This time and motion study in Dar es Salaam, Tanzania estimated the potential of task-shifting in services for prevention of mother to child transmission (PMTCT) to reduce nurses’ workload and health system costs. The time used by nurses to accomplish PMTCT activities during antenatal care (ANC) and postnatal care (PNC) visits was measured. These data were then used to estimate the costs that could be saved by shifting tasks from nurses to community health workers in the Tanzanian public-sector health system. A total of 1121 PMTCT-related tasks carried out by nurses involving 179 patients at ANC and PNC visits were observed at 26 health facilities. The average time of the first ANC visit was the longest, 54 min, followed by the first PNC visit which took 29 minutes on average. ANC and PNC follow-up visits were substantially shorter, 15 and 13 minutes, respectively. During both the first and the follow-up ANC visits, 94% of nurses’ time could be shifted to community health workers, while 84% spent on the first PNC visit and 100% of the time spent on the follow-up PNC visit could be task-shifted. Depending on community health workers salary estimates, the cost savings due to task-shifting in PMTCT ranged from US$ 1.3 to 2.0 (first ANC visit), US$ 0.4 to 0.6 (ANC follow-up visit), US$ 0.7 to 1.0 (first PNC visit), and US$ 0.4 to 0.5 (PNC follow-up visit). Nurses working in PMTCT spend large proportions of their time on tasks that could be shifted to community health workers, giving them more time for specialised PMTCT tasks and reducing the average cost per PMTCT patient.
Community health workers (CHWs) play key roles in delivering health programmes in many countries worldwide. CHW programmes can improve coverage of maternal and child health services for the most disadvantaged and remote communities, leading to substantial benefits for mothers and children. However, there is limited evidence of effective mentoring and supervision approaches for CHWs. This cluster randomised controlled trial investigated the effectiveness of a continuous quality improvement intervention amongst CHWs providing home-based education and support to pregnant women and mothers. Thirty CHW supervisors were randomly allocated to intervention (n = 15) and control (n = 15) arms. Intervention CHWs received a 2-week training in WHO Community Case Management followed by mentoring for 12 months. Baseline and follow-up surveys were conducted with mothers of infants <12 months old living in households served by participating CHWs. At follow-up, compared to mothers served by control CHWs, mothers served by intervention CHWs were more likely to have received a CHW visit during pregnancy and the postnatal period. Intervention mothers had higher maternal and child health knowledge scores and reported higher exclusive breastfeeding rates to 6 weeks. HIV-positive mothers served by intervention CHWs were more likely to have disclosed their HIV status to the CHW. Uptake of facility-based interventions was not significantly different. Improved training and mentoring of CHWs can, it is thus argued, improve quantity and quality of CHW-mother interactions at household level, leading to improvements in mothers’ knowledge and infant feeding practices.
This paper highlights current issues and challenges in public health nutrition in low- and middle-income countries and shares recommendations for the development of this workforce. Several factors are argued to contribute to a scarcity of nutrition professionals in low- and middle-income countries, including: a lack of understanding of the role of public health nutrition in the prevention and management of the various forms of malnutrition; a low-income country priority for doctors and nurses (and sometimes also frontline workers) within meagre health workforce expenditures; a higher priority for undernutrition interventions than for those for nutrition-related chronic diseases, despite their escalation in these countries. Both food system changes, at the level of production, processing and distribution, and behaviour change communication are argued to be needed to reorient the nutrition transition, and nutritionists have a major role to play in this regard. Although it requires sustained efforts, training can be regarded as the easy part of nutrition workforce development in low- and middle-income countries. More challenging steps are recognition of the nutrition profession and its regulation, opening up government jobs for nutrition graduates and financing local training programmes and nutritionists’ salaries in the public sector. The underlying causes of malnutrition, and hence sustained solutions to the problem, lie to a large extent in the non-health sectors. The authors argue that nutrition has to be addressed not only by other health professionals, but also by agriculture and education professionals and field workers, who need to integrate relevant nutrition tasks into their professional activities (such as orienting food production towards meeting the population’s nutrition requirements or teaching healthy eating to schoolchildren).
In Nigeria, several challenges have been reported within the health sector, especially in training, funding, employment, and deployment of the health workforce. The authors reviewed the recent health workforce crises in the Nigerian health sector to identify key underlying causes and provide recommendations toward preventing and/or managing potential future crises in Nigeria. The authors observe that the Nigerian health system is relatively weak, and there is yet a coordinated response across the country. A number of health workforce crises have been reported in recent times due to several months’ salaries owed, poor welfare, lack of appropriate health facilities and emerging factions among health workers. Poor administration and response across different levels of government were found to have played contributory roles to further internal crises among health workers, with different factions engaged in protracted supremacy challenge. These crises have consequently prevented optimal healthcare delivery to the Nigerian population. The authors argue for various measures, including an inclusive stakeholders’ forum in the health sector; and a solid administrative policy foundation that allows coordination of priorities and partnerships in the health workforce and among various stakeholders.
Community Health Workers feel unrecognised and undervalued by community leaders and health professionals. This was the central message from a major thematic discussion held on the HIFA forums and sponsored by The Lancet, Reachout Project/Liverpool School of Tropical Medicine, World Vision International and USAID Assist Project. More than 60 HIFA members contributed their experience and expertise to the discussion, including CHW programme managers, researchers and policymakers, as well as a large number of CHWs and ASHAs from India and Uganda. Countries represented included Burundi, Cameroon, Canada, Ethiopia, France, Ghana, India, Iran, Japan, Kenya, Malaysia, Netherlands, New Zealand, Nigeria, Pakistan, Rwanda, Switzerland, Tanzania, Uganda, UK, and USA. Other major concerns were lack of training and supervision; access to healthcare information; remuneration; equipment, medicines, and need for mobile phones/computers. CHWs said they are asked to carry out a wide range and ever increasing number of tasks, but often without the appropriate facilities to enable this. CHWs feel unrecognised and undervalued by official health care providers which not only reduces morale but also creates a disjoint between perceived influence by community, and their actual influence, reducing their respect from the community. Furthermore, this lack of respect is reflected in their lack of training and supervision, and results in a paucity of avenues for them to voice their needs and concerns.
Young women in Malawi face many challenges in accessing family planning, including distance to the health facility and partner disapproval. The author’s primary objective was to assess if training Health Surveillance Assistants in couples counselling would increase modern family planning uptake among young women. In this cluster randomised controlled trial, 30 Health Surveillance Assistants from Lilongwe, Malawi received training in family planning. The Health Surveillance Assistants were then randomised 1:1 to receive or not receive additional training in couples counselling. All Health Surveillance Assistants were asked to provide family planning counselling to women in their communities and record their contraceptive uptake over 6 months. Sexually-active women <30 years of age who had never used a modern family planning method were included in this analysis. Generalised estimating equations with an exchangeable correlation matrix to account for clustering by Health Surveillance Assistants were used to estimate risk differences and 95% confidence intervals. 430 (53%) young women were counselled by the 15 Health Surveillance Assistants who received couples counselling training, and 378 (47%) were counselled by the 15 Health Surveillance Assistants who did not. 115 (26%) from the couples counselling group had male partners present during their first visit, compared to only 6 (2%) from the other group. Nearly all (99.5%) initiated a modern family planning method, with no difference between groups. Women in the couples counselling group were 8% more likely to receive male condoms and 8% more likely to receive dual methods. Training Health Surveillance Assistants in family planning led to high modern family planning uptake among young women who had never used family planning. Couples counselling training increased male involvement with a trend towards higher male condom uptake.
Social accountability is defined as the responsibility of institutions to respond to the health priorities of a community. There is an international movement towards the education of health professionals who are accountable to communities. There is little evidence of how communities experience or articulate this accountability. In this grounded theory study eight community based focus group discussions were conducted in rural and urban South Africa to explore community members’ perceptions of the social accountability of doctors. The discussions were conducted across one urban and two rural provinces. Group discussions were recorded and transcribed verbatim. Initial coding was done and three main themes emerged following data analysis: the consultation as a place of respect (participants have an expectation of care yet are often engaged with disregard); relationships of people and systems (participants reflect on their health priorities and the links with the social determinants of health) and Ubuntu as engagement of the community (reflected in their expectation of Ubuntu based relationships as well as part of the education system). These themes were related through a framework which integrates three levels of relationship: a central community of reciprocal relationships with the doctor-patient relationship as core, a level in which the systems of health and education interact and together with social determinants of health mediate the insertion of communities into a broader discourse. The paper outlines an ubuntu framing in which the tensions between vulnerability and power interact and reflect rights and responsibility as important for social accountability. Communities are argued to bring a richer dimension to social accountability through their understanding of being human and caring.
In 2010, South Africa’s National Department of Health launched a national primary health care initiative to strengthen health promotion, disease prevention, and early disease detection. The strategy, called Re-engineering Primary Health Care, aims to provide a preventive and health-promoting community-based Primary Health Care model. A key component is the use of community-based outreach teams staffed by generalist community health workers. The authors conducted focus group discussions and surveys on the knowledge and attitudes of 91 Community Health Care Workers working on community-based teams in Eastern Cape Province. The community health workers who were studied enjoyed their work and found it meaningful, as they saw themselves as agents of change. They also perceived weaknesses in the implementation of outreach team oversight, and desired field-based training and more supervision in the community. The authors propose providing community health workers with basic resources like equipment, supplies and transport to improve their acceptability and credibility to the communities they serve.
In low- and middle-income countries, scaling essential health interventions to achieve health development targets is constrained by the lack of skilled health professionals to deliver services. The authors take a labour market approach to project the future health workforce demand using an economic model based on projected economic growth, demographics, and health coverage, and using health workforce data (1990–2013) for 165 countries from the WHO Global Health Observatory. The demand projections are compared with the projected growth in health worker supply and the health worker “needs” as estimated by WHO to achieve essential health coverage. The model predicts that, by 2030, global demand for health workers will rise to 80 million workers, double the current (2013) stock of health workers, while the supply of health workers is expected to reach 65 million over the same period, resulting in a worldwide net shortage of 15 million health workers. Growth in the demand for health workers will be highest among upper middle-income countries, driven by economic and population growth and ageing. This results in the largest predicted shortages which may fuel global competition for skilled health workers. Middle-income countries will face workforce shortages because their demand will exceed supply. By contrast, low-income countries will face low growth in both demand and supply, which are estimated to be far below what will be needed to achieve adequate coverage of essential health services. In many low-income countries, demand may stay below projected supply, leading to the paradoxical phenomenon of unemployed (“surplus”) health workers in those countries facing acute “needs-based” shortages. Opportunities exist to bend the trajectory of the number and types of health workers that are available to meet public health goals and the growing demand for health workers.
The shortage of formal health workers has led to the utilisation of Community-Based Health Volunteers to provide health care services to people especially in rural and neglected communities. This study explored factors affecting retention and sustainability of community-based health volunteers’ activities in a rural setting in Northern Ghana, through a qualitative study with thirty-two in-depth interviews with health volunteers and health workers overseeing their activities. Study participants reported that the desire to help community members, prestige and recognition as doctors in the community were key motivations for the health volunteers. Lack of incentives and logistical supplies such as raincoats, torch lights, wellington boots and transportation in the form of bicycles to facilitate the movement of health volunteers affected their work and discouraged them. Most of the dropout volunteers said lack of support and respect from community members made them to stop working as health volunteers. They recommended that community support, incentives and logistical supplies such as raincoats, torch light, wellington boots and bicycles can help retain community-based health volunteers and also sustain their activities at community level.