Young women in Malawi face many challenges in accessing family planning, including distance to the health facility and partner disapproval. The author’s primary objective was to assess if training Health Surveillance Assistants in couples counselling would increase modern family planning uptake among young women. In this cluster randomised controlled trial, 30 Health Surveillance Assistants from Lilongwe, Malawi received training in family planning. The Health Surveillance Assistants were then randomised 1:1 to receive or not receive additional training in couples counselling. All Health Surveillance Assistants were asked to provide family planning counselling to women in their communities and record their contraceptive uptake over 6 months. Sexually-active women <30 years of age who had never used a modern family planning method were included in this analysis. Generalised estimating equations with an exchangeable correlation matrix to account for clustering by Health Surveillance Assistants were used to estimate risk differences and 95% confidence intervals. 430 (53%) young women were counselled by the 15 Health Surveillance Assistants who received couples counselling training, and 378 (47%) were counselled by the 15 Health Surveillance Assistants who did not. 115 (26%) from the couples counselling group had male partners present during their first visit, compared to only 6 (2%) from the other group. Nearly all (99.5%) initiated a modern family planning method, with no difference between groups. Women in the couples counselling group were 8% more likely to receive male condoms and 8% more likely to receive dual methods. Training Health Surveillance Assistants in family planning led to high modern family planning uptake among young women who had never used family planning. Couples counselling training increased male involvement with a trend towards higher male condom uptake.
Human Resources
Social accountability is defined as the responsibility of institutions to respond to the health priorities of a community. There is an international movement towards the education of health professionals who are accountable to communities. There is little evidence of how communities experience or articulate this accountability. In this grounded theory study eight community based focus group discussions were conducted in rural and urban South Africa to explore community members’ perceptions of the social accountability of doctors. The discussions were conducted across one urban and two rural provinces. Group discussions were recorded and transcribed verbatim. Initial coding was done and three main themes emerged following data analysis: the consultation as a place of respect (participants have an expectation of care yet are often engaged with disregard); relationships of people and systems (participants reflect on their health priorities and the links with the social determinants of health) and Ubuntu as engagement of the community (reflected in their expectation of Ubuntu based relationships as well as part of the education system). These themes were related through a framework which integrates three levels of relationship: a central community of reciprocal relationships with the doctor-patient relationship as core, a level in which the systems of health and education interact and together with social determinants of health mediate the insertion of communities into a broader discourse. The paper outlines an ubuntu framing in which the tensions between vulnerability and power interact and reflect rights and responsibility as important for social accountability. Communities are argued to bring a richer dimension to social accountability through their understanding of being human and caring.
In 2010, South Africa’s National Department of Health launched a national primary health care initiative to strengthen health promotion, disease prevention, and early disease detection. The strategy, called Re-engineering Primary Health Care, aims to provide a preventive and health-promoting community-based Primary Health Care model. A key component is the use of community-based outreach teams staffed by generalist community health workers. The authors conducted focus group discussions and surveys on the knowledge and attitudes of 91 Community Health Care Workers working on community-based teams in Eastern Cape Province. The community health workers who were studied enjoyed their work and found it meaningful, as they saw themselves as agents of change. They also perceived weaknesses in the implementation of outreach team oversight, and desired field-based training and more supervision in the community. The authors propose providing community health workers with basic resources like equipment, supplies and transport to improve their acceptability and credibility to the communities they serve.
In low- and middle-income countries, scaling essential health interventions to achieve health development targets is constrained by the lack of skilled health professionals to deliver services. The authors take a labour market approach to project the future health workforce demand using an economic model based on projected economic growth, demographics, and health coverage, and using health workforce data (1990–2013) for 165 countries from the WHO Global Health Observatory. The demand projections are compared with the projected growth in health worker supply and the health worker “needs” as estimated by WHO to achieve essential health coverage. The model predicts that, by 2030, global demand for health workers will rise to 80 million workers, double the current (2013) stock of health workers, while the supply of health workers is expected to reach 65 million over the same period, resulting in a worldwide net shortage of 15 million health workers. Growth in the demand for health workers will be highest among upper middle-income countries, driven by economic and population growth and ageing. This results in the largest predicted shortages which may fuel global competition for skilled health workers. Middle-income countries will face workforce shortages because their demand will exceed supply. By contrast, low-income countries will face low growth in both demand and supply, which are estimated to be far below what will be needed to achieve adequate coverage of essential health services. In many low-income countries, demand may stay below projected supply, leading to the paradoxical phenomenon of unemployed (“surplus”) health workers in those countries facing acute “needs-based” shortages. Opportunities exist to bend the trajectory of the number and types of health workers that are available to meet public health goals and the growing demand for health workers.
The shortage of formal health workers has led to the utilisation of Community-Based Health Volunteers to provide health care services to people especially in rural and neglected communities. This study explored factors affecting retention and sustainability of community-based health volunteers’ activities in a rural setting in Northern Ghana, through a qualitative study with thirty-two in-depth interviews with health volunteers and health workers overseeing their activities. Study participants reported that the desire to help community members, prestige and recognition as doctors in the community were key motivations for the health volunteers. Lack of incentives and logistical supplies such as raincoats, torch lights, wellington boots and transportation in the form of bicycles to facilitate the movement of health volunteers affected their work and discouraged them. Most of the dropout volunteers said lack of support and respect from community members made them to stop working as health volunteers. They recommended that community support, incentives and logistical supplies such as raincoats, torch light, wellington boots and bicycles can help retain community-based health volunteers and also sustain their activities at community level.
This is a time of unprecedented change in medical education globally. Medical schools, postgraduate bodies and other organisations are responding to rapid advances in medicine and changes in health care delivery. New education approaches are being adopted to exchange information. This enables the institutions to produce relevant health professionals. There are a number of innovations and models that are being explored to improve the learning of students studying medicine and public health. This Kenyan case study reports on how partnerships between the higher education institution and the community are working. It gives an account of the Moi University community programme that uses adaptive instruction for health trainees in the schools of medicine and public health. Adaptive instruction is a student centred approach where they are given real life cases to solve health problems theoretically as tutorial cases. This discussion, with the guidance of a tutor, promotes active learning. The model encourages active learner participation in the provision of health services. It introduces the students to a community health framework where they work in rural health facilities as part of their continuous assessment. It means that graduates entering the profession are able to apply and practise knowledge and skills beyond the theory learnt at the university. The students diagnose issues affecting the local community, develop a research proposal, work with district health management teams and implement activities. They conduct surveillance and monitor diseases and in the event of an epidemic, they are expected to respond effectively. They master the principles of how rural health facilities are run. The programme is divided into five phases: Introduction to the community, Community diagnosis, Writing a research proposal, Investigation executing the research plan, District health service attachment. The research projects designed and implemented in phase three and four have produced fascinating reports with research topics that address issues affecting the communities. It takes 20% to 30% of curriculum content and makes the graduand socially responsible and accountable team players in health care delivery. The authors hope that other tutors in Kenya, Eastern Africa and beyond the continent will benefit from this model. The experience provides tutorial guidance towards building a resilient and experienced crop of health professionals at par with global health training standards.
The South African Department of Health publishes annual guidelines identifying priority groups, including immunosuppressed individuals and healthcare workers (HCW), for influenza vaccination and treatment. How these guidelines have impacted HCW and their patients, particularly those infected with HIV, remains unknown. The authors aimed to describe the knowledge, attitudes and practices regarding influenza and the vaccine among South African HCW. Surveys were distributed by two local non-governmental organisations in public health clinics and hospitals in 21 districts/municipalities (5 of 9 provinces). There were 1164 respondents. One-third (34%) of HCW reported getting influenza vaccine and most (94%) recommended influenza vaccine to patients infected with HIV. The ability to get vaccine free of charge and having received influenza government training were significantly associated with self-reported vaccination in 2013/2014. Self-reported vaccination and availability of influenza vaccine during the healthcare visit were significantly associated with recommending influenza vaccine to patients infected with HIV/AIDS. Free and close access to influenza vaccine were associated with a higher likelihood of getting vaccinated. HCW who reported getting the influenza vaccine themselves, had vaccine to offer during the patient consult and were familiar with guidelines and training were more likely to recommend vaccine to HIV-infected patients.
The Board of the APHRH met on the 30th Nov 2016 in Kampala to discuss key issues that concerning the Health Workforce in Africa. A resolution was made to convene a regional consultation meeting of key stakeholders and networks to develop a consensus on ways to accelerate advocacy for a strengthened health workforce in Africa. The Board made a number of decisions to initiate acceleration of the work of the platform at all levels and enhance lobby and advocate for the prioritization of the Health Workforce agenda in Africa, outlined in this document, including: to request the WHO Regional Director for Africa to urgently consider an enhanced technical support program to African countries to strengthen country level health workforce development and management departments, especially at the ministries of health headquarters of member states; to support African Member states in translating for action key regional and global policies including the African Health Strategy, the Global Health Workforce Strategy and Sustainable Development Goals (SDGs) and to fast track the strengthening of Health Workforce information systems of countries to manage workforce inflows, stock and outflow by implementation of the WHO code on International Recruitment and track progress of strengthening through improved reporting on the code at the 3rd round due in 2018.
In 2010, South Africa’s National Department of Health launched a national primary health care (PHC) initiative to strengthen health promotion, disease prevention, and early disease detection. The strategy, called Re-engineering Primary Health Care (rPHC), aims to provide a preventive and health-promoting community-based PHC model. A key component of rPHC is the use of community-based outreach teams staffed by generalist community health workers (CHWs). The authors conducted focus group discussions and surveys on the knowledge and attitudes of 91 CHWs working on community-based rPHC teams in the King Sabata Dalindyebo (KSD) sub-district of Eastern Cape Province. The CHWs studied enjoyed their work and found it meaningful, as they saw themselves as agents of change. They also perceived weaknesses in the implementation of outreach team oversight, and desired field-based training and more supervision in the community. The authors find that there is a need to provide CHWs with basic resources like equipment, supplies and transport to improve their acceptability and credibility to the communities they serve.
In low- and middle-income countries, scaling essential health interventions to achieve health development targets is constrained by the lack of skilled health professionals to deliver services. The authors project the future health workforce demand based on projected economic growth, demographics and health coverage. They used health workforce data for 1990–2013 for 165 countries from the WHO Global Health Observatory. The demand projections are compared with the projected growth in health worker supply and the health worker “needs” as estimated by WHO to achieve essential health coverage. The model predicts that, by 2030, global demand for health workers will rise to 80 million workers, double the current (2013) stock of health workers, while the supply of health workers is expected to reach 65 million over the same period, resulting in a worldwide net shortage of 15 million health workers. Growth in the demand for health workers will be highest among upper middle-income countries, driven by economic and population growth and ageing. This results in the largest predicted shortages which may fuel global competition for skilled health workers. Middle-income countries will face workforce shortages because their demand will exceed supply. By contrast, low-income countries will face low growth in both demand and supply, both of which are estimated to be far below what will be needed to achieve adequate coverage of essential health services. This may lead to the paradoxical phenomenon of unemployed (“surplus”) health workers in those countries facing acute “needs-based” shortages.