Human Resources

Who are CHWs? An ethnographic study of the multiple identities of community health workers in three rural Districts in Tanzania
Rafiq M; Wheatley H; Mushi H; Baynes C: BMC Health Services Research 19(712) 1-15, 2019

unity health workers (CHWs) possess multiple, overlapping roles and identities, which makes them effective primary health care providers when properly supported with adequate resources. This also limits their ability to implement interventions that only target certain members of their community and prevents them from performing certain duties when it comes to sensitive topics such as family planning. To understand the multiple identities of CHWs qualitative and ethnographic methods involved participant observation, open-ended and semi-structured interviews and focus group discussions with CHWs, their supervisors, and their clients between October 2013 and June 2014 in Rufiji, Ulanga and Kilombero Districts in Tanzania. The findings suggest that it is difficult to distinguish between personal and professional identities among CHWs in rural areas. Important aspects of CHW services such as personalization, access, and equity of health services were influenced by CHWs’ position as local agents. However, the study also found that their personal identity sometimes inhibited CHWs in speaking about issues related to family planning and sexual health. Being local, CHWs were viewed according to the social norms of the area that consider the gender and age of each worker, which tended to constrain their work in family planning and other areas. Furthermore, the communities welcomed and valued CHWs when they had curative medicines; however, when medical stocks were delayed, the community viewed the CHWs with suspicion and disinterest. Community members who received curative services from CHWs also tended to become more receptive to their preventative health care work. Although CHWs’ multiple roles constrained certain aspects of their work in line with prevalent social norms, overall, the multiple roles they fulfilled had a positive effect by keeping CHWs embedded in their community and earned them trust from community members, which enhanced their ability to provide personalized, equitable and relevant services. However, CHWs needed a support system that included functional supply chains, supervision, and community support to help them retain their role as health care providers and enabled them to provide curative, preventative, and referral services.

Health workers’ strikes in low-income countries: the available evidence
Russo G; Xu L; McIsaac M; Matsika-Claquin M; et al: Bulletin of the World Health Organisation 97(7) 460–467H, 2019

In this paper, the authors analysed the characteristics, frequency, drivers, outcomes and stakeholders of health workers’ strikes in low-income countries, using published and grey online sources for 2009 to 2018. They identified 70 unique health workers’ strikes in 23 low-income countries during the period, accounting for 875 strike days. 2018 had the highest number of events, with 170 work days lost. Strikes involving more than one professional category were more frequent, followed by strikes by physicians only. The most commonly reported cause was complaints about pay, followed by protest against the sector’s governance or policies and safety of working conditions. Positive resolution was achieved more often when collective bargaining institutions and higher levels of government were involved in the negotiations.

Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation
Ormel H; Kok M; Kane S; Ahmed R; et al: Human Resources for Health 17(59) 1-12, 2019

This paper aims to critically analyse how using incentives affected community health worker motivation in six countries was undertaken. The motivational factors were defined as financial, material, non-material and intrinsic and semi-structured interviews and focus group discussions with community health workers, supervisors, health managers and selected community members were used. The authors found that incentives influence motivation in similar and sometimes different way across contexts. Motivation was negatively influenced by gaps between incentives and expectations, including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of community health workers. Furthermore, it was found that incentives could cause friction in the interface between community health workers, communities and the health sector. Whether they are employed or volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of community health workers, yet for many who are salaried, payment does not compensate for the demotivation derived from the perceived low level of financial reward. The authors suggest that managing expectations and consistency in payments may be as important as the absolute level of incentives.

Assessment of interventions to attract and retain health workers in rural Zambia: a discrete choice experiment
Prust M; Kamanga A; Ngosa L; McKay C; et al: Human Resources for Health 17(26)1-12, 2019

The authors examined whether non-monetary employment incentives were cost-effective in attracting and retaining public sector health workers in rural areas of Zambia. The study consisted of two key phases: Firstly, in qualitative interviews with 25 health workers and focus group discussions with 253 health students, participants were asked to discuss job attributes and potential incentives that would influence their job choices. Based on this exercise and in consultation with policymakers, job attributes were selected for inclusion in a discrete choice experiment. A questionnaire, consisting of hypothetical job “choice sets,” was presented to 474 practicing health workers and students. Using administrative data, the authors estimated the cost of implementing potential attraction and retention strategies per health worker year worked. Although health workers preferred urban jobs to rural jobs, employment incentives influenced health workers’ decision to choose rural jobs. If superior housing was offered in a rural area compared to a basic housing allowance in an urban job, participants would be five times as likely to choose the rural job. Education incentives and facility-based improvements also increased the likelihood of rural job uptake. Housing benefits were estimated to have the lowest total costs per health worker year worked, and offer high value in terms of cost per percentage point increase in rural job uptake. The authors note that non-monetary incentives such as housing, education, and facility improvements can be important motivators of health worker choice of location and could mitigate rural health workforce shortages.

Posting policies don’t change because there is peace or war”: the staff deployment challenges for two large health employers during and after conflict in Northern Uganda
Ayiasi R; Rutebemberwa E; Martineau T: Human Resources for Health 17(27)1-10, 2019

In this paper, the authors examine how deployment policies and practices were adapted during the conflict and post-conflict periods with the aim of drawing lessons for future responses to similar conflicts. Qualitative data was collected in a cross-sectional survey to investigate deployment policy and practice during the conflict and post-conflict period in Amuru, Gulu and Kitgum districts in Northern Uganda in 2013. Two large health employers from Acholi were selected, the district local government and Lacor hospital, a private provider. Twenty-three key informants’ interviews were conducted at the national and district level, and in-depth interviews with 10 district managers and 25 health workers. There was no evidence of change in deployment policy due to conflict, but decentralisation from 1997 had a major effect for the local government employer. Health managers in government and those working for Lacor hospital both implemented deployment policies pragmatically, especially because of the danger to staff in remote facilities. Lacor hospital introduced bonding agreements to recruit and staff their facilities. While managers in both organisations implemented the deployment policies as best as they could, some deployment-related decisions were noted as possibly leading to longer-term problems. While it may not be possible to change deployment policies during or after conflict, the authors observe that if given sufficient autonomy, local managers can adapt deployment policies appropriately to need, but that they should also be supported with the necessary management skills to enable this.

A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa
Orgill M; Gilson L; Chitha W; Michel J; et al: International Journal for Equity in Health 18(53) 1-15, 2019

The research paper explored, from a bottom up perspective, how efforts by the South African government to disseminate and diffuse innovations were experienced by district level senior managers and why some efforts were more enabling than others. Managers valued the national Minister of Health’s role as a champion in disseminating innovations via a road show and his personal participation in an induction programme for new hospital managers. The identification of a site coordinator in each pilot site was valued as this coordinator served as a central point of connection between networks up the hierarchy and horizontally in the district. Managers leveraged their own existing social networks in the districts and created synergies between new ideas and existing working practices to enable adoption by their staff. Managers also wanted to be part of processes that decide what should be strengthened in their districts and want clarity on the benefits of new innovations, total funding they will receive, their specific role in implementation and the range of stakeholders involved. The authors proposed that those driving reform processes from the top remember to develop well planned dissemination strategies that give lower-level managers relevant information and, as part of those strategies, provide ongoing opportunities for bottom up input into key decisions and processes. Managers in districts should be recognised as leaders of change, not only as implementers who are at the receiving end of dissemination strategies from those at the top. They are integral intermediaries between those at the frontline and national policies, managing long chains of dissemination and natural diffusion.

Health System Factors Constrain HIV Care Providers in Delivering High-Quality Care: Perceptions from a Qualitative Study of Providers in Western Kenya
Genberg B; Wachira J; Kafu C; Wilso I; et al: Journal of the International Association of Providers of AIDS Care 18, 1-10, 2019

This study examined the experiences of HIV care providers in a high patient volume HIV treatment and care program in Western Kenya on health system factors that impact patient engagement in HIV care. Results from thematic analysis demonstrated that providers perceive a work environment that constrained their ability to deliver high-quality HIV care and encouraged negative patient–provider relationships. Providers described their roles as high strain, low control and low support. The study revealed that health system strengthening must include efforts to improve the working environment for providers tasked with delivering antiretroviral therapy to increasing numbers of patients in resource-constrained settings.

Gender equity in the health workforce: Analysis of 104 countries
Boniol M; McIsaac M; Xu Lihui; Wuliji T; et al: Health Workforce Working paper 1, World Health Organisation, 2019

The health and social sector, with its 234 million workers, is one of the biggest and fastest growing employers in the world, particularly of women. Women comprise seven out of ten health and social care workers and contribute US$ 3 trillion annually to global health, half in the form of unpaid care work. While gender issues have been at the top of the global agenda, few comprehensive studies on gender in the health and social workforce have been conducted at the global level. This brief is based on an analysis of WHO NHWA data5 for 104 countries over the last 18 years. The analysis confirms previous findings that women’s share of employment in the health and social sector is high, with an estimated 67% of the health workforce in the 104 countries analysed being female. Analysis based on median wages from 21 countries showed health workers face gender-related gaps in pay, with female health workers earning, on average, 28% less than males. This is slightly greater than global estimates of gender pay gap data, showing that women are paid approximately 22% less than men. Data from 56 countries showed higher average working hours per week for men than women for most occupations and regions. This likely reflects different type of contracts, with more part-time jobs occupied by women. Women represent around 70% of the health workforce, but earn on average 28% less than men. Occupational segregation (10%) and working hours (7%) can explain most of this gap, but even when considering “equal work” an “equal pay” gap of 11% remains. The authors note that it must be recognized that much of the work in health done by women is unpaid work and that investments in creating decent work in the health sector are needed to support the translation of informal work into formal sector employment.

A systematic review on occupational hazards, injuries and diseases among police officers worldwide: Policy implications for the South African Police Service
Mona G; Chimbari M; Hongoro C: Journal of Occupational Medicine and Toxicology 14(2), doi:, 2019

Occupational hazards, injuries and diseases are a major concern among police officers, including in Sub-Saharan Africa. However, there is limited locally relevant literature for guiding policy for police services. A review was done to describe the occupational hazards, injuries and diseases affecting police officers worldwide, in order to benchmark policy implications for local police services. Police officers’ exposure to accident hazards may lead to acute or chronic injuries such as sprains, fractures or fatalities. These hazards may occur during driving, patrol or riot control. Physical hazards such as noise induced hearing loss (NIHL) arise due to exposure to high levels of noise. Exposure to high concentrations of carbon dioxide and general air pollution was associated with cancer, while physical exposure to other chemical substances was linked to dermatitis. There is a risk of exposure to blood borne diseases from needle stick injuries (NSIs) or cuts from contaminated objects. Musculoskeletal disorders can result from driving long distances and lifting heavy objects, while there is also a risk of post-traumatic stress disorder (PTSD), stress and burnout.

Stakeholders’ perceptions of policy options to support the integration of community health workers in health systems
Ajuebor O; Cometto G; Boniol M; Akl E: Human Resources for Health 17(13) 1-13, 2019

This study assesses stakeholders’ valuation of acceptability and feasibility of policy options considered for the CHW guideline development. A cross-sectional mixed methods study targeting stakeholders involved directly or indirectly in country implementation of community health workers programmes was conducted in 2017. Data was collected from 96 stakeholders from five World Health Organization regions using an online questionnaire. A Likert scale was used to grade participants’ assessments of the outcomes of interest, and the acceptability and feasibility of policy options were considered. All outcomes of interest were considered by at least 90% of participants as ‘important’ or ‘critical’. Most critical outcomes were ‘improved quality of community health workers health services’ and ‘increased health service coverage. Out of 40 policy options, 35 were considered as ‘definitely acceptable’ and 36 ‘definitely feasible’ by most participants. The least acceptable option was the selection of candidates based on age. The least feasible option was the selection of community health workers with a minimum of secondary education.