Over the past decades, changes in economic, social and demographic structures have spurred the growth of employment in care-related occupations, according to this special edition of the International Labour Review (ILR). As a result, care workers comprise a large and growing segment of the labour force in both North and South. One impetus for much of the research and policy work in this area is a concern about the labour market disadvantages of particular segments of the care workforce (such as migrant domestic workers, elderly carers, and nursing aides). Although the issue of care work and its vulnerability is a global phenomenon, the collection of papers in the ILR pays particular attention to developing country contexts where issues of worker insecurity and exploitation are most intransigent, and where research has been sparse and data challenges are often significant. The book raises questions about who the care workers are, whether they are recognised as workers, how their wages compare to those of other workers with similar levels of education and skill, the conditions under which they work, and how their interests could be better secured. This ILR contains two research papers relevant to the east, central and southern African region, one of which deals with nurses and home-based caregivers in Tanzania and the other which deals with nurses, social workers and home-based care workers in South Africa.
Human Resources
This summary of a report by the Portfolio Committee on Health and Child Welfare in Zimbabwe notes that the shortage of doctors in Zimbabwe has reached crisis levels with the country having only 21% of the required medical practitioners. The report by the Portfolio Committee on Health and Child Welfare provided statistics showing that vacancy levels stand at 80% for midwives, 62% for nursing tutors, 63% for medical school lecturers and over 50% for pharmacy, radiology and laboratory personnel. Poor working conditions were cited as among the reasons for the high vacancy rates. The report added that these shortages and disruption of transport and telecommunications have compromised patient transfers, malaria indoor residual spraying, drug distribution and supervision of districts and rural health centres.
This study sought to analyse the effect of Kenya’s Emergency Hiring Plan for nurses on their inequitable distribution in rural and underserved areas, using data from the Kenya Health Workforce Informatics System. It found that, of the 18,181 nurses employed in Kenya’s public sector in 2009, 1,836 (10%) had been recruited since 2005 through the Emergency Hiring Plan. Nursing staff increased by 7% in hospitals, 13% in health centres and 15% in dispensaries. North Eastern province, which includes some of the most remote areas, benefited most, with nurses increasing by 37%. By February 2010, 94% of the nurses hired under pre-recruitment absorption agreements had entered the civil service. The study cautions that, despite promising preliminary indicators of sustainability, continued monitoring will be necessary over the long term to evaluate future nurse retention.
A total of 1,000 doctors are to be hired to improve the delivery of health services, according to Uganda’s Health Service Commission. The Commission's chairman said an advert will be placed in the newspapers in December and the interviews will follow thereafter. He said the recruitment of health workers will be a continuous and consistent process every year. Makerere, the most prestigious medical school in the country, produces about 100 doctors a year. In total, the country produces about 250 doctors per year, including other universities. In Uganda, the doctor to patient ratio is 1:24,725, falling short of the 1:600 standard set by the World Health Organisation. The recruitment is part of the five-year new health sector strategic and investment plan. Plans are also in advanced stages to increase salaries for all health personnel, according the directorate of health services. The health service commission has also proposed to the Cabinet to have doctors availed vehicle and housing soft loans. The Government offers newly recruited medical officers a gross monthly salary of Ugandan sh626,181, while the highest medical officer at the level of a consultant takes home sh1.6 million per month. Despite a recent 30% increase in salaries for Ugandan health workers, they still earn three times less than workers in neighbouring Rwanda and Kenya.
Despite scale up of anti-retroviral therapy (ART) in Africa, this study draws attention to the shortage of quality data to assess the impact of task-shifting and the loss of doctors from other parts of the health system to HIV and AIDS programmes. It calls for greater documentation and further studies how past increases in ART coverage have been achieved, for instance, by assessing health worker performance using surveys of ART facilities. However, the paper argues that such research alone is not enough. Some of the most important factors determining the long-term progress towards universal coverage – such as ‘victim of our own success’ mechanisms – may only become apparent with time and as ART coverage increases. The challenge of predicting future need through the study of past outcomes is exacerbated by uncertainties around the definition of ART need (such as increases in the CD4 count threshold for treatment eligibility) and ART-related health problems (such as widespread viral resistance). Health policy-makers need to anticipate these factors with the aid of models, allow for significant uncertainty in their ART strategies, and set realistic expectations for the magnitude of resources required for universal ART coverage.
In response to its critical health worker shortages, the Ministry of Health (MoH) in Zambia plans to double the annual number of health training graduates in the next five years to increase the supply of health workers. This study sought to determine the feasibility and costs of doubling training institution output through an individual school assessment framework. Assessment teams consulted faculty, managers and staff in all of Zambia's 39 public and private health training institutions in 2008. The individual school assessments affirmed the MoH's ability to double the graduate output of Zambia's public health training institutions. Lack of infrastructure was determined as a key bottleneck in achieving this increase while meeting national training quality standards. The authors argue that an investment of US$ 58.8 million is required to meet infrastructure needs, and the number of teaching staff must increase by 111% over the next five years.
Insecure access to food is increasingly recognized as a major contributor to cycles of poverty and HIV and AIDS in sub-Saharan Africa, according to this article. In this context, volunteers espouse desires for economic ‘progress’ amid a mix of pro-social and self-interested motivations to be volunteer AIDS caregivers. For these volunteers, food insecurity was particularly demotivating. Food crisis on top of chronic food insecurity pushed them to reconsider what they deemed as appropriate compensation for their efforts. Ironically, volunteers in such contexts may often be poorer than their clients. Ideally, effective and resilient community health workers should derive mental satisfaction and fair remuneration from their labour. The question for policy-makers is how to generate the spiritual benefits of altruistic, compassionate care as well as a level of remuneration that allows for secure livelihoods among volunteers who are often socioeconomically marginalized. WHO’s recent recommendation challenges various public and private entities to adapt to a system in which funding and other measures are used to create fairly-paid and secure health-care jobs in low-income countries facing pervasive food insecurity and high burdens of chronic and infectious disease. In sub-Saharan Africa, hiring, training and paying community health workers may be a win-win situation: people receive secure jobs that provide food security for their families and communities, and their participation strengthens health-care systems and people in need of care. The article emphasises that health programmers need to listen to what volunteers themselves – and the people whom they serve – say about the benefits and costs of volunteering.
This paper compares the socioeconomic profile of medical students registered at the Faculty of Medicine of Universidade Eduardo Mondlane (FM-UEM), Maputo, for the years 1998/99 and 2007/08. Its objective is to describe the medical students' social and geographical origins, expectations and perceived difficulties regarding their education and professional future. Data was collected through questionnaires administered to all medical students. The response rate in 1998/99 was 51% (227/441) and 50% in 2007/08 (484/968). The main results reflect a doubling of the number of students enrolled for medical studies at the FM-UEM, associated with improved student performance (as reflected by failure rates). Nevertheless, satisfaction with the training received remains low and, now as before, students still identify lack of access to books or learning technology and inadequate teacher preparedness as major problems. In conclusion, there is a high level of commitment to public sector service. However, students, as future doctors, have very high salary expectations that will not be met by current public sector salary scales. This is reflected in an increasing degree of orientation to double sector employment after graduation.
This study looks at successful examples of health-focused online communities, like the Capacity Project’s Global Alliance for Pre-Service Education (GAPS), which provides an online forum to discuss issues related to teaching and acquiring competence in family planning in developing countries, and the Global Alliance for Nursing and Midwifery's ongoing web-based community of practice (CoP), which reaches many participants in a range of settings. In the survey, GAPS members suggested that, instead of focusing solely on family planning competencies, GAPS should include professional competencies (e.g. communication, leadership, cultural sensitivity, teamwork and problem solving) that would enhance the resulting health care graduate's ability to operate in a complex health environment. Resources to support competency-based education in the academic setting must be sufficient and appropriately distributed. The study concludes that online CoPs are a useful interface for connecting developing country experiences. To sustain an online CoP, funds must come from an international organisation (e.g. the World Health Organization) or a university that can carry the long-term costs. Eventually, the long-term effectiveness and sustainability of GAPS rests on its transfer to the members themselves.
In 2007, the Mozambican Ministry of Health (MoH) conducted a nationwide evaluation of the quality of care delivered by non-physician clinicians (técnicos de medicina, or TMs), after a two-week in-service training course emphasising antiretroviral therapy (ART). Forty-four randomly selected TMs were directly observed by expert clinicians as they cared for HIV-infected patients in their usual worksites. Observed clinical performance was compared to national norms as taught in the course. In 127 directly observed patient encounters, TMs assigned the correct WHO clinical stage in 37.6%, and correctly managed co-trimoxazole prophylaxis in 71.6% and ART in 75.5%. Correct management of all five main aspects of patient care (staging, co-trimoxazole, ART, opportunistic infections, and adverse drug reactions) was observed in 10.6% of encounters. The observed clinical errors were heterogeneous. Common errors included assignment of clinical stage before completing the relevant patient evaluation, and initiation or continuation of co-trimoxazole or ART without indications or when contraindicated. In Mozambique, the in-service ART training was suspended. The MoH subsequently revised the TMs' scope of work in HIV/AIDS care, defined new clinical guidelines, and initiated a nationwide re-training and clinical mentoring program for these health professionals. Further research is required to define clinically effective methods of health-worker training to support HIV and AIDS care in Mozambique and similarly resource-constrained environments.