Human Resources

Weak Links in the Chain II: A Prescription for Health Policy in Poor Countries

In an earlier article, the authors outline some reasons for the disappointingly small effects of primary health care programs and identified two weak links standing between spending and increased health care. The first was the inability to translate public expenditure on health care into real services due to inherent difficulties of monitoring and controlling the behavior of public employees. The second was the "crowding out" of private markets for health care, markets that exist predominantly at the primary health care level. This article presents an approach to public policy in health that comes directly from the literature on public economics. It identifies two characteristic market failures in health. The first is the existence of large externalities in the control of many infectious diseases that are mostly addressed by standard public health interventions. The second is the widespread breakdown of insurance markets that leave people exposed to catastrophic financial losses. Other essential considerations in setting priorities in health are the degree to which policies address poverty and inequality and the practicality of implementing policies given limited administrative capacities. Priorities based on these criteria tend to differ substantially from those commonly prescribed by the international community.

What do community health workers have to say about their work, and how can this inform improved programme design? A case study with CHWs within Kenya
Oliver M; Geniets A; Winters N; Rega I; Mbae S: Global Health Action 8, May 2015, doi: http://dx.doi.org/10.3402/gha.v8.27168

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.

What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers
Scott K; Beckham S; Gross M; et al: Human Resources for Health 16(39) 1-17, 2018

The paper synthesizes the current understanding of how community-based health worker programs can best be designed and operated in health systems. The authors searched 11 databases for review articles published between January 2005 and June 2017. The authors identified 122 reviews, 83 from low- and middle-income countries, 29 from high income countries and 10 global. Community-based health worker programs included in these reviews are diverse in interventions provided, selection and training of community-based health workers, supervision, remuneration, and integration into the health system. Features that enable positive community-based health worker program outcomes include community embeddedness, supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of community-based health worker programs into health systems can bolster program sustainability and credibility, clarify community-based health worker roles, and foster collaboration between community-based health workers and higher-level health system actors. The authors found gaps in the review evidence, including on the rights and needs of community-based health workers, on effective approaches to training and supervision, on community-based health workers as community change agents, and on the influence of health system decentralization, social accountability, and governance.

What elements of the work environment are most responsible for health worker dissatisfaction in rural primary care clinics in Tanzania?
Mbaruku GM, Larson E, Kimweri A and Kruk ME: Human Resources for Health (12)38: August 2014

In countries with high maternal and newborn morbidity and mortality, reliable access to quality healthcare in rural areas is essential to save lives. Health workers who are satisfied with their jobs are more likely to remain in rural posts. Understanding what factors influence health workers' satisfaction can help determine where resources should be focused. Although there is a growing body of research assessing health worker satisfaction in hospitals, less is known about health worker satisfaction in rural, primary health clinics. This study explores the workplace satisfaction of health workers in primary health clinics in rural Tanzania. Overall, 70 health workers in rural Tanzania participated in a self-administered job satisfaction survey. Results showed that 73.9% of health workers strongly agreed that they were satisfied with their job; however, only 11.6% strongly agreed that they were satisfied with their level of pay and 2.9% with the availability of equipment and supplies. Two categories of factors emerged from the PCA: the tools and infrastructure to provide care, and supportive interpersonal environment. Nurses and medical attendants (compared to clinical officers) and older health workers had higher satisfaction scale ratings. Two dimensions of health workers' work environment, namely infrastructure and supportive interpersonal work environment, explained much of the variation in satisfaction among rural Tanzanian health workers in primary health clinics. Health workers were generally more satisfied with supportive interpersonal relationships than with the infrastructure. Human resource policies should, it is argued, consider how to improve these two aspects of work as a means for improving health worker morale and potentially rural attrition

What if we decided to take care of everyone who needed treatment? Workforce planning in Mozambique using simulation of demand for HIV/AIDS care
Hagopian A, Micek MA, Vio F, Gimbel-Sherr K and Montoyo P: Human Resources for Health 6(3), 7 February 2008

The growing AIDS epidemic in southern Africa is placing an increased strain on health systems, which are experiencing rising steadily patient loads. Health care systems are tackling the barriers to serving large populations in scaled-up operations. One of the most significant challenges in this effort is securing the health care workforce to deliver care in settings where the manpower is already in short supply. A demand-driven staffing model is presented in this study using simple spreadsheet technology, based on treatment protocols for HIV-positive patients that adhere to Mozambican guidelines. The model can be adjusted for the volumes of patients at differing stages of their disease, varying provider productivity, proportion who are pregnant, attrition rates, and other variables.

What is the point of the point-of-care? A case study of user resistance to an e-health system
Whittaker L, van Zyl J and Soicher AS: Telemedicine and e-Health 17(1): 55-61, 6 February 2011

The purpose of this article is to explore the responses of nurses to a point-of-care e-health system that was implemented in a large private hospital in South Africa, to find out why the nursing staff rejected the implementation of the system. The authors of the study examined user responses with reference to a model designed to account for the use and adoption of mobile handheld devices, having adapted the model for an e-health context. In addition to the input features of technological characteristics and individual differences identified in the model, the added features of nursing culture and group differences were found to be influential factors in fuelling the nurses' resistance to the point-of-care system. Nurses perceived a lack of cultural fit between the system and their work. Their commitment to their nursing culture meant that they were not prepared to adapt their processes to integrate the system into their work, believing it might reduce quality of care. The study shows that the model is useful for understanding adoption in an organisational context and also that the additional elements of nursing culture and group differences are important in an e-health context.

What should the African health workforce know about disasters? Proposed competencies for strengthening public health disaster risk management education in Africa
Olu O, Usman A, Kalambay K, et al.: BMC Medical Education, 18; 60, https://doi.org/10.1186/s12909-018-1163-9, 2018

As part of efforts to implement the human resources capacity building component of the African Regional Strategy on Disaster Risk Management (DRM) for the health sector, the African Regional Office of the World Health Organization, in collaboration with selected African public health training institutions, followed a multistage process to develop core competencies and curricula for training the African health workforce in public health DRM. In this article, we describe the methods used to develop the competencies, present the identified competencies and training curricula, and propose recommendations for their integration into the public health education curricula of African member states. The authors identified 14 core competencies and 45 sub-competencies/training units grouped into six thematic areas: 1) introduction to DRM; 2) operational effectiveness; 3) effective leadership; 4) preparedness and risk reduction; 5) emergency response and 6) post-disaster health system recovery. These were defined as the skills and knowledge that African health care workers should possess to effectively participate in health DRM activities. To suit the needs of various categories of African health care workers, three levels of training courses are proposed: basic, intermediate, and advanced.

WHO alliance aims to tackle the world's lack of health workers
Rehwagen C: British Medical Journal 332:1294, 3 June 2006

A new global partnership that aims to improve the world's shortage of doctors, nurses, midwives, and other health workers was launched at last week's World Health Assembly in Geneva. The announcement came six weeks after the World Health Organization made the issue a priority in its annual report, in which it called for a global action plan to tackle the shortage of an estimated 4.2 million health workers.

Further details: /newsletter/id/31583
Who are CHWs? An ethnographic study of the multiple identities of community health workers in three rural Districts in Tanzania
Rafiq M; Wheatley H; Mushi H; Baynes C: BMC Health Services Research 19(712) 1-15, 2019

unity health workers (CHWs) possess multiple, overlapping roles and identities, which makes them effective primary health care providers when properly supported with adequate resources. This also limits their ability to implement interventions that only target certain members of their community and prevents them from performing certain duties when it comes to sensitive topics such as family planning. To understand the multiple identities of CHWs qualitative and ethnographic methods involved participant observation, open-ended and semi-structured interviews and focus group discussions with CHWs, their supervisors, and their clients between October 2013 and June 2014 in Rufiji, Ulanga and Kilombero Districts in Tanzania. The findings suggest that it is difficult to distinguish between personal and professional identities among CHWs in rural areas. Important aspects of CHW services such as personalization, access, and equity of health services were influenced by CHWs’ position as local agents. However, the study also found that their personal identity sometimes inhibited CHWs in speaking about issues related to family planning and sexual health. Being local, CHWs were viewed according to the social norms of the area that consider the gender and age of each worker, which tended to constrain their work in family planning and other areas. Furthermore, the communities welcomed and valued CHWs when they had curative medicines; however, when medical stocks were delayed, the community viewed the CHWs with suspicion and disinterest. Community members who received curative services from CHWs also tended to become more receptive to their preventative health care work. Although CHWs’ multiple roles constrained certain aspects of their work in line with prevalent social norms, overall, the multiple roles they fulfilled had a positive effect by keeping CHWs embedded in their community and earned them trust from community members, which enhanced their ability to provide personalized, equitable and relevant services. However, CHWs needed a support system that included functional supply chains, supervision, and community support to help them retain their role as health care providers and enabled them to provide curative, preventative, and referral services.

WHO D-G: Shortage of health workers in developing countries undermines essential services, including treatments for HIV/AIDS, TB, malaria
Kaiser Network, 5 April 2007

Thousands of health care professionals have left their homes in developing nations in search of higher paying jobs in wealthier countries, Reuters reports. According to WHO's World Health Report 2006, there is a shortage of more than four million health care workers in 57 developing countries. The report said one-quarter of physicians and one in 20 nurses trained in Africa currently work in 30 industrialized countries included in the Organization for Economic Cooperation and Development. Sub-Saharan Africa has 24% of the global disease burden but only 3% of the health care workforce worldwide and accounts for less than 1% of global health care spending, the report said. The Americas have 10% of the global disease burden, 37% of the health care workforce and account for more than half of global health care spending, the report found.

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