Since 2014, WHO has worked closely with the Nigerian Federal Ministry of Health and other partners to transform how the health workforce is able to respond to the health needs of the population and make genuine progress towards universal health coverage (UHC). In 2014 a project began called ‘Enhancing the Ability of Frontline Health Workers to Improve Health in Nigeria’ and was funded by the Government of Canada through Global Affairs Canada (GAC). The project has an overall goal of improving the health of infants, children, women, and men in Bauchi and Cross River States by strengthening the capacities of frontline health workers to deliver maternal, neonatal and child health care services at the primary care level. The project was implemented by World Health Organization (WHO), the Population Council (PC) and the Global Health Workforce Alliance (GHWA) and partnerships formed with the Federal Ministry of Health, Bauchi State Ministry of Health and its Departments, Agencies and Parastatals and the Cross River State Ministry of Health and its Departments, Agencies and Parastatals. 

Transformative results 

■ At federal and State levels, officials now have better skills to formulate, implement and manage evidencebased human resources for health policies and programmes that respond to the population’s needs. 

■ Health managers at State and local levels are now much better able to deploy, manage and retain health workers to ensure a good mix of skills and distribution across Bauchi and Cross River States. 

■ Federal and State ministries of health,professional associations and regulatory bodies share information and collaboratively managed the frontline health workforce. 

■ State-level managers and decision-makers hold frequent informal policy dialogues about health workforce matters with a range of stakeholders, improving partnerships and coordination for mobilizing resources. 

Coordinated health planning Coordination among intervening partners in human resources for health is of vital importance. At national level, the Nigerian National HRH Partners Forum has been revitalized with WHO’s support. All partners who implement HRH interventions are able to come together, plan together, provide updates on activities, and share knowledge and best practices. This is all coordinated by the government and one of the key outcomes of this Forum is the ability to perform annual operational planning. The Annual Operational planning has transformed approaches to ensuring that the health workforce exists in adequate numbers with the right skillsets. Based on situational analyses and policies adapted to the context of each federal State, the Federal Ministry of Health is able to coordinate with partners who are implementing health workforce projects. In each State, the government and all partners and stakeholders develop joint annual operational plans and conduct joint annual reviews and reports on how the work is going. For the past five years, WHO has provided technical assistance to the Federal Ministry of Health in this area to ensure the smooth running of this approach. "The joint annual operational planning and reviews have improved the health leadership and governance pillar in the HRH sub-sector and also raised consciousness in progress being made in achieving Nigeria health workforce goals.” Dr Moses Ongom, Health Systems Advisor, WHO Nigeria. "In all that we do, we support government. Our core function is to support government by providing technical support and ensuring that the governance platforms are working properly. We know that once the leadership and governance platforms are working well, with technical expertise you can maximize impact.” Dr. Sunny Okoroafor, NPO HSS/HRH, WHO Nigeria. In Bauchi and Cross River States, WHO also supported the government to establish a Health Partners Forum, which brings together all partners supporting the health sector with a clear goal of coordinating and managing health sector interventions. This means that all partners come together every quarter to plan together, hear about the government’s priorities, synchronize activities and support the government to achieve their priorities. It also helped health workforce issues to be mainstreamed into all health activities. For the government, it is immensely beneficial to be able to align its programmes and trainings, and understand the different areas of partner specializations. For partners it means that their pooled resources are being maximized to the fullest extent. "Partnership coordination is helping us to align partners to the priorities of government.” Dr Joseph Bassey, Permanent Secretary, Cross River State Ministry of Health 

Planning and retaining the health workforce

The retention of health workers, particularly in rural areas, is a big issue to overcome. WHO worked with the government to set up Human Resources for Health Desks and put in place health workforce planning officers. WHO mentored them and piloted the Health Workforce Registry, which is a database of all health workers in the Bauchi and Cross River States. The Registry links their names, age, gender and cadre to a specific service delivery point and helps identify the volume and skill mix of health workers in facilities. This is important in knowing the strengths of each facility and where there are gaps that need to be filled. 

WHO conducted a WISN study in 519 ward level primary health care facilities and identified the staffing needs for those facilities. It triangulated data from the District Health Information system (a national service delivery information system) with data from the WHO Workload Indicators of Staffing Need (WISN) tool. For the government, it was eye-opening to have this kind information. They discovered that their workforce had been depleted, and that the workload was surpassing the capacity of staff. WHO presented findings on the pressures on health facilities, and this led the Cross River State Government to recruit 1000 additional health workers for primary level of care. Cross River State also used the data to inform the review of the HRH needs in the State minimum service package for primary care. In Bauchi, the WISN has led to employment and deployment of freshly graduated community midwives based on workloads and the current plans to recruit additional frontline health workers where there were shortages. "With the coming of WISN… we can do the calculations and deploy health workers… and it will be covered by law that you must go where you have been posted. Deployment and redistribution of health workers is much easier with the registry and using WISN…” Dr Dayyabu Mohammed Hassan, Director Planning, Research and Statistics, Bauchi State Ministry of Health” "The registry will tell me how many staff will retire next year, so I can plan and say this is the number of staff that the government will employ to fill this gap. With a click of a button, it will tell me how many midwives we have across the state.” Adamu Ibrahim Gamawa, Executive Chairman, Bauchi State Primary Healthcare Development Agency. The Health Workforce Registry piloted in Bauchi and Cross River States has now been adopted by the Government of Nigeria and WHO is providing technical assistance to the Federal Ministry of Health to roll it in select States with funding from some donors. WHO wanted to generate contextspecific information on the factors influencing the retention of frontline health workers in rural and remote areas. It conducted a study to explore what factors influence both the motivation and losses of frontline health workers in Bauchi and Cross River States. This generated contemporary data for developing evidence-based guidelines for attracting and retaining frontline health workers in remote and rural areas. WHO is currently supporting both States in this regard. 

Health workforce projection and planning

The WHO tool HRH Planning and Projection, as the name suggests, supports long-term planning and projection of health workforce and service delivery needs. For the first time, this tool was applied in Nigeria so that the States can identify the numbers and skill-sets of health workers required to provide quality services for the next ten years, and how that matches with the number of health facilities. The information gathered through this tool is being used to inform the review of the government’s HRH policy and strategic plan currently being reviewed. 

Improving the health workforce in Bauchi State

Prior to the project, Bauchi State had no policy or strategy to direct its human resources for health approach. Nor were there any human resources for health units at State or local government levels, or any kind of information platform. So the distribution of health workers was random, and some facilities were over-staffed while others suffered shortages. This of course had a negative impact on the population and access to services. "We know the gaps to fill in terms of health workers, we are able to advocate to the State government to recruit to fill areas where there are gaps.” Amina Mahdi, Gender Desk Officer, Bauchi State Ministry of Health, Bauchi. The project supported the development of Bauchi State Task Shifting/Sharing Policy for Essential Service which helps various cadres of health workers to do their work properly and addresses current gaps in skillsets. 

Implementation of the Health Workforce Registry meant that focal persons received training on how to collect health workforce information, conduct audits, update the registry and use it to develop profiles for human resources for health planning. Now policy makers and health managers can access real-time information on the health workforce situation in the State. Conclusion "This project has demonstrated that it is possible, through concerted effort by the States themselves with support from the federal level and in partnership with agencies, to achieve remarkable results. Could this be replicated in other States? Absolutely!” Dr Wondimagegnehu Alemu, WHO Representative in Nigeria (2016-2018). These results indeed demonstrate that planning, management and coordination to strengthen the health workforce is critical for Nigeria right now. With the right tools and strategically engaged health partners who are willing to coordinate their work on HRH, the government of Nigeria will make good progress to take those all important steps on the path to UHC.