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.
Human Resources
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.
African medical schools have historically turned to northern partners for technical assistance and resources to strengthen their education and research programmes. In 2010, this paradigm shifted when the United States Government brought forward resources to support African medical schools. The Medical Education Partnership Initiative (MEPI) triggered a number of south-south collaborations between medical schools in Africa. This paper examines the goals of these partnerships and their impact on medical education and health workforce planning, through semi-structured interviews were conducted with the Principal Investigators of the first four MEPI programmes. All of the consortia have prioritised efforts to increase the quality of medical education, support new schools in-country and strengthen relations with government. These in-country partnerships have enabled schools to pool and mobilise limited resources creatively and generate locally-relevant curricula based on best-practices. The established schools are helping new schools by training faculty and using grant funds to purchase learning materials for their students. The consortia have strengthened the dialogue between academia and policy-makers enabling evidence-based health workforce planning. All of the partnerships are expected to last well beyond the MEPI grant as a result of local ownership and institutionalisation of collaborative activities. The consortia demonstrate a paradigm shift in the relationship between medical schools. While schools in Africa have historically worked in silos, competing for limited resources, MEPI funding has created a culture of collaboration, with positive impact reported on the quality and efficiency of health workforce training. It suggests that future funding for global health education should prioritise such south-south collaborations.
There has been a resurgence of interest in national Community Health Worker (CHW) programs in low- and middle-income countries (LMICs). A lack of strong research evidence persists, however, about the most efficient and effective strategies to ensure optimal, sustained performance of CHWs at scale. To facilitate learning and research to address this knowledge gap, the authors developed from document review and consultations a generic CHW logic model that proposes a theoretical causal pathway to improved performance. The logic model draws upon available research and expert knowledge on CHWs in LMICs. The generic CHW logic model posits that optimal CHW performance is a function of high quality CHW programming, which is reinforced, sustained, and brought to scale by robust, high-performing health and community systems, both of which mobilize inputs and put in place processes needed to fully achieve performance objectives. Multiple contextual factors can influence CHW programming, system functioning, and CHW performance.The model is argued to offer new thinking about CHWs. It places CHW performance at the center of the discussion about CHW programming, recognizes the strengths and limitations of discrete, targeted programs, and is comprehensive, reflecting the current state of both scientific and tacit knowledge about support for improving CHW performance. It offers guidance for continuous learning about what works.
The Community Health Workers (CHWs) Programme was launched in Luanda, Angola, in 2007 as an initiative of the provincial government. The aim of this study was to assess its implementation process. This is a case study using document analysis, CHWs reports, individual interviews and focal groups. Until June 2009, the programme had placed in the community 2548 trained CHWs, providing potential coverage for 261 357 families. Analysis of qualitative data suggested an association of CHWs with improvements in maternal and child access to health care, as well as an increase in the demand for health services, generating further need to improve service capacity. Nevertheless, critical points for programme sustainability were identified. For continuity and scaling up, the programme needs medium- and long-term technical, political and financial support.
At health facilities of the Zambian Defence Forces, a performance and quality improvement approach was implemented to improve HIV-related care and was evaluated in 2010/2011. Changes in providers’ work environment and perceived quality of HIV-related care were assessed to complement data on provider performance. The intervention involved on-site training, supportive supervision, and action planning focusing on detailed service delivery standards. The quasi-experimental evaluation collected pre- and post-intervention data from eight intervention and comparison facilities matched on defence force branch and baseline client volume. The intervention group providers reported improvements in the work environment on adequacy of equipment, feeling safe from harm, confidence in clinical skills, and reduced isolation, while the comparison group reported worsening of the work environment on supplies, training, safety, and departmental morale. The performance and quality improvement intervention implemented at Zambian Defence Forces’ health facilities was associated with improvements in providers’ perceptions of work environments consistent with the intervention’s focus on commodities, skills acquisition, and receipt of constructive feedback.
Most African countries lack the required workforce to deliver basic health care, including care for mothers and children. This is especially acute in rural areas and has limited countries' abilities to meet maternal, newborn, and child health (MNCH) targets outlined by Millennium Development Goals 4 and 5. To address the challenges, evidence-based deployment and training policies are required. However, the resources available to country-level policy makers to create such policies are limited. A scoping review was conducted to identify the type, extent, and quality of evidence that exists on workforce policies for rural MNCH in Africa. Fourteen electronic health and health education databases were searched for peer-reviewed papers specific to training and deployment policies for doctors, nurses, and midwives for rural MNCH in African countries with English, Portuguese, or French as official languages. Non-peer reviewed literature and policy documents were also identified through systematic searches of selected international organizations and government websites. There was an overall paucity of information on workforce training and deployment policies for MNCH in rural Africa. Policies focusing exclusively on training or deployment were limited; most documents focused on both training and deployment or were broader with embedded implications for workforce management or MNCH. Relevant government websites varied in functionality and in the availability of policy documents.
In this new piece, Remco van de Pas and Linda Mans, researchers in public health, draw attention to a key chapter, titled ‘The Global Health Workforce Crisis’, of the latest edition of the Alternative World Health Report, Global Health Watch 4. They argue that overcoming the health work force gap is one of the key lessons we should learn from the current Ebola outbreak.
The chapter of GHW4 discusses how 'ceilings’ in the public wage bill imposed by the International Monetary Fund in Africa have contributed to migration of health workforce from the continent towards northern countries. It provides shocking numbers on the cost of health workforce training to governments in the south, and corresponding subsidy to governments in the north. The chapter also highlights that concerns of ‘economic efficiency’ threaten reducing health workers' role to undertaking selective diagnosis and treatment. It concludes that a strong health workforce, supported by public funds, is a requirement for strong, universal health systems.