Under-resourced and poorly managed rural health systems challenge the achievement of universal health coverage, and require innovative strategies worldwide to attract healthcare staff to rural areas. One such strategy is rural health training programmes for health professionals. In addition, clinical leadership (for all categories of health professional) is a recognised prerequisite for substantial improvements in the quality of care in rural settings, argue the authors of this report. Rural health training programmes have been slow to develop in low- and middle-income countries (LMICs); and the impact of clinical leadership is under-researched in such settings. A 2012 conference in South Africa, with expert input from South Africa, Canada and Australia, discussed these issues and produced recommendations for change that will also be relevant in other LMICs. The two underpinning principles were that: rural clinical leadership (both academic and non-academic) is essential to developing and expanding rural training programs and improving care in LMICs; and leadership can be learned and should be taught. Lessons learned: The three main sets of recommendations focused on supporting local rural clinical academic leaders; training health professionals for leadership roles in rural settings; and advancing the clinical academic leadership agenda through advocacy and research. By adopting the detailed recommendations, South Africa and other LMICs could energise management strategies, improve quality of care in rural settings and impact positively on rural health outcomes, the authors conclude.
Human Resources
The authors of this paper consider the perspectives and experiences of key Mozambican public sector health managers who coordinate, implement, and manage a wide variety of donor-driven projects and agencies. Over a four-month period, they conducted 41 individual qualitative interviews with key Ministry workers at three levels in the Mozambique national health system, using open-ended semi-structured interview guides, as well as reviewed planning documents. All respondents emphasized the value and importance of international aid and vertical funding to the health sector and each highlighted program successes that were made possible by recent increased aid flows. However, three serious concerns emerged: difficulties coordinating external resources and challenges to local control over the use of resources channeled to international private organisations; inequalities created within the health system produced by vertical funds channeled to specific services while other sectors remain under-resourced; and the exodus of health workers from the public sector health system provoked by large disparities in salaries and work. The vertical approach starved the Ministry of support for its administrative functions.
On 25 May 2013, 98 community care workers representing over 50 organisations with the Community Care Workers (CCW) Forum, the Wellness Foundation and the People’s Health Movement of South Africa met to reaffirm the importance of community care workers in South Africa’s health system and to expose the terrible working conditions that many community care workers are experiencing. CCWs work in the homes of the poorest of the poor often without protective face masks, gloves and other basic materials. The People’s Health Movement calls for these CCWs to enjoy decent work conditions and receive adequate recognition. It proposes a ‘two-tier’ system like that of Thailand, where high coverage is achieved by instituting where there is one full-time CCW for every 300-500 households, who then supervises 10 part-time CCWs who have more limited training. Such high coverage of households has been shown to have a dramatic impact on health outcomes, especially of young children. The ratio currently proposed in South Africa of one CHW to 270 households is extremely unlikely to have such an effect given South Africa’s very high burden of disease, and the large percentage of people requiring time-consuming home care. In addition to rendering health care more accessible and equitable, the two-tier system would create jobs, and indirectly improve health by reducing the prevalence and depth of poverty.
In this presentation, the author assesses implementation of the World Health Organisation’s (WHO) Code for Ethical Recruitment. She reports that 32 countries achieved valuable steps towards implementing the Code. In some of these countries, actions have taken to communicate and share information across sectors, measures have been taken to involve all stakeholders in decision making processes, including actions considered to introduce to laws or policies, records are maintained of all recruiters authorised by competent authorities to operate within their jurisdiction and good practices are encouraged and promoted among recruitment agencies. In some of these countries, migrant health workers enjoy the same legal rights and responsibilities as those domestically trained, as well as the same opportunities as domestically trained to strengthen their professional education, qualifications, career development , and health personnel are recruited internationally, using mechanisms that allow to assess the benefits and risks associated with employment positions. Furthermore, 22 countries have mechanisms to regulate the authorisation to practice by internationally recruited health personnel and maintain statistical records and 11 have a database of laws and regulations related to health workforce migration and recruitment.
In this blog, the author argues that a palpable effect of Kenya’s new constitution is that it has allowed the formation of new trade unions such as the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU). Since its formation, the group has become a key stakeholder in promoting the needs of Kenyan health professionals. Another change the constitution brought about is the permission of dual citizenship, which has the potential to increase circular migration among health professionals who have previously departed the country. Finally, the new constitution prioritises the right to health in Section 43 (1) (a), noting that every Kenyan has the “right to the highest attainable standard of health which includes the right to health care services including reproductive health care.” This places a high level of expectation on the government and health care workers, creating a basis for the public to demand such a right. To convert these potential gains into practice, however, much work remains to be done, particularly in researching how the health system has responded. One of the greatest challenges the author has faced in conducting her own research on migration is in encountering stakeholders who are unwilling to cooperate either directly or indirectly, which she views as a part of a resistance to an evidence-based culture, even among some in the health sector.
The Tanzania Connect Project is a randomised cluster trial located in three rural districts with a population of roughly 360,000 ( Kilombero, Rufiji, and Ulanga). Connect aims to test whether introducing a community health worker into a general programme of health systems strengthening and referral improvement will reduce child mortality, improve access to services, expand utilisation, and alter reproductive, maternal, newborn and child health seeking behaviour; thereby accelerating progress towards Millennium Development Goals 4 and 5. Connect has introduced a new cadre — Community Health Agents (CHA) — who were recruited from and work in their communities. To support the CHAs, Connect developed supervisory systems, launched information and monitoring operations, and implemented logistics support for integration with existing district and village operations. Connect will not only address Tanzania’s need for policy and operational research, it will bridge a critical international knowledge gap concerning the added value of salaried professional community health workers in the context of a high density of fixed facilities.
In this paper, the authors explored the perspectives and experiences of key Mozambican public sector health managers who coordinate, implement, and manage the myriad donor-driven projects and agencies. Over a four-month period, they conducted 41 individual qualitative interviews with key Ministry workers at three levels in the Mozambique national health system, using open-ended semi-structured interview guides, as well as reviewed planning documents. All respondents emphasized the value and importance of international aid and vertical funding to the health sector and each highlighted program successes that were made possible by recent increased aid flows. However, three serious concerns emerged: 1) difficulties coordinating external resources and challenges to local control over the use of resources channeled to international private organizations; 2) inequalities created within the health system produced by vertical funds channeled to specific services while other sectors remain under-resourced; and 3) the exodus of health workers from the public sector health system provoked by large disparities in salaries and work. The vertical approach starved the Ministry of support for its administrative functions. Few studies have addressed the growing phenomenon of “internal brain drain” in Africa which proved to be of greater concern to Mozambique’s health managers.
To mark International Day of the Midwife (5 May), AMREF is calling on African governments to accelerate implementation of Human Resources for Health (HRH) strategies to increase the number of midwives trained and upgraded in the country, to fast track the attainment of MDG 5 (maternal mortality) in all countries where targets have not been achieved and to adopt innovative mechanisms to support the training, recruitment, deployment and retention of midwives across rural and remote areas. Governments should ensure that midwives access to the UN Commission’s 13 lifesaving commodities for women and children, including long-term family planning methods and other commodities for reproductive health, for them to be able to provide appropriate quality health services. At the same time, AMREF recommends that development partners should adopt and support innovative mechanisms for training, recruitment, deployment and retention of midwives in Africa within the post MDG priority setting processes.
According to this article, health worker density/100,000 population is substantially lower in South Africa compared to the vast majority of countries against which South Africa is benchmarked, including the BRIC (Brazil, Russia, India and China) countries. The existing higher education sector is unable to meet the graduate output required by the health sector while foreign recruitment is constrained by current legislation on the registration and practice of foreign healthcare professionals by the Professional Councils and the WHO Global Code of Practice on the International Recruitment of Health Personnel. Existing and future health workforce production is not commensurate with the healthcare needs of the country. A number of challenges are identified: health challenges have outpaced curriculum reform; fragmented, outdated, static curricula produce ill-equipped health graduates; there are episodic encounters as opposed to a continuum of care; healthcare is hospi-centric as opposed to primary healthcare based; there is narrow technical focus without contextual understanding; there exists a mismatch of competencies and patient/population needs; and there is poor teamwork. Solutions to barriers related to the quantitative aspect of health workforce production in South Africa are presented in the article.
The South African government plans to increase the number of new medical students by 10% over the three to four years, raising the total from 1,800 to 2,395 by 2016. According to the Department of Health’s chief operating officer, the department’s plan to ensure more medical students at South African universities is part of its health systems strengthening strategy and aims to address the critical shortage of public health workers in the country, particularly in rural areas.