Health worker training is a key component of the integrated management of childhood illness (IMCI). The researchers in this study conducted in-depth case studies in two east African countries to examine the factors underlying low training coverage ten years after IMCI had been adopted as policy. A document review and in-depth semi-structured interviews with stakeholders at facility, district, regional/provincial and national levels in two districts in Kenya (Homa Bay and Malindi) and Tanzania (Bunda and Tarime) were carried out in 2007 and 2008. The researchers found that Bunda and Malindi achieved higher levels of training coverage (44% and 25%) compared with Tarime and Homa Bay (5% and 13%). Key factors allowing the first two districts to perform better were: strong district leadership and personal commitment to IMCI, which facilitated access to external funding and encouraged local-level policy adaptation; sensitisation and training of district health managers; and lower staff turnover. However, IMCI training coverage remained well below target levels across all sites. The main barrier to expanding coverage was the cost of training due to its duration, the number of facilitators and its residential nature. Mechanisms for financing IMCI also restricted district capacity to raise funds. Critically, the low priority given to IMCI at national and international levels also limited the expansion of training. Levels of domestic and external funding for IMCI have diminished over time in favour of vertical programmes, partly due to the difficulty in monitoring and measuring the impact of an integrated intervention like IMCI. Alternative, lower cost methods of IMCI training need to be promoted, and greater advocacy for IMCI is needed both nationally and internationally, the authors conclude.
Human Resources
In this study, researchers assessed whether text-message reminders sent to health workers' mobile phones could improve and maintain their adherence to treatment guidelines for outpatient paediatric malaria in Kenya. From March 6, 2009, to May 31, 2010, they conducted a cluster-randomised controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya. Health facilities were randomly allocated to either the intervention group, in which all health workers received text messages on their personal mobile phones on malaria case-management for six months, or the control group, in which health workers did not receive any text messages. They found that 119 health workers received the intervention. Case-management practices were assessed for 2,269 children who needed treatment, indicating that correct artemether-lumefantrine management improved by 23.7% immediately after intervention and by 24.5% six months later. The authors conclude that in resource-limited settings, malaria control programmes should consider use of text messaging to improve health workers' case-management practices.
Using a policy analysis framework, the authors of this study analysed the implementation and perceived effectiveness of a rural allowance policy and its influence on the motivation and retention of health professionals in rural hospitals in the North West province of South Africa. They conducted 40 in-depth interviews with policy-makers, hospital managers, nurses, and doctors at five rural hospitals and found weaknesses in policy design and implementation. These weaknesses included: lack of evidence to guide policy formulation; restricting eligibility for the allowance to doctors and professional nurses; lack of clarity on the definition of rural areas; weak communication; and the absence of a monitoring and evaluation framework. Although the rural allowance was partially effective in the recruitment of health professionals, it has had unintended negative consequences of perceived divisiveness and staff dissatisfaction. The authors recommend that government should take more account of contextual and process factors in policy formulation and implementation so that policies have the intended impact.
In this study, researchers surveyed the alumni of Community-Based Education and Service (COBE) programmes at Makerere University, Uganda, to obtain their perceptions of the management and administration of COBE and whether COBE had helped develop their confidence as health workers, competence in primary health care and willingness and ability to work in rural communities. A total of 150 alumni were contacted, of which 24 (13 females and 11 males) were selected for focus group discussions. The alumni almost unanimously agree that the initial three years of COBES were very successful in terms of administration and coordination. COBES was credited for contributing to development of confidence as health workers, team work, communication skills, competence in primary health care and willingness to work in rural areas. The alumni also identified various challenges associated with administration and coordination of COBES at Makerere. The authors conclude that health planners should take advantage of the long-term positive impact of COBES and provide the programmes with more support.
This study was undertaken to assess the scope and nature of community-based education (CBE) for various health worker cadres in Uganda. Curricula and other materials on CBE programmes in Uganda were reviewed to assess nature, purpose, intended outcomes and evaluation methods used by CBE programmes. In-depth and key informant interviews were conducted with people involved in managing CBE in twenty-two selected training institutions, as well as stakeholders from the community, Ministry of Health, Ministry of Education, civil society organisations and local government. The researchers found that CBE curriculum is implemented in most health training institutions in Uganda and is a core course in most health disciplines at various levels. The CBE curriculum is systematically planned and implemented with major similarities among institutions. Organisation, delivery, managerial strategies, and evaluation methods are also largely similar. Strengths recognised included providing hands-on experience, knowledge and skills generation and the linking learners to the communities. Almost all CBE implementing institutions cited human resource, financial, and material constraints. It is still uncertain whether this approach is increasing the number graduates seeking careers in rural health service, one of the stated programme goals.
Have AIDS external funders harmed or strengthened health workforce development in countries with severe shortages? This research led to six key findings. First, to staff AIDS programmes, external funders have relied on training existing workers and taskshifting, not on training new health workers. Second, AIDS external funders have swamped countries with in-service training programmes for HIV/AIDS-specific skills. Third, PEPFAR and the Global Fund have relied on task-shifting to lower level health workers without assuring adequate resources or support. Fourth, community health workers are employed as a quick fix without considering their long -term role. Fifth, the incentives that AIDS external funders offer health workers to achieve HIV and AIDS programme targets distort allocations of time and resources to the detriment of other health sector objectives. Finally, AIDS external funders pay health workers through short-term special arrangements without addressing long-term constraints on the public and private health workforce.
According to the authors of this study, in southern Africa, the sector most impacted by the brain drain is health. Despite the fact that Southern African Development Community (SADC) countries have adopted a number of financial and non-financial incentives to try to get doctors and nurses to stay, the pull factors attracting health professionals to foreign countries are strong and health workers remain very dissatisfied with existing work conditions. With regard to the migration of health professionals there has been a policy shift away from the early reactive ad hoc policy responses to the development of more comprehensive strategic responses which seek to manage the mobility of health professionals. The authors recommend improving the existing lack of knowledge and data to monitor flows of health professionals into and out of SADC. They also call for bilateral agreements with individual countries involving codes of practice for recruitment and treatment of health workers, exchange programmes for training and development and the provision of health professionals from specific countries. In addition, there is a need for a SADC-wide policy on the movement of health professionals within the region to discourage movement from the poorest and neediest countries to those which are relatively well-endowed, like South Africa.
Rather than making progress towards the Millennium Development Goal of reducing maternal mortality by 75% by 2015, the number of deaths resulting from pregnancy or childbirth in South Africa has doubled in the past 20 years, according to government figures. For every 100,000 babies born, up to 625 mothers die due to childbirth complications. Loveday Penn-Kekana, from the University of the Witwatersrand in Johannesburg, believes South Africa's poor maternal health outcomes are linked to the lack of midwifery services. She called for the government to invest in more and better trained midwives, especially as they bore most of the responsibility for day-to-day operations in maternity wards. Midwives are classified as nurses in South Africa so there are no figures on their numbers, but she argues that there are too few. Low enrolment at nursing colleges is part of the problem, but many midwives have also left the public sector to work for higher salaries overseas or in managerial positions, because of the limited opportunities for career development and advancement in the clinical area. The Society of Midwives of South Africa has noted that lack of midwives means that the quality of the services they provide is declining, as existing midwives are overworked. Also, because they argue that people are first trained as a nurse and then given midwifery skills, midwifery is not prioritised. A plan by South Africa's Health Minister to reopen unused nursing colleges across the country and increase the number of nurses may result in more midwives being trained.
In this brief, Capacity Plus notes that people living in rural areas have less access to health workers, and fail to receive vital preventive, curative, and life-saving services. The problem is especially acute in countries with predominately rural populations. Investment in the development of doctors and nurses is wasted if countries cannot place or keep them in the areas where they are most needed, Capacity Plus argues, nor can they achieve their Millennium Development Goals. A number of recommendations are made. Departments of health should aim to understand and test the factors and incentives that influence health workers’ decisions to accept and remain in rural posts, and develop tailored retention schemes. They should prioritise rural retention schemes and strategies in national health workforce plans, involve professional medical and nursing associations in retention advocacy, strengthen and streamline human resources management (HRM) systems that can affect retention, and address gender discrimination in HRM and gender-based violence in health facilities. Furthermore, they should recruit primary health workers from their own communities and from rural backgrounds, locate health professional schools in rural regions and subsidise health worker education in return for service in rural areas.
Most of the 58 countries covered in this report have been identified as suffering from a crisis in human resources for health. Collectively, across these countries women gave birth to 81 million babies in 2009, accounting for 58% of the world’s total births. The inequitable ‘state of the world’ is most evident in the disproportionate number of deaths in these countries: 91% of the global burden of maternal mortality, 80% of stillbirths and 82% of newborn mortality. These figures partly reflect the distribution of the global workforce: less than 17% of the world’s skilled birth attendants are available to care for women in the 58 countries. There is a triple gap, consisting of competencies, coverage and access. The triad of education, regulation and association has insufficient focus on quality of care, the authors argue. Policy coherence is disjointed and access to the necessary strategic intelligence or evidence for action weak. They urge governments to recognise midwifery as a distinct profession, core to the provision of maternal and newborn health services, and promote it as a career with posts at the national policy level. They also make a number of recommendations for governments, regulatory bodies, schools and training institutions, professional midwifery organisations, international organisations and global partnerships, external funders and civil society organisations.