Health care in South Africa’s rural areas is set to get a major boost, following the launch of the Centre for Rural Health by Wits University, in Johannesburg, recently. The centre’s inaugural Director, Prof Ian Couper, said the centre’s main focus is to ‘recruit human resources for rural health. We can do everything in terms of providing facilities, we can make sure the drug supplies are there, but unless we have the health workers, all of that will mean nothing. The centre is trying to focus on multiple strategies: selecting students in rural areas and supporting them to study health sciences, developing post graduate programmes, researching issues around how we can improve resources for rural health and advocacy to bring these issues to the attention of policy makers, politicians and other stake-holders.’ Deputy Health Minister, Dr Molefi Sefularo, expressed gratitude to the university for highlighting issues relating to rural health. ‘We would like you to become a leading academic centre in the field of human resources for rural health’, he said.
Human Resources
This review provides a comprehensive overview of the most important studies addressing the recruitment and retention of doctors to rural and remote areas. A comprehensive search of the English literature was conducted, 1,261 references were identified and screened and 110 articles were included. The study argues for the formulation of universal definitions to assist study comparison and future collaborative research. Although coercive strategies address short-term recruitment needs, little evidence supports their long-term positive impact. Current evidence only supports the implementation of well-defined selection and education policies, although incentive and support schemes may have value. There remains an urgent need to evaluate the impact of untested interventions in a scientifically rigorous fashion in order to identify winning strategies for guiding future practice and policy.
Hundreds of lay health care workers are deployed in Kenyan communities to fill the gap caused by severe staff shortages in the health sector – but could they be doing more harm than good? Some lay health workers even dispense antiretroviral (ARV) drugs, but health experts have warned that using unqualified personnel to perform medical functions may not be such a good idea. Dr Andrew Suleh, chairman of the Kenya Medical Association, said lay counsellors should not become a long-term replacement for professional health workers. ‘The government must be pressured to train, employ and retain health professionals to ease the disease burden exerted on the health care workers by the twin challenges of HIV and TB – the management and care of HIV and AIDS is very labour intensive,’ he said. Most lay counsellors were volunteers employed by non-governmental organisations whose projects could end, leaving the country with even bigger shortages of health workers. ‘You cannot base health management on volunteerism; it is not sustainable,’ Suleh added.
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.
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.