This paper draws on ethnographic research conducted in HIV clinics and in a public hospital to examine how health workers experience and reflect upon the juxtaposition of 'global' medicine with 'local' medicine. We show that health workers face an uneven playing field. High-prestige jobs are available in HIV research and treatment, funded by donors, while other diseases and health issues receive less attention. Outside HIV clinics, patient's access to medicines and laboratory tests is expensive, and diagnostic equipment is unreliable. Clinicians must tailor their decisions about treatment to the available medical technologies, medicines and resources. How do health workers reflect on working in these environments and how do their experiences influence professional ambitions and commitments? The need to improvise in the face of inadequate diagnostic tools and unreliable facilities was stressful for all health workers. Added to this stress was the degree to which health workers had to attend to patient poverty. While staff within HIV/AIDS clinics also faced these issues, hospital staff often found them overwhelming as they were confronted daily and relentlessly with the moral dilemma of how to deal with patients who could not afford treatment. In this situation, the strain of being forced to practice medicine that was only ‘good enough’ was a source of stress and frustration. Among interns, the moral complexity of their situation added to their uneasy positioning as young professionals struggling to gain a sense of professional identity and competence.
Human Resources
Motivation and job satisfaction have been identified as key factors for health worker retention and turnover in low- and middle-income countries. District health managers in decentralised health systems usually have a broadened 'decision space' that enables them to positively influence health worker motivation and job satisfaction, which in turn impacts on retention and performance at district-level. The study explored the effects of motivation and job satisfaction on turnover intention and how motivation and satisfaction can be improved by district health managers in order to increase retention of health workers. The authors conducted a cross-sectional survey in three districts of the Eastern Region in Ghana and interviewed 256 health workers from several staff categories (doctors, nursing professionals, allied health workers and pharmacists) on their intentions to leave their current health facilities as well as their perceptions on various aspects of motivation and job satisfaction. The effects of motivation and job satisfaction on turnover intention were explored through logistic regression analysis. Overall, 69% of the respondents reported to have turnover intentions. Motivation and job satisfaction were significantly associated with turnover intention and higher levels of both reduced the risk of health workers having this intention. The dimensions of motivation and job satisfaction significantly associated with turnover intention included career development, workload, management, organisational commitment and burnout. The authors’ findings indicate that effective human resource management practices at district level influence health worker motivation and job satisfaction, thereby reducing the likelihood for turnover. Therefore, they argue that it is worth strengthening human resource management skills at district level and supporting district health managers to implement retention strategies.
In countries with high maternal and newborn morbidity and mortality, reliable access to quality healthcare in rural areas is essential to save lives. Health workers who are satisfied with their jobs are more likely to remain in rural posts. Understanding what factors influence health workers' satisfaction can help determine where resources should be focused. Although there is a growing body of research assessing health worker satisfaction in hospitals, less is known about health worker satisfaction in rural, primary health clinics. This study explores the workplace satisfaction of health workers in primary health clinics in rural Tanzania. Overall, 70 health workers in rural Tanzania participated in a self-administered job satisfaction survey. Results showed that 73.9% of health workers strongly agreed that they were satisfied with their job; however, only 11.6% strongly agreed that they were satisfied with their level of pay and 2.9% with the availability of equipment and supplies. Two categories of factors emerged from the PCA: the tools and infrastructure to provide care, and supportive interpersonal environment. Nurses and medical attendants (compared to clinical officers) and older health workers had higher satisfaction scale ratings. Two dimensions of health workers' work environment, namely infrastructure and supportive interpersonal work environment, explained much of the variation in satisfaction among rural Tanzanian health workers in primary health clinics. Health workers were generally more satisfied with supportive interpersonal relationships than with the infrastructure. Human resource policies should, it is argued, consider how to improve these two aspects of work as a means for improving health worker morale and potentially rural attrition
As low- and middle-income countries face continued shortages of human resources for health and the double burden of infectious and chronic diseases, there is renewed international interest in the potential for community health workers to take on a growing role in strengthening health systems. Health surveillance assistants (HSAs) — as the community health cadre in Zomba District, Malawi is known — play a vital role by connecting the community with the formal health care sector. The latest research from the Africa Initiative provides a situational analysis of the HSA cadre and its contribution to the delivery of health services in Malawi. The authors’ findings show that HSAs face numerous challenges related to training, as well as challenges in defining their roles and those of their supervisors. They conclude with recommendations to improve HSA training and policy, with the ultimate goal of improving the effectiveness of this cadre of worker, and improving the health of the population.
The objective of the study was to demonstrate the effectiveness of service-based human resources for health (HRH) planning through its adaptation in two rural Zambian districts, Gwembe and Chibombo. The health conditions causing the greatest mortality and morbidity in each district were identified using administrative data and consultations with community health committees and health workers. The number and type of health care services required to address these conditions were estimated based on their population sizes, incidence and prevalence of each condition, and desired levels of service. The capacity of each district’s health workers to provide these services was estimated using a survey of health workers (n=44) that assessed the availability of their specific competencies. The primary health conditions identified in the two districts were HIV/AIDS in Gwembe and malaria in Chibombo. Although the competencies of the existing health workforces in these two mostly aligned with these conditions, some substantial gaps were found between the services the workforce can provide and the services their populations need. The largest gaps identified in both districts were: performing laboratory testing and interpreting results, performing diagnostic imaging and interpreting results, taking and interpreting a patient’s medical history, performing a physical examination, identifying and diagnosing the illness in question, and assessing eligibility for antiretroviral treatment.
The government of Malawi is committed to the rollout of antiretroviral treatment in Malawi in the public health sector; however one of the primary challenges has been the shortage of trained health care workers. The Practical Approach to Lung Health Plus HIV/AIDS in Malawi (PALM PLUS) package is an innovative guideline and training intervention that supports primary care middle-cadre health care workers to provide front-line integrated primary care. The purpose of this paper is to describe the lessons learned in implementing the PALM PLUS package. A clinical tool, based on algorithm- and symptom-based guidelines was adapted to the Malawian context. An accompanying training program based on educational outreach principles was developed and a cascade training approach was used for implementation of the PALM PLUS package in 30 health centres, targeting clinical officers, medical assistants, and nurses. Lessons learned were identified during program implementation through engagement with collaborating partners and program participants and review of program evaluation findings. Key lessons learned for successful program implementation of the PALM PLUS package include the importance of building networks for peer-based support, ensuring adequate training capacity, making linkages with continuing professional development accreditation and providing modest in-service training budgets. The main limiting factors to implementation were turnover of staff and desire for financial training allowances.
This study investigated factors influencing motivation and retention of HCWs at primary health care facilities in three different settings in Kenya - the remote area of Turkana, the relatively accessible region of Machakos, and the disadvantaged informal urban settlement of Kibera in Nairobi. A cross-sectional cluster sample design was used to select 59 health facilities that yielded interviews with 404 health care workers, grouped into 10 different types of service providers. Data were collected in November 2011 using structured questionnaires and a Focus Group Discussion guide. Findings were analyzed using bivariate and multivariate methods of the associations and determinants of health worker motivation and retention. The levels of education and gender factors were lowest in Turkana with female HCWs representing only 30% of the workers against a national average of 53%. A smaller proportion of HCWs in Turkana feel that they have adequate training for their jobs. Overall, 13% of the HCWs indicated that they had changed their job in the last 12 months and 20% indicated that they could leave their current job within the next two years. In terms of work environment, inadequate access to electricity, equipment, transport, housing, and the physical state of the health facility were cited as most critical, particularly in Turkana. The working environment is rated as better in private facilities. Adequate training, job security, salary, supervisor support, and manageable workload were identified as critical satisfaction factors. Family health care, salary, and terminal benefits were rated as important There are distinct motivational and retention factors that affect HCWs in the three regions. Findings and policy implications from this study point to a set of recommendations to be implemented at national and county levels. These include gender mainstreaming, development of appropriate retention schemes, competitive compensation packages, strategies for career growth, establishment of a model HRH community, and the conduct of a discrete choice experiment.
The objective of this study was to understand the performed versus documented roles of the HSAs, to examine how tasks were prioritized, and to understand HSAs’ perspectives on their roles and responsibilities. A situational analysis of the HSA cadre and its contribution to the delivery of health services in Zomba district, Malawi was conducted. Focus groups and interviews were conducted with 70 HSAs. Observations of three HSAs performing duties and work diaries from five HSAs were collected. Lastly, six policy-maker and seven HSA supervisor interviews and a document review were used to further understand the cadre’s role and to triangulate collected data. HSAs performed a variety of tasks in addition to those outlined in the job description resulting in issues of overloading, specialization and competing demands existing in the context of task-shifting and prioritization. Not all HSAs were resistant to the expansion of their role despite role confusion and HSAs feeling they lacked adequate training, remuneration and supervision. HSAs also said that increasing workload was making completing their primary duties challenging. Considerations for policy-makers include the division of roles of HSAs in prevention versus curative care; community versus centre-based activities; and the potential specialization of HSAs. This study provides insights into HSAs’ perceptions of their work, their expanding role and their willingness to change the scope of their practice. There are clear decision points for policy-makers regarding future direction in policy and planning in order to maximize the cadre’s effectiveness in addressing the country’s health priorities.
In South Africa, community service following medical training serves as a mechanism for equitable distribution of health professionals and their professional development. Community service officers are required to contribute a year towards serving in a public health facility while receiving supervision and remuneration. Although the South African community service programme has been in effect since 1998, little is known about how placement and practical support occur, or how community service may impact future retention of health professionals. National, cross-sectional data were collected from community service officers who served during 2009 using a structured self-report questionnaire. A Supervision Satisfaction Scale (SSS) was created by summing scores of five questions rated on a three-point Likert scale (orientation, clinical advising, ongoing mentorship, accessibility of clinic leadership, and handling of community service officers’ concerns). Research endpoints were guided by community service programmatic goals and analysed as dichotomous outcomes. Bivariate and multivariate logistical regressions were conducted using Stata 12. The sample population comprised 685 doctors and dentists (response rate 44%). Although few participants planned to continue work in rural, underserved communities (n = 171 out of 657 responses, 25%), those serving in a rural facility during the community service year had higher intentions of continuing rural work. Those reporting professional development during the community service year were twice as likely to report intentions to remain in rural, underserved communities. Despite challenges in equitable distribution of practitioners, participant satisfaction with the compulsory community service programme appears to be high among those who responded to a 2009 questionnaire. An emphasis on professional development and supervision is crucial if South Africa is to build practitioner skills, equitably distribute health professionals, and retain the medical workforce in rural, underserved areas.
The active recruitment of health workers from developing countries to developed countries has become a major threat to global health. In an effort to manage this migration, the 63rd World Health Assembly adopted the World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel in May 2010. While the Code has been lauded as the first globally-applicable regulatory framework for health worker recruitment, its impact has yet to be evaluated. The authors offer the first empirical evaluation of the Code’s impact on national and sub-national actors in Australia, Canada, United Kingdom and United States of America, which are the English-speaking high income countries with the greatest number of migrant health workers. Forty two key informants from across government, civil society and private sectors were surveyed. Sixty percent of respondents believed their colleagues were not aware of the Code, and 93% reported that no specific changes had been observed in their work as a result of the Code. 86% reported that the Code has not had any meaningful impact on policies, practices or regulations in their countries. This suggests a gap between awareness of the Code among stakeholders at global forums and the awareness and behaviour of national and sub-national actors. Advocacy and technical guidance for implementing the Code are needed to improve its impact on national decision- makers.