Human Resources

Health System Factors Constrain HIV Care Providers in Delivering High-Quality Care: Perceptions from a Qualitative Study of Providers in Western Kenya
Genberg B; Wachira J; Kafu C; Wilso I; et al: Journal of the International Association of Providers of AIDS Care 18, 1-10, 2019

This study examined the experiences of HIV care providers in a high patient volume HIV treatment and care program in Western Kenya on health system factors that impact patient engagement in HIV care. Results from thematic analysis demonstrated that providers perceive a work environment that constrained their ability to deliver high-quality HIV care and encouraged negative patient–provider relationships. Providers described their roles as high strain, low control and low support. The study revealed that health system strengthening must include efforts to improve the working environment for providers tasked with delivering antiretroviral therapy to increasing numbers of patients in resource-constrained settings.

Gender equity in the health workforce: Analysis of 104 countries
Boniol M; McIsaac M; Xu Lihui; Wuliji T; et al: Health Workforce Working paper 1, World Health Organisation, 2019

The health and social sector, with its 234 million workers, is one of the biggest and fastest growing employers in the world, particularly of women. Women comprise seven out of ten health and social care workers and contribute US$ 3 trillion annually to global health, half in the form of unpaid care work. While gender issues have been at the top of the global agenda, few comprehensive studies on gender in the health and social workforce have been conducted at the global level. This brief is based on an analysis of WHO NHWA data5 for 104 countries over the last 18 years. The analysis confirms previous findings that women’s share of employment in the health and social sector is high, with an estimated 67% of the health workforce in the 104 countries analysed being female. Analysis based on median wages from 21 countries showed health workers face gender-related gaps in pay, with female health workers earning, on average, 28% less than males. This is slightly greater than global estimates of gender pay gap data, showing that women are paid approximately 22% less than men. Data from 56 countries showed higher average working hours per week for men than women for most occupations and regions. This likely reflects different type of contracts, with more part-time jobs occupied by women. Women represent around 70% of the health workforce, but earn on average 28% less than men. Occupational segregation (10%) and working hours (7%) can explain most of this gap, but even when considering “equal work” an “equal pay” gap of 11% remains. The authors note that it must be recognized that much of the work in health done by women is unpaid work and that investments in creating decent work in the health sector are needed to support the translation of informal work into formal sector employment.

A systematic review on occupational hazards, injuries and diseases among police officers worldwide: Policy implications for the South African Police Service
Mona G; Chimbari M; Hongoro C: Journal of Occupational Medicine and Toxicology 14(2), doi:, 2019

Occupational hazards, injuries and diseases are a major concern among police officers, including in Sub-Saharan Africa. However, there is limited locally relevant literature for guiding policy for police services. A review was done to describe the occupational hazards, injuries and diseases affecting police officers worldwide, in order to benchmark policy implications for local police services. Police officers’ exposure to accident hazards may lead to acute or chronic injuries such as sprains, fractures or fatalities. These hazards may occur during driving, patrol or riot control. Physical hazards such as noise induced hearing loss (NIHL) arise due to exposure to high levels of noise. Exposure to high concentrations of carbon dioxide and general air pollution was associated with cancer, while physical exposure to other chemical substances was linked to dermatitis. There is a risk of exposure to blood borne diseases from needle stick injuries (NSIs) or cuts from contaminated objects. Musculoskeletal disorders can result from driving long distances and lifting heavy objects, while there is also a risk of post-traumatic stress disorder (PTSD), stress and burnout.

Stakeholders’ perceptions of policy options to support the integration of community health workers in health systems
Ajuebor O; Cometto G; Boniol M; Akl E: Human Resources for Health 17(13) 1-13, 2019

This study assesses stakeholders’ valuation of acceptability and feasibility of policy options considered for the CHW guideline development. A cross-sectional mixed methods study targeting stakeholders involved directly or indirectly in country implementation of community health workers programmes was conducted in 2017. Data was collected from 96 stakeholders from five World Health Organization regions using an online questionnaire. A Likert scale was used to grade participants’ assessments of the outcomes of interest, and the acceptability and feasibility of policy options were considered. All outcomes of interest were considered by at least 90% of participants as ‘important’ or ‘critical’. Most critical outcomes were ‘improved quality of community health workers health services’ and ‘increased health service coverage. Out of 40 policy options, 35 were considered as ‘definitely acceptable’ and 36 ‘definitely feasible’ by most participants. The least acceptable option was the selection of candidates based on age. The least feasible option was the selection of community health workers with a minimum of secondary education.

Strategic leadership capacity building for Sub-Saharan African health systems and public health governance: a multi-country assessment of essential competencies and optimal design for a Pan African DrPH
Agyepong I; Lehmann U; Rutembemberwa E: Health Policy and Planning 33 (1) (suppl 2), ii35-ii49, 2018

Leadership capacity needs development and nurturing at all levels for strong health systems governance and improved outcomes. The Doctor of Public Health (DrPH) is a professional, interdisciplinary degree focused on strategic leadership capacity building. The concept is not new and there are several programmes globally, but none within Africa, despite its urgent need for strong strategic leadership in health. To address this gap, a consortium of institutions in Sub-Saharan Africa, UK and North America have embarked on a collaboration to develop and implement a pan-African DrPH. This paper presents findings of research to verify relevance, identify competencies and support programme design and customisation. A mixed methods cross sectional multi-country study was conducted in Ghana, South Africa and Uganda. Data collection involved a non-exhaustive desk review, 34 key informant (KI) interviews with past and present health sector leaders and a questionnaire with closed and open ended items administered to 271 potential DrPH trainees. Most study participants saw the concept of a pan-African DrPH as relevant and timely. Strategic leadership competencies identified by KI included providing vision and inspiration for the organisation, core personal values and character qualities such as integrity and trustworthiness, skills in adapting to situations and context and creating and maintaining effective change and systems. There was consensus that programme design should emphasise learning by doing and application of theory to professional practice. Short residential periods for peer-to-peer and peer-to-facilitator engagement and learning, interspaced with facilitated workplace based learning, including coaching and mentoring, was the preferred model for programme implementation.

Challenges to tuberculosis control in Angola: the narrative of medical professionals
Brady P; Vita D: Journal of Public Health 40(4) 820–826, 2018

This study interviewed healthcare workers involved in tuberculosis (TB) control on what they consider to be the drivers of the TB epidemic in Angola. Twenty four in-depth qualitative interviews were conducted with medical staff working in this field in the provinces of Luanda and Benguela. The healthcare professionals see the migrant working poor as a particular problem for the control of TB. Migrants are constructed as ‘Rural People’ and are seen as non-compliant and late-presenting. This is a stigmatized and marginal group contending with the additional stigma associated with TB infection. The healthcare professionals interviewed also see the interruption of treatment and self-medication generally as a better explanation for the TB epidemic than urbanization or lack of medication. The local narrative is in contrast to explanations used elsewhere. To be effective policy must recognize the local issues of the migrant workforce, interruption of treatment and the stigma associated with TB in Angola.

Coming Full Circle: How Health Worker Motivation and Performance in Results-Based Financing Arrangements Hinges on Strong and Adaptive Health Systems
Kane S; Gandidzanwa C; Mutasa R; et al: International Journal of Health Policy and Management 8(2), doi: 10.15171/ijhpm.2018.98, 2018

This paper presents findings from a study which sought to understand why health workers working under the results-based financing (RBF) arrangements in Zimbabwe reported being satisfied with the improvements in working conditions and compensation, but paradoxically reported lower motivation levels compared to those not working under RBF arrangements. A qualitative study was conducted amongst health workers and managers working in health facilities that were implementing the RBF arrangements and those that were not. Through purposeful sampling, 4 facilities in RBF implementing districts that reported poor motivation and satisfaction, were included as study sites. Four facilities located in non-RBF districts which reported high motivation and satisfaction were also included. Data was collected through in-depth interviews and analyzed using the framework approach. Findings reveal that insufficient preparedness of people and processes for this change, constrained managers and workers performance. Results based financing arrangements introduce explicit and tacit changes, including but not limited to, incentive logics, in the system. Findings show that unless systematic efforts are made to enable the absorption of these changes in the system: eg, through reconfiguring the decision space available at various levels, through clarification of accountability relationships, through building personnel and process capacities, before instituting changes, the full potential of the RBF arrangements cannot be realised. This study demonstrates the importance of analysing existing institutional, management and governance arrangements and capabilities and taking these into account when designing and implementing RBF interventions. Introducing RBF arrangements cannot alone overcome chronic systemic weaknesses. For a system wide change, as RBF arguably is, to be effected, explicit organisational change management processes need to be put in place, across the system. The authors argue that carefully designed processes, which take into account the interest and willingness of various actors to change, and which are cognizant of and constructively engage with potential bottlenecks and points of resistance, should accompany any health system change initiative.

Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi
Angwenyi V; Aantjes C; Kondowe K; Mutchiyeni J; et al: British Medical Journal Global Health 3(e000996) 1-10, 2018

This paper reviews Malawi’s strategy, with particular focus on the interface between health surveillance assistants (HSAs), volunteers in community-based programmes and the community health team. The authors analysis identified key challenges that may impede the strategy’s implementation inadequate training, imbalance of skill sets within community health team (CHT) and unclear job descriptions for community health volunteers (CHVs); proposed community-level interventions require expansion of pre-existing roles for most CHT members; and district authorities may face challenges meeting financial obligations and filling community-level positions. For effective implementation, attention and further deliberation is argued to be needed on the appropriate CHV support, CHT composition with possibilities of co-opting trained CHVs from existing volunteer programmes into CHTs, review of CHT competencies and workload and strengthening coordination and communication across all community actors.

Ready to deliver maternal and newborn care? Health providers’ perceptions of their work context in rural Mozambique
Mocumbi S; McKee K; Munguambe K; Chiau R; et al: Global Health Action, 11(1) 1-13, 2018

In this paper, the authors investigated the comprehensibility and the internal reliability of Context Assessment for Community Health and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique. The cross-sectional survey using Context Assessment for Community Health, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique. Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the work culture, leadership, and Informal payment dimensions.

Reflecting strategic and conforming gendered experiences of community health workers using photovoice in rural Wakiso district, Uganda
Musoke D; Ssemugabo C; Ndejjo R; et al: Human Resources for Health 16(41) 1-9, 2018

This paper explores the differential roles of male and female Community health workers (CHWs)in rural Wakiso district, Uganda, using photovoice, a community-based participatory research approach. The authors trained ten CHWs on key concepts about gender and photovoice. The CHWs took photographs for 5 months on their gender-related roles which were discussed in monthly meetings. The discussions from the meetings were recorded, transcribed, and translated to English, and emerging data were analysed using content analysis. Although responsibilities were the same for both male and female CHWs, they reported that in practice, CHWs were predominantly involved in different types of work depending on their gender. Social norms led to men being more comfortable seeking care from male CHWs and females turning to female CHWs. Due to their privileged ownership and access to motorcycles, male CHWs were noted to be able to assist patients faster with referrals to facilities during health emergencies, cover larger geographic distances during community mobilization activities, and take up supervisory responsibilities. Due to the gendered division of labour in communities, male CHWs were also observed to be more involved in manual work such as cleaning wells. The gendered division of labour also reinforced female caregiving roles related to child care, and also made female CHWs more available to address local problems. CHWs reflected both strategic and conformist gendered implications of their community work. The authors argue that the differing roles and perspectives about the nature of male and female CHWs while performing their roles should be considered while designing and implementing CHW programmes, without further retrenching gender inequalities or norms.