Human Resources

Toward Interventions in Human Resources for Health in Ghana
Appiah-Denkyira E, Herbst CH, Soucat A, Lemiere C and Saleh K (Eds): World Bank, 2013

This book was produced to support the policy dialogue on Human Resources for Health (HRH) in Ghana. Despite some recent successes, further improvements in health outcomes are in part hampered by the lack of skilled service providers, or human resources for health (HRH), particularly in rural areas, that prevent critical health services from being accessed and adequately delivered to those that need them most. To address the lack of information to guide the development of policies and programmes on HRH, the book aims to paint a comprehensive picture on HRH, consolidating new and existing evidence on some of the underlying determinants impacting stock, distribution and performance of health workers in Ghana, including health worker production and attrition, management and accountability structures, the capacity of health training institutions, and health worker compensation. As is made clear, any potential policies to improve the situation on HRH need to be well targeted, and take into account some of the fiscal and political challenges that are specific to the health labour market in Ghana. The book is intended to provide a basis for Ghanaian decision makers and external partners to dialogue on HRH and related policies, resulting in concrete HRH actions. More broadly, it will be of interest to all those working to improve HRH in Africa and beyond.

Gender-based distributional skewness of the United Republic of Tanzania’s health workforce cadres: a cross-sectional health facility survey
Exavery A, Lutambi AM, Wilson N, Mubyazi GM, Pemba S and Mbaruku G: Human Resources for Health 11(28), 24 June 2013

In this paper, the authors assess the gender-based distribution of Tanzania’s health workforce cadres. They conducted a secondary analysis of data collected in a cross-sectional health facility survey on health system strengthening, consisting of 815 health workers (HWs) from 88 randomly selected health facilities. Results showed that the mean age of the HWs was 39.7, with 75% women. The proportion of women among maternal and child health aides or medical attendants (MCHA/MA), nurses and midwives was 86%, 86% and 91%, respectively, while their proportion among clinical officers (COs) and medical doctors (MDs) was 28% and 21%, respectively. The authors conclude that the distribution of the Tanzania’s health cadres is dramatically gender skewed, a reflection of gender inequality in health career choices. MCHA/MA, nursing and midwifery cadres are large and female-dominant, whereas COs and MDs are fewer in absolute numbers and male-dominant. While a need for more staff is necessary for an effective delivery of quality health services, the authors call for adequate representation of women in highly trained cadres to enhance responses to some gender-specific roles and needs.

Influence of the US President’s Emergency Plan for AIDS Relief (PEPfAR) on career choices and emigration of health-profession graduates from a Ugandan medical school: a cross-sectional study
Bajunirwe F, Twesigye L, Zhang M, Vanessa BK and Bangsberg DR: British Medical Journal Open 2013(3):e002875, 29 May 2013

In this study, the authors explored the hypothesis that programmes initiated under unprecedented health investments from the US President's Emergency Plan for AIDS Relief have possibly facilitated the drain of healthcare workers from the public-health system in Uganda. They conducted a cross-sectional study between January and December 2010 to survey graduates, using in-person, phone or online surveys using email and social networks. The setting was rural: Mbarara University of Science and Technology (MUST) is one of three government supported medical schools in Uganda. The authors interviewed 85.4% (796) of all MUST alumni since the university opened in 1989, and they found 78% were physicians and 12% of graduates worked outside Uganda. Over 50% worked for an HIV-related non-governmental organisation (NGO) whether in Uganda or abroad. Graduates receiving their degree after 2005, when large HIV programmes started, were less likely to leave the country, but were more likely to work for an HIV-related NGO. The increase in resources and investment in HIV-treatment capacity is temporally associated with retention of medical providers in Uganda, the authors argue. External funds should be channelled to develop and retain healthcare workers in disciplines other than HIV and broaden the healthcare workforce to other areas, they recommend.

Motivation and job satisfaction of health surveillance assistants in Mwanza, Malawi: An explorative study
Kok MC And Muula S: Malawi Medical Journal 25(1): 5-11, 2013

This qualitative assessment was undertaken to identify factors that influence motivation and job satisfaction of health surveillance assistants (HSAs) in Mwanza district, Malawi, in order to inform development of strategies to influence staff motivation for better performance. Seven key informant interviews, six focus group discussions with HSAs and one group discussion with HSAs supervisors were conducted in 2009. Data were supplemented by a district wide survey involving 410 households, which included views of the community on HSAs performance. The main satisfiers identified were team spirit and coordination, the type of work to be performed by an HSA and the fact that an HSA works in the local environment. Dissatisfiers were low salary and position, poor access to training, heavy workload and extensive job description, low recognition, lack of supervision, communication and transport. Managers and had a negative opinion of HSA perfomance, while the community was much more positive: 72.9% of all respondents had a positive view on the performance of their HSA. Activities associated with worker appreciation, such as performance management were not optimally implemented. The district level can launch different measures to improve HSAs motivation, including human resource management and other measures relating to coordination of and support to the work of HSAs.

Nursing and midwifery regulatory reform in east, central, and southern Africa: a survey of key stakeholders
McCarthy CF, Voss J, Salmon ME, Gross JM, Kelley MA and Riley PL: Human Resources for Health 11(29), 25 June 2013

This study describes the perspectives and engagement of key stakeholders in advancing critical regulatory and educational reform in east, central, and southern Africa (ECSA). Researchers surveyed 32 leading stakeholders from 13 ECSA countries with regard to task shifting and the challenges related to practice and education regulation reform. Most (72%) reported task shifting is practiced in their countries; however only 57% reported their national regulations had been revised to incorporate additional professional roles and responsibilities. They also reported different roles and levels of involvement with regard to nursing and midwifery regulation. The most frequently cited challenge impacting nursing and midwifery regulatory reform was the absence of capacity and resources needed to implement change. While guidelines on task shifting and recommendations on transforming health professional education exist, the authors argue that their study provides new evidence that countries in the ECSA region face obstacles to adapting their practice and education regulations accordingly. Stakeholders such as community nursing organisations, nursing associations, and academicians have varied and complementary roles with regard to reforming professional practice and education regulation.

Transforming rural health systems through clinical academic leadership: lessons from South Africa
Doherty JE, Couper ID, Campbell D, Walker J: Rural and Remote Health 13(2618), 8 July 2013

Under-resourced and poorly managed rural health systems challenge the achievement of universal health coverage, and require innovative strategies worldwide to attract healthcare staff to rural areas. One such strategy is rural health training programmes for health professionals. In addition, clinical leadership (for all categories of health professional) is a recognised prerequisite for substantial improvements in the quality of care in rural settings, argue the authors of this report. Rural health training programmes have been slow to develop in low- and middle-income countries (LMICs); and the impact of clinical leadership is under-researched in such settings. A 2012 conference in South Africa, with expert input from South Africa, Canada and Australia, discussed these issues and produced recommendations for change that will also be relevant in other LMICs. The two underpinning principles were that: rural clinical leadership (both academic and non-academic) is essential to developing and expanding rural training programs and improving care in LMICs; and leadership can be learned and should be taught. Lessons learned: The three main sets of recommendations focused on supporting local rural clinical academic leaders; training health professionals for leadership roles in rural settings; and advancing the clinical academic leadership agenda through advocacy and research. By adopting the detailed recommendations, South Africa and other LMICs could energise management strategies, improve quality of care in rural settings and impact positively on rural health outcomes, the authors conclude.

Vertical funding, non-governmental organisations, and health system strengthening: Perspectives of public sector health workers in Mozambique
Mussa AH, Pfeiffer J, Gloyd SS, Sherr K: Human Resources For Health 11(26), 14 June 2013

The authors of this paper consider the perspectives and experiences of key Mozambican public sector health managers who coordinate, implement, and manage a wide variety of donor-driven projects and agencies. Over a four-month period, they conducted 41 individual qualitative interviews with key Ministry workers at three levels in the Mozambique national health system, using open-ended semi-structured interview guides, as well as reviewed planning documents. All respondents emphasized the value and importance of international aid and vertical funding to the health sector and each highlighted program successes that were made possible by recent increased aid flows. However, three serious concerns emerged: difficulties coordinating external resources and challenges to local control over the use of resources channeled to international private organisations; inequalities created within the health system produced by vertical funds channeled to specific services while other sectors remain under-resourced; and the exodus of health workers from the public sector health system provoked by large disparities in salaries and work. The vertical approach starved the Ministry of support for its administrative functions.

Community Health Care Workers: Stop the Exploitation! Decent work and recognition for our front line health workers
People’s Health Movement: 6 June 2013

On 25 May 2013, 98 community care workers representing over 50 organisations with the Community Care Workers (CCW) Forum, the Wellness Foundation and the People’s Health Movement of South Africa met to reaffirm the importance of community care workers in South Africa’s health system and to expose the terrible working conditions that many community care workers are experiencing. CCWs work in the homes of the poorest of the poor often without protective face masks, gloves and other basic materials. The People’s Health Movement calls for these CCWs to enjoy decent work conditions and receive adequate recognition. It proposes a ‘two-tier’ system like that of Thailand, where high coverage is achieved by instituting where there is one full-time CCW for every 300-500 households, who then supervises 10 part-time CCWs who have more limited training. Such high coverage of households has been shown to have a dramatic impact on health outcomes, especially of young children. The ratio currently proposed in South Africa of one CHW to 270 households is extremely unlikely to have such an effect given South Africa’s very high burden of disease, and the large percentage of people requiring time-consuming home care. In addition to rendering health care more accessible and equitable, the two-tier system would create jobs, and indirectly improve health by reducing the prevalence and depth of poverty.

Further details: /newsletter/id/38444
Implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel
Perfilieva G: World Health Organisation, 2010

In this presentation, the author assesses implementation of the World Health Organisation’s (WHO) Code for Ethical Recruitment. She reports that 32 countries achieved valuable steps towards implementing the Code. In some of these countries, actions have taken to communicate and share information across sectors, measures have been taken to involve all stakeholders in decision making processes, including actions considered to introduce to laws or policies, records are maintained of all recruiters authorised by competent authorities to operate within their jurisdiction and good practices are encouraged and promoted among recruitment agencies. In some of these countries, migrant health workers enjoy the same legal rights and responsibilities as those domestically trained, as well as the same opportunities as domestically trained to strengthen their professional education, qualifications, career development , and health personnel are recruited internationally, using mechanisms that allow to assess the benefits and risks associated with employment positions. Furthermore, 22 countries have mechanisms to regulate the authorisation to practice by internationally recruited health personnel and maintain statistical records and 11 have a database of laws and regulations related to health workforce migration and recruitment.

New Constitution, New Hope for Health Professionals in Kenya
Dogbey B: 8 April 2013, Africa Portal

In this blog, the author argues that a palpable effect of Kenya’s new constitution is that it has allowed the formation of new trade unions such as the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU). Since its formation, the group has become a key stakeholder in promoting the needs of Kenyan health professionals. Another change the constitution brought about is the permission of dual citizenship, which has the potential to increase circular migration among health professionals who have previously departed the country. Finally, the new constitution prioritises the right to health in Section 43 (1) (a), noting that every Kenyan has the “right to the highest attainable standard of health which includes the right to health care services including reproductive health care.” This places a high level of expectation on the government and health care workers, creating a basis for the public to demand such a right. To convert these potential gains into practice, however, much work remains to be done, particularly in researching how the health system has responded. One of the greatest challenges the author has faced in conducting her own research on migration is in encountering stakeholders who are unwilling to cooperate either directly or indirectly, which she views as a part of a resistance to an evidence-based culture, even among some in the health sector.