Undergraduate global health teaching has seen a marked growth over the past ten years, partly as a response to student demand and partly due to increasing globalisation, cross-border movement of pathogens and international migration of health care workers. In this study, researchers carried out a survey of medical schools across the world in an effort to analyse their teaching of global health. Results indicate that global health teaching is moving away from its previous focus on tropical medicine towards issues of more global relevance. The authors suggest that there are three types of doctor who may wish to work in global health - the 'globalised doctor', 'humanitarian doctor' and 'policy doctor' - and that each of these three types will require different teaching in order to meet the required competencies. This teaching needs to be inserted into medical curricula in different ways, notably into core curricula, a special developing countries track, optional student selected components, elective programmes, optional intercalated degrees and postgraduate study. The authors argue that teaching of global health in undergraduate medical curricula must reflect the social, political and economic causes of ill health.
Human Resources
To stem the loss of skilled health workers from developing countries, there has recently been an increase in the number of regional Codes of Practice and bilateral Memoranda of Understanding to achieve more effective, equitable and ethical international migration of workers, culminating in the finalisation of the World Health Organisation’s Global Code for Health Worker Recruitment in 2010. Despite this, the authors of this paper point out that there is no agreed definition of ethical international recruitment, and no consensus on the significance and location of harmful recruitment practices. Most codes they analysed covered relatively few regions and exhibited a high degree of generality. Migration, they found, occurs in contexts that do not necessarily involve health issues. Limitations were identified: there are no incentives for recipient countries and agencies to be involved in ethical international recruitment and all codes are voluntary, which has restricted their impact. At the same time, the private sector is effectively excluded from codes. Bilateral agreements and memoranda have a greater chance of success, the authors note, enabling managed migration and return migration, but are more geographically limiting. The most effective constraints to the unregulated flow of skilled health workers are the production of adequate numbers in present recipient countries and provision of improved employment conditions in source countries.
This paper presents policy-makers and programme managers with key considerations for a model to improve the work environment as an important approach to increase community health worker (CHW) productivity and, ultimately, the effectiveness of community-based strategies. Researchers conducted a desk review of selective published and unpublished articles and reports on CHW programmes in developing countries to identify the elements that influence CHW productivity. They found that CHW productivity is determined in large part by the conditions under which they work. Attention to the provision of an enabling work environment for CHWs is essential for achieving high levels of productivity. They present a model in which the work environment encompasses four essential elements: workload, supportive supervision, supplies and equipment, and respect from the community and the health system. Establishing a balance among the four elements that constitute a CHW’s work environment will help make great strides in improving the effectiveness and quality of the services provided by CHWs.
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.
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.