Human Resources

Development assistance for community health workers in 114 low- and middle-income countries, 2007–2017
Lu C; Palazuelos D; Luan Y; Sachs SE; et al: Bulletin of the World Health Organisation 98(1) 1-76, 2020

This study estimated the level and trend of development assistance for community health worker-related projects in low- and middle- income countries between 2007 and 2017. Data was extracted from the Organisation for Economic Co-operation and Development’s creditor reporting system on aid funding for projects to support community health workers (CHWs) in 114 countries over 2007–2017. Between 2007 and 2017, total development assistance targeting CHW projects was around US$ 5 298 million, accounting for 2.5% of the US$ 209 278 million total development assistance for health. Sub-Saharan Africa received a total US$ 3 718 million, the largest per capita assistance over 11 years. Development assistance to projects that focused on infectious diseases and child and maternal health received most funds during the study period. The share of development assistance invested in the CHW projects was, however, small, unstable and decreasing in recent years.

Prolonged health worker strikes in Kenya- perspectives and experiences of frontline health managers and local communities in Kilifi County
Waithaka D; Kagwanja N; Nzinga J; Tsofa B; et al: International Journal for Equity in Health 19(23), doi:, 2020

The authors explored the perceptions and experiences of frontline health managers and community members of the 2017 prolonged health workers’ strikes in Kenya, using informal observations, reflective meetings, individual and group interviews and document reviews, analysed using a thematic approach. In the face of major health facility and service closures and disruptions, frontline health managers enacted a range of strategies to keep key services open, but many were piecemeal, inconsistent and difficult to sustain. Interviewees reported huge negative health and financial impacts on local communities, and especially poor people. They found limited evidence of improved health system preparedness to cope with any future strikes. The 2017 prolonged strikes highlight the underlying and longer-term frustration amongst public sector health workers in Kenya. Reactive responses within the public system and the use of private healthcare led to limited continued activity through the strike, but were not sufficient to confer resilience to the shock of prolonged strikes. To minimise the negative effects of strikes when they occur, the authors suggest that careful monitoring and advanced planning is needed. Planning should aim to ensure that emergency and other essential services are maintained, threats between staff are minimized, health worker demands are reasonable, and that governments respect and honour agreements.

Psychological wellbeing in a resource-limited work environment: examining levels and determinants among health workers in rural Malawi
Lohmann J; Shulenbayev O; Wilhelm D; Muula A; et al: Human Resources for Health (2019) 17(85) 1-11, 2019

Ensuring health workers’ psychological wellbeing is critical to sustaining their availability and productivity. This study investigated levels of and factors associated with psychological wellbeing of mid-level health workers in Malawi, using a cross-sectional sample of 174 health workers from 33 primary and secondary level health facilities in four districts of Malawi. Twenty-five percent of respondents had World Health Organsation-5 scores indicative of poor psychological wellbeing. Analyses of factors related to psychological wellbeing showed no association with sex, cadre, having dependents, supervision, perceived co-worker support, satisfaction with the physical work environment, satisfaction with remuneration, and motivation; a positive association with respondents’ satisfaction with interpersonal relationships at work; and a negative association with having received professional training recently. The high proportion of health workers with poor wellbeing scores is concerning in light of the general health workforce shortage in Malawi and strong links between wellbeing and work performance. While more research is needed to draw conclusions and provide recommendations as to how to enhance wellbeing, the results are argued to underline the importance of considering wellbeing as a key concern for human resources for health.

Public Health Care Spending in South Africa and the Impact on Nurses: 25 years of democracy?
Valiani S: Agenda, 33 (4) 67-78, 2019

Nurses in South Africa - as in the rest of the continent - are the backbone and oxygen of public health care though not adequately acknowledged. This article traces the pattern of public health care spending and its impact on nurses since 1994. Given the nature and quantity of demand for public health care in South Africa, deemed the most unhealthy nation in the world in the 2019 Indigo Wellness Index, the article shows that the 25 year record of democratic South Africa registers low public health care expenditure and nurses are at the coal face of this contradiction.

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.