This paper examines the issue of workforce stability and turnover in the context of policy attempts to improve retention of health workers. The author argues that there are significant benefits to supporting policy makers and managers to develop a broader perspective of workforce stability and methods of monitoring it. The objective of the paper is to contribute to developing a better understanding of workforce stability as a major aspect of the overall policy goal of improved retention of health workers. Some of the limited research is examined on the complex interaction between staff turnover and organisational performance or quality of care in the health sector, with details and examples of the measurement of staff turnover and stability, and an illustration of an approach to costing staff turnover. The paper concludes with the author advocating that these types of assessment can be valuable to managers and policy makers as they examine which policies may be effective in improving stability and retention, by reducing turnover. They can also be used as part of advocacy for the use of new retention measures. The very action of setting up a local working group to assess the costs of turnover can in itself give managers and staff a greater insight into the negative impacts of turnover, and can encourage them to work together to identify and implement stability measures.
Human Resources
A total of 65,000 South African community health workers (CHWs) are largely responsible for providing counselling services in the government’s HIV counselling and testing programme, which aims to test 15 million South Africans for HIV by April 2011. Many other government health programmes also rely on this cadre of workers for their success. Most of them are employed by non-governmental organisations through funding from provincial health departments and others. But their contribution to public health may be at risk, as this article reports that CHWs are working full time without any payment, sometimes waiting up to six months without receiving their salaries. There is uncertainty about whether the non-governmental organisations that manage funds for the salaries of CHWs are receiving these funds from government and, if they are, why they are not paying them out as salaries. The Health Department has registered its concern about the problem. Health Department Director-General, Precious Matsoso, said the department is working on a solution and cited an overlap of responsibility between her department and social development services as to blame for the lack of action to address the claims of failed salary payments.
In this paper, the author elaborates what South African medical specialists find satisfying about working in the public and private sectors, at present, and how to better incentivise retention in the public sector. He conducted 74 qualitative interviews among specialists and key informants in one public and one private urban hospital in South Africa. All qualitative specialist respondents were engaged in dual practice, generally working in both public and private sectors. Results demonstrate that although there are strong financial incentives for specialists to migrate from the public to the private sector, public work provides more of a team environment, more academic opportunities, and greater opportunities to feel 'needed' and 'relevant'. However, public specialists suffer under poor resource availability, lack of trust for the Department of Health, and poor perceived career opportunities. These non-financial issues of public sector dissatisfaction appeared just as important, if not more important, than wage disparities. Policy recommendations centre around boosting public sector resources and building trust of the public sector through including health workers more in decision-making, inter alia. These interventions may be more cost-effective for retention than wage increases, and imply that it is not necessarily just a matter of putting more money into the public sector to increase retention.
In this cross-sectional descriptive survey the authors investigated the performance of health workers after decentralisation of the health services in Uganda to identify and suggest areas for improvement. A structured self-administered questionnaire was used to collect quantitative data from 276 health workers in the districts of Kumi, Mbale, Sironko and Tororo in Eastern Uganda. Results revealed that even though the health workers are generally responsive to the needs of their clients, the services they provide are often not timely. The health workers take initiative to ensure that they are available for work, but low staffing levels undermine these efforts. While the study shows that the health workers are productive, over half (50.4%) of them reported that their organisations do not have indicators to measure their individual performance. The findings indicated that health workers are competent, adaptive, proactive and client oriented.
Despite the clear prohibition against sexual relations with one’s patients, complaints of a sexual nature against practitioners registered with the Health Professions Council of South Africa (HPCSA) have been increasing. The authors of this paper set out to ascertain how a group of medical practitioners felt about the presence of chaperones during the consultation and intimate examination of patients. They distributed a self-administered, questionnaire-based survey to gynaecologists and medical practitioners. There was a 43% response rate with 72% of practitioners in favour of using a chaperone during an intimate examination, although only 27% always do so. Most practitioners felt that consensual sexual relationships with patients are unacceptable; 83% felt that ethical guidelines on this topic were needed. The authors recommend that the HPCSA should develop guidelines on the use of chaperones to assist practitioners. With medical litigation increasing, using chaperones will benefit patients and practitioners.
Undergraduate teaching on global health has seen a marked growth over the past ten years, partly as a response to student demand and partly due to increasing globalisation, cross-border movement of pathogens and international migration of health care workers. In this study, researchers carried out a survey of medical schools across the world in an effort to analyse their teaching of global health. Results indicate that global health teaching is moving away from its previous focus on tropical medicine towards issues of more global relevance. The authors suggest that there are three types of doctor who may wish to work in global health - the 'globalised doctor', 'humanitarian doctor' and 'policy doctor' - and that each of these three types will require different teaching in order to meet the required competencies. This teaching needs to be inserted into medical curricula in different ways, notably into core curricula, a special developing countries track, optional student selected components, elective programmes, optional intercalated degrees and postgraduate study. The authors argue that teaching of global health in undergraduate medical curricula must reflect the social, political and economic causes of ill health.
The purpose of this study was to investigate the performance of health workers since decentralisation of health services in Uganda in the 1990s in order to identify and suggest possible areas for improvement. Researchers conducted a cross-sectional descriptive survey, using quantitative research methods to collect quantitative data from 276 health workers in the districts of Kumi, Mbale, Sironko and Tororo in Eastern Uganda. The study revealed that even though the health workers are generally responsive to the needs of their clients, the services they provide are often not timely. Health workers take initiative to ensure that they are available for work, although low staffing levels undermine these efforts. While the data shows that the health workers are productive, over half (50.4%) of them reported that their organisations do not have indicators to measure their individual performance. In general, the results show that health workers are proficient, adaptive, proactive and client-oriented. Although Uganda is faced with a number of challenges as regards human resources for health, these findings show that the health workers that are currently working in the health facilities are enthusiastic to perform. This may serve as a motivator for the health workers to improve their performance and that of the health sector.
Antiretroviral therapy (ART) adherence clubs, already operating in several high burden areas in Cape Town, have the potential to revolutionise the treatment of millions of HIV-positive South Africans and lighten the load on overburdened health workers, according to Medecins Sans Frontieres (MSF). In a nutshell, the ART adherence clubs are a long-term retention model of care for stable patients on ARVs. Between 20 and 30 patients meet and are facilitated by a non-clinical staff member who provides a quick clinical assessment, a referral where necessary and peer support in the form of a short group meeting. Pre-packed ARVs are distributed, enough to last for two months until the next meeting. Once a year, the patient is referred for blood tests and is seen by a doctor. This means that for one year the patient does not need to be seen by a professional health worker, essentially freeing the workers up to treat more complex cases and creating space in waiting rooms. By August 2012, 149 new clubs had been established in Khayelitsha, Cape Town, totalling 5,195 patients, which represents 20% of those enrolled for ART in the township. A spokesperson from the provincial health department said the province was also looking at integrating the clubs into a chronic care model, which means that patients with for example diabetes or high blood pressure could benefit.
In recognition of the critical shortage of human resources within health services, community health workers in Ethiopia have been trained and deployed to provide primary health care in developing countries. In this study, researchers investigated the knowledge and performance of these health extension workers (HEWs) on antenatal and delivery care, as well as the barriers to and facilitators for the provision of maternal health care. A total of 50 HEWs working in 39 health posts, covering a population of approximately 195,000 people, were interviewed. Almost half of the respondents had at least five years of work experience as a HEW. More than half (54%) of the HEWs had poor knowledge on contents of antenatal care counseling, and most (88%) had poor knowledge on danger symptoms, danger signs, and complications in pregnancy. Health posts, which are the operational units for HEWs, did not have basic infrastructure like water supply, electricity, and waiting rooms for women in labour. On average, within six months, a HEW assisted in only 5.8 births. Only a few births (10%) were assisted at the health posts, most (82%) were assisted at home and only 20% of HEWs received professional assistance from midwives. Based on these findings, there is an urgent need to design appropriate strategies to improve the performance of HEWs by enhancing their knowledge and competencies, while creating appropriate working conditions.
Competency-based education (CBE) is argued to provide a useful alternative to time-based models for preparing health professionals and constructing educational programmes. In this paper, the authors describe the concept of 'competence' and 'competencies' as well as the critical curricular implications that derive from a focus on 'competence' rather than 'time'. These implications include: defining educational outcomes, developing individualised learning pathways, setting standards, and the centrality of valid assessment so as to reflect stakeholder priorities. They also highlight four challenges to implementing CBE: identifying the health needs of the community, defining competencies, developing self-regulated and flexible learning options, and assessing learners for competence. While CBE has been a prominent focus of educational reform in resource-rich countries, the authors argue that it has even more potential to align educational programmes with health system priorities in more resource-limited settings. Because CBE begins with a careful consideration of the competencies desired in the health professional workforce to address health care priorities, it provides a vehicle for integrating the health needs of the country with the values of the profession.