Human Resources

Relaunch of the official community health worker programme in Mozambique: is there a sustainable basis for iCCM policy?
Chilundo B; Cliff J; Mariano A; Rodríguez D; George A: Health Policy and Planning 30 (suppl 2): ii36-ii45, 2015

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.

“Why should I have come here?” - a qualitative investigation of migration reasons and experiences of health workers from sub-Saharan Africa in Austria
Jirovsky E; Hoffmann K; Maier M; Kutalek R: BMC Health Services Research 15(74), 2015

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.

Human resources for primary health care in sub-Saharan Africa: progress or stagnation?
Willcox ML; Peersman W; Daou P; Diakité C; Bajunirwe F; Mubangizi V; Mahmoud EH; Moosa S; Phaladze N; Nkomazana O; Khogali M; Diallo D; De Maeseneer J; Mant D: Human Resources for Health 13(76), 2015

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.

An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational study
Gaziano T; Abrahams-Gessel S; Denman C; Montano C; Khanam M; Puoane T; Levitt N: The Lancet Global Health 3 (9), e556–e563, 2015,

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.

Long-term outcomes of a pediatric HIV treatment program in Maputo, Mozambique: a cohort study
Walter J; Molfino L; Moreno V; Edwards CG; Chissano M; Prieto A; Bocharnikova T; Antierens A; Lujan J: Glob Health Action 8 (26652), 2015

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.

Determining the competences of community based workers for disability-inclusive development in rural areas of South Africa, Botswana and Malawi
Lorenzo T; van Pletzen E; Booyens M: The International Electronic Journal of Rural and Remote Health Research, Education, Practice and Policy 15(2), 2015

This article analyses the work of community disability workers (CDWs) in three southern African countries to demonstrate the competencies that these workers acquired to make a contribution to social justice for persons with disabilities and their families. It points to some gaps and then argues that these competencies should be consolidated and strengthened in curricula, training and policy. Purposive sampling was used to select and interviews held with 16 CDWs who had at least 5 years experience of disability-related work in a rural area. Three main themes emerged, related to the integrated management of health conditions and impairments within a family focus; disability-inclusive community development and coordinated intersectoral management systems. The CDWs were found to facilitate change and manage the multiple transitions experienced by the families at different stages of the disabled person’s development. Disability-inclusive development is argued to require a workforce equipped with skills to work intersectorally and in a cross-disciplinary manner to operationalise the community-based rehabilitation guidelines that are designed to promote delivery of services in remote and rural areas. The author argues for their recognition as a CDWs as a cross-disciplinary profession.

Healthcare service providers’ and facility administrators’ perspectives of the free maternal healthcare services policy in Malindi District, Kenya: a qualitative study
Lang’a E; Mwanri L: Reproductive Health 12(59), 27 June 2015

In Kenya, more than half of the women deliver without the assistance of a skilled attendant and this has contributed to high maternal mortality rates. The free maternal healthcare services policy in all public facilities was initiated as a strategy to improve access to skilled care and reduce poor maternal health outcomes. This study aimed to explore the perspectives of the service providers and facility administrators of the free maternal health care service policy that was introduced in Kenya in 2013. A qualitative inquiry using semi-structured one-on-one interviews was conducted in Malindi District, Kenya. The participants included maternal health service providers and facility administrators recruited from five different healthcare facilities. Free maternal healthcare service provision was perceived to boost skilled care utilisation during pregnancy and delivery. However, challenges including; delays in the reimbursement of funds by the government to the facilities, stock outs of essential commodities in the facilities to facilitate service provision, increased workload amidst staff shortage and lack of consultation and sensitisation of key stakeholders were perceived as barriers to effective implementation of this policy. The authors note that implementation of the policy would be more effective if; the healthcare facilities were upgraded, equipped with adequate supplies, funds and staff; the community are continually sensitised on the importance of seeking skilled care during pregnancy and delivery; and inclusivity and collaboration with other key stakeholders be fostered in addressing poor maternal health outcomes in the country.

Unpaid Care Work Programme: Uganda Country Progress Report (2012–2014)
Nesbitt-Ahmed Z; Malinga Apila H: Institute of Development Studies Evidence Report 126, IDS Sussex, 2015

The Institute of Development Studies (IDS) partnered with ActionAid International (AAI) in Uganda to develop and implement an advocacy strategy to make unpaid care work more visible in public policy, as well as to integrate unpaid care issues into each country’s programming. It used an action learning methodology to look at what works and does not work in making the care economy more visible. It aimed to track and capture changes in policy and practice in order to improve understanding around the uptake of evidence. This report covers the progress of the programme in Uganda over the first two and a half years of the four-year programme. The work identified that making unpaid care work more visible calls for a collective voice amongst those involved and engaging and working effectively with the media with clear messaging.

What do community health workers have to say about their work, and how can this inform improved programme design? A case study with CHWs within Kenya
Oliver M; Geniets A; Winters N; Rega I; Mbae S: Global Health Action 8, May 2015, doi:

Community health workers (CHWs) are often spoken about or for, but there is little evidence of CHWs’ own characterisation of their practice. This paper addresses this issue. A case study approach was undertaken in a series of four steps. Firstly, groups of CHWs from two communities met and reported what their daily work consisted of. Secondly, individual CHWs were interviewed so that they could provide fuller, more detailed accounts of their work and experiences; in addition, community health extension workers and community health committee members were interviewed, to provide alternative perspectives. Thirdly, notes and observations were taken in community meetings and monthly meetings. The data were then analysed thematically, creating an account of how CHWs describe their own work, and the tensions and challenges that they face. CHWs’ accounts of both successes and challenges involved material elements: leaky tins and dishracks evidenced successful health interventions, whilst bicycles, empty first aid kits and recruiting stretcher bearers evidenced the difficulties of resourcing and geography they are required to overcome. CHWs described their work was as healthcare generalists, working to serve their community and to integrate it with the official health system. Their work involves referrals, monitoring, reporting and educational interactions. Whilst they face problems with resources and training, their accounts show that they respond to this in creative ways, working within established systems of community power and formal authority to achieve their goals, rather than falling into a ‘deficit’ position that requires remedial external intervention. Their work is widely appreciated, although some households do resist their interventions, and figures of authority sometimes question their manner and expertise. The material challenges that they face have both practical and community aspects, since coping with scarcity brings community members together. The authors suggest that programmes co-designed with CHWs will be easier to implement because of their relevance to their practices and experiences, whereas those that seek to use CHWs as an instrument to implement external priorities are likely to disrupt their work.

Health workers’ experiences, barriers, preferences and motivating factors in using mHealth forms in Ethiopia
Medhanyie AA, Little Am Yebyo H, Spigt M, Tadesse K, Blanco R, Dinant GJ: Human Resources for Health 13(2), 2015

Mobile health (mHealth) applications, such as innovative electronic forms on smartphones, could potentially improve the performance of health care workers and health systems in developing countries. A pretested semistructured questionnaire was used to assess health workers’ experiences, barriers, preferences, and motivating factors in using mobile health forms on smartphones in the context of maternal health care in Ethiopia. Twenty-five health extension workers (HEWs) and midwives, working in 13 primary health care facilities in Tigray region, Ethiopia, participated in this study. Sixteen (69.6%) workers believed the forms were good reminders on what to do and what questions needed to be asked. Twelve (52.2%) workers said electronic forms were comprehensive and 9 (39.1%) workers saw electronic forms as learning tools. All workers preferred unrestricted use of the smartphones and believed it helped them adapt to the smartphones and electronic forms for work purposes. Identified barriers for not using electronic forms consistently included challenges related to electronic forms and smartphones and health system issues such as frequent movement of health workers. Both HEWs and midwives found the electronic forms on smartphones useful for their day-to-day maternal health care services delivery. However, tyhe authors found that sustainable use and implementation of such work tools at scale would be daunting without providing technical support to health workers, securing mobile network airtime and improving key functions of the larger health system.