harmonisation to fit in their operational sys-
tems. Activities and/or interventions are therefore not limited to those mentioned in this document. In
the course of implementing this strategic plan there are several activities that responsible authorities/
departments/divisions at Member State level will undertake. These will vary in intensity, period of appli-
cation and even nature depending on contextual issues. In the following implementation matrices, the
words “maintain activity” appear to denote the need to ensure maintenance of the activity which will
lead towards achievement of the goal/objective.

38
 Implementation
Integration with health sector strategic plans and national development framework/plan

of agreed expan- Implement gender

2030

Maintain Maintain Assessment and

sion of fiscal Maintain activity mainstreaming
activity activity adjustment
space (budget interventions
ceilings)
Implementation
Assess and of agreed expan- Implement gender
2029

Maintain Assessment and

readjust sion of fiscal Maintain activity mainstreaming
activity review
accordingly space (budget interventions
Strategic Direction 1: Investment in health worker jobs and decent employment Milestones, Activities, Resources and Timelines

ceilings)
for expansion of HWF investment

Country-level
consensus build- Implement gender
2028

Read just if Maintain

ing on expansion Maintain activity Maintain activity mainstreaming
necessary activity
of fiscal space for interventions
HWF investments
Assess impact Follow-up SADC Implement gender
2027

Maintain Adjustment if
in line with HWF investment Maintain activity mainstreaming
activity necessary
needs forum interventions
Implementation
Assess and of agreed expan- Incorporate Implement gender
2026

Maintain Early impact

readjust sion of fiscal into multi-year mainstreaming
activity assessment
accordingly space (budget negotiations interventions
Timelines

ceilings)
Implementation
of agreed expan- Integration with Implement gender
2025

Maintain Maintain
sion of fiscal Maintain activity national systems mainstreaming
activity activity
space (budget and processes interventions
ceilings)
Implementation
Development of
Monitor Policy dialogue of agreed expan- Member States Implement gender
2024

Maintain national implemen-

progress of on HWF sion of fiscal to adapt and mainstreaming
activity tation framework/
implementation investment space (budget operationalise interventions
action plans
ceilings)
SADC consen-
Incremental SADC consensus
sus on reference Implement gender
2023

Review staff hiring of Country-level workshop on the

Comprehensive remuneration and mainstreaming
deployments health consensus build- new HWF OHS
health labour working conditions interventions
workers protocol

39
ing on expansion for health workers
market analysis
of fiscal space for
including invest- Develop a draft
Review HWF investments Review/develop Develop or update
ment case
2022

Resource and employment SADC reference

organisational SADC HWF OHS relevant policies
mobilisation renumeration
structures protocol. and strategies
package
Capacity build- SADC HWF
Establish ing on health investment forum Review existing Conduct a review Analyse gender
2021

staffing needs/ Identify crit- labour market (health, finance, OHS policies in of working condi- mainstreaming
develop staff- ical posts analysis and labour, public including impact tions across the in the health

It is anticipated that 40% will not find employment so increase by 40%

ing plan needs-based services, private of COVID-19 SADC region workforce
HWF planning sector, partners)

SADC reference
trained to use of

Annual budgets
Post provision-

HRH planners,

HRH planners,
WISN for staff

data analysts,

data analysts,
ing at country

Occupational

remuneration
Resources

National and
and training

and training
distribution

institutions

institutions
and Safety
Legislation
HWF team

education,

education,
Needed

package
Health
level

and safety policies and

gies and policies in the

mainstreaming strate-
evidence-based tools

health workers as per

der-equitable salaries
to secure sustainable

competitive and gen-

needs and gap using
Health labour market

health financing from

analysis/need-based

jected staffing needs

international sources

Develop/update and
Engage Ministries of
Finance and Labour

Review and provide

occupational health
Member State pro-

Develop and apply

implement gender
complemented by
domestic sources
Recruit additional
Establish staffing

health workforce
Key Activities

programmes
projections
Member
State(s)
Priority

Member

Member

Member

Member

Member
States

States

States

States

States
All

All

All

All

All
(SADC median) by 2030
from an average of 1.02

implemented strategies
continuously protecting

continuously improving
enable increase invest-

the working conditions

Member States will be

Member States will be

commence expansion

ments in skilled health

to mainstream gender
57% of health budget)
nurses, and midwives

occupational hazards
to a minimum of 4.45
per 1,000 population

equality in the health

of the fiscal space to

have developed and

and remuneration of
health workers from
by at least 40%5 (or
Member States will

Member States will

density of doctors,
SD1.1 Improve the
SD1: Strategic

sector workforce
SD1.2 By 2023

SD1.3 By 2023

SD1.4 By 2023

SD1.5 By 2025
health workers
Intervention
Baseline

workforce

and risks

5
Strategic Direction 2: Harmonisation of Education, Training and Development Milestones, Activities, Resources and Timelines
Priority Timelines
SD2: Strategic Resources
Member Key Activities
Intervention Needed 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
State(s)

assessment adopt Terms of

assessment
Consolidate

Re-evaluate

Assess and
and imple-
implement

ment pro-
ment and

grammes
Planning

Ongoing
capacity

Maintain

Maintain

Maintain
partners
Conduct a needs-based HRH plan-

Engage
training

activity

activity

activity
agree-
Reach

adjust
All Member

and
training requirements and ners, data
States
capacity assessment analysts
SD2.1 By 2026 Member
States will have har-
SADC Develop regional proto-

maintain activity

Maintain activity
Assess / review
works including

implementation

in-depth review

implementation
existing frame- Develop and nego-
monised training and Curriculum

mechanisms

Assess early
experts and
Secretariat type standardized compe-

Prepare fºr

Adjust and

Adjust and
Implement

Implement
Reference

regulatory
Assemble
a team of

Conduct

maintain
development experts

impact
/ SADC tency-based curricula
in health
HRH Consolidate country com-
sciences
Technical petency frameworks into
education
Committee regional frameworks

production capac-
team and conduct

Approve budgets,
SD2.2 By 2027 Member

Mid-term review
Establish expert

Maintain activity

implementation
ity assessment

Conduct major
implement and
tiate multi-year
Ministry of

Adjust where
States will be conducting

Adjust and
Monitoring

Monitoring

necessary

maintain
Conduct specialist need Health /

budgets

monitor

review
specialist health profes- All Member
and production capacity Universities
sions training in line with States
assessment / Colleges
current and emerging
joint forums
population health needs

SD2.3 By 2027 Member

Adjust and maintain

and interventions to
Establish the gap in

Develop strategies
youth and women
States will have policies

Mid-term review

Maintain activity

implementation
Conduct major
Implement the
Ministry of

close the gap

Adjust where
interventions
that promote access to

Monitoring

Monitoring

necessary
inclusivity
Health /

review
education opportuni- All Member Conduct gap analysis on
Universities
ties in health based on States inclusivity
/ Colleges
principles of equality and
joint forums
affordability, inclusive of
youth and women
Strengthen cooperation

Reassess and adjust

Conclude and apply
Develop collabora-

Conduct regional
and collaboration between

Maintain activity

Maintain activity

Maintain activity

Maintain activity

Maintain activity
tion framework

Negotiate with
SADC Ministries
SD2.4 By 2025 regional health sciences faculties

agreement

evaluation
partners
Secretariat of Health /
training centres of excel- in the region
and Universities
lence will have been Develop a framework for
Member / Colleges
designated mutual recognition of titles
States joint forums
and health worker catego-
ries in SADC region
SADC

Advertise and award

Evaluate impact on
Identify qualifying

Technical

Maintain activity

Maintain activity

Maintain activity

Maintain activity

Maintain activity
Review existing

Conduct major
regional review
SD2.5 By 2025 SADC Facilitate the acquisition
programme/s

development
programmes

Team,
Secretariat will have SADC and of competitive scholar-
grants
Ministries
initiated the health Member ships and research grants
of Health /
workforce development States for health workforce
Universities
scheme research
/ Colleges
joint forums

40
Strategic Direction 3: Develop and adopt best practices in strategic HRH Leadership and Management Milestones, Activities, Resources and
Timelines
Priority Timelines
SD3: Strategic Resources
Member Key Activities
Intervention Needed 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
State(s)

Conduct in-depth review /

structures and do budget

Conduct mid-term review

Conduct policy review

Review organizational
Implement approved

Implement approved
Establish (for Member
SD3.1 By 2023 Member

Maintain activity

Maintain activity

Maintain activity

Maintain activity
States that do not

adjustments
States will champion Appropriately

evaluation
currently have)

policies

policies
the mainstreaming of All Member funded
HRH Departments/
health workforce issues States organizational
Directorates in MOH/
in all health policies and structures
Service delivery
interventions
agencies

ing and training resources

Mobilise / organise fund-

Commence regional and

SD3.2 By 2026

Conduct in-depth
Mid-term review
Maintain activity

Maintain activity

Maintain activity

Maintain activity
country training
Member States will

assessment
Expert train-
have strengthened their SADC and Intensive training in
ers in health
capacity in health labour Member the application of evi-
labour market
market analysis, HRH States dence-based tools
analysis
planning, development,
and management

Conduct in-depth review /

Conduct mid-term review
Mobilise funding and
establish platform
Develop terms of
SD3.3 By 2024 SADC Institute an annual

Maintain activity

Maintain activity

Maintain activity

Maintain activity

Maintain activity
will have established SADC SADC meeting or

evaluation
reference
a mechanism for HRH forum of health Funded
peer-to-peer support Technical workforce managers platform
and accountability Team and social partners
mechanism dialogue

Conduct mid-term review

Review existing dialogue

Rollout new social dia-

SD3.4 By 2027

logue mechanism
Member States will have

Maintain activity

Maintain activity

Maintain activity

Maintain activity

Maintain activity
Institute a health Capacity
mechanisms

institutionalised social
workforce social development
dialogue mechanisms All Member
dialogue mechanism programmes
among governments, States
at Member State and and HRH
workers, employers
regional levels trainers
and other relevant
stakeholders

41
Strategic Direction 4: Enhanced Health Workforce Governance and Regulation Milestones, Activities, Resources and Timelines
Priority Timelines
SD4: Strategic Resources
Member Key Activities
Intervention Needed 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
State(s)

of legislative review (where

Commence the process

Popularize role of health

professions regulation

Review legislation (if

Ensure appropriate
Establish (for Member

Maintain activity

Maintain activity

Maintain activity

Maintain activity
SD4.1 By 2021 Member
States that do not Relevant

necessary)

necessary)
regulation
States will enforce the
All Member currently have) health legislation and
upholding of professional
States workforce regulatory enforcement
standards and safeguard
bodies for all health mechanisms
public safety
professions

Develop framework and test

Conduct regional impact

Monitor implementation

Monitor implementation

Monitor implementation
SD 4.2 By 2027 SADC

Negotiate for regional

Assemble experts
Secretariat will have

Run limited pilot

implementation
for applicability
Development and

assessment
developed a framework
adoption of minimum
with strict compliance SADC Curricula
curricula content and
criteria for mutual and Secretariat experts
harmonisation of regu-
reciprocal recognition of
latory mechanisms
health professions edu-
cation and qualification

Develop & design concept

Address cross-country IP

Assess early impact

Assess and adjust

ownership issues
SD4.3 By 2026 Member

Maintain activity

Maintain activity
States will be promoting Member Coordination of data-

Run pilot
exchange programmes States bases for health pro- HRH

-
between the Member and SADC fessionals and other Databases
States especially for Secretariat relevant stakeholders
skills transfer

Monitor and assess impact

create synergies across

Implement programme
Review, compare and

Harmonise with other

SD4.4 By 2026 Member Introduce well-reg- global instruments

Maintain activity

Maintain activity
Conduct review
States will have created Member ulated multisectoral
countries

Legislation
multi-sectoral collabora- States collaboration and
and regulatory
tion/partnerships (PPP) and SADC cooperation between
mechanisms
to facilitate sharing of Secretariat the public and private
HRH resources sector

42
Strategic Direction 5: Develop Reliable Data, Monitoring and Evaluation Systems Milestones, Activities, Resources and Timelines
Priority Timelines
SD5: Strategic Resources
Member Key Activities
Intervention Needed 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
State(s)

SD5.1 By 2021 Member

Adjust accordingly

Regular use and

Maintain activity

Maintain activity
Assess existing

Assess existing
Assess impact

Assess impact
States will have HRIS
Introduce scalable and

reporting
with ability to generate

systems

systems
All Member interoperable with rou- ICT and data
information to track end-
States tine health information experts
to-end health workforce
systems
life cycle (production-
active stock – exit)

impact on workforce
SD5.2 By 2023 Member

Regular reporting

Regular reporting

Regular reporting

Regular reporting

Regular reporting

Regular reporting
Assess use and
States will have a health

observatories

management
NHWA

Access to
workforce registry to Regular use of
All Member and HRH
track health workforce NHWA and HRH
States Observatories
stock, distribution, flows, Observatories
data
exits, demand and
supply

impact on workforce

Regular reporting

Regular reporting

Regular reporting

Regular reporting

Regular reporting

Regular reporting
SD5.3 By 2021 Member

Assess use and

observatories

management
States will have NHWA

Access to
Regular use of
improved multi-sectoral All Member and HRH
NHWA and HRH
dialogue for improved States Observatories
Observatories
management of the data
health workforce

Training and/or skills

Impact assessment
Assess skills base

Assessment and
SD5.4 By 2022 Member Strengthen the imple-

Regular use and

Regular use and

Regular use and

Regular use and

Regular use and

Trained per-
States will have institu- mentation of National

reporting

reporting

reporting

reporting

reporting
updating
sonnel man-

review
tionalised national health All Member Health Workforce
aging health
workforce accounts States Accounts (NHWA) and
workforce
(NHWA) and reporting Human Resources
accounts
annually Observatories
Develop metrics and

Impact assessment
Assess, review and
Apply and monitor
integrate into HIS

SD5.5 By 2026

Maintain activity

Maintain activity

Maintain activity

Maintain activity

Maintain activity
Member States will Develop integrated
Occupational

adjust
have integrated health All Member metrics of health
Health and
worker safety indicators States worker safety
Safety experts
with health information indicators
system

43
4.5 Implementation Framework for a SADC Recruitment Pool
The SADC Recruitment Pool will be designed such that it confers certain duties and benefits on all that
will seek to utilise the system. The system will also provide the following guarantees:

• Subscribe to the ethical principles that are applicable to international recruitment of health personnel

• Alignment with international labour standards

• Protection of the rights of the health worker (job seeker)

• Guarantee the health worker so recruited labour rights that are commensurate with those of its
own health workers

• Health workers so recruited shall not be used to replace existing citizens who may be in dispute
with relevant authority

Some countries may already have reciprocity mechanisms for exchange of skills. However, where rec-
iprocity of recognition of licensure to practice does not exist, the recruiting country takes responsibility
to inform the prospective candidates of specific requirements for successful registration / licensure. It
will remain the responsibility of the recruit to understand and comply with the jurisdictional requirements
around registration and education.

Table 9: Key actions to implement Recruitment Pool mechanism

Action Envisaged Benefit Implementing Agent Timeframe

Establish and electronic • Harmonised hub of individual health SADC Secretariat By 2025
database professionals that seek employment
• Information exchange between coun- Member States
tries and health sector actors

Design system according • Comprehensive list including all rele- SADC Secretariat / HRH By 2025
to categories of the health vant biographical information Technical Committee
professions, specialist, and
non-specialist

Design and develop a formal • Uniform endorsement by a desig- SADC Secretariat / HRH By 2024
registration form and process nated Member States authority Technical Committee

Establish mechanisms for verifi- • Authentication of education SADC Secretariat / HRH By 2023
cation of qualifications qualifications Technical Committee

Establish a mechanism for • Ability to practise in any Member SADC Secretariat / HRH By 2024
reciprocal recognition of licen- State that participates in the recruit- Technical Committee
sure and registration ment pool

44
CHAPTER
05
COSTING OF IMPLEMENTATION PLAN
AND INVESTMENT CASE

The chapter describes in detail the level of resource requirements for the SADC health workforce strate-
gic plan period, including an indicative budget estimate of funds required per strategic direction/priority,
financing gap and strategies that the Member States and SADC Secretariat will seek to mobilize.

5.1 Methodology for costing the implementation plan

The detailed costing component of the Strategic Plan helps prepare the foundation for applying a health
workforce investment case across the SADC region, by supporting member states to apply investment
choices and approaches into their respective specific health workforce strategies and implementation
plans. Additionally, it quantifies the investment options that are required to put in place common regional
initiative that are identified in the HRH strategic plan – for example the SADC regional health workforce
resource pool. It is intended to facilitate more regional and member state engagement on the strategic
use of resources and make choices for increased fiscal space and added investment in the workforce
that also build on and maximise efficiencies across the existing workforce. A macro-costing approach
(Drummond et al., 2015) was adopted for the cost estimation of the strategic plan implementation. As a
guiding principle, a conservative approach to resource use identification was used to estimate the cost
from the perspective of the SADC secretariat and Ministries of Health of the Member States. A standard
costing process (Culyer and Newhouse, 2000; Drummond et al., 2015; Morris et al., 2012) was followed
with some adaption to standardise the unit costs across countries. The process included resource
need identification, assigning of a standardised unit cost, and estimating aggregate cost.

1. Resource needs identification: The resources required as inputs in the implementation of the
different activities of the strategic interventions were obtained directly from the implementation plan
(chapter 4) SADC strategic plan. These inputs/cost drivers were broadly grouped as:

• Conference package (residential and non-residential) for meetings, training etc.

• Technical Assistance (consultants)

• Daily Subsistence Allowance (DSA)/Per Diem

• Printing and dissemination of documents

• Computers, Servers

• Staff cost (Salaries of new staff recruitment and existing wage bill)

46
2. Assigning standard unit costs: There is limited comparable data on the prices of goods and
services across the SADC Member States; hence unit costs were triangulated from prevailing
strategic plans from the Member States and standardised to the equivalent international dollars in
Purchasing Power Parity (PPP). To the convert country-specific unit costs to a standardised cost in
PPP international dollars, which will be applicable in any of the Member States, the following was
undertaken:

a. The unit costs of the resources needed/cost drivers (explained in 1 above) were taken from
costed HRH strategic plans from the Member States that had recent (2018 or later) plans devel-
oped, which has been costed and approved. For each item that unit cost was taken from a
country, that country became the reference for that specific item. The identified unit cost(s) were
in the in Local Currency Unit (LCU) of the reference country.

b. The official exchange rate of the reference country was obtained from the World Bank database
and used to convert the unit cost from LCU to USD (World Bank, 2019).

c. The Consumer Price Index (CPI), a marker of inflation rate was taken from the World Bank to
adjust the unit cost to its current USD value in the reference country.

d. Converted the unit cost in current USD in the reference country by applying price level ratio of a
purchasing power parity (PPP) conversion factor to bring the value to PPP international dollars.
The unit cost in PPP international dollars was then deemed as the standardised unit cost for any
cost element subsequently used in the costing. This implies that if a Member State wishes to
convert the cost estimates into their local currency unit, the estimated cost in PPP international
dollars should be multiplied by the country-specific conversion factor which will give the current
USD equivalence in the country. The currency USD equivalence should then be converted to
the local currency using the official exchange rate.6

3. Estimating the cost of strategic directions and interventions: Using the resources identified
(step 1) and unit costs in PPP int. $ (step 2), the quantity and frequency of the resource need (in the
implementation plan) were combined to compute the cost estimates using the following formula.

Total cost of Strategic Direction i = ∑ j (Resourcei,j,k,m × Unit costj × frequency,k)

… equation 1

Where

• Resourceijkl is the amount of resource, (j) needed during activity, (k) for strategic intervention, (m)
towards the attainment of strategic direction, (i) strategic direction.

• Unit costj is the unit cost for resourcej in PPP international dollars.

• frequency,k is the number of occurrences (or frequency) of activity k during the time horizon of the
strategic plan.

6
Source: https://data.worldbank.org/indicator/PA.NUS.PPPC.RF

47
5.2 Limitations of the costing
The main limitations of the cost estimations relate to data paucity and quality. There was no contem-
poraneous data on the unit costs of goods and services from different member states that could
be directly compared to enhance the precision of the estimates. Hence, the outcome of the costing
is regarded as ordered indicative estimates, which provide useful reference points for advocacy and
resource mobilisation that can be refined during member states’ operational budgeting for the activities.

The estimate of workforce related costs to train and compensate health workers by individual Member
States for their interpretation and implementation of the strategic plan are difficult to benchmark. There is
no comparative cross-country data and analysis of overall health workforce budgets, the compensation of
the workforce, and related costs to train, deploy and retain health workers across the region. The costing
therefore assume that these costs will be determined by each Member States, based on their context-spe-
cific needs and gap analysis, domestic financing mechanisms, health sector budgets, and health workforce
expenditure – including the direct cost of training new health workers, and the recurrent wage and compen-
sation costs needed to sustain the workforce. In this regard, each Member States will need to undertake a
comprehensive analysis of investment requirements to develop a national health workforce investment case.

From a methodological perspective, the approach adopted in this costing exercise well documented
but stack variability between the economic fundamental of the SADC Member States reduces the appli-
cability of using standard cost across countries. Added to this, the ongoing and anticipated economic
downturn occasioned by the COVID-19 pandemic is likely to distort the economic fundamentals further,
and hence the data relied upon for this analysis could soon be outdated. Therefore, a revision of the
cost estimates with improved data when the COVID-19 pandemic and its economic impact eases will
be imperative.

5.3 Estimated cost of operationalising the Strategic Plan

The overall estimated cost of implementing the strategic plan is roughly US$15.7 million over the 10-year
period. Of this amount, about 35% (US$5.6 million) would be needed at both the SADC secretariat
and Member States to generate evidence, facilitate policy dialogue, and mobilize resources to increase
investments substantially to approximately expand health workforce employment by 40% over the
10-year period (strategic direction 1). This cost, however, excludes the cost of training and remuneration
for health workers at the Members States which a country-by-country analysis is highly recommended
as part of the investment case development at the level of Member States.

In addition, about 32% of the estimated cost or approximately US$5.1 million will be needed at both
SADC secretariat and Member States level to develop and institutionalize systems, mechanisms and
capacity for reliable data and evidence generation that will support evidence-based policies, strate-
gies, and operational management of the health workforce across Member States (strategic direction
5). Harmonization of education and training of the health workforce across Member States will cost
approximately US$1.8 million dollars or 12% of the total cost whilst US$2.3 million (15% of the total
cost) is required to strengthen health workforce leadership at the Ministries of Health and enhance best
practices in human resource management towards better retention and improved motivation of health
workers. About 6% of the total cost (US$947,422) will be needed to strengthen health workforce gov-
ernance and regulatory mechanisms. The detailed breakdown across each of the Strategic Directions
and proposed interventions is summarized in table 10 below. The estimated cost of operationalising the
Strategic Plan at country level and the main cost drivers summarised in annex 2.

48
Table 10: Estimated cost of implementing the Strategic Plan
Strategic Estimated Cost Per Year (1,000 Int. $ PPP)
Strategic Interventions
Direction 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Total
SD1.1 Strategies to improve the density of doctors, nurses, and mid-
wives from an average of 1.02 to a minimum of 4.45 per 1,000 popula- 156.4 591.2 1,940.9 2,688.4
tion (SADC median) by 2030

SD 1. SD1.2 By 2023 Member States will commence expansion by at least

Investment 40% of the fiscal space to enable increase investments in skilled health 626.8 136.0 262.5 544.5 200.9 1,770.6
in health workforce
workforce jobs SD1.3 By 2023 Member States will be continuously protecting health
20.9 163.0 170.0 353.9
and decent workers from occupational hazards and risks
employment SD1.4 By 2023 Member States will be continuously improving the work-
95.0 21.7 184.0 300.6
ing conditions and remuneration of health workers
SD1.5 2024 Member States will have developed and implemented strat-
95.0 353.8 42.2 491.0
egies to mainstream gender equality in the health sector workforce
Sub-Total 994.0 1,129.8 2,289.1 446.4 544.5 200.9 5,604.6
SD2.1 By 2025 Member States will have harmonised training and
473.4 170.0 643.4
development
SD2.2 By 2027 Member States will be conducting specialist health
professions training in line with current and emerging population health 531.6 531.6
SD 2. needs
Harmonisation SD2.3 By 2027 Member States will have policies that promote access
of Education to education opportunities in health based on principles of equality and 253.1 253.1
Training and affordability, inclusive of youth and women
Development
SD2.4 By 2025 regional training centres of excellence will have been
385.3 385.3
designated
SD2.5 By 2025 SADC Secretariat will have initiated the health workforce
0.0 0.0
development scheme
Sub-Total 473.4 1,340.0 1,813.4
SD3.1 By 2023 Member States will champion the mainstreaming of
128.6 128.6
health workforce issues in all health policies and interventions
SD 3. Develop SD3.2 By 2025 Member States will have strengthened their capacity
and adopt best in health labour market analysis, HRH planning, development, and 170.0 170.0
practices in management
strategic HRH SD3.3 By 2024 SADC will have established a mechanism for peer-to-
Leadership and 156.4 163.0 170.0 177.2 184.8 192.6 200.9 209.4 218.3 227.6 1,900.3
peer support and accountability mechanism
Management
SD3.4 By 2025 Member States will have institutionalised social dialogue
mechanisms among governments, workers, employers and other rele- 0.0 45.4 54.6 100.0
vant stakeholders
Sub-Total 156.4 291.7 340.0 177.2 230.2 192.6 200.9 209.4 218.3 282.2 2,298.9
Estimated Overall Cost 1,720.0 3,038.0 4,802.7 1,169.0 1,308.8 913.4 945.5 565.2 587.3 664.9 15,714.8

49
 Strategic Estimated Cost Per Year (1,000 Int. $ PPP)
Strategic Interventions
Direction 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Total
SD 4.2 By 2025 SADC Secretariat will have developed a framework
with strict compliance criteria for mutual and reciprocal recognition of 297.7 297.7
SD 4. health professions education and qualification
Enhanced SD4.1 By 2021 Member States will enforce the upholding of profes-
Health 206.4 206.4
sional standards and safeguard public safety
Workforce
Governance SD4.3 By 2025 Member States will be promoting exchange pro-
and Regulation grammes between the Member States especially for skills transfer
SD4.4 By 2025 Member States will have created multi-sectoral collabo-
41.7 203.9 193.6 1.0 1.0 1.0 1.1 443.3
ration/partnerships (PPP) to facilitate sharing of HRH resources
Sub-Total 41.7 504.2 203.9 193.6 1.0 1.0 1.0 1.1 947.4
SD5.1 By 2021 Member States will have HRIS with ability to generate
information to track end-to-end health workforce life cycle (production- 135.7 684.4 34.0 854.1
active stock – exit)
SD5.2 By 2023 Member States will have a health workforce registry
SD 5. Develop to track health workforce stock, distribution, flows, exits, demand and 157.1 162.9 169.0 175.3 181.8 188.5 195.6 202.8 210.4 218.2 1,861.5
Reliable Data supply
Monitoring
SD5.3 By 2021 Member States will have improved multi-sectoral dia-
and Evaluation 107.6 12.3 197.4 317.3
logue for improved management of the health workforce
Systems
SD5.4 By 2022 Member States will have institutionalised national
235.2 122.0 126.5 262.5 136.1 141.2 347.3 151.9 157.6 163.4 1,843.7
health workforce accounts (NHWA) and reporting annually
SD5.5 By 2022 Member States will have integrated health worker
173.9 173.9
safety indicators with health information system
Sub-Total 528.0 1,143.2 329.5 545.3 330.2 527.1 542.9 354.7 367.9 381.6 5,050.5
Estimated Overall Cost 1,720.0 3,038.0 4,802.7 1,169.0 1,308.8 913.4 945.5 565.2 587.3 664.9 15,714.8

50
5.4 Financial space potential for health workforce investments in
the SADC region
Preliminary analysis using data of SADC Member States supports the global evidence that investing in
the right type of health workforce interventions and policy measures could yield a 9:1 return on invest-
ment. This section highlights the fiscal space analysis for the SADC region and for each of the Member
States for which data were submitted. While eight countries submitted data, these data sets were not
complete, and two countries did not provide any data on their projected supply of HRH. Thus, data min-
ing from the World Bank’s World Development Indicators, WHO’s Global Health Expenditure Database,
SADC website and NHWA database to augment where needed for the modelling which followed the
health labour market approach and using the Health Service Development and Analysis (HeSDA) Model
(Asamani, et al., 2018).

The economic demand for health workers is reflected in a country’s ability and willingness to pay for
health workers. This estimates the joint interest of the government and the private market in purchasing
health care, a large part of which includes the cost of health worker wages. The logic underlying this
approach is that countries will not spend more than they can afford on health care even if their level of
health or level of health care utilization is suboptimal relative to an internationally established benchmark
(Scheffler et al., 2016). Therefore, it is recommended that demand-based forecast uses indicators of
overall economic growth or specific health sector indicators that represent spending within the health
care sector.

A previous approach for linearly estimating the financial space was adopted (see Box 2). In applying
the formulae in Box 2 to estimate public sector fiscal space (demand) for employment of health work-
ers, the projected GDP growth of Member States ; general government health expenditure (GGHE) as
a percentage of GDP ; proportion of the GGHE spent on wages and salaries of health workers were
taken from the World Development Indicators of the World Bank and WHO Global Health Expenditure
Database (GHED). Where data on the private sector contribution to health workforce employment was
not available, the private out-of-pocket health expenditure (as a proportion of current health expenditure)
was used as a proxy.

51
Box 2: Financial Space Assumptions

• Public Sector Fiscal Space for the year, i = (GGHE as % GDPi * Nominal GDP Valuesi) *
HRH Expenditure as % GGHEi … (1)
•  Cumulative Economic Capacity for the year, i = Public Sector Fiscal Spacei * (1 + propor-
tion of private sector HRH employment) … (2)
Where:
o i = target year
o GGHE = General Government Health Expenditure
o GDP = Gross Domestic Product
Notes: There are elaborate and recommended econometric equations for estimating the demand
for health workers from macroeconomic indicators and health spending patterns in countries. With
data constraints, these concepts guided the use of the above formulae in which conservatively, it
was assumed that if the government continue to spend similar proportion of GDP on health and
similar proportion of GGHE on HRH, all things being equal, the fiscal space for HRH would be pro-
portional to the size of the GDP. It was further assumed that the private sector would not contract
and that conservatively, a similar proportion of private-sector employment would continue.

As shown in table 7, it is estimated that across the SADC Member States, the cumulative economic
space for the employment of health workers is about 2.5 billion US dollars which is likely to expand to
2.8 billion USD by 2024 and 3.45 billion USD by 2030. Using the minimum normative need for health
workers (using WHO’s threshold of 4.45 per 1,000 population), the cost of need is about 13.3 billion US
dollars which will increase to about 14.4 billion US dollars by 2024 and 16.3 billion US dollars by 2030.

The current and anticipated levels of supply of health workers are estimated to cost 7.5 billion US
dollars in health workforce employment in 2020 which will increase to at least 8.8 billion US dollars in
2030 if the current trend continues. Thus, while potential supply could meet nearly 89 % of minimum
normative need, only 33 % of the number needed may be funded. The foregoing suggests a significant
future financing gap for the health workforce if concerted efforts are not pursued to making the case for
increased investments including harnessing and maximizing the private sector’s potential. One key lim-
itation in this quick and rough estimate is that the contribution of development partners in health wage
bill has not been fully accounted for.

The analysis of eight Member States that participated in the technical consultative meeting shows that
in most cases, the current production or supply of health workers falls short of the countries’ aggre-
gate HRH needs. Only three Member States may be able to meet their estimated need before 2030.
Furthermore, the cumulative demand or ability to pay (in both public and private sectors) is higher than
the supply of HRH. This is evident in the number of expatriate workers that are employed in those
Member States (see figures 5–12).

52
Table 11: Estimated Financial Space and Economic feasibility analysis – SADC Region
(Million US Dollars)
Estimation
Variable
2020 2024 2030

Public Sector Fiscal Space for HRH 1,752.48 1,969.01 2,344.98

Private Sector Economic Demand for HRH 747.82 840.22 1,000.66

Cumulative Financial Space (Economic
2,500.31 2,809.23 3,345.64
Demand) for HRH
Estimated Cost of HRH Stock/Supply 7,496.97 8,770.39 11,097.34
Estimated Cost of Minimum Need (WHO
13,293.67 14,408.09 16,257.30
Threshold)

5.5 The Health Workforce Investment Case for the SADC Region
Global evidence has shown that the contribution of the health workforce transcends its critical role
in the attainment of health (SDG 3) as a clear nexus has been established between health workforce
investment and other SDGs such as goals 4 (quality education), 5 (gender equality), and 8 (decent
work and economic growth) among others. However, the health workforce has been one of the most
affected areas of health care cost containment measures to free up resources for investment in other
competing areas. Recent evidence (Lauer et al., 2017) - as shown in figure 7 has demonstrated at least
six (6) causal pathways through health workforce investments that (as part of health system inputs) can
stimulate inclusive economic growth beyond the health sector.

Box 3: Health Pathway to economic growth

(a) the health pathway - the intrinsic (non-market-valued) health benefits of the health system;

(b) the economic output pathway which concerns the intrinsic (market-valued) economic benefits
of the health system;

(c) the social protection pathway, addressing sickness, disability, unemployment and old-age ben-
efits, as well as financial protection against loss of income and catastrophic health payments;

(d) the social cohesion pathway, addressing the role of a health system in promoting equity and
fostering redistribution and growth;

(e) the innovation and diversification pathway, addressing the role of the health system in driving
technological development and in offering protection against macroeconomic shocks; and

(f) the health security pathway, addressing the role of the health system in protecting against epi-
demic outbreaks and potential pandemics.

53
 Figure 6: Health pathway to economic growth
Source: Adapted from (Lauer, et al., 2017)

The International Labour Organisation (ILO) also analysed the contribution of the health workforce (health
occupations) on employment within the wider health economy, which revealed that, a broad range of
workers and potential multiplier effects in industries providing goods and services for health, the poten-
tial for job creation is even higher, including for low skilled workers. With regard to paid employment, ILO
estimates suggest that globally, for each health occupation job (such as physician, nurse, physiothera-
pist), 1.5 additional jobs are generated for workers in non-health support occupations (administration,
cleaning, manufacturing) both in the health sector and the broader health-related economy. Taking into
consideration additional unpaid long-term elderly care work, this would raise this ratio to 2.3 non-health
jobs per 1 health occupation job. This approach considers all workers producing health-related prod-
ucts and providing services regardless of their occupation, employment status or economic sectors.
Accordingly, the workforce has been estimated to be 234 million workers in the entire health-related
economies globally, consisting of 71 million workers in health occupations, 106 million paid workers in
non-health occupations and 57 million unpaid non-health occupation workers, mostly persons who left
paid employment to provide care to relatives. Figure 8 summarizes the impact of health occupations
employment on job creation across different income groups of countries.

54
 Figure 7: Ratio of Non-Health Occupation (NHO) workers to Health Occupation (HO) workers,
by income group, 2015
Source: Adapted from ILO calculations, 2016

By investing in the 9.2 million health workers needed in Africa by 2030 (which includes 3.1 million supply
and 6.1 shortage), there is the potential to create over 20 million new jobs in the region equivalent to a
40% boost to current rates of job creation (World Health Organisation, 2016). In representing around a
third of the population in the Africa region, efforts in SADC would contribute substantially to addressing
the labour market failures in the region.

A rapid analysis was undertaken with limited data to examine the influence of health workforce invest-
ments on some economic indicators to augment global evidence to make a case for increased invest-
ments, as well as strengthening social dialogue with employers, worker representatives and engaging
other key stakeholders. Due to challenges with data quality and completeness, limited estimations were
applied to explore the relationships between health workforce density and some health and economic
indicators. The emerging correlations reinforces known global evidence that investing in the health
workforce provides a significant return on investment. The simulation showed that in the context of the
SADC region, if the employed health workforce density is collectively increased by one unit per 1,000
population (i.e. by approximately 277,000) it could boost the rate of growth in GDP per capita by eco-
nomic growth by some 39% up to 2030 (adding about US$ 1,340 GDP per capita over 10 years).7 The
economic return on investment ranges between 1:6 and 1:11.

7
At individual country level, the analysis is valid in at least 50% of SADC Member States. When Adjusted net national
income per capita (current US$) is used for the analysis instead of GDP per capita, the return is about a 41% increase over
10 years.
The
analysis was based on data submitted by countries (for those that participated in the meeting) augmented with the latest
available data from global databases of SADC, WHO and the World Bank.

55
In terms of impact on health outcomes, an investment increase of 1 per 1,000 population is also likely to
be associated with an additional 4 to 8 years of life expectancy at birth; and a reduction in the incidence
of HIV (% of uninfected population ages 15-49) by 2.3%. Unlocking these returns would require at least
a 9% increase in total health expenditure, of which 60% to 72% must be invested in health workforce
employment and job creation.

Box 4: Summary of health workforce investment case

• The cumulative fiscal space or economic demand for HRH is below the WHO-determined
threshold of workforce density necessary for achieving UHC.

• From the available data, the modelling projected that should employment of health workforce
be increased by one unit per 1,000 population, it would add 39% to the sub-regional economic
growth in terms of GDP per capita. This represents an additional US$1,340 in GDP per capita
over ten years and a return of investment that ranges between 6:1 and 11:1.

• These investments also relate to positive health outcomes in it would add eight additional years
to the life expectancy at birth for citizens of Member States and a reduction in HIV prevalence
of 2.3% (in the age group 15–49).

• However, to realize these returns would require an investment of at least 9% increase in total
health expenditure across Member States. Additionally, between 60%–72% of the increased
investment must be geared towards decent job creation for health workforce.

56
CHAPTER
06
MONITORING AND EVALUATION

6.1 Introduction
The chapter details the monitoring and evaluation (M&E) framework to guide the implementation of the
strategic plan. The M&E framework aims to have a coordinated and effective mechanism that sup-
ports evidence-based HRH decision-making and accountability. The framework will facilitate tracking
implementation of key strategic interventions, generate information to support decision-making and
make recommendations on improvement areas. The SADC Secretariat and Member States, including
partners, will be involved in the process of strategic monitoring, harmonising at regional level through
the SADC HRH Technical Committee made up of HRH managers. Each Member State will carry out
its own monitoring and evaluation process based on their respective health workforce strategic plans.

6.2 Monitoring
Monitoring of the key regional milestones of this plan will be done on quarterly basis by SADC HRH
Technical Committee. The HRH units of Member States (at the national and sub-national level) will be
responsible for the day to day implementation and coordination of HRH activities to monitor implemen-
tation this strategic plan. Performance reviews will be jointly conducted by stakeholders at national and
sub-national level (both government and non-government actors). The purpose of the joint assessment
is to review performance and inform investment on key priorities with highest impact.

6.3 Evaluation
The SADC Secretariat through the HRH Technical Committee will analyse and report key performance
indicators annually while a mid-term review of the plan will be done in 2025 and an end evaluation in
2030 to determine the extent to which the objectives of this strategic plan are met across the different
key targets. The mid-term review will focus on assessing implementation status, document alignment
of key strategic interventions at Member State level and improvement opportunities, among others. The
results will be used to adjust key strategies, priorities, and objectives.

6.4 Mechanism for collaboration and Accountability

At Member State level, monitoring and evaluation of the plan will be the responsibility of the Ministries of
Health through the HRH divisions / departments. All relevant stakeholders and institutions are required
to report the relevant data periodically within the framework of the national health workforce observa-
tory. The following will be undertaken to ensure accountability:

• Stakeholder collaboration and accountability: The Ministries of Health shall engage its stake-
holders through the HRH division / department forum at least twice a year. Stakeholders (state
and non-state) and institutions shall submit relevant reports and data through available HRH infor-
mation system or using an agreed reporting template.

58
• Timely, reliable and accurate data: The stakeholder shall be requested to submit reports on
implementation of planned activities, program and project arising from this plan using a stand-
ardised format. All stakeholders shall ensure that all data submitted is reliable. Specific attention
should be made to ensure the mainstreaming of gender analysis and sex disaggregation into
health workforce data and reporting.

• Feedback and dissemination: The ministries of health shall review the HRH data, provide feed-
back to the reporting institutions about the quality of the data and reports (completeness, accu-
racy, and timeliness) and periodically disseminate updated information on HRH situation through
HRHICC and other relevant fora.

6.5 Key Performance Indicators and Targets

The strategic plan has key performance indicators (KPIs) to guide monitoring and evaluation. These
indicators will be used by the SADC Secretariat and Member States to facilitate implementation of the
strategic plan. Most KPIs are linked to Global strategy on human resources for health: health work-
force 2030, WHO African regional framework for the implementation of the global strategy on
human Resources for health and NHWA indicators.

Table 12 lists baseline, mid-term, and end-term key indicator targets.

59
Table 12: Monitoring and Evaluation Plan
Strategic
Baseline Mid-Term Target End-Term Periodicity Reporting
Direction Code Key Performance Indicators (KPIs) Source of Data
(2020) (2025) Target (2030) of reporting Responsibility
(SD)

Labour force surveys/

Density of health workers (doctors, nurses and Member States &
SD1.1 1.02 2.3 4.45 NHWA reports/popu- Annual
midwives) per 1,000 population (SADC mean) SADC Secretariat
lation census
National Health
Percentage increase in funds allocated to health (establish Member States
SD1.2 25% 40% Accounts/ National Annual
workforce priorities baseline) (MOH, MOF)
SD 1: budgets
Investment
Number of Member States with updated occupa-
in health (establish Member States &
SD1.3 tional health and safety policies and programmes 12 16 Policy papers Annual
worker jobs baseline) SADC Secretariat
(WHO HW Safety Charter)
and decent
employment Percentage improvement of staff attrition (turno- HRIS, Health
(establish 25% reduction from 50% reduction from Member States,
SD1.4 ver) rate through better working conditions and workforce registry/ Annual
baseline) baseline baseline SADC Secretariat
remuneration observatory
Number of Member States implementing strate-
(establish Member States &
SD1.5 gies to mainstream gender equality in the health 8 16 NHWA reports Annual
baseline) SADC Secretariat
sector workforce
Percentage of Member States with harmonised Accreditation author-
(establish Member States
SD2.1 accreditation mechanisms for health worker 30% 50% ities/professional Annual
baseline) (MOH, MOE)
training and development programmes bodies /HTIs reports

Minimum ratio of trained Specialist cadres to total (establish Professional council/ Member States
SD2.2 20% 40% Annual
stock of active health workers (regulated cadres) baseline) NHWA reports (MOH)
SD 2:
Number of Member States with policies that pro-
Harmonisation Accreditation author-
mote access to education opportunities in health (establish Every three (3) Member States
of Education, SD2.3 16 16 ities/professional
based on principles of equality and affordability, baseline) years (MOH, MOE)
Training and bodies
inclusive of youth and women
Development
Number of established regional health training (establish Every three (3) Member States
SD2.4 5 10 SADC annual reports
institutions (Centres of Excellence) baseline) years (MOH, MOE)

Percentage of Member States with health work-

(establish Every three (3) Member States
SD2.5 force development schemes that promote health 30% 80% SADC annual reports
baseline) years (MOH, MOE)
workforce research

60
 Strategic
Baseline Mid-Term Target End-Term Periodicity Reporting
Direction Code Key Performance Indicators (KPIs) Source of Data
(2020) (2025) Target (2030) of reporting Responsibility
(SD)

Number of Member States with HRH

(establish Member States
SD3.1 Departments/Directorates in MOH/Service deliv- 16 16 HRH strategic plans Annual
baseline) (MOH)
ery agencies
Number of Member States with capacity in health
SD 3: Develop (establish Member States
SD3.2 labour market analysis, HRH planning, develop- 16 16 HRH strategic plans Annual
and adopt best baseline) (MOH)
ment, and management
practices in
strategic HRH Number of Member States with operational Inter-
Member States,
Leadership and SD3.3 agency HRH (intersectoral) mechanism for peer- N/A 2 16 HRH reports Annual
SADC Secretariat
Management to-peer support, accountability and learning
Number of Member States with institutionalised
social dialogue mechanisms among govern- Member States
SD3.4 N/A 8 16 HRH strategic plans Annual
ments, workers, employers and other relevant (MOH)
stakeholders
Number of Member States with health workforce (establish Government/ legisla- Every three (3)
SD4.1 11 16 Member States
regulatory bodies for all health professions baseline) tive records/treaties years
Ratified protocol/framework with strict compli-
SD 4: Enhanced ance criteria for mutual and reciprocal rec- Policy papers/
SD4.2 N/A 1 1 SADC Secretariat
Health ognition of health professions education and approved protocol
Workforce qualification
Governance Number of Member States with exchange pro- Training/skills transfer
and Regulation SD4.3 N/A 4 16 SADC Secretariat
grammes for skills transfer reports
Number of Member States with multi-sectoral
Bilateral treaties/ Every three (3) SADC Secretariat
SD4.4 collaboration/partnerships (PPP) sharing of HRH N/A 16 16
mobility reports years & Member States
resources
Number of Member States with HRIS with ability
Ministries of health,
to generate information to track end-to-end (establish Member States
SD5.1 16 16 education, labour Annual
health workforce life cycle (production- active baseline) (MOH)
reports
stock – exit)
Number of Member States with a health work- Ministries of health,
(establish Member States
SD5.2 force registry to track health workforce stock, 16 16 education, labour Annual
SD 5: Develop baseline) (MOH)
distribution, flows, exits, demand and supply reports
Reliable Data,
Monitoring Number of Member States with multi-sectoral Member States
SD5.3 N/A 16 16 Ministries of health Annual
and Evaluation dialogue platforms (MOH)
Systems
Number of Member States with institutionalised Ministries of health,
Member States
SD5.4 national health workforce accounts (NHWA) and N/A 16 16 education, heath Annual
(MOH)
reporting annually training institutions
Number of Member States with integrated health
(establish National NHWA Every three (3) Member States
SD5.5 worker safety indicators with health information 8 16
baseline) reports years (MOH)
system

61
6.6 Overview of Potential Risks and Mitigation Measures
Implementation of the SADC Health Workforce Strategic plan 2020-2030 may be affected by several
factors beyond its influence. These will be documented as risks and assumptions to be considered
during the annual planning and in the next strategic review and planning cycle. The major risk is secur-
ing and sustaining domestic and development financing the strategic plan, particularly considering
the COVID-19 pandemic and its impact on immediate to long-term economic growth and fiscal space
across the SADC region.

However, it is expected that Member States will endeavour to mitigate these factors through evi-
dence-based advocacy, to make a clear investment case for HRH financing, as well as instituting inno-
vative financing mechanisms through other stakeholders such as the private sector and development
partners in health including local non-governmental partners where applicable. Each Member State has
a responsibility to develop a risk management plan for the implementation of this SADC HRH Strategic
Plan. For illustrative purposes, the risk management framework will address, as a minimum, three broad
risk areas summarized in the table 13 below.

Table 13: Summary of key Risks and Mitigation measures

Type of Potential Risk Potential Mitigating Measure

Strategy related Member States should build the capability of responsible ministries/departments to manage or con-
tain the identified risk events should they occur and address factors that associate this strategy with
uncertainty e.g. capacity at country level for data collection and policy implementation

Policy related Member States should regularly revisit the non-health policy levers which shape health labour mar-
kets e.g. policies that relate to the education and training sector and those impacted by the labour
market dynamics

External risks Member States should institute mechanisms to anticipate and develop mitigation strategies e.g.
workforce responses to risks like epidemics, pandemics, and the ability to maintain a functional
health system and sustain essential health services amid political and major macroeconomic shifts

Preventable risks Member States should align their health workforce strategies with the SADC strategic plan and pro-
vide adequate funding for implementation of the strategy

62
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64
ANNEXURES

Annex 1: Economic Feasibility Analysis

Botswana: Economic feasibility analysis – Health Labour Market

Figure 8: Economic feasibility analysis – Botswana

Comoros: Economic feasibility analysis – Health Labour Market

Figure 9: Economic feasibility analysis – Comoros

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Eswatini: Economic feasibility analysis – Health Labour Market

Figure 10: Economic feasibility analysis – Eswatini

Leshoto: Economic feasibility analysis – Health Labour Market

Figure 11: Economic feasibility analysis – Leshoto

66
Malawi: Economic feasibility analysis – Health Labour Market

Figure 12: Economic feasibility analysis – Malawi

Namibia: Economic feasibility analysis – Health Labour Market

Figure 13: Economic feasibility analysis – Namibia

67
Seychelles: Economic feasibility analysis – Health Labour Market

Figure 14: Economic feasibility analysis – Seychelles

Zimbabwe: Economic feasibility analysis – Health Labour Market

Figure 15: Economic feasibility analysis – Zimbabwe

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Annex 2: Estimated cost of implementing the strategic plan by type of resource needs at the level
Estimated Cost at Country
Strategic Direction Resource Needs Total (1,000 Int. $ PPP) Level (per Country) [1,000 Int
$ PPP]
International conference package including travel $1,023.9 $0.0
International Consultant $506.8 $34.0
National/Local Consultant $295.6 $18.1
SD 1. Investment in health
workforce jobs and decent Non-Residential Conference package/person $79.2 $5.3
employment
Printing $57.5 $4.1
Residential Conference package/person $2,055.1 $133.2
WISN studies $1,586.6 $113.3
Sub-Total $5,604.6 $308.0
International conference package including travel $510.0 $0.0
International Consultant $538.4 $22.7
National/Local Consultant $99.0 $6.2
SD 2. Harmonisation of
Education Training and Non cost item $0.0 $0.0
Development
Non-Residential Conference package/person $169.0 $10.6
Residential Conference package/person $497.0 $31.1
Specialist training $0.0 $0.0
Sub-Total $1,813.4 $70.5
International conference package including travel $2,070.3 $0.0
Leverage on other activities $0.0 $0.0
SD 3. Develop and adopt best National/Local Consultant $37.1 $12.4
practices in strategic HRH
Leadership and Management Non cost item $0.0 $0.0
Non-Residential Conference package/person $100.0 $6.2
Residential Conference package/person $91.5 $30.5
Sub-Total $2,298.9 $49.1

Grand Total $15,714.8 $781.1

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 Estimated Cost at Country
Strategic Direction Resource Needs Total (1,000 Int. $ PPP) Level (per Country) [1,000 Int
$ PPP]
Computers $5.9 $2.0
International conference package including travel $192.6 $0.0
International Consultant $183.6 $47.3
Leverage on other activities $0.0 $0.0
SD 4. Enhanced Health
Workforce Governance and National/Local Consultant $309.6 $19.4
Regulation
Other hosting-related charges $5.9 $0.0
Procurement/development of software $123.2 $0.0
Residential Conference package/person $126.5 $7.9
(blank) $0.0 $0.0
Sub-Total $947.4 $76.5
Computers $135.7 $8.5
International conference package including travel $556.5 $0.0
International Consultant $231.1 $10.9
SD 5. Develop Reliable Data National/Local Consultant $107.6 $6.7
Monitoring and Evaluation
Systems Non-Residential Conference package/person $1,861.5 $116.3
Printing $4.8 $0.0
Residential Conference package/person $1,642.8 $102.7
Server $510.5 $31.9
Sub-Total $5,050.5 $277.0

Grand Total $15,714.8 $781.1

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Annex 3: Reporting Framework Tool by Member States to the
SADC Secretariat
SADC HRH Strategic Summary of Outcome/s Activities utilised to Over what period was Impact on Health
Goal (SD) achieve the outcomes this achieved? Workforce

SD 1: Investment in
health worker jobs and
decent employment

SD 2: Harmonisation of
Education, Training and
Development

SD 3: Develop and
adopt best practices
in strategic HRH
Leadership and
Management

SD 4: Enhanced Health
Workforce Governance
and Regulation

SD 5: Develop Reliable
Data, Monitoring and
Evaluation Systems

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