In this study, researchers assessed health worker motivation as part of a health system strengthening intervention in three rural districts in Zambia. The intervention (Better Health Outcomes Through Mentoring and Assessment (BHOMA) aims to increase health worker motivation through training, mentoring and support. The researchers examined underlying issues grouped around relevant outcome constructs such as job satisfaction, general motivation, burnout, organisation commitment, conscientiousness and timeliness that collectively measure overall levels of motivation. Results showed variation in motivation score by sex, type of health worker, training and time in post. Female participants had the highest motivation scores. Nurses had the highest scores while environmental health technicians had the lowest score. Health workers who had been in their posts longer also had higher scores. Health workers who had received some form of training in the preceding 12 months were more likely to have a higher score; this was also true for those older than 40 years when compared to those less than 40 years of age. Further research is needed to establish why these health worker attributes were associated with motivation and whether health system interventions targeting health workers, such as the current intervention, could influence health worker motivation.
Human Resources
A key component of the proposed primary health care (PHC) re-engineering model in South Africa is creating ward-based outreach teams linked to primary health care clinics. Each team consists of a professional nurse team leader, three staff nurses and six community health workers (CHWs), with each team serving a population of approximately 6,000 people in a demarcated area. The model envisages the professional nurse team leader and two of the three staff nurses being based at the clinic, while the rest of the team is based in the community. Team leaders will spend 20-30% of their time in the community supporting the work of the team and visiting high risk households. The managers of the clinics to which these teams are linked are expected to lead, manage and oversee the outreach teams’ work in the community and their interactions with other stakeholders working in the same communities. The model requires clinic managers to promote an understanding of the facility catchment area’s epidemiology and burden of disease using health information and data collected during community activities, and to identify strategies to address the local health issues. The addition of these responsibilities will expand the clinic managers’ scope of work.
The authors of this study examined literature on the roles of mid-level managers to understand how they might influence service delivery quality in Kenyan hospitals. A total of 23 articles were finally included in the review from over 7,000 titles and abstracts initially identified. The most widely documented roles of mid-level managers were decision-making or problem-solving, strategist or negotiator and communicator. Others included being a therapist or motivator, goal setting or articulation and mentoring or coaching. In addition to these roles, the authors identified important personal attributes of a good manager, which included interpersonal skills, delegation and accountability, and honesty. Most studies included in the review concerned the roles that mid-level managers are expected to play in times of organisational change. The review highlights the possible significance of mid-level managers in achieving delivery of high-quality services in Kenyan public hospitals and strongly suggests that approaches to strengthen this level of management will be valuable. The findings from this review should also help inform empirical studies of the roles of mid-level managers in these settings.
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.
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.