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.
Human Resources
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.
Ethiopia is preparing for a major influx of medical doctors within three to four years, as government intends to save a public health system that has been losing doctors and specialists to internal and external migration. Medical schools report enrollment of more than 3,100 students, representing a tenfold increase from 2005, when less than 300 students enrolled. A draft of the country's Human Resource for Health Strategic Plan shows an intended increase in the number of physicians to 1 per 5,000 people by 2020. The plan seems on course, with a report presented to parliament in May 2012 revealing that 2,628 students had been enrolled in 22 universities over the previous nine months. Currently fewer than 200 doctors graduate annually. With the strong emphasis on health personnel numbers, experts have expressed concerns about the quality of medical education, a allegation that the Health Minister acknowledges, adding that government is taking steps to strengthen training of doctors through the Medical Education Partnership Initiative (MEPI), networking with known universities in the United States and offering students incentives to study further.
Salaries and other benefits are an obvious pull factor towards foreign countries, given the often-extreme differences in wages internationally. The introduction of the Occupation Specific Dispensation (OSD) in 2007 sought to address the challenge of high levels of South African health workers migrating overseas. In this study, researchers evaluate the effectiveness of the OSD by comparing salaries of health workers in South Africa with their counterparts in developed countries. Using a representative basket of commonly bought goods (including food, entertainment, fuel and utilities), they used a purchasing power parity (PPP) ratio to adjust earnings in order measure real differences in salaries. Their results showed that salaries of most South African health workers, particularly registered nurses, are dwarfed by their international counterparts, notably in the United States, Canada and Saudi Arabia, although the OSD has gone some way to reduce that disparity. These countries generally offer higher salaries on a PPP-adjusted basis, while other foreign countries also show large salary advantages if health workers emigrated. Given that their findings suggest that the OSD has narrowed the gap between South African and overseas salaries, the authors call for further research into the push factors underlying high levels of worker out-migration in the country.
In 2006, the World Health Organization (WHO) reported that 57 countries, most of them in Africa and Asia, face a severe health workforce crisis. They estimate that over 2 million health service providers and 1.8 million management support workers are needed to fill the gap (WHO, 2009). Health workers play a critical role in the effective delivery of health services, especially in high disease-burdened countries like South Africa. Constraints in the health workforce have emerged as a key obstacle to scaling-up access to prevention and treatment for the 5.7 million people currently living with HIV/AIDS in South Africa. A recent strategic plan, released in 2012 by the South African government, aims to address the gaps in human resources for health and is expected to mitigate the resource shortage within the next 15 to 25 years. This report analyses the plan and proposes that actors in other health systems, especially those in high HIV-burden, low-resource countries, may be able to learn from the forthcoming experience of implementing the strategy in South Africa.