PALM PLUS (Practical Approach to Lung Health and HIV/AIDS in Malawi) is an intervention designed to simplify and integrate existing Malawian national guidelines into a single, simple, user-friendly guideline for mid-level health care workers. Training utilises a peer-to-peer educational outreach approach. Research is being undertaken to evaluate this intervention to generate evidence that will guide future decision-making for consideration of roll out in Malawi. In the first phase of qualitative inquiry respondents from intervention sites demonstrated in-depth knowledge of PALM PLUS compared to those from control sites. Participants in intervention sites felt that the PALM PLUS tool empowered them to provide better health services to patients. Interim staff retention data shows that there were, on average, three to four staff departing from the control and intervention sites per month. Additional qualitative, quantitative and economic analyses are planned. This initiative is an example of South-South knowledge translation between South Africa and Malawi, mediated by a Canadian academic-NGO hybrid. Success in developing and rolling out PALM PLUS in Malawi suggests that it is possible to adapt and implement this intervention for use in other resource-limited settings.
Human Resources
This paper presents a framework for the health system with health workers at the core. The authors reviewed existing health-system frameworks and the role they assign to health workers, finding that earlier frameworks either do not include health workers as a central feature of system functioning or treat them as one among several components of equal importance. As every function of the health system is either undertaken by or mediated through the health worker, the authors argue that the health worker should be placed at the centr of the health system. They describe six research issues on the health workforce: metrics to measure the capacity of a health system to deliver healthcare; the contribution of public- vs private-sector health workers in meeting healthcare needs and demands; the appropriate size, composition and distribution of the health workforce; approaches to achieving health-worker requirements; the adoption and adaption of treatments by health workers; and the training of health workers for horizontally vs vertically structured health systems.
The nature of armed conflict is changing, putting health workers increasingly in harm’s way. A new campaign by the Red Cross, the Health Care in Danger strategy, aims to raise awareness and improve conditions on the ground for health workers and facilities in conflict zones. The harm done when health workers are attacked is not limited to the assault itself, but has a knock on effect that can deprive patients of treatment. The intensity of attacks on health care workers has increased, according to Physicians for Human Rights, but they acknowledge there is a lack of reliable data. Because of the blurred nature of contemporary war, health facilities find themselves providing services to both sides of a conflict and exposing themselves in doing so. According to this article, it has become more common for soldiers to enter a hospital to settle scores, for example, or indeed for government forces to come looking for insurgents and prevent doctors from treating opponents. Médecins Sans Frontières (MSF), recommends negotiating what may be called the “parameters of intervention” before starting operations, which requires communicating and negotiating with all the relevant military and paramilitary actors to create the neutral space in which medical services can be offered.
In this paper, the authors describe the way the human resources for health (HRH) establishment is distributed in the different provinces of Zambia, with a view to assess the dimension of shortages and of imbalances in the distribution of health workers by province and by level of care. They used secondary data from the "March 2008 payroll data base", which lists all the public servants on the payroll of the Ministry of Health and of the National Health Service facilities. Results indicate that workers are maldistributed across Zambia. This case study documents how a peaceful, politically stable African country with a longstanding tradition of strategic management of the health sector and with a track record of innovative approaches dealt with its health worker issues, but still remains with absolute and relative shortages of health workers. The Zambia case reinforces the idea that training more staff is necessary to address the health worker crisis, but it is not sufficient and has to be completed with measures to mitigate attrition and to increase productivity.
The May 2010 adoption of the World Health Organisation Global Code of Practice on the International Recruitment of Health Personnel created a global architecture, including ethical norms and institutional and legal arrangements, to guide international cooperation and serve as a platform for continuing dialogue on the critical problem of health worker migration. Highlighting the contribution of non-binding instruments to global health governance, this article describes the Code negotiation process from its early stages to the formal adoption of the final text of the Code. Detailed are the vigorous negotiations amongst key stakeholders, including the active role of non-governmental organisations. The article emphasises the importance of political leadership, appropriate sequencing, and support for capacity building of developing countries’ negotiating skills to successful global health negotiations. It also reflects on how the dynamics of the Code negotiation process evidence an evolution in global health negotiations amongst the WHO Secretariat, civil society, and WHO Member States.
This study compares what is known about insecticide-treated nets (ITNs) to the related knowledge and practices of healthcare providers in four low- and middle-income countries. A new questionnaire was administered to 497 healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania (121). In the survey, few participating healthcare providers correctly answered all five knowledge questions about ITNs (13%) or self-reported performing all five clinical practices according to established evidence (2%). Statistically significant factors associated with higher knowledge within each country included: training in acquiring systematic reviews through the Cochrane Library and ability to read and write English well or very well. Statistically significant factors associated with better clinical practices within each country included: reading scientific journals from their own country; working with researchers to improve their clinical practice or quality of working life; training on malaria prevention since their last degree; and easy access to the internet. The researchers conclude that improving healthcare providers' knowledge and practices is an untapped opportunity for expanding ITN utilisation and preventing malaria. Training on acquiring systematic reviews and facilitating internet access may be particularly helpful.
Lay health workers are key to achieving universal health-care coverage, therefore measuring worker attrition and identifying its determinants should be an integral part of any lay health worker programme. Both published and unpublished research on lay health workers has largely focused on the types of interventions they can deliver effectively. This is an imperative since the main objective of these programmes is to improve health outcomes. However, high attrition rates can undermine the effectiveness of these programmes. There is a lack of research on lay health worker attrition, the authors of this paper note. Research that aims to answer the following three key questions would help address this knowledge gap. What is the magnitude of attrition in programmes? What are the determinants of attrition? What are the most successful ways of reducing attrition? With community-based interventions and task shifting high on the United Nations Millennium Development Goals’ policy agenda, research on lay health worker attrition and its determinants requires urgent attention, the authors conclude.
The objective of this study was to estimate the lost investment of domestically educated doctors migrating from sub-Saharan African countries to Australia, Canada, the United Kingdom, and the United States. Researchers calculated the financial cost of educating a doctor in nine source countries with a high HIV and AIDS burden (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), which ranged from US $21,000 in Uganda to $58,700 in South Africa. The overall estimated loss of returns from investment for all doctors currently working in the destination countries was $2.17bn, with costs for each country ranging from $2.16m (1.55m to 2.78m) for Malawi to $1.41bn (1.38bn to 1.44bn) for South Africa. The ratio of the estimated compounded lost investment over gross domestic product showed that Zimbabwe and South Africa had the largest losses. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom ($2.7bn) and United States ($846m). They conclude that destination countries should consider investing in measurable training for source countries and strengthening of their health systems.
Communication between non-language-concordant health care workers (HCWs) and patients has been shown by international studies to adversely affect patient and staff satisfaction, yet the authors of this study note that, to the best of their knowledge, no such intervention studies have been conducted in Africa. They conducted research in South Africa to determine whether teaching Xhosa language skills and cultural understanding to HCWs affects patient satisfaction, HCWs’ ability to communicate effectively with Xhosa-speaking patients and HCWs’ job satisfaction levels. A before-and-after interventional study was performed at two community health centres and a district hospital in the Western Cape Province. Fifty-four randomly selected patients (27 pre- and 27 post-intervention) assessed communication with HCWs and rated their satisfaction. Six non-Xhosa-speaking HCW participants completed pre- and post-intervention questionnaires. HCWs completed a ten-week basic language course consisting of ten 120-minute interactive contact sessions developing basic Xhosa speaking and listening skills and cultural competence. Results showed that patient satisfaction showed significant improvements after the intervention. Patients perceived HCWs to be more understanding, respectful and concerned, and to show better listening skills, after the intervention. They were also better able to understand HCWs and their instructions. HCWs’ ability to communicate improved and HCWs experienced decreased frustration levels.
The aim of this study was to determine the need for resuscitation at the birth of babies delivered by elective caesarean section (CS) and to record the time spent by doctors attending such deliveries. Data were collected prospectively on all elective CSs performed at Groote Schuur Hospital in Cape Town, South Africa, over a three-month period. Data collected included: total time involved for paediatrician from call to leaving theatre, management of infant (requiring any form of resuscitation), Apgar scores and neonatal outcome (e.g. admission to nursery). The CSs were classified as low-risk or high-risk. Data were recorded for 138 deliveries. One-hundred-and-fifteen deliveries were classified as uncomplicated and 20 as high-risk. Only one of the babies born from the 115 low-risk CSs needed brief resuscitation, whereas nine of the 20 high-risk deliveries resulted in newborn resuscitation. The reasons for low-risk CS were: previous CS (81); infant of diabetic mother (IDM) and previous CS (16); IDM alone (6); estimated big baby (10); and other (2).The average time spent at each elective CS by the paediatrician was 37 minutes. The authors conclude that, for low-risk CS, the same medical attendance (i.e. a midwife) as for an uncomplicated normal vaginal delivery (NVD) would be appropriate. This would free up a doctor for other duties and assist in de-medicalising a low-risk procedure.