Results from the AIDS Treatment for Life International Survey (ATLIS 2010), a multi-country survey of more than 2,000 people living with HIV/AIDS (PLWHA), were presented at the International AIDS Conference in Vienna, held from 19–23 July 2010. The results revealed a significant gap in patient-physician dialogue about critical health-related conditions that may negatively impact patients’ overall long-term health, quality of life, and treatment outcomes. While the ATLIS 2010 findings showed a high degree of patient satisfaction with HCPs globally (97%), and the majority of patients believe they are being treated according to their individual needs (84%), some respondents claim to have never engaged in important discussions related to their long-term wellness, such as health history, present medical conditions, treatment side effects, new treatment options, or how all of these factors may impact their overall health and treatment outcomes. The report calls for more in-depth discussions to reinforce the importance of adherence to HIV medicines and avoidance of HIV drug resistance. The main findings were that co-morbid conditions are increasingly affecting PLWHAs, there is a critical need for patient literacy in treatment adherence and drug resistance, and that side effects caused by anti-retrovirals need to be monitored closely.
Human Resources
This paper reports and analyses health workforce responses in Malawi and Zambia during a period of large increases in global health initiative (GHI) funds. Health facility record reviews were conducted in 52 facilities in Malawi and 39 facilities in Zambia in 2006/07 and 2008, as well as interviews with staff. Facility data confirmed significant scale-up in HIV and AIDS service delivery in both countries. In Malawi, this was supported by a large increase in lower trained cadres and only a modest increase in clinical staff numbers. In Zambia, total staff and clinical staff numbers stagnated between 2004 and 2007. Key informants described the effects of increased workloads in both countries and attributed staff migration from public health facilities to non-government facilities in Zambia to PEPFAR. Malawi, which received large levels of GHI funding from only the Global Fund, managed to increase facility staff across all levels of the health system: urban, district and rural health facilities, supported by task-shifting to lower trained staff. The more complex GHI arena in Zambia, where both Global Fund and PEPFAR provided large levels of support, may have undermined a coordinated national workforce response to addressing health worker shortages, leading to a less effective response in rural areas.
The World Health Organization’s (WHO) recommendations focus on education, regulatory mechanisms, financial incentives, and personal and professional support. In terms of education, WHO recommends that countries use targeted admission policies to enrol students with a rural background in education programmes to increase the likelihood of graduates choosing to practise in rural areas. Undergraduate students should be exposed to rural community experiences and clinical rotations and study curricula should be revised to include rural health topics. Regulatory recommendations include introducing and regulating enhanced scopes of practice in rural and remote areas to increase the potential for job satisfaction. Compulsory service requirements in rural and remote areas should be accompanied with appropriate support and incentives to increase recruitment and subsequent retention of health professionals in these areas. Governments should use a combination of fiscally sustainable financial incentives, such as hardship allowances, grants for housing, free transportation and paid vacations, to improve rural retention. Personal and professional support should also be offered by improving living conditions for health workers and their families and investing in infrastructure and services. A good and safe working environment should be provided, with sufficient equipment and supplies.
Compulsory service programmes have been used worldwide as a way to deploy and retain a professional health workforce within countries. This study identified three different types of compulsory service programmes in 70 countries. These programmes are all governed by some type of regulation, ranging from a parliamentary law to a policy within the ministry of health. Depending on the country, doctors, nurses, midwives and all types of professional allied health workers are required to participate in the programme. Some of the compliance-enforcement measures include withholding full registration until obligations are completed, withholding degree and salary, or imposing large fines. This paper aims to explain these programmes more clearly, to identify countries that have or had such programmes, to develop a typology for the different kinds and to discuss the programmes in the light of important issues that are related to policy concepts and implementation. As governments consider the cost of investment in health professionals’ education, the loss of health professionals to emigration and the lack of health workers in many geographic areas, they are using compulsory service requirements as a way to deploy and retain the health workforce.
This paper reports on two separate experiences of costing for Human Resources Development Plans (HRDP) costing in Mozambique and Guinea Bissau, with the objective of providing an insight into the practice of costing exercises in information-poor settings, as well as to contribute to the existing debate on human resources costing methodologies. The study adopts a case-study approach to analyse the methodologies developed in the two countries, their contexts, policy processes and actors involved. From the analysis of the two cases, it emerged that the costing exercises represented an important driver of the HRDP elaboration, which lent credibility to the process, and provided a financial framework within which HRH policies could be discussed. In both cases, bottom-up and country-specific methods were designed to overcome the countries' lack of cost and financing data, as well as to interpret their financial systems. Such an approach also allowed the costing exercises to feed directly into the national planning and budgeting process. The authors conclude that bottom-up and country-specific costing methodologies have the potential to serve adequately the multi-faceted purpose of the exercise. However, adopting pre-defined and insufficiently flexible tools may undermine the credibility of the costing exercise, and reduce the space for policy negotiation opportunities within the HRDP elaboration process.
This review of human resources in the health sector indicates that the African Region is faced with severe shortages of doctors and nurses, with only 590,198 health workers against an estimated requirement of 1,408,190 health workers. This situation is compounded by inappropriate skill mixes and gaps in service coverage. The estimated critical shortages of doctors, nurses and midwives is over 800,000. The problem is more severe in rural and remote areas where most people typically live in the countries in the African Region. This review provides information about the efforts and commitments by World Health Organization Member States and the various opportunities created by regional and global partners, including the progress made. The paper also explores issues and challenges related to the underlying factors of the health worker crisis, such as chronic underinvestment in health systems development in general, and specifically in human resources for health development, migration of skilled health personnel as a result of poor working conditions and remuneration, lack of evidence-based strategic planning, insufficient production of health workers and poor management systems.
According to this paper, about 59 million people make up the health workforce of paid full-time health workers world-wide. However, enormous gaps remain between the potential of health systems and their actual performance, and there are far too many inequities in the distribution of health workers between countries and within countries. Sub-Saharan Africa, with about 11% of the world’s population, bears over 24% of the global disease burden, is home to only 3% of the global health workforce, and spends less than 1% of the world’s financial resources on health. In most developing countries, the health workforce is concentrated in the major towns and cities, while rural areas can only boast of about 23% and 38% of the country’s doctors and nurses respectively. The imbalances exist not only in the total numbers and geographical distribution of health workers, but also in the skills mix of available health workers. Countries in sub-Saharan Africa would need to increase their health workforce by about 140% to achieve enough coverage for essential health interventions to make a positive difference in the health and life expectancy of their populations. The paper argues that the global health workforce crisis can be tackled if there is global responsibility, political will, financial commitment and public-private partnership for country-led and country-specific interventions that seek solutions beyond the health sector. Only when enough health workers can be trained, sustained and retained in sub-Saharan African countries will there be meaningful socio-economic development and the faintest hope of attaining the Millennium Development Goals in the sub-continent.
The authors of this study developed a model to forecast the size of the public sector health workforce in Zambia over the next ten years to identify a combination of interventions that would expand the workforce to meet staffing targets. The key forecasting variables are training enrolment, graduation rates, public sector entry rates for graduates, and attrition of workforce staff. With no changes to current training, hiring, and attrition conditions, the total number of doctors, clinical officers, nurses, and midwives will increase from 44% to 59% of the minimum necessary staff by 2018. No combination of changes in staff retention, graduation rates, and public sector entry rates of graduates by 2010, without including training expansion, is sufficient to meet staffing targets by 2018 for any cadre except midwives. Training enrolment needs to increase by a factor of between three and thirteen for doctors, three and four for clinical officers, two and three for nurses, and one and two for midwives by 2010 to reach staffing targets by 2018. Necessary enrolment increases can be held to a minimum if the rates of retention, graduation, and public sector entry increase to 100% by 2010, but will need to increase if these rates remain at 2008 levels.
According to this review, researchers and policymakers in the past have paid little attention to the role of health workers in developing countries but a new generation of studies are providing a fuller understanding of these issues using more sophisticated data and research tools. The review refers to recent research that views health workers as active agents in dynamic labour markets who are faced with many competing incentives and constraints. Studies using this approach appear to provide greater insights into human resource requirements in health, the motivations and behaviours of health workers and health worker migration. The review urges for more high-quality research on the role of health workers in developing countries.
The objective of this paper was to understand the factors influencing health workers’ choice to work in rural areas as a basis for designing policies to redress geographic imbalances in health worker distribution. Data from a cohort survey of 412 nursing and medical students in Rwanda was used to examine the determinants of future health workers’ willingness to work in rural areas as measured by rural reservation wages. The data was combined with data from an identical survey in Ethiopia to enable a two-country analysis. The research found that health workers with higher intrinsic motivation – measured as the importance attached to helping the poor – as well as those who had grown up in a rural area and Adventists who had participated in a local bonding scheme were all significantly more willing to work in a rural area. The main result for intrinsic motivation in Rwanda was strikingly similar to the result obtained for Ethiopia and Rwanda combined. In conclusion, intrinsic motivation and rural origin play an important role in health workers’ decisions to work in a rural area, in addition to economic incentives, while faith-based institutions can also influence the decision.