The Diabetes Awareness and Care (DAC) project funded by the World Diabetes Foundation (WDF) is a collaboration between the Federal Ministry of Health, Nigeria and Health Strategy and Delivery Foundation (HSDF), which began in 2018. It is currently in its third year of implementation in the two pilot states, the FCT and Imo, Nigeria. One of the project’s objectives is to increase and improve access to Type 2 Diabetes Mellitus (T2DM) care through health care workers’ training at the primary care level. However, despite 22 months of implementation and the project’s approach for sustainable capacity building, staff attrition, and the absence of standardized processes at the facility level (to ensure knowledge and skill retention) have posed a challenge that the project continues to address.

At commencement, the project trained 250 health care workers from 110 facilities (in the FCT and Imo) on T2DM, diagnostic criteria, appropriate screening techniques, risk factor assessment, counselling, education, and proper reporting on data collection tools. The facilities were also provided with how-to guides and visual charts, Information Education and Communication (IEC) materials, data collection registers, screening equipment, and consumables. The health care workers were responsible for conducting step-down training sessions for as many staff available within their facilities. Also, facilities are further supported with regular coaching and mentoring visits and in real-time through a virtual platform.

Following 22 months of implementation, staff attrition remains a challenge to smooth and continuous implementation and data reporting in some project facilities.

• 38 facilities out of the 110 trained (i.e. 35% of all participating facilities) have experienced either a transfer, leaving for school, retirement, or resignation of one or more trained staff. See figures 1 and 2 below for more details per state.
• In some instances, the trained staff may not have handed over to another staff, the replacement staff does not receive induction on T2DM screening and sensitization, or the human resource gap is left unfilled.
• Also, some facilities did not conduct step-down training.

The selection criteria for health care workers’ participation in the DAC project training takes into cognizance this unavoidable challenge of staff attrition and its impact. For example:

• We request that nominated health care workers are those unlikely to be transferred or retired soon.
• The health care workers should be willing to and capable of conducting step-down training sessions for other staff within two (2) weeks of the training.
• During mentoring visits, facility leadership and staff are reminded of the importance of ensuring adequate handover before trained staff leave and induction for new staff.

But the reality is not always as planned. In this instance, contributing factors include weak facility management and staff buy-in/commitment, poor teamwork (where individuals hoard knowledge and equipment/tools only for their use), human resources shortages, workload, and misaligned views on the project incentives.

It is ideal that when the DAC project ends, benefiting facilities continue to create awareness on T2DM, provide quality care, and provide and use quality T2DM data through the facilities’ lifetime. However, continuity will be hampered if health care workers’ awareness and knowledge are lost due to the lack of institutionalized mitigating processes to minimize the impact of unavoidable staff attrition. It may not be attainable to curb this completely, but different key stakeholders have a synergistic role to play at the state level to minimize this, as is the case with the DAC project.

Lessons Learned and Key Recommendations for Various Stakeholders

The DAC project continues to engage all key stakeholders to address the challenges from staff attrition. Critical project multi-stakeholder engagement meetings such as policy review meetings, facility data review meetings, and mentoring visits are platforms leveraged to bring this issue to the burning platform. The following recommendations are being applied on the DAC project to mitigate and minimize the staff attrition impact.

The State Ministries of Health and other health Ministries, Departments and Agencies

• Facility governing bodies should be actively engaged in project beneficiary facility selection and provide oversight throughout implementation to demonstrate ownership of programs implemented in the State. Facilities will be more responsive to their oversight bodies and where appropriate, acceptable incentives are provided. It is paramount to understand the oversight structures and processes for engaging private facilities and what incentives they respond to best.
• During human resource planning, facility governing bodies could ensure adequate human resources and reduced staff transfer in project facilities. Especially in pilot projects, which are a proof of concept for results achievable and human resources needed for scale. Although, other state human resource needs and challenges can make this an unrealistic expectation.

Facility Leadership and Management

• Successful project implementation at the facility level will always require the facility leadership and management’s buy-in and commitment. A committed facility leadership and management will be more interested in monitoring progress and is approachable by staff to provide updates and discuss challenges. They will be proactive towards resolving challenges for seamless and continuous project implementation. They would also be more receptive to feedback from the project implementation team.
• Facility leadership and management have a crucial role in ensuring the right staff is selected for training and supporting step-down training within agreed timelines. They are also responsible for ensuring appropriate handover, and induction processes are in place and monitored. Their ownership of this role would facilitate sustainable capacity building and enable the seamless continuation of services when staff leave.

Trained Health Care Worker

• Trained health care workers must be committed to sharing and transferring knowledge and skills immediately after they return to their facilities with support from management.
• They should notify the project implementation team whenever a trained staff would be exiting the facility. This will ensure a timely assessment of the facilities needs for support.

Implementing Partners

• Collaborative project designing and implementation with key stakeholders are critical for proper contextualization, stakeholder commitment, and support.
• Implementing partners must continue to factor in staff attrition when designing projects that rely heavily on human resources for health. They should also plan for the time and resources to address the knowledge gaps that may result from this.
• Trained facilities should be expected to complete an action plan, accompanied by an action tracker, a checklist of relevant modules, training manual/handout, how-to guides, visual aids, etc. These will guide, facilitate, and support the smooth transition of knowledge during facility step-down training, handover, and induction for new staff.
• Project design should include a channel for notification by facilities when any trained staff is scheduled to leave. Support can be provided towards ensuring a smooth handover and knowledge transfer where necessary. The same applies to supporting the induction of new staff. Routine coaching and mentoring will also support this process.
• Implementers should engage facility management towards developing, implementing, and monitoring strategies to minimize staff attrition and its impact when it occurs. Management should be supported to appreciate the role human resource plays in the utilization and uptake of services and the impact on revenue generation.
• It is essential to re-assess leadership and management’s commitment at every encounter, to understand why there is a change and mutually seek a solution to improve it. However, in rare circumstances, it might be better for the project that facilities are disengaged when commitment is beyond resolve within the project’s scope.

In Nigeria, health care is challenged at all levels by a marked shortage of skilled human resources for health. This is doubly so at the primary level of care, which has traditionally been under-resourced. Whilst we work towards an ideal situation where we have the full complement of staff across all cadres of the health workforce, we must work collaboratively to ensure effective and efficient utilization of existing resources with a sustainability lens.

By HSDF’s Public Health Advisory team. Specific contributors were: Oluwadamilola Oko and Christine Ezenwafor