1. Working in Health: Financing and Managing the Public Sector Health Workforce Appendix A – Comparative Analysis of Health Outcomes, Service Delivery, and Health Workforce Levels in Kenya, Zambia, Rwanda, and the Dominican Republic Marko Vujicic, Kelechi Ohiri, Susan Sparkes The World Bank, Washington, DC

2. Outline  Comparison of health outcomes  Comparison of service delivery outcomes  Comparison of health workforce levels  Key messages

3. Health Outcomes  IMR and MMR in the Dominican Republic are lower than global average and close to LAC average  Kenya’s outcomes are better than the SSA average; Rwanda and Zambia well below SSA and global average Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

4. Health Outcomes  Relative to health spending and GDP levels, all four countries have above average IMR and MMR  In other words, these countries have worse health outcomes than countries with similar income and health spending levels Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

5. Health Service Delivery Outcomes  Health services are provided mainly through the public sector in all four countries  Rwanda is only regional outlier – much higher public sector provision that SSA average Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

6. Health Service Delivery Outcomes  For births attended by skilled health personnel the Dominican Republic has very high coverage. In Kenya, Rwanda, and Zambia rate is below average for SSA  For DPT3 immunization all countries exceed their regional average Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

7. Health Outcomes  For skilled birth attendance, relative to health spending and GDP levels, Dominican Republic is a good performer. Zambia, Rwanda and Kenya are below average.  For DPT3 immunization, Kenya and Dominican Republic are below average relative to health spending and GDP levels. Rwanda and Zambia are above average. Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

8. Health Workforce Levels  The Dominican Republic has above average staffing levels relative to the LAC average, GDP and health spending – especially doctors  Kenya, Zambia, and Rwanda have above average staffing levels relative to GDP and health spending – but not for doctors.  The skill mix in Dominican Republic emphasizes doctors  The skill mix in Kenya, Zambia, and Rwanda emphasizes non-doctors Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

9. Health Workforce Levels  The Dominican Republic has above average staffing levels relative to the LAC average, GDP and health spending – especially doctors  Kenya, Zambia, and Rwanda have above average staffing levels relative to GDP and health spending – but not for doctors.  The skill mix in Dominican Republic emphasizes doctors  The skill mix in Kenya, Zambia, and Rwanda emphasizes non-doctors Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.

10. Key Messages  In Rwanda, Kenya, and Zambia, health outcomes and service delivery coverage are both below average.  Low utilization of services might partly explain poor health outcomes.  In Rwanda, Kenya, and Zambia utilization of services is low despite high total staffing levels. Suggests a potential skill mix issue (supported by the fact that there are relatively few doctors) geographic distribution, productivity, or quality of care issue.  In the Dominican Republic, health outcomes are below average despite very high service utilization. Staffing levels are high and the skill mix is skewed toward doctors Suggests a quality of care rather than access issue. Suggests that with respect to workforce policy, the main issues could relate to productivity and quality of care.  Analysis is meant only as a broad overview of the countries and to motivate in-depth country case studies Source: Vujicic, Ohiri and Sparkes (2009), Working in Health: Financing and Managing the Public Sector Health Workforce, Washington, DC: World Bank.