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Health Policy and Development, Vol. 9, No. 1, Januray-April, 2011, pp. 6-15 EVIDENCE OF STRATEGIC HUMAN RESOURCE MANAGEMENT PRACTICE IN A PUBLIC SECTOR ORGANISATION: A Content Analysis of the HRM Policy and Strategy of the Ministry of Health of Ghana, 2007- 2011. Robert Bella Kuganab Lem Head of Department, Allied Health Sciences, School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana. Email: kuga_robert@hotmail.com, Tel: 0247021507, 07127000 Code Number: hp11003 Abstract Competitive forces coupled with new and continuing demands require public sector organisations to be increasingly careful in thinking about their strategies. This is complicated especially for the health sector because it must do so in a multi-sectoral environment where system interdependencies complicate decision making. This paper examines the evidence of Human Resource Management Strategies and practices in a public sector organization, the Ministry of Health of Ghana. The paper examines strategies of the Human Resources of the Ministry of Health of Ghana to achieve the objectives of reforms which are largely to make quality health care accessible and affordable to the people of Ghana with the right staff doing the right job at the right place. It is an established fact that the success of every organization depends greatly on its human resource. However having the right quantity and quality of employees at the right place is the problem. HRM strategy is about providing the right numbers and calibre of staff, as well as retaining and motivating staff to enhance productivity. There are difficulties in developing appropriate HRM strategies to enable especially public sector organisations achieve their objectives. There is no perfect solution as to how to evolve an effective HRM strategy. Nonetheless there are some general principles of best practice that policy makers should keep in mind. Where these principles are not considered and a balance is not achieved, a policy may be impotent at birth and not facilitate organisational success. Keywords: Strategic Human Resource Management, Policy, Public Sector Organisation. Ghana like most other nations is pursuing health sector reformation and organisation. The reforms among others aim at addressing problems of inequalities in the health status of the people. Among the many resources to be mobilized to do this are the human resources. The Human Resource Policy of the Ghana Ministry of Health is the document that spells out how the human resource is going to be managed to achieve this general objective. This is in acknowledgement of the fact that investment in developing and maintaining effective Human Resource Management (HRM) policy and practice can make a significant and measurable positive contribution to organisational performance (Buchan 2004). Of all the resources that are put into the provision of health care, human resources are the most important constituting up to 75% of expenditure in some countries (Green, 2003 p.42). But until recently, the importance of HRM to the success or failure of health system performance has been generally overlooked. In recent years it has been increasingly recognised that getting Human Resource (HR) policy and management right has to be at the core of any sustainable solution to health system performance. This is partly a result of the need to upscale capacity in many country health systems to meet the Millennium Development Goals. A well motivated and appropriately skilled and deployed workforce is crucial to the success of health delivery systems. The Ghana HRM policy document lays out the current situation in relation to human resources for health in Ghana and defines the goals which the Ministry of Health intends to achieve over the five year plan period. The policy document also lays down the strategies that are to be pursued over the five years to try to ensure that sufficient human resources are available and effectively managed and utilized to enable the health sector to achieve its service delivery goals. The main thrust of the policy is to ensure staff retention and deployment according to health needs with an overall goal of improving and sustaining the health of the population of Ghana by supporting appropriate human resources planning, management and training so that there is adequate production of appropriately trained staff, motivated to perform effectively. The Ghana HRM policy acknowledges that HRM has not received the needed attention, hence the persisting significant gaps between ongoing reforms in the health sector and the management of human resources for health. The policy notes that it is therefore crucial that the changes taking place in the organization functioning and financing of health care systems be accompanied by appropriate measures for developing human resources for health. The question then is, given this awareness, to what extent does the HRM policy of the Ghana Ministry of Health conform to HRM practice principles that will enable it achieve its objectives of ensuring that there is the right number of personnel with the appropriate skills available in the right place at the right time? Many attempts at modernisation have been launched in public organisations during the last decade, focused on the renewal of HR policies. Public organisations are increasingly challenged by the ideological and political pressures towards new ways of governance, improved efficiency and customer orientation. Despite the limited, but growing, evidence base of the impact of HRM on organisational performance in other sectors, there have been relatively few attempts to assess the implications of this evidence for the health sector. This research hypothesises that despite the change processes that are ongoing in public sector organisations including the ministry of Health of Ghana, most human resource policies lack ownership, and internal and external coherence and this invariably undermines the implementation of such policies. Research Aims and Objectives The intention of this paper is to contribute to knowledge by providing a better understanding of the adoption of Strategic Human Resource Management (SHRM) practice in a public sector organisation, particularly the health sector of a developing nation. The paper intends to consider how “good practices” in SHRM have been observed and defined in the Ghana policy. Some authors hold the view that no single HRM intervention, like a magic bullet, is likely to provide a sustainable solution to all the workforce challenges facing an organisation. With this caution, and looking at different approaches to analysing HRM, Pfeffer (1998) cited in Bach (2001) summarised seven core characteristics that maximise organisational gains through people. These are: an emphasis on providing employment security; self management teams and decentralisation of decision making; comparatively high compensation; extensive training; selective hiring of new personnel; reduced status distinctions and barriers; and extensive sharing of financial and performance information. Bach (2001) noted that no pre-packaged model is appropriate to the range of circumstances within health care systems and therefore it is important to craft a strategy appropriate to local conditions and culture and to implement it effectively. Bach also noted that in this regard it is important to move beyond generic models to distil the core processes and values that underpin successful HRM. Using the seven characteristics and through other research, Bach (2001) drew three broad conclusions that can be considered as critical factors for an effective HR strategy. These are: Ownership - where people are regarded as a strategic resource to be nurtured and developed with top managers supporting such a strategy; External Fit - where organisations are alert to the external environment and plan their HR requirements in a way that takes note of the HR implications of a changing external environment and able to modify the strategy or taking note of the problems arising from any environmental changes; and finally, Internal Fit - where there is a coherent approach to HR policy, with no over reliance on one element of HR (e.g. training) but combining all HR policies into an integrated whole of strategies, policies and processes. This paper uses these three characteristics to analyse the HRM policy of the Ministry of Health of Ghana. The policy is subjected to rigorous content analysis to determine the extent to which it covers these core elements of HRM strategy that will enable the ministry to achieve its objective of having an effective and efficient human resource that will deliver quality health care to the people of Ghana. The main benefit of using the core characteristics as outlined in Bach (2001) as a theoretical framework lies in its theoretical openness. The three different explanatory approaches can be integrated in order to reach an articulated vision of the HRM strategy of the Ministry of Health of Ghana. Not all HR-based initiatives in public organisations may be considered as clear successes. Nonetheless, the growing empirical evidence concerning the links between the firm performance and innovative HRM practices have led more and more government agencies to adopt such practices within public organisations, expecting similar positive effects (Soni 2004). However, literature devoted to the impact of HRM in public organisations remains limited (Gould-Williams 2003). Exploring two national cases (the UK and New Zealand) in which individualised contracts were introduced for top civil servants, Hood (1998) highlights the different results obtained after these reforms, banishing any idea of universal ‘best practices’ that could be applied in this field. Such reforms appear highly dependent on the institutional starting point of civil service employment contracts existing in each case. Lodge and Hood (2003), in their analysis of public reforms based on competency management in the UK Department of Trade and Industry and the German Federal Economics Ministry, pinpoint that such reforms led to the reinforcement of traditional bureaucratic skills and avoided taking into account the necessary renewal of organisational ways of working. Pettigrew et al. (1992) highlighted, in their study on the strategic change in the NHS, that even in receptive settings, the process of change remains highly unpredictable. In particular, they show the impact of local features on the change agenda in HRM. Boyne et al. (1999) conclude that, after two decades of reforms engaged by Conservative governments, exhorting public managers to adopt a style of HRM closer to private sector practices, the traditional style of paternal, standardized and collectivized HRM is still more prevalent in public organizations. Similar conclusions are offered by Harel and Tzafrir (2001) in their comparison of HRM practices in public and private organisations in Israel. Their study shows that some practices are prevalent in the public sphere (employee selection, grievance procedures) while employee development and performance-related pay remain limited to the private sphere. Demmke (2004) observes that most reform strategies in the European public sphere are full of ‘proverbs’ (more flexibility, innovation, performance and responsibility), which resemble rather empty concepts, not filled with any substance. The observation made by Demmke may not be far-fetched as this report will later reveal. Bach (2001) notes that building HR capacity requires greater co-ordination between training/education institutions, workforce planners and health care providers. Bach is of the view that where employees are insufficiently involved in formulating the HR agenda, change precipitates defensive reactions from staff. Ianus (1999) notes the legacy of insufficient attention to HR, and that in the majority of countries there are problems with shortages, misdistribution and poor staff utilisation that often co-exist with problems of chronic over-supply linked to lack of co-ordination within the organisation. It is generally noted that in the health sector, HR strategy needs to take account of a range of different stakeholder perspectives and to be focused at national as well as lower organisational levels. According to Ianus (1999), where these realities are ignored, unrealistic and naïve HR Strategies may be formulated. This point is well noted because in many countries including Ghana, there is a tradition that the distribution and allocation of health professionals is decided centrally, with local managers having little discretion over staffing. Literature reveals a lot of different perspectives on what human resource strategy is. Most writers see Strategy being about getting from where we are now to where we want to be and that this may be manifest or implicit in organisational behaviour. A comprehensive definition of HR strategy was made by Tyson (1997) who defined HR strategy as a set of ideas, policies and practices that management adopts in order to achieve a people management objective. Ulrich (1997) on the other hand proposed that HR strategy is the agenda or plan for the HR functions or for the development of HR processes. According to Ulrich, HR strategy is concerned with how the various systems that are typically the responsibility of HR will be developed and managed in the future. These systems include recruitment and selection, reward, training and development and performance management. Walker (1992) defined Strategic HRM as “the means of aligning the management of human resources with the strategic content of business” and Boxall (1994) expressed the view that “the critical concerns of human resource management are integral to strategic management in any business” (Armstrong, 1999. p.248). From these definitions we observe that strategic human resources is about making organisational plans in line with the human resource that an organisation has and that these plans are effective to enable the organisation achieve its objectives. This involves making an analysis to enable the organisation know where it is, what it has and where it wants to go and with what. Developing an HR strategy is therefore about doing an outline of Human Resource Management functions and activities in full purpose to help organisations to achieve the goals set out in their mission statements. It is in this line that Armstrong (1999) notes that the connection of human resources with strategic goals and objectives in order to improve business performance and develop organisational culture that promotes innovation and flexibility is what strategic human resource management is all about. For many organisations there is a need to develop a HR strategy due to the increasingly competitive environment in which they find themselves. HR strategy derives from the desire to fully exploit the potential of people as a source of competitive advantage but also to meet the needs of HR practitioners. The only real source of sustainable competitive advantage for many organisations is unleashing the power of its people. The people and processes in an organisation not only provide incredible competitive advantage, they are also difficult to copy or buy in and this gives the uniqueness of an organisation (Armstrong, 1999). The essence of HR strategy is therefore a sustained focus on the people who do the work of the organisation. An HR strategy is essential for maintaining quality customer care, attracting and retaining high quality staff and ensuring continued commitment from the staff to continuously improve the organisation. It entails the development of strategies to attract the right people to the organisation with the appropriate skills and competencies and strategies to retain them once they are recruited. Key issues in attracting and retaining staff are Recruitment and Selection, Rewards and Pay, Training and Development and Appraisal Management. The ultimate aim of any HR strategy is to create the highest value organisation. There are various approaches to developing a HR strategy. The three most popular models are the Harvard model, The Michigan model and Guest’s model. The Harvard approach sees employees as resources. However they are viewed as being fundamentally different from other resources as they cannot be managed in the same way. The emphasis is on the people as human resources. The Harvard Map, as it is known in various literature, outlines four HR policy areas: Human resource flows – recruitment, selection, placement, promotion, appraisal and assessment, promotion and termination. Reward Systems – reward and pay systems, motivation etc Employee Influence – delegated levels of authority, responsibility and power. Work systems – definition/design of work and alignment of work. This model suggests that these HR policy choices are more superior to others. These policy choices will be influenced by Stakeholders and situational factors e.g. Labour market. It notes that it is management’s task to make strategic policy choices in light of these factors. If appropriate choices are made bearing in mind the “four C’s” (commitment, congruence, competence and cost effectiveness), then they will lead to beneficial HR outcomes for the organisation. The Harvard model, an example of “soft” HRM, sees employees as valued assets. Its strengths are that it draws on the human relations aspect, it emphasises communication, teamwork and the utilisation of individual talents. The second model, the Michigan model has a less humanistic edge and comes under the “hard” HRM approach. It has a more strategic approach and a unitary outlook and endorses management views. It proposes that employees are resources in the same way as any other business resources. It states that they must be obtained as cheaply as possible and used sparingly. It also states that they must be developed and exploited as much as possible. The third model, the Guest model, draws on the Harvard model and the Michigan model. Guest acknowledges the differences between these approaches and incorporates both into the normative HRM model. Guest explains the underlying interconnections between a particular set of policy choices and a desired set of outcomes such as quality and choice. The concept of normative HRM has been adopted by many organisations and has two common themes. The first is that HR policies should be integrated with strategic business planning and used to reinforce or change appropriate organisational culture. The second notes that human resources are valuable and a source of competitive advantage and are tapped most effectively through policies that promote commitment. There is a lot of research on the relationship between the HR practices and the organisation’s strategy. This is, basically, the contingency approach to HR strategy. To give a clearer understanding of the link between HR and Strategy this paper discusses the three theoretical perspectives of the relationship between HR practice and the organisation’s strategy. These three are contingency, universalistic, and configurational approaches. The universalistic perspective suggests there is a “best practice” approach to HR strategy, with a set of HR policies to be identified which will improve performance. These “best practice” policies may be embodied in a variety of concrete and detailed HR techniques or practices. The configurational approach is concerned with “the pattern of planned human resource deployments and activities intended to enable an organisation to achieve its goals” (Wright & McMahon, 1992). This approach suggests that an organisation must develop HR as a system so that both horizontal and vertical fit can be achieved. The view held by the contingency approach is that to be effective, organisation HR policies must be consistent with other aspects of the organisation. “HR strategy becomes more effective when it is designed to fit certain critical contingencies in the firm’s specific context”, (Boxall & Purcell 2000). The organisation’s strategy is generally considered the primary contingency factor. This enables the Human Resource policies and practices to be consistent with the organisation’s strategy. The contingency approach also states that the context in which an organisation makes strategy decisions will be limited and depends on the organisation’s size, technology and stability. To us, this approach seems more practical than the other two as HR strategy has to fit the different parts of an organisation such as sub-cultures or climates. Many organisations have subcultures or an organisational culture, which may clash with the HR strategies. Sub cultures play a significant role influencing the degree to which HR strategies are successfully translated into HR practice. Bach (2001) notes that no pre-packaged model is appropriate to the range of circumstances within health care systems and therefore it is the ability to craft a strategy appropriate to local conditions and culture and to implement it effectively that matters. In this regard Bach (2001) moved beyond generic models to distil the core processes and values that underpin successful HR. Through research, Bach then distilled the three core processes and values that are essential for an effective HR strategy, Ownership, External fit and Internal fit. Bach notes that in ownership, people are regarded as a strategic resource to be nurtured and developed with top managers supporting such an approach strongly. There is clear leadership of the reform process with sufficient HR capacity to maintain the momentum of change or reform. Under External fit, organisations are alert to the external environment and plan their HR requirements in a manner that incorporates the HR implications of a changing external environment and are able to modify the strategy or resolve the problems that may arise from any environmental changes. In Internal fit there is a coherent approach to HR policy which is not over-reliant on one element for example training but combines HR policies into an integrated bundle of policies and processes (Bach 2001). Bossert et al (1998) note that research evidence had shown that ensuring the importance and ownership of HR with the health sector remains a major challenge. They observe that in many developing countries HR activity is located within a specific HR unit or directorate within the Ministry. The difficulty is that many of these units are not staffed by HR specialists and they tend to concentrate on issues of personnel administration and training. This operational focus can contribute to the sense as in the case of Colombia, that the ministry forms part of the problem rather than part of the solution and this weakness prevented it from building consensus for reform with other stakeholders. The situation in Ghana may not be very different as will be revealed latter. Implications of the review findings The literature reviewed has established a foundation for measuring good practice in developing strategic HRM policy which this paper seeks to establish. The literature has illustrated several issues, viewpoints and perspectives of strategic HRM. It also establishes that HRM policies across the globe aim at one thing, to maximise the value obtained from the allocation of the human capital. For an organisation to succeed in today’s competitive and results-oriented environment, it is imperative for the organisation to develop a good and implementable HRM strategy. Research Approach and Methodology The important consideration that guided the choice of method for this study is time and finance. The Ghana HRM Policy was two years old at the time of this study and its implementation was not yet in full force. The researcher intends to do a follow-up study later, looking at the implementation of the policy to see if the results of implementation were rightly predicted by the policy content analysis done in this paper. This study reviews the policy and corroborates this with other secondary data from peer-reviewed literature, reports, health journals, published works and grey material. This provides a clear and evidence-based picture for the research questions that this research tries to answer. The HRM policy of the MOH was in the public domain. Subjecting the policy to an academic and theoretical analysis leads to no harm or negative effects to individuals or groups of persons. Therefore, no special permission was required, sought or obtained for this exercise. FINDINGS AND ANALYSIS The findings as recorded in this chapter are extracted from the Ministry of Health HRH document entitled “Human Resource Policies and Strategies for the Health Sector (HRPSHS) 2007-2011” (Ghana MOH, 2007). The policy development process started in October 2005 when a forum on Human Resources for Health was conducted (Ghana MOH, 2007). The Minister for Health gave the mandate to a technical team to transpose the forum’s recommendations into a human resources policy. The technical team facilitated the planning, training and management of HRH at a series of meetings with representatives of stakeholders. Among these stakeholders were Quality Health Partners (QHP), a USAID-funded programme and the World Health Organisation (WHO) AFRO. They were very instrumental in supporting the development and dissemination of the policy. Other contributors were the Ghana Health Service, Teaching Hospitals, Christian Health Association of Ghana (CHAG) and some regional directors of health. The HR policy 2007 to 2011 is built on the previous 2002-2006 HR policy. The MOH had seen the need to update the policy to address implementation gaps as well as current gaps facing the sector. This was conceived under the view that it was necessary to undertake a complete shift of paradigm in health goals and policies to strategies that will ensure wealth creation for the nation. This was to ensure harmonisation of national health policies with the development of human resources for health in both public and private sectors. The goal of the policy is to improve and sustain the health of Ghana’s population by supporting appropriate human resource planning, management and training so that there is adequate production of appropriately trained staff and that staff is motivated and retained to perform effectively and efficiently. There are five HRM policy measures. These are: Increase the production and recruitment of health workers focusing on mid-level staff Retain, distribute equitably and increase productivity of health workers by strengthening supervision, refining compensation and incentive schemes and enhancing legislation and regulation Advocate and mobilise other professionals related to health care to contribute to the promotion and maintenance of health and Empower environmental health inspectors to enforce standards for environment hygiene. The policy also intends to improve upon the decentralisation of personnel emolument. Human Resource Management Situation The Human Resource Directorate at the MOH is the custodian for the policy on recruitment, placement and promotion with the Ghana Health Service, its main implementation agency. The directorate has training, planning and management units (Ghana MOH, 2007). There are human resource managers at the regional and teaching hospitals. The main functions of the Directorate at the national level are: HRH policy and strategy initiation and formulation; HRH planning and distribution of new health professionals among the agencies; coordination of pre-service training and linking up relevant universities and health facilities for graduate internships; HRH development and staff training functions and coordination of the health sector fellowship scheme; HRH monitoring and evaluation and; responsibility for other HRH functions that may be cross-cutting and likely to generate conflict and mistrust among executing agencies (Ghana MOH, 2007). The total workforce of the Health Sector is approximately 52,258 (Ghana MOH, 2007). Out of this, the MOH employs a total of 42,299 staff for the Ghana Health Service, Teaching Hospitals, Health Training Institutions, Regulatory Bodies and the Headquarters. The total number of women is 22,000 which represents 59% of the workforce. The largest section of the workforce (37.6%) falls within the 40-50 age groups. People in the age of 18-39 years form about 25.9% of the total work force and include those likely to migrate to more developed countries for higher incomes. In 2005, the MOH was allocated 26.5 million Ghana Cedis (about US$ 18.6m) for recruitment of new staff. This amount was significantly low as the Health sector had a backlog of staff to be recruited formally. The amount could support only 20% of the sector’s total recruitment needs. Staff attrition in the health sector has seen a decline in recent years though vacation of posts and resignation continue to top the reasons for attrition (Ghana MOH, 2007). The decline is partly due to the fact that over the last five years the MOH has instituted measures to attract and retain health workers. These measures include: provision of hire-purchase saloon cars; a tax waiver for imported saloon cars; provision of housing schemes for health workers; continuing professional development; establishment of Ghana College of Physicians and Surgeons, for postgraduate training of medical officers; and improved human resource management practices in recruitment, placement, redeployment and promotions (Ghana MOH, 2007). Training of health professionals has been a shared responsibility between the Ministries of Health and Education Service. The policy document acknowledges that there have not been clearly defined roles and strategies for this collaboration. It also notes that the current HR policies and strategies give some direction on training but do not adequately provide guidelines for training institutions. Human Resource Challenges The national health system currently faces compound challenges, including: inequitable distribution of workers at different levels of services delivery; inadequate staff numbers; low morale and motivation of the health workforce; inadequate supportive /facilitative supervision; high attrition of health workers; weak performance management systems; limited training capacity to meet increasing numbers of applicants into the training institutions and; inadequate collaboration between MOH and Ministry of Education training institutions. The policy document notes the following six key principles as underlying the human resource policies for the five year period 2007 -2011: improving access to quality health care through rational production and equitable distribution of health personnel; focusing on health promotion, prevention of disease and regenerative health; using human resources to achieve the MDG’s for health; providing equal opportunities in training, recruitment and deployment; creating an enabling environment for health personnel to function effectively and; preserving and maintaining ethical standards that will ensure clients’ and staff’s rights (Ghana MOH, 2007). The policy recognises that staff shortages in the health sector are further compounded by mal-distribution with a skew towards rural facilities and more unskilled staff than skilled ones. Skills needed to function effectively in some positions are often lacking resulting in job and qualification mismatch. The policy notes that these have contributed to ineffectiveness and sometimes compromise quality of health care services. The policy therefore adopts a number of strategies and supportive mechanisms for equitable distribution and rational utilization of available HRH. The first policy thrust is for the MOH to strengthen human resource management systems that are relevant to all levels and sectors of health in the country. The policy intends to achieve this by: strengthening the HRH directorates and units with human resource managers and officers at all levels and sectors; building capacity for human resource managers and officers at all levels; disseminating policies and guidelines on human resource management functions to all human resource directorates, sectors and units; providing technical support to all directorates, sectors and units; and ensuring that systems are instituted to facilitate monitoring of human resource functions at all levels, especially the private sector (Ghana MOH, 2007). The policy also intends to ensure equitable distribution of health professionals in the health sector. It intends to achieve this through: redistributing health professionals and support staff within the country based on local health needs and staffing norms; ensuring that policies on deployment of staff favour rural and deprived areas; instituting a two-year compulsory, post-graduation deployment to rural area schemes for health workers; and ensuring that health workers are rotated between peripheral health centres, hospitals, health posts and agencies where appropriate (Ghana MOH, 2007). The policy also intends to improve upon the decentralisation of personnel emolument. It hopes to do this through: strengthening the management structures and systems in the peripheries to promote good human resource practices; developing human resource capacity and providing technical support to the various levels; providing HRH operational policies and guidelines at the peripheries; and facilitating the decentralisation of salaries and other allowances to the budget and management centres in phases (Ghana MOH, 2007). The policy aims at ensuring fairness in promotions for all categories of staff and also institutes general compensation and benefit schemes as part of efforts to motivate deserving individuals, groups, institutions and establishments. To achieve this, the policy intends to: provide guidelines for promotion of staff for adoption by all agencies and sectors; ensure that the number of years required to be eligible for promotion is reduced by one year for personnel working in officially designated deprived areas; standardise promotions in all agencies and sectors to prevent competition; ensure adequate and constant inflow of government of Ghana funds; maintain the existing benefits and rewards schemes; and to operationalise staff housing schemes in the agencies (Ghana MOH, 2007). The policy wishes to introduce measures to motivate and retain trained staff in all sectors and also facilitate the development of specific job descriptions that match with worker remuneration for all health employees. To achieve this, the policy intends to: provide clear career paths for progression and opportunities for professional development; provide access to fellowships for eligible staff at all levels; encourage support and recognise essential non-clinical programmes; continue to expand existing benefits schemes for health staff; improve working conditions and environment in facilities for efficient and effective service delivery; expedite the implementation of performance related reward systems; provide a framework for agencies to develop job descriptions for their staff; ensure that remuneration and allowances are based on job evaluations; ensure that staff operations are in accordance with their job requirements (Ghana MOH, 2007). In order to achieve the goals of the policy, there is an implementation plan. The plan is divided into a short and long term components. It also estimates the budget requirements necessary to implement the strategies. The policy recognises that the success of the implementation plan depends on the commitment of all stakeholders involved through a collaborative approach. This section discusses the results of the study as synthesised from the policy document. The discussion is in line with the core values of ownership, external fit and internal fit according to Bach as earlier described. Ownership Bach (2001) notes rightly that it is at the national level that Ministries of Health are expected to lead health reforms, including HR activity. In the case of Ghana, this was rightly so. It was the ministry that initiated the formulation of the policy through its appropriate directorate, the Human Resource Development Directorate (HRDD). In 2005, the Ministry conducted a forum on Human Resources for Health, at which a technical team was mandated to transpose the forum’s recommendations into a human resources policy. The team brought together representatives from various agencies. Perez (1996) supports this view point by noting that it is important to establish a specialist and independent capacity at central level to thrash out detailed plans for implementation at the lower levels. Bach (2001) notes that ownership of HR issues is diffused among different actors and for HR policies to be effective there should be agreement and co-ordination among these different actors. For example HR policy invariably has pay bill implications for the Ministry of Finance and its involvement should be critical for a successful HR policy. The Ministry of Finance has close interest in HR matters as do other Ministries, Departments and Agencies. HR policies will invariably only be effective if there is agreement and co-ordination at central level (Bach 2001). A critical look at the Ghana policy does not indicate the awareness of the policy to this critical fact. The Ghana policy acknowledges the dependency on educational institutions such as the medical schools and the need to involve them in policy-making. But these institutions are autonomous and they independently determine the numbers of students to admit. The policy document acknowledges the Ministry of Health’s poor co-ordination with the Ministry of Education but barely mentions how to deal with this problem, yet its resolution is critical for numbers and skilled manpower requirements. The physical involvement of some educational institutions in policy formulation alone is not enough. In Peru for example, private and loosely regulated educational institutions are creating an over-supply of physicians, an issue that has not been adequately addressed by the state even though it has exacerbated existing problems of staff utilisation and deployment (Kolehmainen-Aitken, 1998). Bach (2001) notes that there is often a reluctance to include trade unions, and yet their exclusion can store up problems for later. For example in Costa Rica, a relatively closed policy making process at the behest of the World Bank and Inter-American Development Bank, marginalised union involvement and led to an incoherent HR policy and similar problems have been reported in Fiji and Guinea-Bissau. On the other hand widespread consultation with stakeholders in Angola and Botswana facilitated a strong sense of local participation and ownership (Egger et al., 2000). The Ghana policy, like in the case of Costa Rica, does not mention the role of trade unions. Yet it is critical that in planning HR strategies, management works with the unions establishing clearly their role in the policy making process and implementation. Another issue that undermines ownership and exacerbates problems for the central Ministry of Health is the constant change amongst senior staff. There is some anecdotal evidence that the top positions within the Ministry of Health are subject to political fluctuations in which there is frequent changes and the allocation of senior roles is done on the basis of political patronage. Bach (2001) notes that this discourages a longer term perspective, erodes organisational memory and expertise, reducing the capacity to implement reforms and be effective in collaborating with other stakeholders. External Fit A planned framework that enables alignment between HR and the external environment is the second key component in developing a strategic approach in making a successful HR policy. To be effective, organisations should plan their HR noting the external environment to their organisation and thus plan their HR requirements in a manner that incorporates the HR implications to changes in the external environment (Bach 2001). A strategic planning framework that ensures external fit has to focus attention usually on HR audit and the HR plan. The Ghana policy does not provide a clear audit of staff (professional and non-professional). The policy provides a table of staffing norms for health sector facilities. It would have been more appropriate to position this against the real situation on the ground and projects designed to bring this in line with the norms. The policy document notes that the attrition rate for health staff is very high. Vacation of post and resignation top the reasons. In most cases those who vacate their post migrate to other countries where there are better conditions of service. The strategies to reduce migration are very impressive but lack indicators for measurability. Moreover, the suggested measures appear like a wish list, hard to achieve. While they are laudable, as a strategic plan, they should have measurable indicators. A strategic plan of an organisation should also outline in qualitative and quantitative terms the expectations of its entire staff and how these will be met. In developing an HRM plan it is critical that the task that the human resource has to confront is clearly established. The Ghana policy fails to provide a more detailed and explicit consideration of key health trends, even though scanning the environment is a central component of ensuring external fit. Another critical external fit issue which the policy ignores is private practice of public sector workers. In many African countries, professional staff in the public service carries out private practice to boost their salaries. This practice has ambiguous status and compromises work at the public sector. It is imperative that the policy incorporates private practice and the activities of NGO’s into an analysis of HR requirements and how to deal with the situation. This will increase the credibility of HR planning. Another key environmental factor, facing developing countries including Ghana is that the health sector, particularly at the national level, is subject to political manipulations and interference in which there is frequent change in key personnel due to change in government and the allocation of senior roles on the basis of patronage. Kolehmainen-Aitken (1998) notes that this discourages a longer term perspective, erodes organisational memory and expertise, reducing the capacity to implement reform strategies and undermines the management of the human resource, the very basis for the existence of an HRM plan. Internal Fit Public sector organisations need to ensure the use of competency frameworks that ensure that the requirements of the HR strategy can be linked to the specified attitudes and behaviours of staff to ensure internal consistency. To achieve this, cohesive HR policy should be heavily dependent on effective recruitment and selection practices. But in the case of Ghana, decisions about recruitment and selection are often handled by a central government body using standard staffing ratios that are often poorly linked to local requirements. These difficulties are exacerbated by poor links between recruitment requirements and training outputs. Graduates from training institutions have to wait for months and years before being recruited. The Ghana HR policy also notes poor distribution of staff with majority of staff preferring to work in urban centres. It plans to redistribute health professionals and support staff within the country based on local health needs and staffing norms, but it does not say how it is going to redistribute the staff. The strategies that the policy wishes to adopt appear to be a wish list rather than clearly defined actions with indicators for success. Bach (2001) notes that salaries are generally poor in developing countries and this has encouraged staff to supplement their income by private practice with detrimental consequence for public health. The Ghana policy does not take note of the issue of poor salaries and private practice which is detrimental to the health sector achieving its goals. The Ghana HR policy however has noted actions that will improve non-pay benefits and working conditions. It has also noted that rewarding good performance through promotion, more responsibility and incentives such as housing and provision of hire-purchase vehicles can be a prominent recruitment and retention strategy. In the case of Ghana there is evidence of failure to invest in HR expertise at the peripheral levels, that is, the district, regional and hospital levels. This certainly undermines the message that HR issues are important. In the case of Ghana, as evidenced from the HR policy, there appear to be no concrete support and guidance to district, regional and teaching hospitals about how to implement HR strategies. This can only make thought out strategies to be implemented at the lower levels redundant. In order to achieve the goals of the policy there is an implementation plan. The policy however recognises that the success of the implementation plan solely depends on the commitment of all stakeholders involved through a collaborative approach. However, the detailed strategy to ensure this collaboration is lacking. The process of policy making and implementation in the Ministry of Health is complex. The situation where human resource and sectoral planning are carried out in isolation is the beginning of the problems for human resource management. The large number of stakeholders for the health sector, which includes many ministries, departments and agencies, make the problems more complicated. This complex process is again compounded by the weak capacity for the planning and management of HR within the health sector itself. This paper argued that despite the emphasis in the last decade on health care reforms little has been achieved because of insufficient attention and lack of capacity in HRM activities. Strategic HRM for health ensures that the right mix of skills with the right orientation is available in the right place and that this is achieved with minimum waste. The success of a strategy involves embracing core principles of best practice in HRM. A good strategy requires an attempt to understand and apply values of ownership, internal, external fit factors into designing strategic human resource management plans that ensures coherence. REFERENCES
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