Human Resources

Limits and opportunities to community health worker empowerment: A multi-country comparative study.
Kane S; Kok M; Ormel H; Otiso L; et al.: Social Science & Medicine 164, 2016, doi:

In LMICs, Community Health Workers (CHW) increasingly play health promotion related roles involving 'empowerment of communities'. To be able to empower the communities they serve, the authors argue, it is essential that CHWs themselves be, and feel, empowered. The authors present here a critique of how diverse national CHW programs affect CHW's empowerment experience. They present an analysis of findings from a systematic review of literature on CHW programs in LMICs and 6 country case studies (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique). Lee & Koh's analytical framework (4 dimensions of empowerment: meaningfulness, competence, self-determination and impact), is used. CHW programs empower CHWs by providing CHWs, access to privileged medical knowledge, linking CHWs to the formal health system, and providing them an opportunity to do meaningful and impactful work. However, these empowering influences are constantly frustrated by - the sense of lack/absence of control over one's work environment, and the feelings of being unsupported, unappreciated, and undervalued. CHWs expressed feelings of powerlessness, and frustrations about how organisational processual and relational arrangements hindered them from achieving the desired impact. While increasingly the onus is on CHWs and CHW programs to solve the problem of health access, attention should be given to the experiences of CHWs themselves. CHW programs need, it is argued, to move beyond an instrumentalist approach to CHWs, and take a developmental and empowerment perspective when engaging with CHWs. CHW programs should systematically identify disempowering organisational arrangements and take steps to remedy these. Doing so will not only improve CHW performance, it will pave the way for CHWs to meet their potential as agents of social change, beyond perhaps their role as health promoters.

‘Why do an MPH?’ Motivations and intentions of physicians undertaking postgraduate public health training at the University of Cape Town
Zweigenthal VE, Marquez E; London L: Global Health Action, 9(1), 2017

Public health (PH) approaches underpin the management and transformation of health systems in low- and middle-income countries. Despite the Master of Public Health (MPH) rarely being a prerequisite for health service employment in South Africa, many physicians pursue MPH. This study identified their motivations and career intentions and explored MPH programme strengths and gaps in under- and post-graduate PH training. A cross-sectional study using an online questionnaire was completed by physicians graduating with an MPH between 2000 and 2009 and those enrolled in the programme in 2010 at the University of Cape Town. Nearly a quarter of MPH students were physicians. Of the 65 contactable physicians, 48% responded. They were mid-career physicians who wished to obtain research training (55%), who wished to gain broader perspectives on health (32%), and who used the MPH to advance careers (90%) as researchers, policy-makers, or managers. The MPH widened professional opportunities, with 62% changing jobs. They believed that inadequate undergraduate exposure should be remedied by applying PH approaches to clinical problems in community settings, which would increase the attractiveness of postgraduate PH training. The MPH was found to allow physicians to transition from pure clinical to research, policy and/or management work, preparing them to innovate changes for effective health systems, responsive to the health needs of populations.

Crisis and resilience at the frontline: Coping strategies of Kenyan primary health care managers in a context of devolution and uncertainty
Nyikuri M; Barasa E; Molyneux S; Tsofa B: Kemri Wellcome Trust Research Programme, Kenya, 2016

Primary health care (PHC) plays a vital role in maintaining population health, preventing suffering and providing coverage of essential services. In Kenya, primary health centres and dispensaries are often managed by the most senior clinical staff member at the facility who is responsible for performing both clinical and managerial duties. PHC managers, also known as in-charges, play a key role in the functioning of health services on a day-to-day basis. KEMRI-Wellcome Trust has conducted research in one of the 47 counties in Kenya to better understand the role and responsibilities of PHC managers and their coping strategies within the context of devolution and uncertainty. The key findings from the research are set out in this brief, as well as recommendations to support PHC managers. The research found that PHC managers carry out a variety of tasks to ensure facilities can function effectively. These include: developing annual work plans, ensuring coverage and delivery of services, providing leadership and management to frontline staff. Despite the challenges faced by PHC managers in the period since devolution, facilities remained open and functioning. A key support system for in-charges was the sub-county managers, some of whom had played the role of line managers to in- charges for decades.

Predictors of nurses’ and midwives’ intentions to provide maternal and child healthcare services to adolescents in South Africa
Jonas K; Reddy P; van den Borne B; Sewpaul R; Nyembezi A; Naidoo P; Crutzen R: BMC Health Services Research 16(658) 2016

This study was conducted to gain an understanding of nurses’ and midwives’ intentions to provide maternal and child healthcare and family planning services to adolescents in South Africa. A total of 190 nurses and midwives completed a cross-sectional survey. The survey included components on demographics, knowledge of maternal and child healthcare (MCH) and family planning (FP) services, attitude towards family planning services, subjective norms regarding maternal and child healthcare and family planning services, self-efficacy with maternal and child healthcare and family planning services, and intentions to provide maternal and child healthcare and family planning services to adolescents. Self-efficacy to conduct MCH and FP services and years of experience as a nurse- midwife were associated with stronger intentions to provide the services. Self-efficacy had a strong and positive association with the intentions to provide both MCH and FP services, while there is a moderate association with attitude and norms. The authors argue that there is a need to improve and strengthen nurses’ and midwives’ self-efficacy in conducting both MCH and FP services in order to improve the quality and utilisation of the services by adolescents in South Africa.

eSIP-Saúde: Mozambique’s novel approach for a sustainable human resources for health information system
Waters K; Mazivila M; Dgedge M; Necochea E; Manharlal D; Zuber A; de Faria Leão B; Bossemeyer D; Vergara A: Human Resources for Health 14(66), 2016

Over the past decade, governments and international partners have responded to calls for health workforce data with ambitious investments in human resources information systems (HRIS). However, documentation of country experiences in the use of HRIS to improve strategic planning and management has been lacking. This case presentation documents for the first time Mozambique’s novel approach to HRIS, sharing key success factors and contributing to the scant global knowledge base on HRIS. Core components of the system are a Government of Mozambique (GOM) registry covering all workers in the GOM payroll and a “health extension” which adds health-sector-specific data to the GOM registry. Separate databases for pre-service and in-service training are integrated through a business intelligence tool. The first aim of the HRIS was to identify the following: who and where are Mozambique’s health workers? As of July 2015, 95 % of countrywide health workforce deployment information was populated in the HRIS, allowing the identification of health professionals’ physical working location and their pay point. HRIS data are also used to quantify chronic issues affecting the Ministry of Health (MOH) health workforce. Examples include the following: HRIS information was used to examine the deployment of nurses trained in antiretroviral therapy (ART) vis-à-vis the health facilities where ART is being provided. Such results help the MOH align specialized skill sets with service provision. Twenty-five percent of the MOH health workforce had passed the 2-year probation period but had not been updated in the MOH information systems. For future monitoring of employee status, the MOH established a system of alerts in semi-monthly reports. As of August 2014, 1046 health workers were receiving their full salary but no longer working at the facilities. The MOH is now analysing this situation to improve the retirement process and coordination with Social Security. The Mozambican system is an important example of an HRIS built on a local platform with local staff. Notable models of strategic data use demonstrate that the system is empowering the MOH to improve health services delivery, health workforce allocation, and management. Combined with committed country leadership and ownership of the program, this suggests strong chances of sustainability and real impact on public health equity and quality.

The Role of Nurses and Community Health Workers in Confronting Neglected Tropical Diseases in Sub-Saharan Africa: A Systematic Review
Corley A; Thornton C; Glass N: PLOS Neglected Tropical Diseases 10(9), 2016,

Neglected tropical diseases produce an enormous burden on many of the poorest and most disenfranchised populations in sub-Saharan Africa, where a dearth of skilled health providers limits primary care efforts to address such diseases. Consequently, many countries rely on nurses and community health workers to engage with under-served and hard-to-reach populations. This review of the literature was conducted to assess the role nurses and community health workers play in the primary, secondary, and tertiary prevention of neglected tropical diseases in sub-Saharan Africa. Articles published between January 2005 and December 2015 were reviewed in order to capture the full scope of nurses’ and community health workers’ responsibilities for neglected tropical disease control within their respective countries’ health systems. A total of 59 articles were identified that fit all inclusion criteria. It reports that successful disease control requires deep and meaningful engagement with local communities and that horizontal or multidisease control programs can create complimentary interactions between their different control activities as well as reduce costs through improved program efficiencies.

Factors influencing motivation and job satisfaction among supervisors of community health workers in marginalised communities in South Africa
Akintola O; Chikoko G: Human Resources for Health 14(54), 2016

Management and supervision of community health workers (CHWs) is important for the success of CHW programmes. This study explored factors influencing motivations of supervisors in CHW programmes. The authors conducted qualitative interviews with 26 programme staff providing supervision to CHWs in eight community-based organisations in marginalised communities in the greater Durban area of South Africa from July 2010 to September 2011. Findings show that all the supervisors had previous experience working in the health or social services sectors and most started out as unpaid CHWs. Most of the participants were poor women from marginalised communities. Supervisors’ activities include the management and supply of material resources, mentoring and training of CHWs, record keeping and report writing. Supervisors were motivated by intrinsic factors like making a difference and community appreciation and non-monetary incentives such as promotion to supervisory positions; acquisition of management skills; participation in capacity building and the development of programmes; and support for educational advancement like salary, bonuses and medical benefits. Hygiene factors that serve to prevent dissatisfaction are salaries and financial, medical and educational benefits attached to the supervisory position. Demotivating factors identified are patients’ non-adherence to health advice and alienation from decision-making. Dis-satisfiers include working in crime-prevalent communities, remuneration for CHWs, problems with material and logistical resources, job insecurity, work-related stressors and navigating the interface between CHWs and management. While participants were dissatisfied with their low remuneration, they were not demotivated but continued to be motivated by intrinsic factors. The authors findings suggest that CHWs’ quest for remuneration and a career path continues even after they assume supervisory positions. Supervisors continue to be motivated to work in mid-level positions within the health and social services sectors. Global efforts to develop and increase the sustainability of CHW programmes will benefit immensely from insights gained from an exploration of supervisors’ perspectives. Further, they suggest that national CHW programmes be conceptualised with the dual purpose of building the capacity of CHWs to strengthen health systems and reducing unemployment especially in marginalised communities.

Motivation and incentive preferences of community health officers in Ghana: an economic behavioural experiment approach
Shiratori S; Agyekum EO; Shibanuma A; et al., EMBRACE Implementation Research Team: Human Resources for Health 14(54), 2016

The health worker shortage in rural areas is a problems in many African countries, in part due to fewer incentives and support systems available to attract and retain health workers in these areas. This study explored the willingness of community health officers (CHOs) to accept and hold rural and community job postings in Ghana. A discrete choice experiment was used to estimate the motivation and incentive preferences of CHOs in Ghana. All CHOs working in three Health and Demographic Surveillance System sites in Ghana, 200 in total, were interviewed between December 2012 and January 2013. Respondents were asked to choose from choice sets of job preferences. Mixed logit analyses of the data found a shorter projected time frame before study leave as the most important motivation for most CHOs, while an education allowance for children, a salary increase and housing provision also played a role. While male CHOs had a high affinity for an early opportunity to go on study leave, CHOs who had worked at the same place for a long time valued more a salary increase. To reduce health worker shortage in rural settings, policymakers could provide “needs-specific” motivational packages.

Perception and attitude of healthcare workers towards the use of a female condom in Gaborone, Botswana
Mashanda-Tafaune B; Monareng L: Health SA Gesondheid 21, 163-170, 2015

Although the female condom (FC) is viewed as an effective female controlled barrier contraceptive device that can be used by women to prevent them from contracting the Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), other sexually transmitted infections (STIs) and unwanted or unintended pregnancy, the perception and attitude of healthcare workers (HCW) plays a key role in its effective use and distribution amongst women. This study aimed to identify and examine factors that influences the perception and attitude of HCWs towards the use and distribution FCs. A quantitative, explorative and descriptive design was used to conduct the study based on the Health Belief Model as a conceptual framework in June 2013 with a convenience sample of 164 HCWs. The results showed that 64% of the respondents perceived unavailability of FCs as contributing to lack of adequate use. Only 32% of them reported using the FC. There was an association with increasing use of a FC with age, marital status and training. The results revealed that lack of knowledge and training on the use of a FC might prevent its effective use and distribution. The results showed evidence that the FC was a safe method of contraception and protection against STIs and that it empowers women to make decisions related to sexuality. However, awareness campaigns, increased availability of FCs and training of HCWs are essential to enhance positive perception and attitudinal change to reduce sexual risks related infections and poor quality of life for women.

Reforming essential health competencies and training in Africa in light of the Sustainable Development Goals
Houeto D; Bambini N: Global Health Promotion 23(1), 2016, doi: 10.1177/1757975916629737

Many African countries were not able to meet their Millennium Development Goals (MDGs) by the 2015 deadline. While this poor performance can be attributed to several factors, many analyses have revealed the main cause to be the absence of systematic and coordinated action on the social determinants of health, which are in large part outside of the health sector. Today, in light of the Sustainable Development Goals (SDGs), it is absolutely necessary to address this shortcoming. The authors indicate that reaching the SDGs calls for action on the social determinants of health and reduction of social inequalities. However, the current way health systems in the region operate emphasise treatment of disease, as if health systems are waiting for people to fall ill before taking care of them. In light of the SDGs, they argue that it has grown urgent for the African region to accelerate training of professionals who are skilled in acting on the social determinants of health to help reorient health services and place health in all policies.