This study attempts to assess if and how informal payments occur in Kibaha, Tanzania. Moreover, it aims to assess how informal earnings might help boost health worker motivation and retention. Nine focus groups were conducted in three health facilities of different levels in the health system. In total, 64 health workers participated in the focus group discussions (81% female, 19% male) and, where possible, focus groups were divided by cadre. Participants mentioned that they felt enslaved by patients as a result of being bribed and this resulted in loss of self-esteem, with fear of detection as a main demotivating factor. Informal payments were not found to be related to retention of health workers in the public health system. The findings suggest that the practice of informal payments contributes to the general demotivation of health workers and negatively affects access to health care services and quality of the health system. Policy action is needed.
Human Resources
This review provides a comprehensive overview of the most important studies addressing the recruitment and retention of doctors in rural and remote areas. A comprehensive search identified 1,261 references and, of these, 110 articles were included. Available evidence was classified into five intervention categories: selection, education, coercion, incentives and support. The review argues for the formulation of universal definitions for the above categories 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.
In January, 2009, the World Health Organization’s (WHO) Executive Board considered the adoption of a global code of practice to address the movement of health workers from developing countries, the ‘WHO Draft Code of Practice for the International Recruitment of Health Workers’. This attention to brain drain is welcome, but the initiative does not begin to adequately address the consequences or roots of health-worker migration from sub-Saharan Africa to the rich developed world, especially to the United Kingdom, United States and Canada. The movement of skilled health workers constitutes a major transfer of riches from poor societies to the affluent, and the only appropriate redress is a bilaterally managed scheme of direct reimbursement of the value lost, along the lines proposed by Mensah and colleagues in 2005.
This study was conducted to review the effectiveness of lay counsellors in addressing staff shortages and the provision of HIV counselling and testing services. Quantitative and qualitative data were collected by means of semistructured interviews from all active lay counsellors in each of the facilities, including a facility manager or counselling supervisor, and through focus group discussions with health care workers at each facility. The study found that lay counsellors provide counselling and testing services of quality and relieve the workload of overstretched health care workers, providing up to 70% of counselling and testing services at health facilities. The data review revealed lower error rates for lay counsellors, compared to health care workers, in completing the counselling and testing registers.
This study aimed to describe perceptions of medical students, recent medical graduates, faculty of the College of Medicine, University of Malawi and private medical practitioners (PMPs) towards an attachment of undergraduate medical students in private medical doctors' offices. A qualitative cross-sectional study was conducted in Blantyre, Malawi in 2004 using in-depth key informant interviews and content analysis. In general, private medical practitioners were favourable to the idea of having medical students within their consulting offices while the majority of students, recent graduates and faculty opposed, fearing compromising teaching standards. Private medical practitioners (PMPs) were seen as outdated in skills and knowledge. Faculty, medical students and recent graduates of the Malawi College of Medicine do not perceive PMPs as a resource to be tapped for the training of medical students.
This paper set out to estimate systematically the inflow and outflow of health workers in Africa and examine whether current levels of pre-service training in the region suffice to address this serious problem. Most data came from the 2005 WHO health workforce and training institutions' surveys. The study was restricted to 12 countries in sub-Saharan Africa. It found that the health workforce shortage in Africa is even more critical than previously estimated. In 10 of the 12 countries studied, current pre-service training is insufficient to maintain the existing density of health workers once all causes of attrition are taken into account - it would take 36 years for physicians and 29 years for nurses and midwives to reach WHO's recent target of 2.28 professionals per 1,000 population for the countries taken as a whole - and some countries would never reach it.
As part of ART services expansion in Lusaka, Zambia, this study implemented a comprehensive task-shifting programme among existing health providers and community-based workers. It provides on-going quality assessment using key indicators of clinical care quality at each site. Programme performance is reviewed with clinic-based staff quarterly. When problems are identified, clinic staff members design and implement specific interventions to address targeted areas. Ongoing quality assessment demonstrated improvement across clinical care quality indicators, despite rapidly growing patient volumes. The task-shifting strategy was designed to address current health care worker needs and to sustain ART scale-up activities. While this approach has been successful so far, long-term solutions to the human resource crisis are urgently needed.
Researchers conducted a cost-benefit analysis of a health care education scholarship that is conditional on the recipient committing to work for several years after graduation delivering ART in sub-Saharan Africa. Such a scholarship could address two of the main reasons for the low numbers of health workers in sub-Saharan Africa: low education rates and high emigration rates. Conditional scholarships for a HAHW team sufficient to provide ART for 500 patients have an expected net present value (eNPV) of US$1.24 million per year. The eNPV of the education effect of the scholarships is larger than eNPV of the migration effect. Policy makers should consider implementing ‘conditional scholarships’ for HAHW, especially in countries where health worker education capacity is currently underutilised or needs to be rapidly expanded.
This study examined the relationship between doctor and nurse concentrations and utilisation rates of six essential health services in developing countries: antenatal care, attended delivery, caesarean section, measles immunisation, tuberculosis case diagnosis and care for acute respiratory infection. It found that nurses were associated with high levels of utilisation of skilled birth attendants and doctors were associated with high measles immunisation rates, but neither were associated with the remaining four services. It is plausible that other health workers, such as clinical officers and community health workers, may be providing a substantial proportion of these health services, which means that the human resources for health research agenda must be expanded to include these other workers.
Through distance education, the School of Public Health of the University of the Western Cape, South Africa has provided access to master's level public health education for health professionals from more than 20 African countries while they remain in post. Since 2000, interest has increased overwhelmingly to a point where four times more applications are received than can be accommodated. This brief paper describes the innovative aspects of the programme, offering some evaluative indications of its impact, and reviews how the delivery of text-led distance learning has helped realise the objectives of public health training. Strategies are proposed for scaling up such a programme to meet the growing need for health professional development in Africa.