Human Resources

Kenyan medical students are learning through a community outreach model
Mining S: The Conversation, March 2017

This is a time of unprecedented change in medical education globally. Medical schools, postgraduate bodies and other organisations are responding to rapid advances in medicine and changes in health care delivery. New education approaches are being adopted to exchange information. This enables the institutions to produce relevant health professionals. There are a number of innovations and models that are being explored to improve the learning of students studying medicine and public health. This Kenyan case study reports on how partnerships between the higher education institution and the community are working. It gives an account of the Moi University community programme that uses adaptive instruction for health trainees in the schools of medicine and public health. Adaptive instruction is a student centred approach where they are given real life cases to solve health problems theoretically as tutorial cases. This discussion, with the guidance of a tutor, promotes active learning. The model encourages active learner participation in the provision of health services. It introduces the students to a community health framework where they work in rural health facilities as part of their continuous assessment. It means that graduates entering the profession are able to apply and practise knowledge and skills beyond the theory learnt at the university. The students diagnose issues affecting the local community, develop a research proposal, work with district health management teams and implement activities. They conduct surveillance and monitor diseases and in the event of an epidemic, they are expected to respond effectively. They master the principles of how rural health facilities are run. The programme is divided into five phases: Introduction to the community, Community diagnosis, Writing a research proposal, Investigation executing the research plan, District health service attachment. The research projects designed and implemented in phase three and four have produced fascinating reports with research topics that address issues affecting the communities. It takes 20% to 30% of curriculum content and makes the graduand socially responsible and accountable team players in health care delivery. The authors hope that other tutors in Kenya, Eastern Africa and beyond the continent will benefit from this model. The experience provides tutorial guidance towards building a resilient and experienced crop of health professionals at par with global health training standards.

Knowledge, attitudes and practices of South African healthcare workers regarding the prevention and treatment of influenza among HIV-infected individuals
Duque J; Gaga S; Clark D et al.: PLoS ONE 12(3) 2017, doi:10.1371/journal.pone.0173983

The South African Department of Health publishes annual guidelines identifying priority groups, including immunosuppressed individuals and healthcare workers (HCW), for influenza vaccination and treatment. How these guidelines have impacted HCW and their patients, particularly those infected with HIV, remains unknown. The authors aimed to describe the knowledge, attitudes and practices regarding influenza and the vaccine among South African HCW. Surveys were distributed by two local non-governmental organisations in public health clinics and hospitals in 21 districts/municipalities (5 of 9 provinces). There were 1164 respondents. One-third (34%) of HCW reported getting influenza vaccine and most (94%) recommended influenza vaccine to patients infected with HIV. The ability to get vaccine free of charge and having received influenza government training were significantly associated with self-reported vaccination in 2013/2014. Self-reported vaccination and availability of influenza vaccine during the healthcare visit were significantly associated with recommending influenza vaccine to patients infected with HIV/AIDS. Free and close access to influenza vaccine were associated with a higher likelihood of getting vaccinated. HCW who reported getting the influenza vaccine themselves, had vaccine to offer during the patient consult and were familiar with guidelines and training were more likely to recommend vaccine to HIV-infected patients.

3rd Board Meeting of the African Platform on Human Resources for Health (APHRH)
APHRH: Kampala, Uganda, 2016

The Board of the APHRH met on the 30th Nov 2016 in Kampala to discuss key issues that concerning the Health Workforce in Africa. A resolution was made to convene a regional consultation meeting of key stakeholders and networks to develop a consensus on ways to accelerate advocacy for a strengthened health workforce in Africa. The Board made a number of decisions to initiate acceleration of the work of the platform at all levels and enhance lobby and advocate for the prioritization of the Health Workforce agenda in Africa, outlined in this document, including: to request the WHO Regional Director for Africa to urgently consider an enhanced technical support program to African countries to strengthen country level health workforce development and management departments, especially at the ministries of health headquarters of member states; to support African Member states in translating for action key regional and global policies including the African Health Strategy, the Global Health Workforce Strategy and Sustainable Development Goals (SDGs) and to fast track the strengthening of Health Workforce information systems of countries to manage workforce inflows, stock and outflow by implementation of the WHO code on International Recruitment and track progress of strengthening through improved reporting on the code at the 3rd round due in 2018.

Community health worker perspectives on a new primary health care initiative in the Eastern Cape of South Africa
Austin-Evelyn K; Rabkin M; Machete T; Mutiti A; Mwansa-Kambafwile J; Dlamini T; El-Sadr W: PLoS ONE 12(3) 2017, doi:10.1371/journal.pone.0173983

In 2010, South Africa’s National Department of Health launched a national primary health care (PHC) initiative to strengthen health promotion, disease prevention, and early disease detection. The strategy, called Re-engineering Primary Health Care (rPHC), aims to provide a preventive and health-promoting community-based PHC model. A key component of rPHC is the use of community-based outreach teams staffed by generalist community health workers (CHWs). The authors conducted focus group discussions and surveys on the knowledge and attitudes of 91 CHWs working on community-based rPHC teams in the King Sabata Dalindyebo (KSD) sub-district of Eastern Cape Province. The CHWs studied enjoyed their work and found it meaningful, as they saw themselves as agents of change. They also perceived weaknesses in the implementation of outreach team oversight, and desired field-based training and more supervision in the community. The authors find that there is a need to provide CHWs with basic resources like equipment, supplies and transport to improve their acceptability and credibility to the communities they serve.

Global Health Workforce Labor Market Projections for 2030
Liu J; Goryakin Y; Maeda A; Bruckner T; Scheffler R: Human Resources for Health 15(11) 3, 2017

In low- and middle-income countries, scaling essential health interventions to achieve health development targets is constrained by the lack of skilled health professionals to deliver services. The authors project the future health workforce demand based on projected economic growth, demographics and health coverage. They used health workforce data for 1990–2013 for 165 countries from the WHO Global Health Observatory. The demand projections are compared with the projected growth in health worker supply and the health worker “needs” as estimated by WHO to achieve essential health coverage. The model predicts that, by 2030, global demand for health workers will rise to 80 million workers, double the current (2013) stock of health workers, while the supply of health workers is expected to reach 65 million over the same period, resulting in a worldwide net shortage of 15 million health workers. Growth in the demand for health workers will be highest among upper middle-income countries, driven by economic and population growth and ageing. This results in the largest predicted shortages which may fuel global competition for skilled health workers. Middle-income countries will face workforce shortages because their demand will exceed supply. By contrast, low-income countries will face low growth in both demand and supply, both of which are estimated to be far below what will be needed to achieve adequate coverage of essential health services. This may lead to the paradoxical phenomenon of unemployed (“surplus”) health workers in those countries facing acute “needs-based” shortages.

Kenyan doctors’ strike: Why the centre can no longer hold
Oyoo S: Pambuzuka News, February 2017

The doctors’ strike now in its third month in Kenya has caused great suffering to the majority poor people who cannot afford medical care in private hospitals. The author writes that the strike is not merely about the welfare of the healthcare workers, but about a public health system crumbling under deliberate state neglect and corruption. By mid-February Kenyan doctors had been on strike for over two months. They have made several demands including: better remuneration, availability of more doctors in public hospitals, better equipment and availability of drugs in these facilities, and more allocation of funds to health research. They are, according to the author, demanding better healthcare for all Kenyan citizens. The author comments that the doctors’ demands have been spurned by government, and the media to some extent, in what is part of a wider effort to portray the doctors as greedy individuals. The negotiation process has been long and tortuous, with the government side not keen on implementing a Collective Bargaining Agreement (CBA) it signed with the doctors in 2013. Private healthcare providers on the other hand are argued to stealthily lie like vultures – waiting for the public healthcare system to implode so they can expand their ‘investments’ in Kenya, a country that’s been described as ‘a lucrative market for private healthcare service provision’. One can almost imagine that this is part of a wider scheme to privatise the Kenyan healthcare system, a move which would drive the cost of treatment beyond reach of the majority. Kenya was ranked 145 out of 176 in Transparency International’s corruption perception index in 2016. The author writes that it is no longer possible to stand by and watch as up to a third of the Kenyan budget is lost to corruption, and disappears into the pockets of a select few. Kenyans can no longer stand by and watch the state audaciously claim it cannot pay their doctors. Kenyans just cannot afford to be spectators in such a matter of life and death.

Limits and opportunities to community health worker empowerment: A multi-country comparative study.
Kane S; Kok M; Ormel H; Otiso L; et al.: Social Science & Medicine 164, 2016, doi:

In LMICs, Community Health Workers (CHW) increasingly play health promotion related roles involving 'empowerment of communities'. To be able to empower the communities they serve, the authors argue, it is essential that CHWs themselves be, and feel, empowered. The authors present here a critique of how diverse national CHW programs affect CHW's empowerment experience. They present an analysis of findings from a systematic review of literature on CHW programs in LMICs and 6 country case studies (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique). Lee & Koh's analytical framework (4 dimensions of empowerment: meaningfulness, competence, self-determination and impact), is used. CHW programs empower CHWs by providing CHWs, access to privileged medical knowledge, linking CHWs to the formal health system, and providing them an opportunity to do meaningful and impactful work. However, these empowering influences are constantly frustrated by - the sense of lack/absence of control over one's work environment, and the feelings of being unsupported, unappreciated, and undervalued. CHWs expressed feelings of powerlessness, and frustrations about how organisational processual and relational arrangements hindered them from achieving the desired impact. While increasingly the onus is on CHWs and CHW programs to solve the problem of health access, attention should be given to the experiences of CHWs themselves. CHW programs need, it is argued, to move beyond an instrumentalist approach to CHWs, and take a developmental and empowerment perspective when engaging with CHWs. CHW programs should systematically identify disempowering organisational arrangements and take steps to remedy these. Doing so will not only improve CHW performance, it will pave the way for CHWs to meet their potential as agents of social change, beyond perhaps their role as health promoters.

‘Why do an MPH?’ Motivations and intentions of physicians undertaking postgraduate public health training at the University of Cape Town
Zweigenthal VE, Marquez E; London L: Global Health Action, 9(1), 2017

Public health (PH) approaches underpin the management and transformation of health systems in low- and middle-income countries. Despite the Master of Public Health (MPH) rarely being a prerequisite for health service employment in South Africa, many physicians pursue MPH. This study identified their motivations and career intentions and explored MPH programme strengths and gaps in under- and post-graduate PH training. A cross-sectional study using an online questionnaire was completed by physicians graduating with an MPH between 2000 and 2009 and those enrolled in the programme in 2010 at the University of Cape Town. Nearly a quarter of MPH students were physicians. Of the 65 contactable physicians, 48% responded. They were mid-career physicians who wished to obtain research training (55%), who wished to gain broader perspectives on health (32%), and who used the MPH to advance careers (90%) as researchers, policy-makers, or managers. The MPH widened professional opportunities, with 62% changing jobs. They believed that inadequate undergraduate exposure should be remedied by applying PH approaches to clinical problems in community settings, which would increase the attractiveness of postgraduate PH training. The MPH was found to allow physicians to transition from pure clinical to research, policy and/or management work, preparing them to innovate changes for effective health systems, responsive to the health needs of populations.

Crisis and resilience at the frontline: Coping strategies of Kenyan primary health care managers in a context of devolution and uncertainty
Nyikuri M; Barasa E; Molyneux S; Tsofa B: Kemri Wellcome Trust Research Programme, Kenya, 2016

Primary health care (PHC) plays a vital role in maintaining population health, preventing suffering and providing coverage of essential services. In Kenya, primary health centres and dispensaries are often managed by the most senior clinical staff member at the facility who is responsible for performing both clinical and managerial duties. PHC managers, also known as in-charges, play a key role in the functioning of health services on a day-to-day basis. KEMRI-Wellcome Trust has conducted research in one of the 47 counties in Kenya to better understand the role and responsibilities of PHC managers and their coping strategies within the context of devolution and uncertainty. The key findings from the research are set out in this brief, as well as recommendations to support PHC managers. The research found that PHC managers carry out a variety of tasks to ensure facilities can function effectively. These include: developing annual work plans, ensuring coverage and delivery of services, providing leadership and management to frontline staff. Despite the challenges faced by PHC managers in the period since devolution, facilities remained open and functioning. A key support system for in-charges was the sub-county managers, some of whom had played the role of line managers to in- charges for decades.

Predictors of nurses’ and midwives’ intentions to provide maternal and child healthcare services to adolescents in South Africa
Jonas K; Reddy P; van den Borne B; Sewpaul R; Nyembezi A; Naidoo P; Crutzen R: BMC Health Services Research 16(658) 2016

This study was conducted to gain an understanding of nurses’ and midwives’ intentions to provide maternal and child healthcare and family planning services to adolescents in South Africa. A total of 190 nurses and midwives completed a cross-sectional survey. The survey included components on demographics, knowledge of maternal and child healthcare (MCH) and family planning (FP) services, attitude towards family planning services, subjective norms regarding maternal and child healthcare and family planning services, self-efficacy with maternal and child healthcare and family planning services, and intentions to provide maternal and child healthcare and family planning services to adolescents. Self-efficacy to conduct MCH and FP services and years of experience as a nurse- midwife were associated with stronger intentions to provide the services. Self-efficacy had a strong and positive association with the intentions to provide both MCH and FP services, while there is a moderate association with attitude and norms. The authors argue that there is a need to improve and strengthen nurses’ and midwives’ self-efficacy in conducting both MCH and FP services in order to improve the quality and utilisation of the services by adolescents in South Africa.