The Institute of Development Studies (IDS) partnered with ActionAid International (AAI) in Uganda to develop and implement an advocacy strategy to make unpaid care work more visible in public policy, as well as to integrate unpaid care issues into each country’s programming. It used an action learning methodology to look at what works and does not work in making the care economy more visible. It aimed to track and capture changes in policy and practice in order to improve understanding around the uptake of evidence. This report covers the progress of the programme in Uganda over the first two and a half years of the four-year programme. The work identified that making unpaid care work more visible calls for a collective voice amongst those involved and engaging and working effectively with the media with clear messaging.
Human Resources
Community health workers (CHWs) are often spoken about or for, but there is little evidence of CHWs’ own characterisation of their practice. This paper addresses this issue. A case study approach was undertaken in a series of four steps. Firstly, groups of CHWs from two communities met and reported what their daily work consisted of. Secondly, individual CHWs were interviewed so that they could provide fuller, more detailed accounts of their work and experiences; in addition, community health extension workers and community health committee members were interviewed, to provide alternative perspectives. Thirdly, notes and observations were taken in community meetings and monthly meetings. The data were then analysed thematically, creating an account of how CHWs describe their own work, and the tensions and challenges that they face. CHWs’ accounts of both successes and challenges involved material elements: leaky tins and dishracks evidenced successful health interventions, whilst bicycles, empty first aid kits and recruiting stretcher bearers evidenced the difficulties of resourcing and geography they are required to overcome. CHWs described their work was as healthcare generalists, working to serve their community and to integrate it with the official health system. Their work involves referrals, monitoring, reporting and educational interactions. Whilst they face problems with resources and training, their accounts show that they respond to this in creative ways, working within established systems of community power and formal authority to achieve their goals, rather than falling into a ‘deficit’ position that requires remedial external intervention. Their work is widely appreciated, although some households do resist their interventions, and figures of authority sometimes question their manner and expertise. The material challenges that they face have both practical and community aspects, since coping with scarcity brings community members together. The authors suggest that programmes co-designed with CHWs will be easier to implement because of their relevance to their practices and experiences, whereas those that seek to use CHWs as an instrument to implement external priorities are likely to disrupt their work.
Mobile health (mHealth) applications, such as innovative electronic forms on smartphones, could potentially improve the performance of health care workers and health systems in developing countries. A pretested semistructured questionnaire was used to assess health workers’ experiences, barriers, preferences, and motivating factors in using mobile health forms on smartphones in the context of maternal health care in Ethiopia. Twenty-five health extension workers (HEWs) and midwives, working in 13 primary health care facilities in Tigray region, Ethiopia, participated in this study. Sixteen (69.6%) workers believed the forms were good reminders on what to do and what questions needed to be asked. Twelve (52.2%) workers said electronic forms were comprehensive and 9 (39.1%) workers saw electronic forms as learning tools. All workers preferred unrestricted use of the smartphones and believed it helped them adapt to the smartphones and electronic forms for work purposes. Identified barriers for not using electronic forms consistently included challenges related to electronic forms and smartphones and health system issues such as frequent movement of health workers. Both HEWs and midwives found the electronic forms on smartphones useful for their day-to-day maternal health care services delivery. However, tyhe authors found that sustainable use and implementation of such work tools at scale would be daunting without providing technical support to health workers, securing mobile network airtime and improving key functions of the larger health system.
New medical schools in Africa have developed curricula that include community and rural health components, long-term family attachments, and admission processes that are more equitable for disadvantaged students. These worthwhile innovations have been incorporated in previous reforms of medical education, but the authors ask in this paper if they are sufficient to meet the challenges of achieving universal health care.
Tanzania suffers a severe shortage of pharmaceutical staff negatively affecting the provision of pharmaceutical services and access to medicines, particularly in rural areas. Task shifting has been proposed as a way to mitigate this. This study aimed to understand the context and extent of task shifting in pharmaceutical management in Dodoma Region, Tanzania. The authors explored 1) the number of trained pharmaceutical staff as compared to clinical cadres managing medicines, 2) the national establishment for staffing levels, 3) job descriptions, 4) supply management training conducted and 5) availability of medicines and adherence to Good Storage Practice in 270 public health facilities in 2011. In 95.5% of studied health facilities medicines management was done by non-pharmaceutically trained cadres, predominantly medical attendants. Task shifting was found to be a reality in the pharmaceutical sector in Tanzania occurring mainly as a coping mechanism rather than a formal response to the workforce crisis. Pharmacy-related tasks and supply management were informally shifted to clinical staff without policy guidance, explicit job descriptions, and without the necessary support through training. It was argued that implicit task shifting be recognised and formalised and job orientation, training and operational procedures be used to support non-pharmaceutical health workers to effectively manage medicine supply.
Nurses have long been identified as key contributors to strategies to reduce health inequalities. This qualitative research project explored public health nurse educators’ understanding of public health as a strategy to reduce health inequalities. 26 semi-structured interviews were conducted with higher education institution-based public health nurse educators. Public health nurse educators described health inequalities as the foundation on which a public health framework should be built. Two distinct views emerged of how health inequalities should be tackled: some proposed a population approach focusing on upstream preventive strategies, whilst others proposed behavioural approaches focusing on empowering vulnerable individuals to improve their own health. Despite upstream interventions to reduce inequalities in health being proved to have more leverage than individual behavioural interventions in tackling the fundamental causes of health inequalities, some nurses have a better understanding of individual interventions than population approaches.
Like many sub-Saharan African countries, Malawi is facing a critical shortage of skilled healthcare workers. In response to this crisis, a formal cadre of lay health workers (LHW) has been established and now carries out several basic health care services, including outpatient TB care and adherence support. While ongoing training and supervision are recognised as essential to the effectiveness of LHW programs, information is lacking as to how these needs are best addressed. The objective of this qualitative study was to explore LHWs responses to a tailored knowledge translation intervention they received, designed to address a previously identified training and knowledge gap. Forty-five interviews were conducted with 36 healthcare workers. Fourteen to sixteen interviews were done at each of 3 evenly spaced time blocks over a one year period, with 6 individuals interviewed more than once to assess for change both within and across individuals overtime. Reported benefits of the intervention included: increased TB, HIV, and job-specific knowledge; improved clinical skills; and increased confidence and satisfaction with their work. Suggestions for improvement were less consistent across participants, but included: increasing the duration of the training, changing to an off-site venue, providing stipends or refreshments as incentives, and adding HIV and drug dosing content. Despite the significant departure of the study intervention from the traditional approach to training employed in Malawi, the intervention was well received and highly valued by LHW participants. Given the relative low-cost and flexibility of the methods employed, this appears a promising approach to addressing the training needs of LHW programs, particularly in Low- and Middle-income countries where resources are most constrained.
Approximately a third of the world population – and about half in the most underdeveloped settings – have been estimated to lack access to essential medicines and diagnostics. Effective supply chains are vital to deliver essential health commodities. In high-income countries the availability of medicines in the public and private sector is taken as a given: quality assurance is managed by robust national regulatory agencies; supply and distribution are increasingly privatised, with performance measured against timeliness and cost. Conversely, in many low- and middle-income countries, stock-outs of essential commodities are commonplace, with a mean availability of core medicines in the public sector ranging from 38.2% in sub-Saharan Africa to 57.7 % in Latin America and the Caribbean. Vulnerability of supply chain functions also increases the potential for the entry of counterfeit and substandard products.
Nurses have long been identified as key contributors to strategies to reduce health inequalities. This raises questions about: convergence between policy makers’ and nurses’ understanding of how inequalities in health are created and sustained and educational preparation for the role as contributors in reducing health inequalities. This qualitative research project determined public health nurse educators’ understanding of public health as a strategy to reduce health inequalities, through semi-structured interviews. Public health nurse educators described health inequalities as the foundation on which a public health framework should be built. Two distinct views emerged of how health inequalities should be tackled: some proposed a population approach focusing on upstream preventive strategies, whilst others proposed behavioural approaches focusing on empowering vulnerable individuals to improve their own health. Despite upstream interventions to reduce inequalities in health being proved to have more leverage than individual behavioural interventions in tackling the fundamental causes of health inequalities, some nurses have a better understanding of individual interventions than population approaches.
Sub-Saharan Africa faces a severe health worker shortage, which community health workers (CHWs) may fill. This study describes tasks shifted from clinicians to CHWs in Kenya, places monetary valuations on CHWs’ efforts, and models effects of further task shifting on time demands of clinicians and CHWs. Interviews were conducted with 28 CHWs and 19 clinicians in 17 health facilities throughout Kenya. Twenty CHWs completed task diaries over a 14-day period to examine current CHW tasks and the amount of time spent performing them. A modelling exercise was conducted examining a current task-shifting example and another scenario in which additional task shifting to CHWs has occurred. CHWs worked an average of 5.3 hours per day and spent 36% of their time performing tasks shifted from clinicians. The authors estimated a monthly valuation of US$ 117 per CHW. The modelling exercise demonstrated that further task shifting would reduce the number of clinicians needed while maintaining clinic productivity by significantly increasing the number of CHWs. The authors’ argue that this costing of CHW contributions raises evidence for discussion, research and planning regarding CHW compensation and programmes.