Human Resources

Community health workers and accountability: reflections from an international “think-in”
Schaaf M; Fox J; Topp S; et al: International Journal for Equity in Health 17(66) 1-5, 2018

Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and as a means for improvement in health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” This jointly authored commentary resulted from the authors’ deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. Several propositions were made for further conceptual development and research related to the question of CHWs and accountability.

Community-based training of medical students is associated with malaria prevention and treatment seeking behaviour for children under 5 years in Uganda: a study of MESAU-MEPI COBERS in Uganda
Obol J; Akera P; Ochola P; et al: BMC Medical Education 18(131), doi:, 2018

This paper seeks to assess if targeted community-based medical education programme is associated with better prevention and treatment seeking behaviours in the management of malaria, a leading cause of morbidity and mortality of children under five in Uganda. A cross-sectional survey was done to compare communities around health facilities where medical students were placed at community-based education and Research Service (COBERS) sites with communities around similar health facilities where medical students were not placed (non-COBERS sites). The authors randomly selected two villages near each health facility and consecutively selected 10 households per village for interviews using nearest-neighbour method. The authors used a structured questionnaire to interview household heads on malaria prevention and treatment seeking behaviour for children under 5 years. The authors performed univariate analysis to determine site and demographic characteristics and performed a multivariate logistic regression to assess association between dependent and independent variables. Five hundred twenty-three of the children under 5 years in COBERS communities slept under insecticide treated nets the night before survey compared with 1451 in non-COBERS communities. 100 of children under 5 years in COBERS communities sought care for fever within 24 h of onset compared with 268 in non-COBERS communities. The presence of COBERS in communities is associated with improved malaria prevention and treatment-seeking behaviour for parents of children under 5 years. Further study needs to be done to determine the long-term impact of COBERS training program on malaria control and prevention in Uganda, along with its other effects.

Grandmothers help to scale up mental health care
Fleck F, Chibanda D: Bulletin of the World Health Organisation 96(66), doi:, 2018

Dixon Chibanda developed the Friendship Bench approach to mental health care in Zimbabwe. In this interview he tells Fiona Fleck how he is taking the innovative approach to other countries. The idea of the Friendship Bench arose when he lost a patient to suicide in 2005. After identifying a large burden of mental health conditions, Chibanda talked to the authorities, but they had no money, staff or facilities to offer. So in 2007 he worked with 14 grandmothers in Mbare, a suburb of Harare that was badly affected by the clearance operation of informally built suburbs in the city. The grandmothers were from the community and already doing community work and the friendship bench formalized their role. The first four years were focused on developing a culturally appropriate evidence-based intervention that they could deliver. They developed a problem-solving therapy in the local language drawing on familiar concepts in the local culture while incorporating elements of cognitive behavioural therapy. Together with the grandmothers, they came up with key terms – kuvhura pfungwa, which means opening the mind, kusimudzira, (uplifting), and kusimbisa(strengthening) – that formed the basis of the Friendship Bench approach. The benches are outside each health facility, initially they were set apart, but now they are quite public, because the programme is widely accepted in the communities. Harare has more than 53 primary health care facilities, each with one to four of these benches. When people come to these facilities seeking mental health services, they are screened with the Shona Symptoms Questionnaire 14 to determine the level of mental health disorders and referred to the grandmothers –lay health workers who have been trained and who are supervised by health professionals. Chibanda’s own grandmother lived in Mbare and – although she was not one the therapists – she was instrumental in coming up with the income generating component of the approach, which is an important part of the group peer support. After finishing sessions on the bench, the grandmothers sit in a circle and share the challenges they face with their colleagues, while crocheting bags with recycled plastic to sell. Now, after completing therapy, the grandmothers give their patients further support and show them how to make the bags, as a forum for problem solving and income generation. In Zimbabwe, the approach has been scaled up in more than 70 communities in Harare, Chitungwiza and Gweru and further roll out is taking place, with a component for adolescents under development. The approach is being rolled out in Tanzania, the USA, Canada, Australia and New Zealand.

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,, 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.

Nursing education challenges and solutions in Sub Saharan Africa: an integrative review
Bvumbwe T; Mtshali N: BMC Nursing, 17:3,, 2018

This integrative review examined literature on nursing education challenges and solutions in Sub Saharan Africa to inform development of a model for improving the quality, quantity and relevance of nursing education at local level through a search of online libraries. Twenty articles and five grey sources were included. The findings of the review generally support World Health Organisation framework for transformative and scale up of health professions education. Six themes emerged; curriculum reforms, profession regulation, transformative teaching strategies, collaboration and partnership, capacity building and infrastructure and resources. Challenges and solutions in nursing education are common within countries. The review shows that massive investment by development partners is resulting in positive development of nursing education in Sub Saharan Africa. However, strategic leadership, networking and partnership to share expertise and best practices are argued from the evidence to be critical. The authors propose that Sub Saharan Africa needs more reforms to increase capacity of educators and mentors, responsiveness of curricula, strongly regulatory frameworks, and availability of infrastructure and resources.

Practitioner Expertise to Optimize Community Health Systems: Harnessing Operational Insight
Ballard M; Schwarz R; Johnson A; et al: Community Health Worker Impact, USA, 2017

To harness the potential of community health workers (CHWs) to extend health services to poor and marginalized populations the authors argue that there is a need to better understand how CHW programs can be optimized. This paper presents the experience of and insights from application by selected organizations that have developed high-impact CHW programs with governments and communities in different countries globally. They present a series of design principles that, in their experience, drive programmatic quality and are debated or not commonly found in programs across the globe: CHWs must meet minimum standards before working; point of care fees should be avoided when possible; CHWs should go door to door and provide training on when to seek help; continuing training should be a requirement; CHWs should benefit from a dedicated supervisor and be paid and should be part of a strong local health system and data feedback loops.

Exploring the care provided to mothers and children by community health workers in South Africa: missed opportunities to provide comprehensive care
Wilford A; Phakathi S; Haskins L; et al: BMC Public Health 18(171), doi:, 2018

In this study the authors explored the performance of by community health workers (CHWs) providing maternal and child health services at household level and the quality of the CHW-mother interaction using observations and in-depth interviews. Fifteen CHWs and 30 mothers/pregnant women were purposively selected in three rural districts of KwaZulu-Natal, South Africa. CHWs provided appropriate and correct health information but there were important gaps in the content provided. Mothers expressed satisfaction with CHW visits and appreciation that CHWs understood their life experiences and therefore provided advice and support that was relevant and accessible. CHWs expressed concern that they did not have the knowledge required to undertake all activities in the household, and requested training and support from supervisors during household visits. The authors assert that key building blocks for a successful CHW programme are in place to provide services for mothers and children in households but further training and supervision is required if the gaps in CHW knowledge and skills are to be filled.

How to do (or not to do)… Measuring health worker motivation in surveys in low- and middle-income countries
Borghi J; Lohmann J; Dale E; et al: Health Policy and Planning 33(2) doi:, 2018

A health system’s ability to deliver quality health care depends on the availability of motivated health workers, which are insufficient in many low income settings. Increasing policy and researcher attention is directed towards understanding what drives health worker motivation and how different policy interventions affect motivation, as motivation is key to performance and quality of care outcomes. As a result, there is growing interest among researchers in measuring motivation within health worker surveys. However, there is currently limited guidance on how to conceptualize and approach measurement and how to validate or analyse motivation data collected from health worker surveys, resulting in inconsistent and sometimes poor quality measures. This paper begins by discussing how motivation can be conceptualized, then sets out the steps in developing questions to measure motivation within health worker surveys and in ensuring data quality through validity and reliability tests. The paper also discusses analysis of the resulting motivation measure/s.

The gendered health workforce: mixed methods analysis from four fragile and post-conflict contexts
Witter S; Namakula J; Wurie H; et al.: Health Policy and Planning 32(Suppl 5) v52–v62 2017

The authors examine the experiences of health workers through a gender lens, especially in fragile and post-conflict states. In these contexts, there may not only be opportunities to (re)shape occupational norms and responsibilities in the light of challenges in the health workforce, but also threats that put pressure on resources and undermine gender balance, diversity and gender responsive human resources for health (HRH). The authors used a mixed method for research in Sierra Leone, Zimbabwe, northern Uganda and Cambodia to understand how gender influences the health workforce. They applied a gender analysis framework to explore access to resources, occupations, values, and decision-making and draw largely on life histories with male and female health workers to explore their lived experiences, complemented by surveys, document reviews, key informant interviews, human resource data and stakeholder mapping. The findings shed light on patterns of employment: in all contexts women predominate in nursing and midwifery cadres, are under-represented in management positions and are clustered in lower paying positions. Gendered power relations shaped by caring responsibilities at the household level affect attitudes to rural deployment and women in all contexts face challenges in accessing both pre- and in-service training. Coping strategies within conflict emerged as a key theme, with experiences shaped by gender, poverty and household structure. Most health worker regulatory frameworks did not sufficiently address gender concerns. The authors argue that unless these are proactively addressed post-crisis, health workforces will remain too few, poorly distributed and unable to meet the health needs of vulnerable populations. Practical steps need to be taken to identify gender barriers proactively and engage staff and communities on best approaches for change.

How do health workers experience and cope with shocks? Learning from four fragile and conflict-affected health systems in Uganda, Sierra Leone, Zimbabwe and Cambodia
Witter S; Wurie H; Chandiwana P; et al.: Health Policy and Planning 32(Suppl 3) iii3–iii13, 2017

This article is grounded in a research programme which set out to understand how to rebuild health systems post-conflict. Four countries were studied—Uganda, Sierra Leone, Zimbabwe and Cambodia—which were at different distances from conflict and crisis, as well as having unique conflict stories. The authors captured insights from 128 life histories and in-depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict-affected contexts. The authors examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political-economic crises), and how staff coped. They find that the impact of shocks and coping strategies are similar between conflict/post-conflict and epidemic contexts—particularly in relation to physical threats and psychosocial threats—while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but important gaps were found which point to ways in which they should be better protected and supported in the future.