This study aimed to document the kinds of leadership styles are practiced at primary health care (PHC) centres and how these styles can be explained by the contexts, characteristics of the health centre in charge (IC) and subordinate trained health staff (STHS). Self-administered questionnaires were distributed at 47 centres in three districts. A total of 347 STHSs (95%) and 46 ICs (98%) responded. Two leadership styles were revealed: ‘trans’ style contained all relation and the majority of task and change items, while ‘control’ style focused on health statistics, reporting and evaluation. The researchers found that frontline PHC leadership may be forced by situation and context to use a comprehensive style, which could lack the diversity and flexibility needed for effective leadership. The missing associations between staff characteristics and leadership styles might indicate that this group is not sufficiently considered and included in leadership processes in the PHC organisation. Leadership competency for the ICs seems not to be based on formal training, but substituted by young age and work experience. In conclusion, the authors call for a reassessment of PHC leadership and formal leadership training.
Human Resources
This study compared the effectiveness of trained Health Surveillance Assistants (HSAs) versus trained volunteer Key Informants (KIs) in identifying blind children in southern Malawi. A cluster community based study was conducted in Mulanje district, population 435 753. Six clusters each with a population of approximately 70,000 to 80,000, 42% of whom were children were identified and randomly allocated to either HSA or KI training. A total of 59 HSAs and 64 KIs were trained. HSAs identified five children of whom two were confirmed as blind (one blind child per 29.5 HSAs trained). On the other hand, the KIs identified a total of 158 children of whom 20 were confirmed blind (one blind child per 3.2 KIs trained). More blind boys than girls were identified (77.3% versus 22.7%) respectively. Key Informants were found to be much better at identifying blind children than HSAs, even though both groups identified far fewer blind children compared with WHO estimates. HSAs reported lack of time as a major constraint in identifying blind children. Based on these findings using HSAs for identifying blind children would not be successful in Malawi, the authors argue. Gender differences need to be addressed in all childhood blindness programs to counteract the imbalance.
To increase the quality of service delivery in the public health sector, Tanzania has implemented the Open Performance Review and Appraisal System (OPRAS) and a new results-based payment system, Payment for Performance (P4P). This paper addresses health workers' experiences with OPRAS, expectations towards P4P and how lessons learned from OPRAS can assist in the implementation of P4P. The broader aim is to generate knowledge on health worker motivation in low-income contexts. The authors conducted focus group discussions and in-depth interviews with public health nursing staff, clinicians and administrators. Results showed a general reluctance towards OPRAS as health workers did not see the system as leading to financial gains nor did it provide feedback on performance. In contrast, great expectations were expressed towards P4P due to its prospects of topping up salaries, but the links between the two performance enhancing tools were unclear. The authors conclude that health workers respond to performance enhancing tools based on whether the tools are found appropriate or yield any tangible benefits.
As significant numbers of medical school students continue to emigrate from Malawi upon graduation, the authors of this study explored the postgraduate plans of current medical students to find out why, and to determine the extent to which their decision is influenced by their background. A self-administered questionnaire was distributed to all medical and premedical students on campus over one week and collected by an independent researcher. One hundred and forty-nine students completed the questionnaire out of a student body of 312, a response rate of 48%. When questioned on their plans for after graduation, 49% of students said they planned to stay in Malawi. However, 38.9% were planning to leave Malawi immediately upon graduation. Medical students who completed a 'premedical' foundation year at the medical school were significantly more likely to have immediate plans to stay in Malawi compared to those who completed A-levels, an advanced school-leaving qualification. The authors caution that the government’s plans to substantially upscale medical education may be undermined unless more medical students plan to work in Malawi after graduation.
In this study, researchers examined health care workers' attitudes toward sexual and reproductive health services to unmarried adolescents in Ethiopia. The study took the form of a descriptive cross-sectional survey, which was conducted among 423 health care service providers working in eastern Ethiopia in 2010. A pre-tested structured questionnaire was used to collect data. The results showed that most health workers had a positive attitude towards providing reproductive health services to unmarried adolescents, with 30% having a negative attitude. Close to half (46.5%) of the respondents were opposed to providing family planning to unmarried adolescents, while about 13% of health workers felt penal rules and regulations should be implemented against adolescents who practice pre-marital sexual intercourse. Negative attitudes were associated with being married, lower education level, being a health extension worker and lack of training on reproductive health services. The authors call for a targeted effort toward alleviating negative attitudes toward adolescent-friendly reproductive health service and re-enforcing the positive ones.
In 2011 an experienced HIV nurse from the UK was deployed for three months to act as a mentor to nurses learning to initiate antiretroviral therapy (ART) in primary care clinics in a small town in the Eastern Cape, South Africa. In this study, researchers assessed effectiveness of the mentoring process. A review of 286 existing pre-ART patient files was carried out and lost-to-follow-up HIV patients were recalled. Results showed that only 24% of patients had attended the clinics within the preceding six months and 20% had not attended for longer than two years. Two lay counsellors visited 222 patients to encourage them to return to care: of these 23% were untraceable, 4% had relocated, 10% declined and 3% had died. In the six weeks following recall, 18% of patients returned to the clinics. CD4 count testing was repeated and screening for tuberculosis (TB) and other opportunistic infections was performed for all patients. ART was initiated in 25% of patients, while isionazid prophylaxis was initiated in 45%. The cost of recall was R130 (US$16) per patient. Within six months, all clinics began providing full ART services, 17 professional nurses were mentored and they initiated ART in 55 patients. The authors conclude that mentoring played an important role in professional nurse training and support. Recall of lost-to-follow-up patients was shown to be feasible and effective in improving ART services in rural settings.
The authors of this study aimed to assess the effects on mortality, viral suppression, and other health outcomes and quality indicators of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) programme, which provides educational outreach training of nurses to initiate and represcribe ART, and to decentralise care. They undertook a pragmatic, parallel, cluster-randomised trial in South Africa between 28 January 2008 and 30 June 2010, randomly assigning 31 primary-care ART clinics to implement the STRETCH programme (intervention group) or to continue with standard care (control group). A total of 5,390 patients in cohort 1 and 3,029 in cohort 2 were in the intervention group, and 3,862 in cohort 1 and 3,202 in cohort 2 were in the control group. Median follow-up was 16.3 months in cohort 1 and 18 months in cohort 2. In cohort 1, 20% of patients analysed in the intervention group and 19% of patients in the control group with known vital status had died at the end of the trial. Time to death did not differ. In a preplanned subgroup analysis of patients with baseline CD4 counts of 201-350 cells per μL, mortality was slightly lower in the intervention group than in the control group, but it did not differ between groups in patients with baseline CD4 of 200 cells per μL or less. In cohort 2, viral load suppression 12 months after enrolment was equivalent in intervention (71%) and control groups (70%). Interpretation suggests that expansion of primary-care nurses' roles to include ART initiation and represcription can be done safely, and improve health outcomes and quality of care, but might not reduce time to ART or mortality.
This observational study was conducted to estimate the degree of internal and external brain drain among Mozambican nationals qualifying from domestic and foreign medical schools between 1980 and 2006. Data were collected 26 months apart in 2008 and 2010, and included current employment status, employer, geographic location of employment and main work duties. Results showed that of 723 qualifying physicians between 1980 and 2006, a quarter had left the public sector, of which 62.4% continued working in-country and 37.6% emigrated. Of those cases of internal migration, 66.4% worked for non-governmental organisations (NGOs), 21.2% for external funders and 12.4% in the private sector. Annual incidence of physician migration was estimated to be 3.7%, predominately to work in the growing NGO sector. An estimated 36.3% of internal migration cases had previously held senior-level management positions in the public sector. The authors conclude that internal migration is an important contributor to capital flight from the public sector, accounting for more cases of physician loss than external migration. They call on external funders and NGOs to assess how their hiring practices may undermine the very systems they seek to strengthen.
In Tanzania, the authors of this study found that increasing numbers of universities are training many more health professionals to address the country’s extreme shortage of health care workers. In 2009 six universities admitted 756 medical students, but this is still many fewer than are needed based on population growth. Tanzania’s universities have the ability to support health professionals to build and maintain critical competencies by strengthening curricula and pre-service and internship training, and providing opportunities for continuing professional development, according to the study. For example, Muhimbili University of Health and Allied Sciences (MUHAS), the oldest health sciences academic institution in Tanzania, is partnering with the University of California San Francisco to transform MUHAS's educational environment through curricula revision and faculty development. However, enhancing the educational process involves a great deal of commitment from faculty across MUHAS and will only succeed if supported by long-term institutional reform. Sharing of early lessons learned by institutions undergoing educational reform will start to build a body of knowledge and experience to inform transformation of health professions education in Tanzania and elsewhere in Africa.
Little is known in Kenya on the extent to which community health workers (CHWs) are utilised, the characteristics of families who report utilising CHWs and whether utilisation is associated with improved access to prompt and effective malaria treatment. This paper addresses this research gap by examining factors associated with utilisation of CHWs in improving access to malaria treatment among children under five years of age by women caregivers in 113 hard-to-reach and poor rural villages in Malindi and Lamu districts Results indicate an increase in reported utilisation of CHWs as source of advice/treatment for child fevers from 2% to 35%, accompanied by a decline in care-seeking from government facilities (from 67% to 48%) and other sources (26% to 2%) including shops. The most poor households and poor households reported higher utilisation of CHWs at 39.4% and 37.9% respectively, compared to the least poor households (17%). Prompt access to timely and effective treatment was 5.7 times higher when CHWs were the source of care sought. The authors conclude that the utilisation of CHWs in improving access to malaria treatment at the community level will not only enhance access to treatment by the poorest households but also provide early and appropriate treatment to vulnerable individuals, especially those living in hard to reach areas.