This presentation is based on a literature review that was carried out as part of a research collaboration between the School of Public Health Wits University and the African Population Health Research Centre, Nairobi, Kenya, with feedback from colleagues in Kenya, Uganda, Nigeria and South Africa. The review found that mid-level workers (MLWs) were active in 25 of the 47 sub-Saharan African countries reviewed: 18 countries had non-nurse based programmes for training secondary school leavers, which avoided depleting scarce ranks of nurses. MLWs were treated as second-best or a temporary stop gap until enough physicians were trained, instead of being recognised as key front line health workers responsible for care of their communities. Problems affecting MLWs were identified as: poor work environment; perceptions of resource inadequacy, with staff members indicating that they had neither sufficient staff nor time to do their work; poor pay and low status; inadequate management support and a sense of not being valued by their managers; and burnout, emotional exhaustion and low personal accomplishment. The presentation cautions that increasing numbers of MLWs is not a solution on its own. Accompanying investment is needed in supervision, district team strengthening, morale building and training. Recognition, career and skills development are strong motivators for MLWs, while positive feedback from patients is valued and seen as indicator of professional conduct. The need for professionalisation of MLWs is also underscored.
Human Resources
This study presents an innovative approach to healthcare worker (HCW) training using mobile phones as a personal learning environment. Twenty physicians used individual Smartphones, each equipped with a portable solar charger. A set of 3D learning scenarios simulating interactive clinical cases was developed and adapted to the Smartphones for a continuing medical education programme lasting three months. A mobile educational platform supporting learning events tracked participant learning progress. Learning outcomes were verified through mobile quizzes using multiple choice questions at the end of each module. Training, supervision and clinical mentoring of health workers are the cornerstone of the scaling up process of HIV and AIDS care in resource-limited settings. Educational modules on mobile phones can give flexibility to HCWs for accessing learning content anywhere. However lack of software interoperability and the high investment cost for the Smartphones' purchase could represent a limitation to the wide spread use of such learning programmes.
This compendium of examples of promising practices for evidence-based planning and decision-making for dealing with the HIV pandemic is based on the premise that building national strategic information (SI) and monitoring and evaluation (M&E) capacity requires supportive policies for health workers, as well as organisational and leadership development and individual technical capacity development. The promising practices cover the core components of SI (M&E; surveys and surveillance; and health management information systems, including geographical information systems) and span six ‘action fields’ (policy, leadership, partnership, finance, human resource management systems and education) to provide a comprehensive lens through which to strategically plan for and implement M&E workforce strengthening initiatives. By examining the experiences in detail, reviewing available results and supporting materials as well as considering the implementation context, users of the compendium may be able to identify approaches worth testing in their own countries. While the list of practices is by no means exhaustive or representative, it does provide an important starting point upon which to build a more comprehensive learning resource for human resources capacity building for effective HIV M&E systems and strategic information.
Retaining health workers in rural facilities remains a major challenge facing South Africa and other developing nations. But an initiative in the Western Cape shows that the challenge of retaining health workers in rural facilities can be overcome. After unsuccessful attempts by Tygerberg Hospital to recruit and retain rural health workers, the hospital decided to open a nursing college in the Boland region, a large farming area nearby. Helise Schumann, who co-ordinates the activities of the college, pointed out that 70% of all nursing staff in the Boland area (about 800 nursing staff) have been trained through the school. The school uses a step-ladder approach by first starting with training the school’s own staff, like cleaners, porters, food services aid and laundry staff, so they could qualify as nursing assistants. Neighbouring facilities, like Worcester and a number of district hospitals, also owe their staffing levels to the nursing college. She says the college follows a strict selection process when recruiting candidates. The nursing college trains up to 100 students per year. It targets unemployed people and school leavers.
Physician anaesthetists are scarce in many developing countries and not available at first referral level health facilities. According to this article, the shortage exists because there is not enough recognition of the need for surgical and anaesthesia services at all levels of the health system and their potential to reduce mortality and morbidity. As a result, there is a serious lack of equitable services in developing countries, especially in rural and remote areas. Creating awareness through better documentation of the burden of disease, in terms of death and disability that can be prevented by availability of surgical and anaesthesia services, would be an important step to generate political commitment and local investments in education, training and retention of the health workforce. This needs to be followed up by appropriate policies, legislation, and the establishment of innovative and effective anaesthesia training programmes that address both the immediate need as well as the long-term needs of the health system.
There is currently limited published evidence of health-related training programmes in Africa that have produced graduates, who remain and work in their countries after graduation. However, anecdotal evidence suggests that the majority of graduates of field epidemiology training programmes (FETPs) in Africa stay on to work in their home countries, many as valuable resources to overstretched health systems. In this study, alumni data from African FETPs were reviewed in order to establish graduate retention. Retention was defined as a graduate staying and working in their home country for at least three years after graduation. African FETPs are located in a number of African countries – this paper only includes the Uganda and Zimbabwe FETPs, as all the others are recent programmes. The review shows that enrolment increased over the years, and that there is high graduate retention, with 85.1% of graduates working within country of training, mostly for Ministries of Health and non-governmental organisations. Retention of graduates with a medical undergraduate degree was slightly higher than for those with other undergraduate qualifications. The paper concludes that African FETPs have unique features which may explain their high retention of graduates, including: programme ownership by ministries of health and local universities; well defined career paths; competence-based training coupled with a focus on field practice during training; awarding degrees upon completion; extensive training and research opportunities made available to graduates; and the social capital acquired during training.
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.
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.