Human Resources

A political economy analysis of human resources for health (HRH) in Africa
Fieno JV; Dambisya YM; George G; Benson K: Human Resources for Health 14:44 2016

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.

How equitable are community health worker programmes and which programme features influence equity of community health worker services? A systematic review
McCollum R; Gomez W; Theobald S; Taegtmeyer M: BMC Public Health 16(419) 2016 doi: 10.1186/s12889-016-3043-8

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.

Close-to-community providers of health care: increasing evidence of how to bridge community and health systems
Theobald S; Hawkins K; Kok M; Rashid S; Datiko D; Taegtmeyer M:Human Resources for Health 14(32), June 2016

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.

Setting targets for human resources for eye health in sub-Saharan Africa: what evidence should be used?
Courtright P; Mathenge W; Kello A; Cook C; Kalua K; Lewallen S: Human Resources for Health14(1)11, 2016

With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence.

Community Health Worker Data for Decision-Making
One Million Community Health Workers (1mCHW) Campaign; mPowering Frontline Health Workers (mPowering): 2016

In 2015, the One Million Community Health Workers (1mCHW) Campaign and mPowering Frontline Health Workers (mPowering) conducted a series of interviews and held an online discussion, hosted on the Healthcare Information for All forum, on the need for improved data on community health workers (CHWs) to help achieve the Sustainable Development Goals. The key findings showed that CHWs deliver life-saving health care services than can address health issues in poor rural communities. They help keep track of disease outbreaks and overall public health, and offer a vital link between underserved populations and the primary health care system. CHWs have been recognised for their success in reducing morbidity and averting mortality in mothers, newborns and children. While they have proven crucial in settings where the primary health care system is weak, or where there are health workforce shortages, they are most effective when properly supported and deployed within the context of an appropriately financed health system.

The complexity of rural contexts experienced by community disability workers in three southern African countries
Booyens M; van Pletzen E; Lorenzo T: African Journal of Disability 4(1) doi: 10.4102/ajod.v4i1.167, 2015

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.

Explaining retention of healthcare workers in Tanzania: moving on, coming to ‘look, see and go’, or stay?
Shemdoe A; Mbaruku G; Dillip A; Bradley S; William J; Wason D; Hildon Z: Human Resources for Health14(1)2, 2016

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.

Global health leadership training in resource-limited settings: a collaborative approach by academic institutions and local health care programs in Uganda
Nakanjako D; Namagala E; Semeere A; et al: Afya Bora Consortium members: Human Resources for Health 13(87), November 2015

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.

Training needs for research in health inequities among health and demographic researchers from eight African and Asian countries
Haafkens J; Blomstedt Y; Eriksson M; Becher H; Ramroth H; Kinsman J: BMC Public Health 14(1254), 2014

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.

Health worker migration from South Africa: causes, consequences and policy responses
Labonté R; Sanders D; Mathole T; Crush J; Chikanda A; Dambisya Y; Runnels V; Packer C; MacKenzie A; Murphy G; Bourgeault I: Human Resources for Health,13(92), December 2015

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.

Pages