An understanding of rural communities is fundamental to effective community-based rehabilitation work with persons with disabilities. The authors argue that insufficient attention has been paid to the challenges that rural community disability workers face. This qualitative interpretive study, involving in-depth interviews with 16 community disability workers in Botswana, Malawi and South Africa, revealed the complex ways in which poverty, inappropriately used power and negative attitudes of service providers and communities combine to create formidable barriers to the inclusion of persons with disabilities in families and rural communities. The paper highlights the importance of understanding and working with the concept of ‘disability’ from a social justice and development perspective. It stresses that by targeting attitudes, actions and relationships, community disability workers can bring about social change in the lives of persons with disabilities and the communities in which they live.
In Tanzania staff shortages in the healthcare system are a persistent problem, particularly in rural areas. To explore this the authors explored which cadres are most problematic to recruit and keep in post, for what reasons and why do some stay and cope? Qualitative data were generated through semi-structured interviews with Council Health Management Teams, and Critical Incident Technique interviews with mid-level cadres. Complementary quantitative survey data were collected from district health officials. Mid-level cadres were problematic to retain and caused significant disruptions to continuity of care when they left. Reasons for wanting to leave included perceptions of personal safety, feeling patient outcomes were compromised by poor care or as a result of perceived failed promises. Staying and coping with unsatisfactory conditions was often about being settled into a community, rather than into the post. The Human Resources for Health system in Tanzania was reported to lack transparency. The authors suggest that centralised monitoring could help to avoid early departures, misallocation of training, and to enable other incentives. It should match workers' profiles to the most suitable post for them and track their progress and rewards; training managers and holding them accountable. In addition, they argue that priority should be given to workplace safety, late night staff transport, modernised and secure compound housing, and in measures to involve the community in reforming the culture and practices in services.
Due to a limited health workforce, many health care providers in Africa must take on health leadership roles with minimal formal training in leadership. Hence, the need to equip health care providers with practical skills required to lead high-impact health care programs. In Uganda, the Afya Bora Global Health Leadership Fellowship is implemented through the Makerere University College of Health Sciences (MakCHS) and her partner institutions. Lessons learned from the program, presented in this paper, may guide development of in-service training opportunities to enhance leadership skills of health workers in resource-limited settings. The Afya Bora Consortium, a consortium of four African and four U.S. academic institutions, offers 1-year global health leadership-training opportunities for nurses and doctors. Applications are received and vetted internationally by members of the consortium institutions in Botswana, Kenya, Tanzania, Uganda, and the USA. Fellows have 3 months of didactic modules and 9 months of mentored field attachment with 80% time dedicated to fellowship activities. Fellows’ projects and experiences, documented during weekly mentor-fellow meetings and monthly mentoring team meetings, were compiled and analysed manually using pre-determined themes to assess the effect of the program on fellows’ daily leadership opportunities. Between January 2011 and January 2015, 15 Ugandan fellows (nine doctors and six nurses) participated in the program. Each fellow received 8 weeks of didactic modules held at one of the African partner institutions and three online modules to enhance fellows’ foundation in leadership, communication, monitoring and evaluation, health informatics, research methodology, grant writing, implementation science, and responsible conduct of research. In addition, fellows embarked on innovative projects that covered a wide spectrum of global health challenges including critical analysis of policy formulation and review processes, bottlenecks in implementation of national HIV early infant diagnosis and prevention of mother-to-child HIV-transmission programs, and use of routine laboratory data about antibiotic resistance to guide updates of essential drug lists. In-service leadership training was feasible, with ensured protected time for fellows to generate evidence-based solutions to challenges within their work environment. With structured mentorship, collaborative activities at academic institutions and local health care programs equipped health care providers with leadership skills.
To support equity focussed public health policy in low and middle income countries, more evidence and analysis of the social determinants of health inequalities is needed. This requires specific know how among researchers. The INDEPTH Training and Research Centres of Excellence (INTREC) collaboration identified learning needs among INDEPTH researchers from Ghana, Tanzania, South Africa, Kenya, Indonesia, India, Vietnam, and Bangladesh to conduct research on the causes of health inequalities in their country. Using an inductive method, online concept-mapping, participants were asked to generate statements in response to the question what background knowledge they would need to conduct research on the causes of health inequalities in their country. Of the 150 invited researchers, 82 participated in the study: 54 from Africa; 28 from Asia. African participants assigned the highest importance to further training on methods for assessing health inequalities. Asian participants assigned the highest importance to training on research and policy.
This paper arises from a four-country study that sought to better understand the drivers of skilled health worker migration, its consequences, and the strategies countries have employed to mitigate negative impacts. This paper presents the findings from South Africa. The study began with a scoping review of the literature on health worker migration from South Africa, followed by empirical data collected from skilled health workers and stakeholders. The study found that there has been a decrease in out-migration of skilled health workers from South Africa since the early 2000s largely attributed to a reduced need for foreign-trained skilled health workers in destination countries, limitations on recruitment, and tighter migration rules. Low levels of worker satisfaction persist, although the Occupation Specific Dispensation (OSD) policy (2007), which increased wages for health workers, has been described as critical in retaining South African nurses. Return migration was reportedly a common occurrence. The consequences attributed to skilled health worker migration are mixed, but shortages appear to have declined. Most promising initiatives are those designed to reinforce the South African health system and undertaken within South Africa itself. In the near past, South Africa’s health worker shortages as a result of emigration were viewed as significant and harmful. Currently, domestic policies to improve health care and the health workforce including innovations such as new skilled health worker cadres and OSD policies appear to have served to decrease shortages to some extent.
In Mozambique, integrated community case management (iCCM) of diarrhoea, malaria and pneumonia is embedded in the national community health worker (CHW) programme, mainstreaming it into government policy and service delivery. Since its inception in 1978, the CHW programme has functioned unevenly, was suspended in 1989, but relaunched in 2010. To assess the long-term success of iCCM in Mozambique, this article addresses whether the current CHW programme exhibits characteristics that facilitate or impede its sustainability. The authors undertook a qualitative case study based on document review (n = 54) and key informant interviews (n = 21) with respondents from the Ministry of Health (MOH), multilateral and bilateral agencies and non-governmental organizations (NGOs) in Maputo in 2012. Interviews were mostly undertaken in Portuguese and all were coded using NVivo. A sustainability framework guided thematic analysis according to nine domains: strategic planning, organizational capacity, programme adaptation, programme monitoring and evaluation, communications, funding stability, political support, partnerships and public health impact. Government commitment was high, with the MOH leading a consultative process in Maputo and facilitating successful technical coordination. The MOH made strategic decisions to pay CHWs, authorize their prescribing abilities, foster guidance development, support operational planning and incorporate previously excluded ‘old’ CHWs. Nonetheless, policy negotiations excluded certain key actors and uncertainty remains about CHW integration into the civil service and their long-term retention. In addition, reliance on NGOs and donor funding has led to geographic distortions in scaling up, alongside challenges in harmonization. Finally, dependence on external funding, when both external and government funding are declining, may hamper sustainability. The authors’ analysis represents a nuanced assessment of the various domains that influence CHW programme sustainability, highlighting strategic areas such as CHW payment and programme financing. These organizational and contextual determinants of sustainability are central to CHW programme strengthening and iCCM policy support.
This paper explored the reasons African health workers raised for migration to Austria, as well as their personal experiences concerning the living and working situation in Austria. The authors conducted semi-structured, qualitative interviews with African health workers approached via professional networks and a snowball system. For most of the participants, the decision to migrate was not professional but situation dependent. Austria was not their first choice as a destination country. Several study participants left their countries to improve their overall working situation. The main motivation for migrating to Austria was partnership with an Austrian citizen. Other immigrants were refugees. Most of the immigrants found the accreditation process to work as a health professional to be difficult, resulting in some not being able to work in their profession. There was also reported experience of discrimination, but also of positive support.
The World Health Organization defines a “critical shortage” of health workers as being fewer than 2.28 health workers per 1000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. The authors aimed to quantify the number of health workers in five African countries and the proportion of these currently working in primary health care facilities, to compare this to estimates of numbers needed and to assess how the situation has changed in recent years. This study is a review of published and unpublished “grey” literature on human resources for health in Mali, Sudan, Uganda, Botswana and South Africa. Health worker density has increased steadily since 2000 in South Africa and Botswana which already meet WHO targets but has not significantly increased since 2004 in Sudan, Mali and Uganda which have a critical shortage of health workers. In all five countries, a minority of doctors, nurses and midwives are working in primary health care, and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in primary health care settings than at higher levels. Even South Africa has a shortage of doctors in primary health care in poorer districts. Although most countries recognize village health workers, traditional healers and traditional birth attendants, there are insufficient data on their numbers. There is an “inverse primary health care law” in the countries studied: staffing is inversely related to poverty and level of need, and health worker density is not increasing in the lowest income countries. Unless there is money to recruit and retain staff in these areas, training programmes will not improve health worker density because the trained staff will simply leave to work elsewhere. The author argues that information systems need to be improved in a way that informs policy on the health workforce. It may be possible to use existing resources more cost-effectively by involving skilled staff to supervise and support lower level health care workers who currently provide the front line of primary health care in most of Africa.
Cardiovascular disease contributes substantially to the non-communicable disease (NCD) burden in low-income and middle-income countries, which also often have substantial health personnel shortages. In this observational study the authors investigated whether community health workers could do community-based screenings to predict cardiovascular disease risk as effectively as could physicians or nurses, with a simple, non-invasive risk prediction indicator in low-income and middle-income countries. This observation study was done in Bangladesh, Guatemala, Mexico, and South Africa. Each site recruited at least ten to 15 community health workers based on usual site-specific norms for required levels of education and language competency. Community health workers had to reside in the community where the screenings were done and had to be fluent in that community's predominant language. These workers were trained to calculate an absolute cardiovascular disease risk score with a previously validated simple, non-invasive screening indicator. Community health workers who successfully finished the training screened community residents aged 35–74 years without a previous diagnosis of hypertension, diabetes, or heart disease. Health professionals independently generated a second risk score with the same instrument and the two sets of scores were compared for agreement. The study found that community health workers can be adequately trained to effectively screen for, and identify, people at high risk of cardiovascular disease.
This paper describes long-term treatment outcomes of a paediatric HIV cohort in Mozambique, in the Chamanculo Health District of Maputo. The subjects involved a total of 1,335 antiretroviral treatment (ART) naïve children <15 years of age enrolled in HIV care between 2002 and 2010. The interventions included HIV care, ART (since 2003), task shifting to lower cadre nurses, counseling by lay counselors, active patient tracing, nutritional support, support by a psychologist, targeted viral load testing, and switch to second-line treatment. The main outcome measures included Kaplan–Meier estimates for retention in care (RIC), CD4 cell percentage, body mass index for age z-score, and adjusted incidence rate ratios for attrition (death or loss to follow-up) as calculated by Poisson regression. The RIC at 6 years in the pre-ART cohort was 44% and the one at 8 years in the ART cohort was 70%. Risk factors for attrition included young age, low CD4 percentage, underweight, active tuberculosis, and enrollment/treatment initiation after 2006. The mean CD4 percentage increased strongly at 1 year on treatment and remained high thereafter. The body mass index for age sharply increased at 1 year after treatment initiation before stabilizing at pre-ART levels thereafter. The study concludes that good clinical and immunological treatment outcomes up to 8 years of follow-up on ART can be achieved in a context of shortage of health workers and a high level of task-shifting approach.