In this cross-sectional descriptive survey the authors investigated the performance of health workers after decentralisation of the health services in Uganda to identify and suggest areas for improvement. A structured self-administered questionnaire was used to collect quantitative data from 276 health workers in the districts of Kumi, Mbale, Sironko and Tororo in Eastern Uganda. Results revealed that even though the health workers are generally responsive to the needs of their clients, the services they provide are often not timely. The health workers take initiative to ensure that they are available for work, but low staffing levels undermine these efforts. While the study shows that the health workers are productive, over half (50.4%) of them reported that their organisations do not have indicators to measure their individual performance. The findings indicated that health workers are competent, adaptive, proactive and client oriented.
Human Resources
While there is optimism surrounding Africa’s growth potential, the continent appears to be lagging behind in training the necessary people to match its economic growth, according to this article. Although the number of students enrolling for tertiary education has been growing, the numbers are still low. Only 6% of students in sub-Saharan Africa are enrolled in tertiary institutions. Educationists and economists have observed that if Africa is going to compete in the global economy, this needs to increase to 15%. Africa can overcome barriers to student enrollment by using e-Learning and correspondence to extend education to students who face time and space constraints. There are significant challenges to this, such as limited and high cost internet connectivity on the continent, intermittent power disruption, a lack of national and institutional policies, a scarcity of experienced human resources and a perception that distance education may not offer the same quality as face-to-face education.
In this study, the authors quantify the number of HIV health workers (HHWs) required to be added to the current HIV workforce to achieve universal access to HIV treatment in South Africa, under different eligibility criteria. They performed a time and motion study in three HIV clinics in a rural, primary care-based HIV treatment program in KwaZulu-Natal, South Africa, to estimate the average time per patient visit for doctors, nurses, and counselors. They estimated that, for universal access to HIV treatment for all patients with a CD4 cell count of less than or equal to 350 cells/muL, an additional 2,200 nurses, 3,800 counselors, and 300 doctors would be required, at additional annual salary cost of R929 million, equivalent to US$ 141 million. For universal treatment ('treatment as prevention'), an additional 6,000 nurses, 11,000 counselors, and 800 doctors would be required, at an additional annual salary cost of R2.6 billion (US$ 400 million). Universal access to HIV treatment for patients with a CD4 cell count of less than or equal to 350 cells/mul in South Africa may be affordable, but the number of HHWs available for HIV will need to be substantially increased. Unfortunately, treatment as prevention strategies will require considerable additional financial and human resource commitments.
South Africa has begun producing a new type of health professional - a clinical associate. Clinical associates are people ideally suited to working in hospitals, helping doctors carry out some of their tasks – like dealing with emergencies and doing procedures. They don’t replace doctors or nurses – they work with them, sharing some of their workload, and allowing them to concentrate on the tasks for which only they are qualified. There is no doubt that more doctors and nurses need to be trained and recruited into the South African health system. But will this alone solve the country’s staff shortages? It takes less time to train a clinical associate. They can become very skilled at what they do because they focus on a special set of skills and are supervised by doctors. They are recruited from rural and disadvantaged communities. So, the author argues, clinical associates could do a lot to address staff shortages in the public sector, especially in district hospitals. Clinical associates are noted as a priority in the latest government human resource strategy but the future of clinical associates and the strategy of National Health Insurance need to become much more closely intertwined.
Undergraduate global health teaching has seen a marked growth over the past ten years, partly as a response to student demand and partly due to increasing globalisation, cross-border movement of pathogens and international migration of health care workers. In this study, researchers carried out a survey of medical schools across the world in an effort to analyse their teaching of global health. Results indicate that global health teaching is moving away from its previous focus on tropical medicine towards issues of more global relevance. The authors suggest that there are three types of doctor who may wish to work in global health - the 'globalised doctor', 'humanitarian doctor' and 'policy doctor' - and that each of these three types will require different teaching in order to meet the required competencies. This teaching needs to be inserted into medical curricula in different ways, notably into core curricula, a special developing countries track, optional student selected components, elective programmes, optional intercalated degrees and postgraduate study. The authors argue that teaching of global health in undergraduate medical curricula must reflect the social, political and economic causes of ill health.
To stem the loss of skilled health workers from developing countries, there has recently been an increase in the number of regional Codes of Practice and bilateral Memoranda of Understanding to achieve more effective, equitable and ethical international migration of workers, culminating in the finalisation of the World Health Organisation’s Global Code for Health Worker Recruitment in 2010. Despite this, the authors of this paper point out that there is no agreed definition of ethical international recruitment, and no consensus on the significance and location of harmful recruitment practices. Most codes they analysed covered relatively few regions and exhibited a high degree of generality. Migration, they found, occurs in contexts that do not necessarily involve health issues. Limitations were identified: there are no incentives for recipient countries and agencies to be involved in ethical international recruitment and all codes are voluntary, which has restricted their impact. At the same time, the private sector is effectively excluded from codes. Bilateral agreements and memoranda have a greater chance of success, the authors note, enabling managed migration and return migration, but are more geographically limiting. The most effective constraints to the unregulated flow of skilled health workers are the production of adequate numbers in present recipient countries and provision of improved employment conditions in source countries.
This paper presents policy-makers and programme managers with key considerations for a model to improve the work environment as an important approach to increase community health worker (CHW) productivity and, ultimately, the effectiveness of community-based strategies. Researchers conducted a desk review of selective published and unpublished articles and reports on CHW programmes in developing countries to identify the elements that influence CHW productivity. They found that CHW productivity is determined in large part by the conditions under which they work. Attention to the provision of an enabling work environment for CHWs is essential for achieving high levels of productivity. They present a model in which the work environment encompasses four essential elements: workload, supportive supervision, supplies and equipment, and respect from the community and the health system. Establishing a balance among the four elements that constitute a CHW’s work environment will help make great strides in improving the effectiveness and quality of the services provided by CHWs.
This study aimed to document the kinds of leadership styles are practiced at primary health care (PHC) centres and how these styles can be explained by the contexts, characteristics of the health centre in charge (IC) and subordinate trained health staff (STHS). Self-administered questionnaires were distributed at 47 centres in three districts. A total of 347 STHSs (95%) and 46 ICs (98%) responded. Two leadership styles were revealed: ‘trans’ style contained all relation and the majority of task and change items, while ‘control’ style focused on health statistics, reporting and evaluation. The researchers found that frontline PHC leadership may be forced by situation and context to use a comprehensive style, which could lack the diversity and flexibility needed for effective leadership. The missing associations between staff characteristics and leadership styles might indicate that this group is not sufficiently considered and included in leadership processes in the PHC organisation. Leadership competency for the ICs seems not to be based on formal training, but substituted by young age and work experience. In conclusion, the authors call for a reassessment of PHC leadership and formal leadership training.
This study compared the effectiveness of trained Health Surveillance Assistants (HSAs) versus trained volunteer Key Informants (KIs) in identifying blind children in southern Malawi. A cluster community based study was conducted in Mulanje district, population 435 753. Six clusters each with a population of approximately 70,000 to 80,000, 42% of whom were children were identified and randomly allocated to either HSA or KI training. A total of 59 HSAs and 64 KIs were trained. HSAs identified five children of whom two were confirmed as blind (one blind child per 29.5 HSAs trained). On the other hand, the KIs identified a total of 158 children of whom 20 were confirmed blind (one blind child per 3.2 KIs trained). More blind boys than girls were identified (77.3% versus 22.7%) respectively. Key Informants were found to be much better at identifying blind children than HSAs, even though both groups identified far fewer blind children compared with WHO estimates. HSAs reported lack of time as a major constraint in identifying blind children. Based on these findings using HSAs for identifying blind children would not be successful in Malawi, the authors argue. Gender differences need to be addressed in all childhood blindness programs to counteract the imbalance.
To increase the quality of service delivery in the public health sector, Tanzania has implemented the Open Performance Review and Appraisal System (OPRAS) and a new results-based payment system, Payment for Performance (P4P). This paper addresses health workers' experiences with OPRAS, expectations towards P4P and how lessons learned from OPRAS can assist in the implementation of P4P. The broader aim is to generate knowledge on health worker motivation in low-income contexts. The authors conducted focus group discussions and in-depth interviews with public health nursing staff, clinicians and administrators. Results showed a general reluctance towards OPRAS as health workers did not see the system as leading to financial gains nor did it provide feedback on performance. In contrast, great expectations were expressed towards P4P due to its prospects of topping up salaries, but the links between the two performance enhancing tools were unclear. The authors conclude that health workers respond to performance enhancing tools based on whether the tools are found appropriate or yield any tangible benefits.