This study was undertaken to assess the scope and nature of community-based education (CBE) for various health worker cadres in Uganda. Curricula and other materials on CBE programmes in Uganda were reviewed to assess nature, purpose, intended outcomes and evaluation methods used by CBE programmes. In-depth and key informant interviews were conducted with people involved in managing CBE in twenty-two selected training institutions, as well as stakeholders from the community, Ministry of Health, Ministry of Education, civil society organisations and local government. The researchers found that CBE curriculum is implemented in most health training institutions in Uganda and is a core course in most health disciplines at various levels. The CBE curriculum is systematically planned and implemented with major similarities among institutions. Organisation, delivery, managerial strategies, and evaluation methods are also largely similar. Strengths recognised included providing hands-on experience, knowledge and skills generation and the linking learners to the communities. Almost all CBE implementing institutions cited human resource, financial, and material constraints. It is still uncertain whether this approach is increasing the number graduates seeking careers in rural health service, one of the stated programme goals.
Human Resources
Have AIDS external funders harmed or strengthened health workforce development in countries with severe shortages? This research led to six key findings. First, to staff AIDS programmes, external funders have relied on training existing workers and taskshifting, not on training new health workers. Second, AIDS external funders have swamped countries with in-service training programmes for HIV/AIDS-specific skills. Third, PEPFAR and the Global Fund have relied on task-shifting to lower level health workers without assuring adequate resources or support. Fourth, community health workers are employed as a quick fix without considering their long -term role. Fifth, the incentives that AIDS external funders offer health workers to achieve HIV and AIDS programme targets distort allocations of time and resources to the detriment of other health sector objectives. Finally, AIDS external funders pay health workers through short-term special arrangements without addressing long-term constraints on the public and private health workforce.
According to the authors of this study, in southern Africa, the sector most impacted by the brain drain is health. Despite the fact that Southern African Development Community (SADC) countries have adopted a number of financial and non-financial incentives to try to get doctors and nurses to stay, the pull factors attracting health professionals to foreign countries are strong and health workers remain very dissatisfied with existing work conditions. With regard to the migration of health professionals there has been a policy shift away from the early reactive ad hoc policy responses to the development of more comprehensive strategic responses which seek to manage the mobility of health professionals. The authors recommend improving the existing lack of knowledge and data to monitor flows of health professionals into and out of SADC. They also call for bilateral agreements with individual countries involving codes of practice for recruitment and treatment of health workers, exchange programmes for training and development and the provision of health professionals from specific countries. In addition, there is a need for a SADC-wide policy on the movement of health professionals within the region to discourage movement from the poorest and neediest countries to those which are relatively well-endowed, like South Africa.
Rather than making progress towards the Millennium Development Goal of reducing maternal mortality by 75% by 2015, the number of deaths resulting from pregnancy or childbirth in South Africa has doubled in the past 20 years, according to government figures. For every 100,000 babies born, up to 625 mothers die due to childbirth complications. Loveday Penn-Kekana, from the University of the Witwatersrand in Johannesburg, believes South Africa's poor maternal health outcomes are linked to the lack of midwifery services. She called for the government to invest in more and better trained midwives, especially as they bore most of the responsibility for day-to-day operations in maternity wards. Midwives are classified as nurses in South Africa so there are no figures on their numbers, but she argues that there are too few. Low enrolment at nursing colleges is part of the problem, but many midwives have also left the public sector to work for higher salaries overseas or in managerial positions, because of the limited opportunities for career development and advancement in the clinical area. The Society of Midwives of South Africa has noted that lack of midwives means that the quality of the services they provide is declining, as existing midwives are overworked. Also, because they argue that people are first trained as a nurse and then given midwifery skills, midwifery is not prioritised. A plan by South Africa's Health Minister to reopen unused nursing colleges across the country and increase the number of nurses may result in more midwives being trained.
In this brief, Capacity Plus notes that people living in rural areas have less access to health workers, and fail to receive vital preventive, curative, and life-saving services. The problem is especially acute in countries with predominately rural populations. Investment in the development of doctors and nurses is wasted if countries cannot place or keep them in the areas where they are most needed, Capacity Plus argues, nor can they achieve their Millennium Development Goals. A number of recommendations are made. Departments of health should aim to understand and test the factors and incentives that influence health workers’ decisions to accept and remain in rural posts, and develop tailored retention schemes. They should prioritise rural retention schemes and strategies in national health workforce plans, involve professional medical and nursing associations in retention advocacy, strengthen and streamline human resources management (HRM) systems that can affect retention, and address gender discrimination in HRM and gender-based violence in health facilities. Furthermore, they should recruit primary health workers from their own communities and from rural backgrounds, locate health professional schools in rural regions and subsidise health worker education in return for service in rural areas.
Most of the 58 countries covered in this report have been identified as suffering from a crisis in human resources for health. Collectively, across these countries women gave birth to 81 million babies in 2009, accounting for 58% of the world’s total births. The inequitable ‘state of the world’ is most evident in the disproportionate number of deaths in these countries: 91% of the global burden of maternal mortality, 80% of stillbirths and 82% of newborn mortality. These figures partly reflect the distribution of the global workforce: less than 17% of the world’s skilled birth attendants are available to care for women in the 58 countries. There is a triple gap, consisting of competencies, coverage and access. The triad of education, regulation and association has insufficient focus on quality of care, the authors argue. Policy coherence is disjointed and access to the necessary strategic intelligence or evidence for action weak. They urge governments to recognise midwifery as a distinct profession, core to the provision of maternal and newborn health services, and promote it as a career with posts at the national policy level. They also make a number of recommendations for governments, regulatory bodies, schools and training institutions, professional midwifery organisations, international organisations and global partnerships, external funders and civil society organisations.
The authors of this article examined the influence of gender on workplace violence, and synthesised their findings with other research from Rwanda, before they examined the subsequent impact of the study on Rwanda's policy environment. Fifteen out of 30 districts were selected at random. Forty-four facilities at all levels were randomly selected in these districts. From these facilities, 297 health workers were selected at random, of whom 205 were women and 92 were men. Researchers administered health worker survey, facility audits, key informant and health facility manager interviews and focus groups to collect data in 2007. They found that 39% of health workers had experienced some form of workplace violence in year prior to the study. The study identified gender-related patterns of perpetration, victimisation and reactions to violence. Negative stereotypes of women, discrimination based on pregnancy, maternity and family responsibilities and the 'glass ceiling' affected female health workers' experiences and career paths and contributed to a context of violence. Addressing gender discrimination and violence simultaneously should be a priority for workplace and violence research, workforce policies, strategies, laws and human resources management training, the authors conclude.
Workplace health promotion (WHP) is a common strategy used to enhance on-the-job productivity. The primary objective of this study was to determine if WHP programmes are effective in improving workers presence at work. The Cochrane Library, Medline, and other electronic databases were searched from 1990 to 2010. After 2,032 titles and abstracts were screened, 47 articles were reviewed, and 14 were accepted (4 strong and 10 moderate studies). These studies contained preliminary evidence for a positive effect of some WHP programmes. Successful programmes offered organisational leadership, health risk screening, individually tailored programs, and a supportive workplace culture. Potential risk factors contributing to presenteeism included being overweight, a poor diet, a lack of exercise, high stress, and poor relations with co-workers and management.
This qualitative study was undertaken to understand how practising doctors and medical leaders in Ghana describe the key factors reducing recruitment and retention of health professionals into remote areas, and to document their proposed policy solutions. In-depth interviews were carried out with 84 doctors and medical leaders, including 17 regional medical directors and deputy directors from across Ghana, and 67 doctors chosen to represent progressively more remote distances from the capital of Accra. All participants felt that rural postings must have special career or monetary incentives given the loss of locum (i.e. moonlighting income), the higher workload, and professional isolation of remote assignments. Career 'death' and prolonged rural appointments were a common fear, and proposed policy solutions focused considerably on career incentives, such as guaranteed promotion or a study opportunity after some fixed term of service in a remote or hardship area. Short-term service in rural areas would be more appealing if it were linked to special mentoring and/or training, and led to career advancement.
This paper proposes a framework for carrying out a costing analysis of interventions to increase the availability of health workers in rural and remote areas with the aim to help policy decision makers. The authors review the evidence on costing interventions to improve health workforce recruitment and retention in remote and rural areas, provide guidance to undertake a costing evaluation of such interventions and investigates the role and importance of costing to inform the broader assessment of how to improve health workforce planning and management. They show show that while the debate on the effectiveness of policies and strategies to improve health workforce retention is gaining impetus and attention, there is still a significant lack of knowledge and evidence about the associated costs. To address the concerns stemming from this situation, key elements of a framework to undertake a cost analysis are proposed and discussed, which should help policy makers gain insight into the costs of policy interventions, to clearly identify and understand their financing sources and mechanisms, and to ensure their sustainability.