Human Resources

Integration of eye health into primary care services in Tanzania: a qualitative investigation of experiences in two districts
Jolley E; Mafwiri M; Hunter J; et al: BMC Health Services Research 17(1), doi:10.1186/s12913-017-2787-x, 2017

This study seeks to understand how eye health services are delivered by primary health workers who have received training and what constraints remain to effective service provision. A qualitative investigation into the experiences of 20 primary health workers trained in primary eye care and eight key informants working within specialist eye health services or regional and district health management positions in two districts in Tanzania. Despite feeling confident in their own eye care skills, most primary health workers felt constrained in the services they could provide to their communities by insufficient resources needed for diagnosis and treatment, and by lack of systematic supportive supervision to their work. Specialist ophthalmic staff were aware of this issue, although for the most part they felt it was not within their capacity to remedy and that it fell within the remit of general health managers. Many participants discussed the low support to eye health from the national government, evidenced through the lack of dedicated funding to the area and traditional reliance on outside funds including international charities. The authors noted that although training of primary health workers is useful, it is not sufficient to address the burden of eye health disease present in rural communities in Tanzania. It is likely that broader engagement with the general health system, and most likely with the private sector, will be necessary to improve the coverage of eye health care to remote and poor communities such as those in Morogoro.

Women on the move: migration, care work and health
World Health Organisation: WHO, Geneva, 2017

Care workers - who are largely migrant women, often working in informal home settings - make a considerable contribution to public health in many countries but are themselves exposed to health risks, face barriers to accessing care, and enjoy few labour and social protections. This WHO report, and its reflection on potential next steps, aims to foster debate about approaches to ensure that the global community meets its obligations in relation to these care workers. The report focuses on paid home-based care workers who attend to the varied needs of children, older people, people with disabilities and the disabled and ill people.It notes that a significant knowledge gap exists when it comes to how migrant care workers’ health is influenced – both positively and negatively – by the labour they perform and the contexts in which they undertake this work. The report highlights three key steps for all countries and regions to consider to improve the health and well-being of migrant care workers and their families:1. To generate evidence on the nature of migrant care work, the contributions to global health care and the terms and conditions of their employment. 2. To improve access to health services through specific measures to address non-discrimination, promote inclusion and participation of migrant care workers. 3. Promote and recognize care as a global public good that contributes to global health and well-being. The authors advocate for holistic, universal and person-centred health and social care systems.

Optimising the benefits of community health workers' unique position between communities and the health sector: A comparative analysis of factors shaping relationships in four countries.
Kok M; Ormel H; Broerse J; et al: Global Public Health 12(11) 1404-1432, 2017

This qualitative comparative study aimed at understanding similarities and differences in how relationships between community health workers, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and community health workers’ relationships with their communities and actors in the health sector. Mechanisms influencing relationships were feelings of (dis)connectedness, (un)familiarity and serving the same goals, and perceptions of received support, respect, competence, honesty, fairness and recognition. Sometimes, constrained relationships between community health workers and the health sector resulted in weaker relationships between community health workers and communities. The broader context and programme context in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust community health worker programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. This can contribute to enabling community health workers to perform well and responding to the opportunities offered by their unique intermediary position.

Improving the performance of community health workers in Swaziland: findings from a qualitative study
Geldsetzer P; De Neve JW; Boudreaux C; et al.: Human Resources for Health 15(68)1-9, 2017

This qualitative formative research study aimed to inform the design of interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, the authors aimed to determine what leads to improved performance of CHWs. The CHW cadres studied were the rural health motivators, mothers-to-mothers mentors, HIV expert clients, and a community outreach team for HIV. Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: increased monetary compensation of CHWs, a more reliable supply of equipment and consumables, additional training, and an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as key factors.

Job satisfaction and turnover intentions among health care staff providing services for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania
Helga N; Mujinja P; Kilewo C; et al.: Human Resources for Health 15(61)1-12, 2017

From March to April 2014, a questionnaire asking about job satisfaction and turnover intentions was administered to all nurses at 36 public-sector health facilities offering antenatal and prevention of mother-to-child transmission services in Dar es Salaam, Tanzania. Slightly over half of the providers were dissatisfied with their current job, and 35% intended to leave it. Most providers were dissatisfied with low salaries and high workload, but satisfied with workplace harmony and being able to follow their moral values. The following factors were associated with providers’ intention to leave their current job: dissatisfaction at not being recognized by one’s superior, and poor feedback on the overall unit performance. Providing reasonable salaries and working hours, clearer job descriptions, appropriate safety measures, job stability, and improved supervision and feedback are argued to be key to retaining satisfied health workers for prevention of mother-to-child transmission providers.

Sharing Histories—a transformative learning/teaching method to empower community health workers to support health behaviour change of mothers
Altobelli L: Human Resources for Health 15(54)1-9, 2017

One way of improving health globally is promoting mothers’ adoption of healthy home practices for improved nutrition and illness prevention in the first 1000 days of life from conception. The challenge is how to promote learning and behaviour change of mothers more effectively in low-resource settings where access to health information is poor, educational levels are low, and traditional beliefs are strong. In addressing that challenge, a new learning/teaching method called “Sharing Histories” is in development to improve the performance of female community health workers in promoting mothers’ behaviours for maternal, neonatal and child health. This method builds self-confidence and empowerment of community health workers in learning sessions that are built on guided sharing of their own memories of childbearing and child care. Community Health Workers can later share histories with the mother, building her trust and empowerment to change. For professional primary health care staff who are not educators, Sharing Histories is simple to learn and use so that the method can be easily incorporated into government health systems and ongoing community health workers programs. The author presents the Sharing Histories method, describes how it differs from other social and behaviour change methods, and discusses selected literature from psychology, communications, and neuroscience that helps to explain how and why this method works as a transformative tool to engage, teach, transform, and empower Community Health Workers to be more effective change agents with other mothers in their communities.

Working with community health workers to improve maternal and newborn health outcomes: implementation and scale-up lessons from eastern Uganda
Namazzi G; Okuga M; Tetui M; et al.: Global Health Action 10(S4)72-81, 2017

This paper explores knowledge levels of community health workers (CHWs), describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy in eastern Uganda. The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The visits aimed to promote birth preparedness and utilization of maternal and newborn health (MNH) services. CHWs’ knowledge of MNH improved after training. However, knowledge of new born danger signs declined after a year. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57% and CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and maintained low dropout rates at 3.6%. Their challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of a means of transport, such as bicycles.

Pilot study of quality of care training and knowledge in Sub-Saharan African medical schools
Bowser D; Abbas Y; Odunleye T; et al.: International Journal of Medical Education 8, 24 doi: 10.5116/ijme.595b.b38c, 2017

This study identified the level of knowledge and competencies related to quality of care during medical education in sub-Saharan African medical schools. A cross-sectional study design was utilised to examine the capacity of medical schools in sub-Saharan African countries to teach about the concepts of quality of care and the inclusion of these concepts in their curriculum. A purposeful convenience sampling technique was used to select participants from 25 medical schools in 5 sub-Saharan African countries. Respondents included medical school deans or senior academic personnel. While 45% of the schools surveyed are teaching on at least one of the six domains of the Institute of Medicine’s definition of quality of care, there are some schools who report not teaching about quality at all, or that they “do not know”. Despite these low numbers, when asked about topics related to quality of care, many schools are teaching applied management related topics and almost all schools teach about equity and patient-centred care. The results have implications for incorporating quality of care in medical education and for practitioners. The tool developed for this study could be used in future qualitative and quantitative studies to further understanding of how to improve the teaching and learning about quality of care in medical schools.

‘I am treated well if I adhere to my HIV medication’: putting patient–provider interactions in context through insights from qualitative research in five sub-Saharan African countries
Ondenge K; Renju J; Bonnington O; et al.: Jo Sexually Transmitted Infections 93 (Issue Supplement 3), doi: http://dx.doi.org/10.1136/sextrans-2016-052973, 2017

The nature of patient–provider interactions and communication is widely documented to significantly impact on patient experiences, treatment adherence and health outcomes. Yet little is known about the broader contextual factors and dynamics that shape patient–provider interactions in high HIV prevalence and limited-resource settings. Drawing on qualitative research from five sub-Saharan African countries, the authors seek to unpack local dynamics that serve to hinder or facilitate productive patient–provider interactions. This qualitative study, conducted in Kisumu (Kenya), Kisesa (Tanzania), Manicaland (Zimbabwe), Karonga (Malawi) and uMkhanyakude (South Africa), draws upon 278 in-depth interviews with purposively sampled people living with HIV with different diagnosis and treatment histories, 29 family members of people who died due to HIV and 38 HIV healthcare workers. Data were collected using topic guides that explored patient testing and antiretroviral therapy treatment journeys. The authors analysis revealed an array of inter-related contextual factors and power dynamics shaping patient–provider interactions. These included participants’ perceptions of roles and identities of ‘self’ and ‘other’; conformity or resistance to the ‘rules of HIV service engagement’ and a ‘patient-persona’; the influence of significant others’ views on service provision; and resources in health services. They observed that these four factors/dynamics were located in the wider context of conceptualisations of power, autonomy and structure. They argue that patient–provider interaction is complex, multidimensional and deeply embedded in wider social dynamics, and that interventions to improve patient experiences and treatment adherence through enhanced interactions need to go beyond the existing focus on patient–provider communication strategies.

Non-physician clinicians in rural Africa: lessons from the Medical Licentiate programme in Zambia
Gajewski J; Mweemba C; Cheelo M; et al.: Human Resources for Health 15(53), doi: https://doi.org/10.1186/s12960-017-0233-0, 2017

Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the difficulty in retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians, medical licentiates, trained initially to the level of a higher diploma and from 2013 up to a Bachelor of Science degree. Medical licentiates have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations. This qualitative study aimed to describe the role, contributions and challenges surgically active medical licentiates have experienced. Based on 43 interviewees, it includes the perspective of medical licentiates, their district hospital colleagues—medical officers, nurses and managers; and surgeon-supervisors and national stakeholders. In Zambia, medical licentiates play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with medical officers, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, medical licentiates often face professional recognition problems and tensions around relationships with medical officers that impact their ability to utilise their surgical skills. The paper provides new evidence concerning the benefits of ‘task shifting’ and identifies challenges that need to be addressed if medical licentiates are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use non-physician clinicians to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.

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