Human Resources

Redressing the gender imbalance: a qualitative analysis of recruitment and retention in Mozambique’s community health workforce
Steege R; Taegtmeyer M; Ndima S; Give C; et al: Human Resources for Health 18(37) doi:, 2020

Mozambique’s community health programme has a disproportionate number of male community health workers (known as Agentes Polivalentes Elementares (APEs)). This paper seeks to explore the current recruitment imbalance processes for APEs and how these are shaped by gender norms, roles and relations, as well as how they influence the experience and retention of APEs in Maputo Province, Mozambique. The authors employed qualitative methods with APEs, APE supervisors, community leaders and a government official in two districts within Maputo Province. Women reported difficulty leaving family responsibilities behind, and men reported challenges in providing for their families during training as other income-generating opportunities were not available to them. These dynamics were particularly acute in the case of single mothers, serving both a provider and primary carer role. Differences in attrition by gender were reported: women are likely to leave the programme when they marry, whereas men tend to leave when offered another job with a higher salary. Age and geographic location were also important intersecting factors, younger male and female APEs seek employment opportunities in neighbouring South Africa, whereas older APEs are more content to remain. The authors suggest that responsive policies to support gender equity within APE recruitment processes are required to support and retain a gender-equitable APE cadre.

Training Exposure and Self-Rated Competence among HIV Care Providers Working with Adolescents in Kenya
Karman E; Wilson K; Mugo C; Slyke J; et al: Journal of the International Association of Providers of AIDS Care (19) doi:, 2020

This paper examined the training coverage and self-reported competence, knowledge, abilities, and attitudes, of health care workers caring for adolescents living with HIV in Kenya. Surveys were conducted with 24 managers and 142 health care workers. Health care workers had a median of 3 years of experience working with adolescents living with HIV, and 40% reported exposure to any adolescents living with HIV training. Median overall competence was 78%. More years caring for adolescents living with HIV and any prior training in adolescent HIV care were associated with significantly higher self-rated competence. Training coverage for adolescent HIV care remains sub-optimal. The authors suggest that targeting health care workers with less work experience and training exposure may be a useful and efficient approach to improve quality of youth-friendly HIV services.

Coordinating health workforce management in a devolved context: lessons from Kenya
Thuku M; Muriuki J; Adano U; et al: Human Resources for Health 18 (26), 1-7, 2020

This case study describes how Kenya created an inter-county, multi-stakeholder coordination framework that promotes consensus, commitment, and cooperation in devolved human resources management. The coordination framework has been instrumental in expediting development, customization, and dissemination of policies, enabling national human resources for health officers to mentor their county counterparts, and providing collaborative platforms for multiple stakeholders to resolve challenges and harmonize practices nationwide. Successes catalyzed through the inter-county forums include hiring over 20 000 health workers to address shortages; expanding the national human resources information system to all 47 counties; developing guidelines for sharing specialist providers; and establishing professionalized human resources for health units in all 47 counties. The coordination framework supports alignment of county health operations with national goals while enabling national policy responses to health gaps in the counties.

COVID-19 in Africa: care and protection for frontline healthcare workers
Chersich M; Gray G; Fairlie L; Eichbaum Q; et al: Globalization and Health 16(46), 1-6, 2020

This paper provides a survey of the challenges and proposed interventions to protect healthcare workers on the continent, drawing on articles identified on Medline (Pubmed) in a search on 24 March 2020. Global jostling means that supplies of personal protective equipment are limited in Africa. Even low-cost interventions such as facemasks for patients with a cough and water supplies for handwashing may be challenging, as is ‘physical distancing’ in overcrowded primary health care clinics, raising the risk for healthcare workers and their families. The authors argue, however, that the continent has learnt invaluable lessons from Ebola and HIV control. HIV counselors and community healthcare workers are key and could promote social distancing and related interventions, dispel myths, support healthcare workers, perform symptom screening and trace contacts. Staff motivation and retention may be enhanced through carefully managed risk ‘allowances’ or compensation. International support with personnel and protective equipment, especially from China, could turn the pandemic’s trajectory in Africa around. Telemedicine holds promise as it rationalises personnel and reduces patient contact and thus infection risks. The authors argue that healthcare workers, using their authoritative voice, can promote effective COVID-19 policies and prioritization of their safety. Prioritizing healthcare workers for SARS-CoV-2 testing, hospital beds and targeted research, as well as ensuring that public figures and the population acknowledge the commitment of healthcare workers may help to maintain morale, while international support and national commitment could help safeguard healthcare workers in Africa, essential for limiting the pandemic’s impacts on the continent.

The integration of occupational- and household-based chronic stress among South African women employed as public hospital nurses
Cohen J; Venter W: PLOS One 15(5), e0231693, 2020

This study explored the lived experience of public hospital-employed, black women nurses’ to better understand their stressors and what may help to reduce it. Through semi-structured life history interviews with 71 nurses in Johannesburg, nurses described daily lives of chronic distress, with extreme pressures on their incomes, time, and resources. Much of this pressure was said to come from the number and intensity of family dependents, related financial obligations and debt. This revised from social norms which assign women primary responsibility for unpaid household work, which nurses struggle with as unsustainable, anxiety-inducing and with pay and paid work schedules that make meeting that responsibility virtually impossible. The structure of the nursing occupation contributes to stress outside the workplace, while the structure of nurses’ households contributes to stress and emotional exhaustion. This implies that workplace-oriented interventions may assist but alone are unlikely to adequately address the overall level of stress.

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.