The May 2010 adoption of the World Health Organisation Global Code of Practice on the International Recruitment of Health Personnel created a global architecture, including ethical norms and institutional and legal arrangements, to guide international cooperation and serve as a platform for continuing dialogue on the critical problem of health worker migration. Highlighting the contribution of non-binding instruments to global health governance, this article describes the Code negotiation process from its early stages to the formal adoption of the final text of the Code. Detailed are the vigorous negotiations amongst key stakeholders, including the active role of non-governmental organisations. The article emphasises the importance of political leadership, appropriate sequencing, and support for capacity building of developing countries’ negotiating skills to successful global health negotiations. It also reflects on how the dynamics of the Code negotiation process evidence an evolution in global health negotiations amongst the WHO Secretariat, civil society, and WHO Member States.
Human Resources
This study compares what is known about insecticide-treated nets (ITNs) to the related knowledge and practices of healthcare providers in four low- and middle-income countries. A new questionnaire was administered to 497 healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania (121). In the survey, few participating healthcare providers correctly answered all five knowledge questions about ITNs (13%) or self-reported performing all five clinical practices according to established evidence (2%). Statistically significant factors associated with higher knowledge within each country included: training in acquiring systematic reviews through the Cochrane Library and ability to read and write English well or very well. Statistically significant factors associated with better clinical practices within each country included: reading scientific journals from their own country; working with researchers to improve their clinical practice or quality of working life; training on malaria prevention since their last degree; and easy access to the internet. The researchers conclude that improving healthcare providers' knowledge and practices is an untapped opportunity for expanding ITN utilisation and preventing malaria. Training on acquiring systematic reviews and facilitating internet access may be particularly helpful.
Lay health workers are key to achieving universal health-care coverage, therefore measuring worker attrition and identifying its determinants should be an integral part of any lay health worker programme. Both published and unpublished research on lay health workers has largely focused on the types of interventions they can deliver effectively. This is an imperative since the main objective of these programmes is to improve health outcomes. However, high attrition rates can undermine the effectiveness of these programmes. There is a lack of research on lay health worker attrition, the authors of this paper note. Research that aims to answer the following three key questions would help address this knowledge gap. What is the magnitude of attrition in programmes? What are the determinants of attrition? What are the most successful ways of reducing attrition? With community-based interventions and task shifting high on the United Nations Millennium Development Goals’ policy agenda, research on lay health worker attrition and its determinants requires urgent attention, the authors conclude.
The objective of this study was to estimate the lost investment of domestically educated doctors migrating from sub-Saharan African countries to Australia, Canada, the United Kingdom, and the United States. Researchers calculated the financial cost of educating a doctor in nine source countries with a high HIV and AIDS burden (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), which ranged from US $21,000 in Uganda to $58,700 in South Africa. The overall estimated loss of returns from investment for all doctors currently working in the destination countries was $2.17bn, with costs for each country ranging from $2.16m (1.55m to 2.78m) for Malawi to $1.41bn (1.38bn to 1.44bn) for South Africa. The ratio of the estimated compounded lost investment over gross domestic product showed that Zimbabwe and South Africa had the largest losses. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom ($2.7bn) and United States ($846m). They conclude that destination countries should consider investing in measurable training for source countries and strengthening of their health systems.
Communication between non-language-concordant health care workers (HCWs) and patients has been shown by international studies to adversely affect patient and staff satisfaction, yet the authors of this study note that, to the best of their knowledge, no such intervention studies have been conducted in Africa. They conducted research in South Africa to determine whether teaching Xhosa language skills and cultural understanding to HCWs affects patient satisfaction, HCWs’ ability to communicate effectively with Xhosa-speaking patients and HCWs’ job satisfaction levels. A before-and-after interventional study was performed at two community health centres and a district hospital in the Western Cape Province. Fifty-four randomly selected patients (27 pre- and 27 post-intervention) assessed communication with HCWs and rated their satisfaction. Six non-Xhosa-speaking HCW participants completed pre- and post-intervention questionnaires. HCWs completed a ten-week basic language course consisting of ten 120-minute interactive contact sessions developing basic Xhosa speaking and listening skills and cultural competence. Results showed that patient satisfaction showed significant improvements after the intervention. Patients perceived HCWs to be more understanding, respectful and concerned, and to show better listening skills, after the intervention. They were also better able to understand HCWs and their instructions. HCWs’ ability to communicate improved and HCWs experienced decreased frustration levels.
The aim of this study was to determine the need for resuscitation at the birth of babies delivered by elective caesarean section (CS) and to record the time spent by doctors attending such deliveries. Data were collected prospectively on all elective CSs performed at Groote Schuur Hospital in Cape Town, South Africa, over a three-month period. Data collected included: total time involved for paediatrician from call to leaving theatre, management of infant (requiring any form of resuscitation), Apgar scores and neonatal outcome (e.g. admission to nursery). The CSs were classified as low-risk or high-risk. Data were recorded for 138 deliveries. One-hundred-and-fifteen deliveries were classified as uncomplicated and 20 as high-risk. Only one of the babies born from the 115 low-risk CSs needed brief resuscitation, whereas nine of the 20 high-risk deliveries resulted in newborn resuscitation. The reasons for low-risk CS were: previous CS (81); infant of diabetic mother (IDM) and previous CS (16); IDM alone (6); estimated big baby (10); and other (2).The average time spent at each elective CS by the paediatrician was 37 minutes. The authors conclude that, for low-risk CS, the same medical attendance (i.e. a midwife) as for an uncomplicated normal vaginal delivery (NVD) would be appropriate. This would free up a doctor for other duties and assist in de-medicalising a low-risk procedure.
In June 2010 a conference entitled ‘Innovative Health Management in the Public Sector’ was held in Cape Town under the banner of the Oliver Tambo Fellowship Programme at the University of Cape Town. Participants offered a number of key messages for policy makers. 1. Prioritise leadership and management development as a key element of health systems strengthening, providing strong political support yet avoiding political interference. 2. Develop a recruitment strategy that appoints appropriately skilled and committed managers to appropriate positions. 3. Recognise that improving physical infrastructure and the quality of services is essential to successful retention. 4. Build and affirm managers’ good values while challenging those who exhibit inappropriate values. 5. Prioritise leadership and management training across the Department of Health and at all levels by developing mentoring mechanisms. 6. Remove unnecessary bureaucratic obstacles that impede dynamic health systems management, decentralise authority for decision-making and reduce management fragmentation to create an enabling environment for managers. 6. Adopt a systemic approach to health systems transformation that includes experimenting with new management practices, creating the space for managers to act proactively rather than simply reacting to daily crises. 7. Explore team work and the creative use of information in developing interventions and assessing progress in an iterative cycle of change. 8. Strengthen the accountability of managers within a supportive environment that allows some mistakes to be made as part of the process of innovation. 9. Develop a strategy and mechanisms for managers around the country to share best practices and experience on an ongoing basis. 10. Create a platform for managers to express their views to senior provincial and national policy-makers. 11. Recognise, value and celebrate the achievements of managers.
This presentation was delivered at BioMed’s Open Access Conference, held from 24-26 October 2011, in Kumasi, Ghana. It documents work by the African Medical And Research Foundation (AMREF), an international African non-governmental organisation (NGO) that focuses on community health development, with programme offices in seven African countries and direct reach through training, partnerships and consultancy in 33 other African countries. With major information challenges facing African health workers and systems, the use of emerging information and innovations have a huge role to play in improving health and health systems in Africa, the presenter argues, but he warns that tools alone cannot do it – the content needs to be developed and made available. Therefore, publishing and making information available to Africa’s health workers and practitioners is an urgent issue for the improvement of health services delivery in Africa. AMREF focuses on three broad health system approaches: capacity building for community and health systems including development and support to community health workers; improving health information; and human resources for health, particularly regarding the issues of health worker numbers and skills, training approaches including task shifting, and deployment and retention. Challenges in accessing research were identified as: low investment in research within the continent; lack of infrastructure for accessing research online in appropriate platforms to share research; and the prohibitive cost of accessing research (in print or online).
To address the shortage of healthcare workers providing comprehensive emergency obstetrical care (CEmOC) in Tanzania, an intensive three-month course was developed to train non-physician clinicians for remote health centres. Competency-based curricula for assistant medical officers' (AMOs) training in CEmOC, and for nurses, midwives and clinical officers in anaesthesia and operation theatre etiquette were developed and implemented in Ifakara. A total of 43 care providers from 12 health centres located in 11 rural districts in Tanzania and two from Somalia were trained from June 2009 to April 2010. Of these 14 were AMOs trained in CEmOC and 31 nurse-midwives and clinical officers trained in anaesthesia. The first eight months after introduction of CEmOC services in three health centres resulted in 179 caesarean sections, an increase of institutional deliveries by up to 300%, decreased fresh stillbirth rate and reduced obstetric referrals. There were two maternal deaths, both arriving in a moribund condition. The authors conclude that the training was a success and their model can be used for further training.
A stakeholder and sustainability analysis of 25 key informant interviews was conducted among past, current and potential stakeholders of Makerere University College of Health Sciences (MakCHS) to obtain their perspectives and contributions to sustainability of the College in its role to improve health outcomes. Results showed that the College has multiple internal and external stakeholders. Stakeholders from Uganda wanted the College to use its enormous academic capacity to fulfil its vision, take initiative, and be innovative in conducting more research and training relevant to the country’s health needs. External stakeholders felt that MakCHS was insufficiently marketing itself and not directly engaging the private sector or Parliament. Stakeholders also indicated MakCHS could better embrace information technology in research, learning and training, and many also wanted MakCHS to start leadership and management training programmes in health systems. This study points towards the need for MakCHS and other African public universities to build a broad network of partnerships to strengthen their operations, relevance and sustainability.