This paper summarises the literature on e-learning in low- and middle-income countries (LMIC), and presents the spectrum of tools and strategies used. Using standard decision criteria, reviewers narrowed the article suggestions to a final 124 relevant articles. Of the relevant articles found, most referred to e-learning in Brazil (14 articles), India (14), Egypt (10) and South Africa (10). While e-learning has been used by a variety of health workers in LMICs, most (58%) reported on physician training, while 24% focused on nursing, pharmacy and dentistry training. Blended learning approaches were the most common methodology presented (49 articles) of which computer-assisted learning (CAL) comprised the majority (45 articles). Other approaches included simulations and the use of multimedia software (20 articles), web-based learning (14 articles), and eTutor/eMentor programmes (3 articles). The authors conclude that e-learning in medical education is a means to an end, rather than the end in itself. Utilising e-learning can result in greater educational opportunities for students while simultaneously enhancing faculty effectiveness and efficiency. However, this potential of e-learning assumes a certain level of institutional readiness in human and infrastructural resources that is not always present in LMICs.
In Tanzania, the authors of this study found that increasing numbers of universities are training many more health professionals to address the country’s extreme shortage of health care workers. In 2009 six universities admitted 756 medical students, but this is still many fewer than are needed based on population growth. Tanzania’s universities have the ability to support health professionals to build and maintain critical competencies by strengthening curricula and pre-service and internship training, and providing opportunities for continuing professional development, according to the study. For example, Muhimbili University of Health and Allied Sciences (MUHAS), the oldest health sciences academic institution in Tanzania, is partnering with the University of California San Francisco to transform MUHAS's educational environment through curricula revision and faculty development. However, enhancing the educational process involves a great deal of commitment from faculty across MUHAS and will only succeed if supported by long-term institutional reform. Sharing of early lessons learned by institutions undergoing educational reform will start to build a body of knowledge and experience to inform transformation of health professions education in Tanzania and elsewhere in Africa.
The Global Assessment of Functioning (GAF) is the standard method and an essential tool for representing a clinician’s judgment of a patient’s overall level of psychological, social and occupational functioning. It is probably the single most widely used method for assessing impairment among the patients with psychiatric illnesses. The authors of this study set out to assess the effects of one-hour training on application of the GAF by Psychiatric Clinical Officers’ in a Ugandan setting. They randomly selected five psychiatrists and five psychiatric clinical officers (PCOs) or assistant medical officers who hold a two-year diploma in clinical psychiatry to take part. Before receiving an hour of training on how to rate the GAF scale, they were asked to rate a video-recorded psychiatric interview, and they assessed the video again after training. The PCOs were then offered and asked to rate the video case interview again. Results showed that the interclass correlations (ICCs) between the psychiatrists and the PCOs before training in the past one year, at admission and current functioning were +0.48, +0.51 and +0.59 respectively. After training, the ICC coefficients were +0.60, +0.82 and +0.83. The findings of this study indicate that brief training given to PCOs improved the applications of their ratings of GAF scale to acceptable levels. There is need for formal training to this cadre of psychiatric practitioners in the use of the GAF.
Drawing on IntraHealth International's lessons learned in designing reproductive health and HIV/AIDS training and performance improvement programmes, this commentary discusses promising practices for strengthening human resources for health through more efficient and effective training and learning programmes that avoid the same old traps. These promising practices include the following: assessing performance gaps and opportunities before designing a training initiative; addressing performance factors other than skills and knowledge that health workers need to perform well; applying a ‘learning for performance’ approach; standardising curricula throughout a country; linking pre-service education, in-service training and professional associations; enhancing traditional education; strengthening human resources information systems to improve workforce planning, policies and management; and applying technology to meet training needs.
This report provides examples of professional and academic associations which work across three or more African countries, and which have some evidence of success. The author aims to identify the characteristics of these organisations which enable their success. Types of impact are varied, but are usually identified as strong membership, attendance at national or international meetings, awareness of the organisation in the wider sphere, dissemination and uptake of publications, and connection or influence on policy and policy-makers. The report particularly tries to draw out any impacts on governance in the wider public sphere, however, most of the indicators of success are input or output rather than outcome-focused, and do not identify broader social or policy change. The author emphasises the need for strongly committed individuals at the centre of the organisation, personal leadership, involvement of policy-makers and the quality of outputs. Independence and neutrality are seen as important values, allowing professional development free from politics.
Health facility supervisors are in a position to increase motivation, manage resources, facilitate communication, increase accountability and conduct outreach. This study evaluated the effectiveness of a training intervention for on-site, in-charge reproductive health supervisors in Kenya using an experimental design with pre- and post-test measures in 60 health facilities. Cost information and data from supervisors, providers, clients and facilities were collected. Regression models with the generalized estimating equation approach were used to test differences between study groups and over time, accounting for clustering and matching. Total accounting costs per person trained were calculated. The intervention resulted in significant improvements in quality of care at the supervisor, provider and client–provider interaction levels. Indicators of improvements in the facility environment and client satisfaction were not apparent. The costs of delivering the supervision training intervention totalled US$2113 per supervisor trained. In making decisions about whether to expand the intervention, the costs of this intervention should be compared with other interventions designed to improve quality.
The impact of intermittent preventive treatment (IPTp) on malaria in pregnancy is well known. However, in countries where this policy is implemented, poor access and low compliance have been widely reported. Novel approaches are needed to deliver this intervention. This paper assesses whether or not traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilisers can administer IPTp with sulphadoxine–pyrimethamine (SP) to pregnant women, reach those at greatest risk of malaria, and increase access and compliance with IPTp. The report found that the community approach was effective for the delivery of IPTp, although women still accessed and benefited from malaria treatment and other services at health units. However, the costs for accessing malaria treatment and other services are high and could be a limiting factor.
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.
Communication between non-language-concordant health care workers (HCWs) and patients has been shown by international studies to adversely affect patient and staff satisfaction, yet the authors of this study note that, to the best of their knowledge, no such intervention studies have been conducted in Africa. They conducted research in South Africa to determine whether teaching Xhosa language skills and cultural understanding to HCWs affects patient satisfaction, HCWs’ ability to communicate effectively with Xhosa-speaking patients and HCWs’ job satisfaction levels. A before-and-after interventional study was performed at two community health centres and a district hospital in the Western Cape Province. Fifty-four randomly selected patients (27 pre- and 27 post-intervention) assessed communication with HCWs and rated their satisfaction. Six non-Xhosa-speaking HCW participants completed pre- and post-intervention questionnaires. HCWs completed a ten-week basic language course consisting of ten 120-minute interactive contact sessions developing basic Xhosa speaking and listening skills and cultural competence. Results showed that patient satisfaction showed significant improvements after the intervention. Patients perceived HCWs to be more understanding, respectful and concerned, and to show better listening skills, after the intervention. They were also better able to understand HCWs and their instructions. HCWs’ ability to communicate improved and HCWs experienced decreased frustration levels.
The active recruitment of health workers from developing countries to developed countries has become a major threat to global health. In an effort to manage this migration, the 63rd World Health Assembly adopted the World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel in May 2010. While the Code has been lauded as the first globally-applicable regulatory framework for health worker recruitment, its impact has yet to be evaluated. The authors offer the first empirical evaluation of the Code’s impact on national and sub-national actors in Australia, Canada, United Kingdom and United States of America, which are the English-speaking high income countries with the greatest number of migrant health workers. Forty two key informants from across government, civil society and private sectors were surveyed. Sixty percent of respondents believed their colleagues were not aware of the Code, and 93% reported that no specific changes had been observed in their work as a result of the Code. 86% reported that the Code has not had any meaningful impact on policies, practices or regulations in their countries. This suggests a gap between awareness of the Code among stakeholders at global forums and the awareness and behaviour of national and sub-national actors. Advocacy and technical guidance for implementing the Code are needed to improve its impact on national decision- makers.