Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 1 | P a g e c REVIEW ARTICLE Post Covid-19 Agenda: Maximizing human resources for health towards Universal Health Coverage in Africa McKing I. Amedari 1, Ifunanya Carista Ejidike 2 1Department of Preventive and Community Dentistry, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria; 2Access to Medicine Foundation, Amsterdam Netherlands; Corresponding author: Dr. McKing I. Amedari BDS, MPH; Department of Preventive and Community Dentistry, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria; Email: mckingamedari@yahoo.com mailto:mckingamedari@yahoo.com Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 2 | P a g e Abstract Aim: To analyse options for maximising the capacity of human resources for health to achieve Universal Health Coverage (UHC) in Africa. Methods: Articles were retrieved from a Pubmed search and additional snowballing was con- ducted to provide other relevant sources. Further utilizations were made of Campbell's modified framework of the Human Resources for Health (HRH) and Universal Health Coverage with the WHO labour market dynamics framework for Universal Health Coverage. Four sub-themes viz improved HRH performance, Labour Market Factors, Rural Health Workers Retention Factors, and Information Technology Factors were analysed. Results: Labour market factors such as the dynamics of demand and supply of health workers determine the availability of health workers. Supportive supervision enables the health workers to improve in their performance and enhance optimised utilisation of available resources. This su- pervision can be more effective by complementing it with tools such as information technology that focus on improving the quality of health care, considering the growth in the number of internet and broadband users in the continent. Conclusion: Expanding the training opportunities for health workers and also increasing the fund- ing to human resources for health are useful policy options to consider. Cost-effective approaches such as a focus on community health committees which stimulate the demand for health services in rural communities to tackle the disproportionate distribution of health workers should be con- sidered in the context of the uncertain economic aftermath of the covid-19 outbreak. Keywords: Covid-19, Human Resources for Health, Supportive Supervision, Market factors, In- formation Technology. Sources of Funding Nil Acknowledgement We express profound gratitude to Prof Flavia Senkubuge for providing technical help and writing assistance during the preparation of this manuscript. We also appreciate Dr. Aborisade Adetayo for assisting with editing of the manuscript. Conflicts of Interest The authors declare no conflict of interest. Author Contributions MIA drafted the entire manuscript. ICE provided a critical review and made substantial contribu- tions to the design of the manuscript. Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 3 | P a g e Introduction Africa is inundated with a dual burden of diseases (1). Communicable diseases are more prevalent on the African continent than elsewhere, and it is mainly linked with extreme poverty and the poor living condi- tions that many experience (1). Non-com- municable diseases (NCDs) are also on the rise, especially among poorer communities: its under-reporting, however, makes the spectrum complicated to detect and treat. In countries like Namibia, Seychelles, and Mauritius, 50% of deaths among adults are attributable to NCDs (1,2). The covid-19 outbreak has exacerbated poor health out- comes in badly affected countries on the continent culminating in rising cases of NCD related morbidities and mortalities (3). This invariably overburdens health sys- tems that are previously struggling to re- spond to health needs and further weakens the capacity of human resources to play a central role in mounting a robust response to the emerging health problems in the con- text of an epidemiologic and demographic transition (1,4). It has become imperative that "adequate, skilled, well trained and mo- tivated" human resources for health is needed in the trajectory towards Universal Health Coverage (4). Many countries in Af- rica face socio-economic challenges, with constraints on their fiscal space and limited government expenditure on health (5). Some countries are only just emerging from conflict situations or security challenges, or natural disasters that impose specific limi- tations on the healthcare worker's availabil- ity. The number of healthcare workers pre- sent at the health centres and the actual number needed at these facilities is custom- arily imbalanced and although there have been attempts at planning workforce using epidemiological and demographic surveys, not much more attention has been given to the evolving market factors that also influ- ence this situation (6,7). The shortage of health workers is a global challenge, but this is more prevalent in Africa with its per- ilous shortages projected to be up to 6 mil- lion health workers by 2030 (7). This short- age becomes glaring in the context of the rural-urban disproportionate health worker distribution despite a larger population size in rural communities (8). Beyond availabil- ity, possession of adequate competency, motivation to deliver quality health services provided in a culturally acceptable way as well as an equitable distribution of health workers are necessary considerations for ef- fective coverage of the health system (7). Community Health Workers remain an in- tegral part of the workforce in rural commu- nities and have to deal with multifarious tasks and poor remuneration in carrying out their duties. Nevertheless, with attention to supportive supervision, it is suggested that this will enhance the motivation and the performance of these workers and also im- prove the quality of health care (9). Addi- tionally, investment in innovative technolo- gies for health systems has also been sug- gested as a cost-effective solution to chal- lenges such as lack of trainers or quality guidance for the workers in the frontline (10). While the focus is on human resources for health, implementation and contextual factors limit interventions to improve health outcomes in Africa. This review seeks to analyse options for maximising human re- sources for health to achieve Universal Health Coverage in Africa. Methods The review uses themes from the Camp- bell's modified framework of the Human Resources for Health (HRH) and Universal Health Coverage (UHC) with the WHO la- bour market dynamics framework for Uni- versal Health Coverage presented in the WHO global strategy for workforce to- wards UHC in 2030. By focusing on the common difficulties that affect health Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 4 | P a g e worker training, retention, performance and quality of service provision according to the HRH Strategy document (7), sub-themes were purposively determined to guide the analysis in this review. These include La- bour Market and the availability of health workers, Retention of health workers in the rural areas, Training (supportive supervi- sion) and Information Technology to im- prove performance. A detailed search was next conducted utilizing the Pubmed data- base. This database was selected because it comprises the largest collection of peer-re- viewed articles globally. There are over 30 million citations on the database and full- text contents are linked with it. The search was guided by the four study sub-themes and conducted using several keywords in- cluding: "Market forces", "Market factors" "Human Resource for Health", "HRH", "Africa", "Retention", "Communities", "Rural", "Supportive supervision", "Qual- ity", "Health care", "Universal health cov- erage"," UHC", "Information Technology", Appropriate Boolean terms "AND" "OR" were utilized to facilitate the search. No date filter was used and relevant articles to the topic were selected from a large pool of 173 articles at the first search. (Please refer to appendix). Targeted snowballing from the list of references was also conducted to complement the list of scientific publica- tions used, following the guidance of: Fig- ure 1. Human Resources for Health and Ef- fective Coverage (Campbell et al, 2013 as cited by (7): p.11); Figure 2. WHO Labour Market dynamics. (Sousa A, Scheffler M R, Nyoni J, et al, 2013 as cited by (7): p. 13). Results The results will be presented considering, the main factors influencing the availabil- ity, accessibility, acceptability, and overall quality of HRH divided into four umbrella factors or subthemes namely, Labour Mar- ket Factors, Rural Health Workers Reten- tion Factors, Health Workers Obligatory Education and Supportive Supervision Fac- tors and Information Technology Factors. Furthermore, these four factors are under- pinned by financial, professional, infra- structural, and procedural support, See Fig- ure 3 in the appendix. Labour Market Factors Attention should be focused on the health worker preferences and the dynamic labour market (6). Health workers may be inter- ested in alternative positions or may emi- grate against the health care needs that re- quire their availability. Furthermore, there is an imbalance between the supply (health workers available) and the demand for health workers (health workers hired) re- sulting in either inefficiency of government spending or under-employment (6). The la- bour market in the health sector is deter- mined by the interactions between the sup- ply and the demand for health workers. The demand for health workers has hinged on the government, private or external donor readiness to pay (hire) health workers (6). This is a function of the flexibility of spend- ing or the fiscal space from which health care expenses can be determined. Notably, per capita income and health worker den- sity are both lowest in Africa compared to other continents (5,7,11). Supply of health workers, on the other hand, depends on the emoluments and upon other socio-eco- nomic, political and demographic factors. An analysis of these market conditions is necessary to guide policymaking concern- ing human resources for health towards achieving universal health coverage. Poli- cies can be directed towards the increase of training opportunities for health workers when the challenge is supply related or to- wards increased government allocation of funds for the health workforce in when the challenge is demand related. Additionally, a more comprehensive approach will be a bidirectional policy inclination (6). Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 5 | P a g e While the two options require major gov- ernment spending to increase the availabil- ity of HRH, many African countries lack the capacity for flexible expenditure (5). A pragmatic way is to invest in more cost-ef- fective spending such as funding commu- nity-based health workers. This category of health workers requires training of shorter duration and lower financial investment. They also play a prominent role in stimulat- ing demand for health services in rural ar- eas, expanding coverage of health services and improving health outcomes in ne- glected communities. This has been exem- plified in countries like Ethiopia and Niger where constraining macroeconomic condi- tions informed this approach. Similarly, this category of health workers are shown to be more readily retained in underserved areas and not as easily affected by the conditions of the labour market in the health sector (6, 11, 12). Furthermore, wage bills can influ- ence health workforce availability or the at- tractiveness of the health sector to unem- ployed health workers. Government wage bill policies have been implemented in some African countries such as Rwanda, Kenya and Zambia. Vujicic et al. (13) stud- ied the consequences of the bill on the health workforce of these countries with mixed outcomes. Expansion of the health workforce occurred in Rwanda while the wages were maintained. In Zambia how- ever, challenges with occupying budgeted posts were identified as the obstacle to ex- pansion and in Kenya reduction of the wage bill prevented the growth of the workforce. In Ghana, Government spending on the public sector wage bill increased from 3.6 in 2000 to 6.7% in 2008, while the health sector wage bill rose as a percentage of the total wage bill from 9% to 15% (14). Alt- hough with minor changes, in monetary terms, the public spending on health in- creased. During the same period, while the wage bill increased by 5 times the health sector workforce increased substantially. With a largely decentralized health work- force to regions and districts, the resource allocation was channeled to districts, sub- districts and community-based committees and funding increased by 10%, while allo- cation to tertiary hospitals dropped by 3% (14). Rural Health Workers Retention Factors The disproportionate distribution of health care workers between rural and urban areas despite a majority of the population resid- ing in rural communities, results in higher mortality rates from these remote and rural areas. This leaves many residents seeking primary care and overcrowding the health centres in urban areas (8). This inefficient delivery of health care causes skilled work- ers to be underutilized and consequently overburdened; this could also be compli- cated by emigration of these workers for a more rewarding income package. Against this backdrop, the WHO provided evi- dence-based recommendations to improve retention of health workers in rural commu- nities (8). These include a focus on training (enrolling students with a background in the rural communities), regulation (such as en- suring a required posting in rural and re- mote areas) and providing enabling incen- tives in the form of financial and/or profes- sional support (8,15). In Nigeria, recruit- ment at the Primary Health Centre (PHC) is at the call of the local government (for jun- ior workers) and the state government (sen- ior cadres). Due to this form of governance, health worker attrition is highest at the PHC and unlike the doctors and nurses, only the community health workers are readily available at the PHCs (16). In Zambia, HRH decentralization was also recom- mended for easy resource allocation to ena- ble task shifting for essential service provi- sion where trained professionals are una- vailable (15). Community health commit- tees which are recognized in the National health policy, along with the PHCs form an Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 6 | P a g e extra tier of governance that plays a key role in the retention of health workers at the PHC in Nigeria. These committees are made up of key persons in the community such as teachers, religious leaders and other respectable persons in the community. They support the retention of health work- ers by intervening when salaries to health workers are delayed or not paid and also provide social and financial support of these workers in rural communities. The re- surgent awareness of the role of community health committees in retaining health work- ers in rural communities calls for policies that reinforces the establishment of these committees. The Government and policy analysts should consider the role of com- munity engagements such as educating the workers on their various roles to adequately uphold the provision for the scheme. Nota- bly, also, community engagements through the community health committee offer var- ious incentives for retention of worker with or without financial investment (16). In Zambia, the Ministry of Health introduced strategies to facilitate retention of health workers at rural communities (15). These incentives included adjunct allowances such as on-call allowances, hardship allow- ance, retention allowances etc. However, there was no relationship between these strategies and the worker’s desire to remain in the sector. Thus, it was recommended that strategies that enable the health work- ers to perceive and understand the context and the characteristics of working in the fa- cilities should be implemented. Similarly, updating the financial incentives in line with the realities of inflation as it affects the cost of living should be considered for the different training duration, working hours or level of experience (15). Implementation of the WHO recommendations on retention of health workers in rural communities re- quires contextualization according to indi- vidual country’s need. South Africa contex- tualized it’s strategies to deal with a HRH crisis. In the aspect of education, it focused on training health workers in underserved communities, it also developed a social ac- countability framework to better respond to the communities need. Other strategies in- cluded having students trained from com- munities where the need is greatest as well as using target community health and social needs to guide education (17). Health Workers Obligatory Education and Supportive Supervision Factors At the heart of achieving universal health coverage is the certainty of quality of healthcare. Clients are not willing to utilize healthcare in situations where the services are poor, hindering realistic achievement of UHC. And in some situations where the health service is still utilized, the health out- comes are also undermined. There are few, sufficiently trained and motivated health care staff with the requisite resources to of- fer essential health care in many African countries which: this culminates in poor quality of care (18,19). Continuous Profes- sional Development (CPD) has been identi- fied as a means of maintaining knowledge capacity through ‘on the job’ training of nurses and midwives to function compe- tently and attain Universal Health Coverage (20). About 70% of the Anglophone coun- tries (n=21) including Nigeria and Ghana and only Rwanda among francophone countries (n=20) have demonstrated evi- dence of mandatory CPD being operational. These programs are run by the nursing councils and the health professional coun- cils. Through this obligatory system of ed- ucation, targeting Global Health indicators such as HIV is made possible vis the WHO Afro region dictating licensure from spe- cific CPD modules. Also, some countries require CPD points to ensure license re- newal on an annual basis. Nevertheless, only 10 member states in the WHO-Afro- region make CPD a mandatory program to complete, and there is still a shortage of nurses as well as a lack of interest among Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 7 | P a g e nurses which slows the movement towards UHC and SDG attainment in the region (20). Supportive supervision is a process that promotes quality at all levels of the health system by strengthening relation- ships within the system, focusing on the identification and the resolution of prob- lems. It also helps to optimize the allocation of resources'. (9: p.989) It involves enabling the health workers to always get better at the performance of their work in a non- forceful but respectful manner through su- pervisory visits (21). A reported increase in the proportion of health workers (commu- nity health workers), improved quality of care and sustained performance as a result of supportive supervision has been docu- mented in the literature (22). In a systematic review of supportive supervision carried out on PHC workers in low and in middle- income countries in Africa, it was revealed that efficiency, quality of care, motivation and job satisfaction were positively influ- enced (22). Critical to the improved moti- vation and performance was an open two- way communication and feedbacks, a fer- vent team spirit and the development of mu- tual trust between the supervisor(s) and the health worker(s) (22). The performance of community health workers is a function of the interaction with the complex health sys- tem, and it may also be influenced by intrin- sic factors such as the personality of an in- dividual. A supportive environment is thus needed to enable these health workers to play their roles as agents of social change. This implies a need to be skilled in building confidence, solving problems and com- municating well with the immediate com- munity (23). Perceptibly, the higher-level health workers do not regard the inputs or efforts of these community health workers, hence organizing joint training sessions of the higher-level health workers and the community health workers aids in building better relationships between both catego- ries. The supervisors also need to be trained about the significant roles community health workers play in strengthening the re- lationship with the community and its peo- ple. Management and technical skills should be inculcated into the training. Like- wise, team building activities should be in- cluded in the training of supervisors to re- duce the social distance between the super- visor and the community health workers; this will result in better relationships and an overall better performance. The community will more likely recognize the community health worker due to better supervision oc- curring within the health sector (23). To make supportive supervision more effective Renggli et al. (19). in their Tanzanian study described the effectiveness of an electronic tool to improve the quality of health care (e- TIQH). It was found that across different contexts in Tanzania, the quality standard of primary health care was improved, and it was demonstrated to have shown a direct impact on the overall quality of care that was obtained. With strong supervision, a 'virtuous cycle' is built. There is an increase in community health worker's confidence, more cohesion between all cadres of health workers, a sense of inclusion with the health system and recognition by the com- munity, as well as an effective referral sys- tem (22). Supportive supervision, however, is not without its problems. These include the propensity for diverting attention to quantity rather than quality, also supervi- sory visits may be fragmented, infrequent, and inconsistent. A gap also often exists be- tween what is known and what is done. There is often no ownership of quality de- velopment activities at the facility level without feedback on this development up to the council level as described in countries like Tanzania. Similarly, supervision could be de-motivating when carried out with fault-finding and can be irregularly exe- cuted. Weak supervisions can also lead to a 'vicious' cycle of neglect among the health workers, absence of technical assistance, weak referral of patients and bad treatments (19, 24). Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 8 | P a g e Information Technology Factors Between 2007 and 2011, the number of subscribers for mobile broadband in devel- oping countries rose astronomically to 458 million from 43 million, representing over 10-fold increase in the number of users (10). This implies more users of mobile de- vices, as well as increased access to the in- ternet. The internet and mobile devices are also fast becoming essential tools for the health professionals in urban and rural com- munities. The use of mobile devices to practice medicine and public health has fa- cilitated services in the difficult terrains and geographically inaccessible areas in devel- oping countries. The adoption of this tech- nology has been proposed to limit the rural health worker isolation that is usually expe- rienced, and a study revealed that mobile dependent technologies are gradually being embraced by the health workers. It is trans- formative and can bridge the existing gap in human resources for health accessibility and acceptability (10). Information technol- ogy can be utilized to support communica- tion between the health providers and the clients as well as enable the capacity build- ing of the health worker which engenders more demand for a high quality of care from the community. Health workers are usually exposed to standard educators through webcasting, recording, and video confer- encing. This mode of training is shown to be more cost-effective compared to educa- tional programs held face to face. It is not considered an alternative to face-to-face ed- ucation, rather it aids in reducing the chal- lenges faced by this traditional method. It has been reported that presenting educa- tional content and gaining competency is the goal of an educational strategy and when complemented by information tech- nology, this goal can be essentially achieved (10). In a study on a post-conflict setting on the utilization of information technology for the retention of health work- ers, there was a positive perception about information technology among health worker(s) even in a setting where the appli- cations of information technology were rare and remote. Thus, there is a need to increase investments in information and technology, mobilise health workers and train the work- ers on the use of information technology for the delivery of health services (25). Addi- tionally, studies have proposed that infor- mation technology can serve as a major boost to health worker retention apart from other traditional strategies for retention (25,26). Despite the general benefits of in- formation technology, there are barriers to its implementation. These barriers include unreliable internet connection, unstable power supply, lack of knowledge on infor- mation technology, expensive access to computers and lack of effective policies on information technology (25). Other barriers include cultural barriers and deficient in- teroperability between technologies and platforms (10). In addressing some of these challenges, interventions on information technology should be prioritized especially at post-conflict settings as well as for rural communities. Computers are not indispen- sable, as smartphones can be provided for health workers in the rural communities which are useful in accessing health infor- mation and communication with profes- sional colleagues. Incentives might be re- quired to enable health workers to accept information technology and overcome their reluctance with the approach. Similarly, the collaboration between relevant ministries such as information, finance, education and health are important to develop a synergy and proper coordination of information technology use among health workers (10, 25). Discussion and conclusions The post-Covid-19 agenda must include Human Resources for Health as a key criti- cal component. Human resources for health forms an essential component of any health system. Yet this component of the health Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 9 | P a g e system is faced with immense crisis that borders on the shortage, maldistribution, and performance. Market factors such as demand and supply issues, wage bill incre- ments as well as socioeconomic factors play a role in influencing human resources availability. Existing rural-urban inequali- ties create a disproportionate distribution of health workers in the African region which demands steps to ensure health workers are retained especially in rural communities and post-conflict communities. Consider- ing the limited fiscal space and constrained macro-economic environment in many Af- rican countries, cost-effective interventions should be adopted to ensure the sustenance in the delivery of quality health care in the remote and inaccessible areas. Thus, ap- proaches that utilize the services of commu- nity health workers who play a crucial role in stimulating demand for health care should be applied. The duration of training is shorter, they can be recruited from com- munities with highest health need, they form a pragmatic alternative to higher earn- ing and higher cadres of health workers and are usually closer to the members of the community. Supervision of these health workers is a vital part of the promotion of the delivery of quality health services. By focusing on the virtuous cycle created by strong supervision of community health workers, a cohesive and confident health workforce with a strong connection with the community is built and inherent in this approach is health system strengthening. Embracing information technology also presents an effective means of maximizing human resources for universal health cover- age. By multi-stakeholder collaboration, the challenges with the use of technology can be overcome and technology can be uti- lized to prevent the isolation of health workers in remote areas, encourage their re- tention at rural communities, facilitate their training and interaction with other health professionals. Policy formulation should, therefore, focus on market factors that in- fluence health worker retention, as well as developing sustainable supportive supervi- sion of community health workers and the establishment of pathways for utilizing in- formation technology as leverages in the trajectory towards Universal Health Cover- age in Africa. Recommendations 1. Financial Support: The need to im- prove financial investment in edu- cation and training of health work- ers cannot be overemphasized. More attention should be given to the provision of incentives for health workers in remote and largely inaccessible areas. 2. Professional Support: A broader view into health worker demand and the availability of health workers to deliver the needed services espe- cially in the context of a post-covid- 19 era reveals the need for the deliv- ery of essential health services through delegated roles in form of task shifting with a combination supportive supervision to maximize the performance. 3. Infrastructural Support: Consider- ing the growth in the number of us- ers of mobile technology on the continent and the benefit it brings to the health system, efforts should be directed at removing the outlined barriers such as unstable internet and irregular power supply to aid its proper functioning in maximizing HRH capacity. 4. Procedural Support: An improved understanding of the contextual fac- tors that influence retention of health workers especially at remote and rural communities is expedient for the decision-makers and govern- ment stakeholders in health. 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(Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 12 | P a g e © 2021 McKing et al; This is an Open Access article distributed under the terms of the Creative Commons Attrib- ution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and re- production in any medium, provided the original work is properly cited. 0.1186/1478-4491-11-44 (accessed :July 18, 2020). ____________________________________________________________ Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 13 | P a g e Quality of HRH Service Utiliza- tion Acceptabil- ity of HRH Acceptabil- ity to HRH Availability of HRH Theoretical coverage by ‘availability’ of health workforce EFFECTIVE COVERAGE GAP Population + health needs: Who is provided EFFECTIVE COVERAGE? APPENDIX Overview of Article Selection Because no date filter was initially used at the first search, a total of 173 articles emerged. This was via the use of keywords and bolean terms on PubMed as stated in the main text. The titles and abstracts of these publications were next evaluated for suitability based on the two guiding frame- works: The Human Resource for Health and Effective Coverage and the WHO labour market dy- namics. The number of articles were thus reduced to 40 articles for consideration. Selection criteria was then determined. These included publications not older than 20 years, WHO bulletins and publications and a targeted snow balling from key WHO articles on the themes. This was inde- pendently agreed upon by the two authors, MIA and ICE. Consequently, this led to a final selection of 22 articles used for the review. Figure 1. Human Resources for Health and Effective Coverage Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 14 | P a g e Figure 2. WHO: Labour market dynamics Economy, population, and broader societal drivers Education sector Labour market dynamics Education in health Education in other fields Pool of qualified health workers* Abroad Employed Unemployed Out of labour force Health care sector** Other sectors H ig h s ch o o l Health workforce equipped to deliver quality health ser- vice U n iv e rs a l h e a lt h c o v e ra g e w it h s a fe , e ff e ct iv e , p e rs o n - ce n tr e d h e a lt h s e rv ic e s. Policies on production  On infrastructure and material  On enrolment  On selecting students  On teaching staff Policies to address inflows and outflows  To address migration and emigration  To attract unemployed health workers  To bring healthy workers back into the Health care sector Policies to address maldistribution and insuff- ciencies To improve productivity and performance To improve skill mix composition. To retain health workers in underserved areas Policies to regulate the private sector  To manage dual practice  To improve quality of training  To enhance service delivery Migration Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 15 | P a g e Amedari MI, Ejidike IC. Post Covid-19 Agenda: Maximizing human resources for health towards universal health coverage in Africa. (Review Article). SEEJPH 2021, posted: 08 April 2021. DOI: 10.11576/seejph-4318 16 | P a g e Figure 3. Factors influencing the maximizing of human resources for health towards Universal Health Coverage in Africa.  Labour Market Factors  Rural Health Workers Reten- tion Factors  Health Workers Supportive Su- pervision Factors  Information Technology Fac- tors 4 Main HRH Factors in Africa These 4 Main Factors Affect HRH  HRH Availability  HRH Accessibility,  HRH Acceptability,  Overall HRH Quality Financial Support | Professional Support | Infrastructural Support |Procedural Support These Factors are underpinned by  Information Technology Factors