The authors of this paper undertook a systematic review to consolidate existing evidence on the impact of financial and non-financial incentives on health worker motivation and retention. They searched four literature databases, as well as Google Scholar and the journal, Human Resources for Health. Grey literature studies and informational papers were also captured. Twenty articles met the inclusion criteria, consisting of a mix of qualitative and quantitative studies. Seven major motivational themes were identified: financial rewards, career development, continuing education, hospital infrastructure, resource availability, hospital management and recognition/appreciation. There was some evidence to suggest that the use of initiatives to improve motivation had been effective in helping retention, but less clear evidence on the differential response of different cadres. While motivational factors are undoubtedly country specific, the authors identified financial incentives, career development and management issues as core factors. The authors concluded that financial incentives alone are not enough to motivate health workers, that recognition is highly influential in health worker motivation and that adequate resources and appropriate infrastructure can improve morale significantly.
Human Resources
The National Institutes of Health has announced a new initiative to strengthen medical education in sub-Saharan Africa, in collaboration with the President’s Emergency Plan for AIDS Relief (PEPFAR). The programme, called the Medical Education Partnership Initiative, is a joint effort of the Office of the United States Global AIDS Coordinator, the Health Resources and Services Administration, the Centres for Disease Control and Prevention, the United States Department of Defense and 19 components of NIH. This programme is in support of PEPFAR's goal to increase the number of new health care workers by 140,000, and will also serve the related objectives of strengthening host-country medical education systems and enhancing clinical and research capacity in Africa. Foreign institutions and their partners in PEPFAR-supported Sub-Saharan African countries are invited to submit proposals to develop or expand models of medical education. These models are intended to contribute to the sustainability of country HIV and AIDS responses by expanding the pool of well-trained clinicians. The awards will also build the capacity of local scientists and health care workers to conduct multidisciplinary research, so that discoveries can more effectively be adapted and implemented in their communities and countries. Nine programmatic awards are available.
This study aimed to evaluate the relative effectiveness of different policies in attracting nurses to rural areas in Kenya, South Africa and Thailand using data from a discrete choice experiment (DCE). A labelled DCE was designed to model the relative effectiveness of both financial and non-financial strategies designed to attract nurses to rural areas. Data were collected from over 300 graduating nursing students in each country. Mixed logit models were used for analysis and to predict the uptake of rural posts under different incentive combinations. The study found that nurses’ preferences for different human resource policy interventions varied significantly between the three countries. In Kenya and South Africa, better educational opportunities or rural allowances would be most effective in increasing the uptake of rural posts, while in Thailand better health insurance coverage would have the greatest impact. In conclusion, it recommends that DCEs can be designed to help policy-makers choose more effective interventions to address staff shortages in rural areas. Intervention packages tailored to local conditions are more likely to be effective than standardised global approaches.
This study conducted a systematic literature review of task shifting and found 2,960 articles, of which 84 were included in the core review. Fifty-one articles reported outcomes, including research from ten countries in sub-Saharan Africa. The most common type of task shifting studied was the delegation of tasks from doctors to nurses and other non-physician clinicians, especially initiating and monitoring highly active anti-retroviral therapy (HAART). Five studies showed increased access to HAART through expanded clinical capacity; four concluded task shifting is cost effective; nine showed staff could deliver equal or better quality of care; and studies on whether non-physicians and physicians were in agreement with their clinical decisions offered mixed results, with most showing good agreement. The study argues that task shifting is an effective strategy for addressing shortages of health workers in HIV treatment and care and believes it offers high-quality, cost-effective care to more patients than a physician-centered model could. The main challenges to implementation include adequate and sustainable training, support and pay for staff in new roles, the integration of new members into healthcare teams, and the compliance of regulatory bodies. The study recommends that task shifting should be considered for careful implementation where health worker shortages threaten rollout programmes.
This qualitative paper reports on the experience of three community health worker (CHW) supervisors who were responsible for supporting infant feeding peer counsellors. The intervention took place in three diverse settings in South Africa. Each setting employed one CHW supervisor, each of whom was individually interviewed for this study. The study forms part of the process evaluation of a large-scale randomised controlled trial of infant feeding peer counselling support. The findings highlight the complexities of supervising and supporting CHWs. In order to facilitate effective infant feeding peer counselling, supervisors in this study had to move beyond mere technical management of the intervention to broader people management. While their capacity to achieve this was based on their own prior experience, it was enhanced through being supported themselves. In turn, resource limitations and concerns over safety and being in a rural setting were raised as some of the challenges to supervision. Adding to the complexity was the issue of HIV. Supervisors not only had to support CHWs in their attempts to offer peer counselling to mothers who were potentially HIV positive, but they also had to deal with supporting HIV-positive peer counsellors. This study highlights the need to pay attention to the experiences of supervisors so as to better understand the components of supervision in the field.
Durban health workers who treat patients with drug-resistant TB are noted to face increase risk of drug resistant TB. According to Dr Iqbal Master, head of clinical services at King George V Hospital in Durban, the province’s specialist hospital for drug-resistant TB, they should be given special incentives to recognise this. King George V Hospital has been trying to get itself declared 'inhospitable', which would mean that staff would get additional incentives for this. Workers at the facility are reported to be six times more likely to get drug-resistant TB than ordinary members of the public. In the last decade, 14 staff members are reported to have died of the TB and one staff member was being treated for drug-resistant (XDR) TB.
This study evaluated two models of routine HIV testing of hospitalised children in a high HIV-prevalence resource-constrained African setting. Both models incorporated task shifting, namely the allocation of tasks to the least-costly, capable health worker. Two models were piloted for three months each within the paediatric department of a referral hospital in Lilongwe, Malawi between January 1 and June 30, 2008. Model 1 utilised lay counsellors for HIV testing instead of nurses and clinicians, while Model 2 further shifted programme flow and advocacy responsibilities from counsellors to volunteer parents of HIV-infected children, called 'patient escorts'. The strategy presented here in the two models, namely task shifting from lay counsellors alone to lay counsellors and patient escorts, was found to improve programme outcomes greatly, while only marginally increasing operational costs. The wider implementation of this strategy could accelerate paediatric HIV care access in high-prevalence settings.
This paper is based on the premise that medical schools can play an important role in solving the problem of geographical imbalance of doctors in the United Republic of Tanzania. It reviews available research evidence that links medical students' characteristics with human resource imbalances and the contribution of medical schools in perpetuating an inequitable distribution of the health workforce. Structured questionnaires were also administered to 130 fifth-year medical students at the medical faculties of MUCHS (University of Dar es Salaam), HKMU (Dar es Salaam) and KCMC (Tumaini University, Moshi campus) in Tanzania. The study found a lack of a primary interest in medicine among medical school entrants, biases in recruitment, the absence of rural-related clinical curricula in medical schools, and a preference for specialisation not available in rural areas. These were considered the main obstacles for building a motivated health workforce to help correct the inequitable distribution of doctors in the Tanzania. The study suggests that there is a need to re-examine medical school admission policies and practices.
This dossier offers practical up to date information about how to address human resource problems and issues, drawing upon evidence about what works, and identifying innovations in approaches, policy and practice. Developing countries have committed to achieving the Millennium Development Goals (MDGs). They will need to make the most effective use of all available resources to achieve the MDGs - this includes human resources. Many countries are improving their short and medium term financial planning and budgetary processes but in the past, few, if any, have given human resource management a similar focus. Now, however, human resources are being seen to be as crucial as money in improving services for poor people. Sections include: planning for human resources; strengthening capacity; migration; management issues; international initiatives; and a section focusing on Africa.
This paper highlights and discusses changing patterns of outward migration of Zambian nurses in the light of policy developments in Zambia and in receiving countries. Prior to 2000, South Africa was the most important destination for Zambian registered nurses. In 2000, new destination countries, such as the United Kingdom, became available, resulting in a substantial increase in migration from Zambia. This was attributed to a policy of active recruitment by the United Kingdom's National Health Service and Zambia's policy of offering Voluntary Separation Packages: early retirement lump-sum payments promoted by the government, which nurses used towards migration costs. The dramatic decline in migration to the United Kingdom since 2004 was reported to be most likely due to increased difficulties in obtaining United Kingdom registration and work permits. Despite smaller numbers, enrolled nurses were also noted now to be leaving Zambia for other destination countries. This paper argues that the focus of any migration strategy should be on how to retain a motivated workforce through improving working conditions and policy initiatives to encourage nurses to stay within the public sector.