This paper draws on studies of financial incentive programmes and other initiatives with similar objectives to discuss seven management functions that are essential for the long-term success of financial incentive programmes aimed at retaining staff in underserved areas: using innovative financing; promoting health as a career; introducing specific selection criteria to ensure programme success and achieve goals; ensuring correct placement of new employees; offering support by staying in close contact with participants throughout enrolment and assigning them mentors; enforcement (programmes may use community-based monitoring or outsource enforcement to existing institutions); and routine performance evaluation of programmes. To improve the strength of the evidence on the effectiveness of financial incentives, controlled experiments should be conducted where feasible.
Human Resources
This paper uses a forecasting model to estimate the need for, supply of, and shortage of doctors, nurses, and midwives in thirty-nine African countries for 2015, the target date of the United Nations Millennium Development Goals. It forecasts that thirty-one countries will experience needs-based shortages of doctors, nurses, and midwives, totalling approximately 800,000 health professionals. It further estimates the additional annual wage bill required to eliminate the shortage at about US$2.6 billion, more than 2.5 times current wage-bill projections for 2015. Additional funds would be required to hire health care support staff, train and support staff, and pay for expenses. Raising the money required to eliminate the shortfall would be difficult for the countries involved, even under the most optimistic assumptions regarding economic growth and governmental commitments to the health sector. Global aid can help but will still not provide enough resources, the researchers say. They call for changes in the skills mix, worker incentives and improvements in training for health care workers.
Ugandan health workers are dissatisfied with their jobs, especially their compensation and working conditions, says this study. It found a shocking statistic – about one in four health workers, which includes half of all physicians, would like to leave the country. What can be done about this medical brain drain? The researchers urge that strategies for strengthening the health care workforce in Uganda should focus on salary and benefits, especially health coverage. Poor working conditions and excessive workloads should also be dealt with. Facility infrastructure needs to be upgraded to provide a decent work environment, including the supply of water and electricity. Management needs to be improved, as well as workforce camaraderie.
The successful continuation of existing HIV care and treatment programmes is threatened by health care worker burnout and HIV-related illness. This study, conducted between March to June 2007, looks at occupational burnout and utilisation of HIV services among health providers in the Lusaka public health sector. Providers from thirteen public clinics were given a 36-item, self-administered questionnaire and invited for focus group discussions and key informant interviews. Focus group participants described burnout as feeling overworked, stressed and tired. In the survey, 51% reported occupational burnout. Risk factors were having another job and knowing a co-worker who left in the last year. Both discussion groups and survey respondents identified confidentiality as the prime reason for not undergoing HIV testing. In Lusaka primary care clinics, overwork, illness and death were common reasons for attrition. Programmes to improve access, acceptability and confidentiality of health care services for clinical providers and to reduce workplace stress could substantially benefit workforce stability.
Participatory research approaches such as the Health Workers for Change (HWC) initiative have been successful in improving provider-client relationships in various developing country settings, but have not yet been reported in the complex environment of hospital wards. This study evaluated the HWC approach for improving the relationship between nurses and parents on a paediatric ward in a busy regional hospital in Tanzania. Six workshops were held, attended by 29 of 31 trained nurses and nurse attendants working on the paediatric ward. Two focus-group discussions were held with the workshop participants six months after the intervention. Some improvement was reported in the responsiveness of nurses to client needs (41.2% of parents were satisfied, up from 38.9%). But nurses felt hindered by persisting problems in their working environment, including poor relationships with other staff and a lack of response from hospital administration to their needs.
Financial-incentive programmes for return of service, whereby participants receive payments in return for a commitment to practise for a period of time in a medically underserved area, can alleviate local and regional health worker shortages through a number of mechanisms. First, they can redirect the flow of those health workers who would have been educated without financial incentives from well-served to underserved areas. Second, they can add health workers to the pool of workers who would have been educated without financial incentives and place them in underserved areas. Third, financial-incentive programmes may improve the retention in underserved areas of those health workers who participate in a programme, but who would have worked in an underserved area without any financial incentives. Fourth, the programmes may increase the retention of all health workers in underserved areas by reducing the strength of some of the reasons why health workers leave such areas, including social isolation, lack of contact with colleagues, lack of support from medical specialists and heavy workload.
According to this survey, more than half of nurses (53%) in South Africa said their workload was worse today when compared to five years ago. Nurses in South Africa indicated that the least favourable aspects of their profession were overwhelming workloads (32%), insufficient pay and benefits (22%), lack of recognition (11%), budget cuts and inadequate health care systems (11%). In contrast, the most favourable aspect was patient contact (39%). In South Africa, as in other countries surveyed, most nurses (85%) said they faced time constraints that prevented them from spending as much time with individual patients as they thought necessary. Some 87% of the nurses surveyed in South Africa said spending more time with individual patients would have a significant impact on patient health. On the plus side, they saw their professional associations as effective in advancing their interests (86%) and supportive of their needs (87%), and 63% perceived the nation's health care system as better than it was five years ago.
Migration has been one of the more important means of greater global integration, and, as the economic crisis has gripped the developed world, many have worried about its impact on such integration, especially falling remittances. A closer examination of the nature of migrant workers' role in the economy suggests more complex outcomes, with somewhat less of an impact than feared. It is true that most of this migration has been driven by economic forces and has given rise to rapidly expanding remittance flows, which have become the most important source of foreign exchange for many developing countries. The International Monetary Fund estimated total remittance flows to developing countries to be nearly US$300 billion in 2009, significantly more than all forms of capital flows put together. In any case, one of the basic pull factors still remains significant: the demographic transition in the North that is increasing the share of the older population that requires more care from younger workers, who must therefore come from abroad. So the current crisis may temporarily slow down the ongoing process of international migration for work, but it is unlikely to reverse it.
This study analysed data from a human resources health facility survey conducted in 2005 in 52 health centres and 22 public hospitals (including all provincial hospitals) across all eight provinces in Kenya. The study looked into the status of attrition rates and the proportion of attrition due to retirement, resignation or death among doctors, clinical officers, nurses and laboratory and pharmacy specialists in surveyed facilities. Results showed that overall health workers attrition rates from 2004 to 2005 were similar across type of health facility: provincial hospitals lost on average 4% of their health workers, compared to 3% for district hospitals and 5% for health centres. The main reason for health worker attrition (all cadres combined) at each level of facility was retirement, followed by resignation and death. Appropriate policies to retain staff in the public health sector may need to be tailored for different cadres and level of health facility. Further studies, perhaps employing qualitative research, need to investigate the importance of different factors in the decision of health workers to resign.
South African (SA) public servants, including doctors and nurses, are demanding a 15% wage increase across the board and want this year's pay talks to centre on the creation of ‘decent work’. Although SA is now under a new administration, one which is considered to be worker friendly, government spokesman Themba Maseko said after a Cabinet briefing earlier this month that the state would make its shrinking spending power known when the wage negotiations started. This year's wage negotiations are likely to be intense considering SA is in its first recession in seventeen years and that the state has still not made good on its occupation specific dispensation (OSD) offer on pay structures agreed to during the last talks in 2007. If the state spent all its money on wage increases, nothing would be left for essential services like textbooks and medical supplies, Maseko said. The state has not yet made known what increases it is willing to offer its employees and is expected to respond to their shortly.