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.
Human Resources
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.
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.
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.
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.
The 2013–2016 Ebola virus disease outbreak in West Africa exposed an urgent need to strengthen health surveillance and health systems in low-income countries, not only to improve the health of populations served by these health systems but also to promote global health security. Chronically fragile and under-resourced health systems enabled the initial outbreak in Guinea to spiral into an epidemic of over 28 616 cases and 11 310 deaths (as of 5 May 2016) in Guinea, Liberia and Sierra Leone, requiring an unprecedented global response that is still ongoing. Control efforts were hindered by gaps in the formal health system and by resistance from the community, fuelled by fear and poor communication. Lessons learnt from this Ebola outbreak have raised the question of how the affected countries, and other low-income countries with similarly weak health systems, can build stronger health systems and surveillance mechanisms to prevent future outbreaks from escalating. Factors that were important in the growth and persistence of the Ebola virus outbreak were lack of trust in the health system at the community level, the spread of misinformation, deeply embedded cultural practices conducive to transmission (e.g. burial customs), inadequate reporting of health events and the public’s lack of access to health services. Community health workers are in a unique position to mitigate these factors through surveillance for danger signs and mobilisation of communities when an outbreak has been identified. In this paper the authors make the case for investing in robust national community health worker programmes as one of the strategies for improving global health security, for preventing future catastrophic infectious disease outbreaks and for strengthening health systems.
This study aimed to determine the knowledge, opinions and practices of healthcare workers in maternity wards in a regional hospital in Bloemfontein, Free State Province, South Africa, regarding infant feeding in the context of HIV. For this descriptive cross-sectional study, all the healthcare workers in the maternity wards of Pelonomi Regional Hospital who voluntarily gave their consent during the scheduled meetings (n = 64), were enrolled and given self-administered questionnaires. Only 14% of the respondents considered themselves to be experts in HIV and infant feeding. Approximately 97% felt that breastfeeding was an excellent feeding choice provided proper guidelines were followed. However, 10% indicated that formula feeding is the safest feeding option. 45% stated that heat-treated breast milk is a good infant feeding option; however, 29% considered it a good infant feeding option but it requires too much work. Only 6% could comprehensively explain the term “exclusive breastfeeding” as per World Health Organisation (WHO) definition. Confusion existed regarding the period for which an infant could be breastfed according to the newest WHO guidelines, with only 26% providing the correct answer. Twenty per cent reported that no risk exists for HIV transmission via breastfeeding if all the necessary guidelines are followed. Healthcare workers' knowledge did not conform favourably with the current WHO guidelines, even though these healthcare workers were actively involved in the care of patients in the maternity wards where HIV-infected mothers regularly seek counselling on infant feeding matters.
Despite a global recognition from all stakeholders of the gravity and urgency of health worker shortage in Africa, little progress has been achieved to improve health worker coverage in many of the African human resources for health (HRH) crisis countries. The problem consists in how policy is made, how leaders are accountable, how the World Health Organization (WHO) and foreign funders encourage (or distort) health policy, and how development objectives are prioritized in these countries. The paper uses political economy analysis, which stems from a recognition that the solution to the shortage of health workers across Africa involves more than a technical response. A number of institutional arrangements dampen investments in HRH, including a mismatch between officials’ tenure in office and program results, the vertical nature of health programming, the modalities of Overseas Development Assistance in health, the structures of the global health community, and the weak capacity in HRH units within Ministries of Health. A major change in policy-making would only occur with a disruption to the political or institutional order. The case study of Ethiopia, who has increased its health workforce dramatically over the last 20 years, disrupted previous institutional arrangements through the power of ideas—HRH as a key intermediate development objective. The framing of HRH created the rationale for the political commitment to investment in health workers. The authors argue that Ethiopia demonstrates that political will coupled with strong state capacity and adequate resource mobilization can overcome the institutional hurdles above.
Community health workers (CHWs) are uniquely placed to link communities with the health system, playing a role in improving the reach of health systems and bringing health services closer to hard-to-reach and marginalised groups. A systematic review was conducted to determine the extent of equity of CHW programmes and to identify intervention design factors which influence equity of health outcomes. In accordance with published protocol, the authors systematically searched eight databases from 2004 to 2014 for quantitative and qualitative studies which assessed access, utilisation, quality or community empowerment following introduction of a CHW programme according to equity stratifiers (place of residence, gender, socio-economic position and disability). Thirty four papers met inclusion criteria. A thematic framework was applied and data extracted and managed, prior to charting and thematic analysis. The authors believe this to be the first systematic review that describes the extent of equity within CHW programmes and identifies CHW intervention design features which influence equity. CHW programmes were found to promote equity of access and utilisation for community health by reducing inequities relating to place of residence, gender, education and socio-economic position. CHWs can also contribute towards more equitable uptake of referrals at health facility level. There was no clear evidence for equitable quality of services provided by CHWs and limited information regarding the role of the CHW in generating community empowerment to respond to social determinants of health. Factors promoting greater equity of CHW services include recruitment of most poor community members as CHWs, close proximity of services to households, pre-existing social relationship with CHW, provision of home-based services, free service delivery, targeting of poor households, strengthened referral to facility, sensitisation and mobilisation of community. However, if CHW programmes are not well planned some of the barriers faced by clients at health facility level can replicate at community level. CHWs promote equitable access to health promotion, disease prevention and use of curative services at household level. However, care must be taken by policymakers and implementers to take into account factors which can influence the equity of services during planning and implementation of CHW programmes.
The recent thematic series on close-to-community providers published in this journal brings together 14 papers from a variety of contexts and that use a range of research methods. The series clearly illustrates the renewed emphasis and excitement about the potential of close-to-community (CTC) providers in realising universal health coverage and supporting the sustainable development goals. This editorial discusses key themes that have emerged from this rich and varied set of papers and reflect on the implications for evidence-based programming. The authors argue that it is a critical stage in the development of CTC programming and policy which requires the creation and communication of new knowledge to ensure the safety, sustainability, quality and accessibility of services, and their links with both the broader health system and the communities that CTCs serve.