This paper summarises the literature on e-learning in low- and middle-income countries (LMIC), and presents the spectrum of tools and strategies used. Using standard decision criteria, reviewers narrowed the article suggestions to a final 124 relevant articles. Of the relevant articles found, most referred to e-learning in Brazil (14 articles), India (14), Egypt (10) and South Africa (10). While e-learning has been used by a variety of health workers in LMICs, most (58%) reported on physician training, while 24% focused on nursing, pharmacy and dentistry training. Blended learning approaches were the most common methodology presented (49 articles) of which computer-assisted learning (CAL) comprised the majority (45 articles). Other approaches included simulations and the use of multimedia software (20 articles), web-based learning (14 articles), and eTutor/eMentor programmes (3 articles). The authors conclude that e-learning in medical education is a means to an end, rather than the end in itself. Utilising e-learning can result in greater educational opportunities for students while simultaneously enhancing faculty effectiveness and efficiency. However, this potential of e-learning assumes a certain level of institutional readiness in human and infrastructural resources that is not always present in LMICs.
Human Resources
This study was conducted to determine how 20 low- and middle-income countries are operationalising health governance to improve health workforce performance. The 20 countries assessed showed mixed progress in implementing the eight governance principles. Strengths highlighted include increasing the transparency of financial flows from sources to providers by implementing and institutionalising the National Health Accounts methodology; increasing responsiveness to population health needs by training new cadres of health workers to address shortages and deliver care to remote and rural populations; having structures in place to register and provide licensure to medical professionals upon entry into the public sector; and implementing pilot programs that apply financial and non-financial incentives as a means to increase efficiency. Common weaknesses included difficulties with developing, implementing and evaluating health workforce policies that outline a strategic vision for the health workforce; implementing continuous licensure and regulation systems to hold health workers accountable after they enter the workforce; and making use of health information systems to acquire data from providers and deliver it to policymakers. Further research is warranted into the effectiveness of specific interventions that enhance the links between the health workforce and governance to determine approaches to strengthening the health system.
The South African government wants to use the newly launched Academy for Leadership and Management in Healthcare to set benchmarks, norms and standards for the leadership and management of hospitals in South Africa. The academy was launched in November 2012 to provide leadership and management skills to hospital CEOs. Just over a hundred CEOs started orientation week on 4 February 2013. At the start of orientation week, Minister of Health Aaron Motsoaledi argued that hospital CEOs were key to addressing problems such as staff constraints and fraud. In the future, he expected that no person would become a hospital CEO or manager without first having attended the academy. He added that problems in South African hospitals often related to leadership and management, rather than staffing.
In 2007, the South African government introduced the occupation-specific dispensation (OSD), a financial incentive strategy to attract, motivate, and retain health professionals in the public sector. Implementation commenced with the nursing sector. In this paper, researchers examine implementation of the OSD for nurses and highlight the conditions for the successful implementation of financial incentives. They conducted a qualitative case study design using a combination of a document review and in-depth interviews with 42 key informants, finding several implementation weaknesses. Only a few of the pre-conditions were met for OSD policy implementation. The information systems required for successful policy implementation, such as the public sector human resource data base and the South African Nursing Council register of specialised nurses, were incomplete and inaccurate, thus undermining the process. Insufficient attention was paid to time and resources, dependency relationships and task specification. In conclusion, the implementation of financial incentives requires careful planning and management in order to avoid loss of morale and staff grievances.
For this study, researchers analysed health worker policies in developing countries to assess current strategies aimed at alleviating the ‘brain drain’ of medical professionals from these countries. Although governments and private organisations have tried to address this policy challenge, the researchers found that brain drain continues to destabilise public health systems and their populations globally. Most importantly, lack of adequate financing and binding governance solutions continue to fail to prevent health worker brain drain. In response to these challenges, the establishment of a Global Health Resource Fund in conjunction with an international framework for health worker migration could create global governance for stable funding mechanisms encourage equitable migration pathways, and provide data collection that is desperately needed.
Although task-shifting is widely promoted as the solution to expanding anti-retroviral therapy (ART) access, this article notes that the evidence for non-physician-provided ART in Africa is limited, with few studies comparing the performance of non-physicians with doctors. However, field reports from programmes that have used non-physicians to deliver ART, including from rural settings in South Africa, are more plentiful and report similarly positive (although less reliable) results in terms of both ART outcomes and improved access. The authors argue that positive results from trials in South Africa regarding nurse initiation and management of patients on ART may mean that this may become a key strategy for expanding ART access. Along with basic training and support and an appropriately phased implementation, the authors recommend drafting guidelines that are designed for and specific to nurses and that clarify referral options, so that nurses will feel adequately prepared and supported for their ART tasks.
In the absence of benchmarks on the density and distribution of health workers required to achieve universal health coverage (UHC) in developing countries, the authors of this study call for more specific targets that consider country needs and realities, as well as the potential contribution of non-traditional cadres, such as community health workers and mid-level health providers. Multi-pronged approaches for health workforce development, such as task shifting, training and retention efforts, were found to have led to progress in improving coverage for infectious disease control. The authors argue that comprehensive strengthening of the health workforce, and scaling up workforce production for the continuum of maternal, newborn and child health care should be central to the UHC agenda. They recommend that governments and other stakeholders should implement policies and approaches of proven efficacy, such as those enshrined in the Kampala Declaration and Agenda for Global Action, and strengthen the evidence base to better inform policy making. The authors report success stories in the literature review in achieving universal health coverage, but they call for further research into contextual differences enabling these successes before findings may be extrapolated to other contexts.
In 2007, when Médicins Sans Frontières (MSF) came to Swaziland to assist the Ministry of Health in its response to HIV co-infection with tuberculosis (TB) in the Shiselweni region, treatment for co-infection was not available at any of the rural region’s 21 clinics. Instead, patients had to travel to urban facilities. MSF worked with government to bring services to the clinics, but some patients were either too weak or too poor to reach the clinics. So the organisation trained 80 community caregivers, who live close to the patients, on how to administer multi-drug resistant TB injections. Experts from MSF, from time to time, visit the patients and their caregivers to monitor if the medication is administered properly. MSF reports that task-shifting has helped in the decentralisation of HIV/TB services in the region, where trained lay people help with basic responsibilities such as collecting sputum, counselling and education. Critics maintain that administering a TB injection incorrectly can cause complications, and the legal implications of a lay person administering the injection incorrectly are not clear, but MSF argues that a health service provided by a lay person is better than no service at all.
This review and assessment of Tanzania’s current distance learning programmes for health care workers, as well as those in countries with similar human resource challenges, was undertaken to determine the feasibility of using distance learning to meet the need of an increased and more skilled health workforce. Data was collected from 25 distance learning programmes at health training institutions, universities and non-governmental organizations throughout Tanzania from May to August 2008. The authors identified a number of challenges, including: a lack of guidelines for administrators, instructors and preceptors of distance learning programmes regarding roles and responsibilities; absence of competencies for clinical components of curricula; and technological constraints such as lack of access to computers and to the internet. Insufficient funding resulted in personnel shortages, lack of appropriate training for personnel and lack of materials for students. Nonetheless, current and prospective students expressed overwhelming enthusiasm for scale-up of distance learning. The authors argue that a blended print-based distance learning model is most feasible at the national level due to current resource and infrastructure constraints.
The Southern African Network of Nurses and Midwives (SANNAM) met in Johannesburg, South Africa, from 2–4 December 2010, and made a number of resolutions for 2011. SANNAM called on the World Health Organization (WHO) and the Southern African Development Community to recognise the network as a partner in monitoring the implementation of WHO’s Global Code of Practice for recruiting health workers, and resolved to maintain a database on information on health worker migration in the southern African region. To help countries in the region to reach their child and maternal health Millennium Development Goal targets, SANNAM will lobby for midwifery to be declared a specialisation after midwives have completed their basic training, as well as lobby for nursing regulatory bodies in countries that don’t have them and help to implement these bodies. SANNAM will also develop a position statement that seeks to remove bureaucratic obstacles to free movement of nurses wishing to work in different countries in the region.