The aim 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 included nine sub-Saharan African countries with an HIV prevalence of 5% or greater or with more than one million people with HIV/AIDS and with at least one medical school (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), and data available on the number of doctors practising in destination countries. In the nine source countries the estimated government subsidised cost of a doctor’s education 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 for Malawi to $1.41bn for South Africa. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom ($2.7bn) and United States ($846m). Destination countries should consider investing in measurable training for source countries and strengthening of their health systems, the authors conclude.
Human Resources
The human resource crisis affects developed and developing countries, but the global poor suffer disproportionately, not only because they have a much smaller workforce but also because their needs are so much greater, according to this paper. Of the 57 countries with critical shortages, 36 are in Africa. Africa has 25% of the world’s disease burden, but only 3% of the world’s health workers and 1% of the economic resources. The causes of the human resource shortages are multifaceted and complex, but not so complex that they cannot be understood and acted upon, the authors argue. They make several recommendations. The United States (US) administration, using an “all-of-government” approach, should develop a strategic plan to address the global health worker shortage. The US government should also reform US global health assistance programmes to increase health workforce capacity in partner countries, as well as increase financial assistance for global health workforce capacity development. Finally, Congress should empower the Department of Health and Human Services or another appropriate agency to regulate the recruiters of foreign-trained health workers.
Lesotho faces a severe human resource shortage as it attempts to manage its HIV pandemic, with more than 25% of the population infected with HIV. This paper reports on a programme that provided HIV services in seven rural clinics in Lesotho. LHWs played an important role in the provision of HIV services that ranged from translation, adherence counseling, voluntary counseling and testing (VCT) for HIV and patient triage, to medication distribution and laboratory specimen processing. Training the LHWs was part of the clinic physicians' responsibilities and thus required no additional funding beyond regular clinic operations. This lent sustainability to the training of the LHWs. This paper describes the recruitment, training, activities, and perceptions of the LHW work between June 2006 and December 2008. LHWs participated successfully in the care of thousands of people with HIV in Lesotho and their experience can serve as a model for other countries facing the disease, the authors conclude.
The objective of this study was to determine the percentage of South African nurses initiating new HIV-positive patients on therapy within two months of attending the Nurse Initiation and Maintenance of Antiretroviral Therapy (NIMART) course, and to identify possible barriers to nurse initiation. A brief telephonic interview using a structured questionnaire of a randomly selected sample (126/1736) of primary care nurses who had attended the NIMART course between October 2010 and 31 March 2011 at primary care clinics in seven provinces. Outcome measures were the number of nurses initiating ART within two months of attending the FPD-facilitated NIMART course. Results showed that, of the nurses surveyed, 62% (79/126) had started initiating new adult patients on ART, but only 7% (9/126) were initiating ART in children. The main barrier to initiation was allocation to other tasks in the clinic as a result of staff shortages. In conclusion, despite numerous challenges, many primary care nurses working in the seven provinces surveyed have taken on the responsibility of sharing the task of initiating HIV-positive patients on ART. The barriers preventing more nurses initiating ART include the shortage of primary care nurses and the lack of sufficient consulting rooms. Expanding clinical mentoring and further training in clinical skills and pharmacology would assist in reaching the target of initiating a further 1.2 million HIV-positive patients on ART by 2012.
In this study, researchers examined the performance of community antiretroviral therapy and tuberculosis treatment supporters (CATTS) in scaling up antiretroviral therapy (ART) in Reach Out, a community-based ART program in Uganda. Retrospective data on home visits made by CATTS were analysed to examine the CATTS ability to perform home visits to patients based on the model's standard procedures. Qualitative interviews conducted with 347 randomly selected patients and 47 CATTS explored their satisfaction with the model. The CATTS ability to follow-up with patients worsened from patients requiring daily, weekly, monthly, to three-monthly home visits. Only 26% and 15% of them correctly home visited patients with drug side effects and a missed clinic appointment, respectively. Additionally, 83% visited stable pre-ART and ART patients (96%) more frequently than required. Six hundred eighty of the 3,650 (18%) patients were lost to follow-up (LTFU) during the study period. Ninety-two percent of the CATTS felt the model could be improved by reducing the workload. In conclusion, the Reach-Out CHW model may be too labour-intensive. Triaged home visits could improve performance and allow CATTS time to focus on patients requiring more intensive follow-up.
The aim of this study was to identify workforce ratios in nine allied health professions and to identify whether these measures are useful for planning allied health workforce requirements. A systematic literature search using relevant MeSH headings of business, medical and allied health databases and relevant grey literature for the period 2000-2008 was undertaken. Twelve articles were identified which described the use of workforce ratios in allied health services. Only one of these was a staffing ratio linked to clinical outcomes. The most comprehensive measures were identified in rehabilitation medicine. The authors conclude that evidence for use of staffing ratios for allied health practitioners is scarce and lags behind the fields of nursing and medicine.
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.
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.