Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the difficulty in retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians, medical licentiates, trained initially to the level of a higher diploma and from 2013 up to a Bachelor of Science degree. Medical licentiates have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations. This qualitative study aimed to describe the role, contributions and challenges surgically active medical licentiates have experienced. Based on 43 interviewees, it includes the perspective of medical licentiates, their district hospital colleagues—medical officers, nurses and managers; and surgeon-supervisors and national stakeholders. In Zambia, medical licentiates play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with medical officers, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, medical licentiates often face professional recognition problems and tensions around relationships with medical officers that impact their ability to utilise their surgical skills. The paper provides new evidence concerning the benefits of ‘task shifting’ and identifies challenges that need to be addressed if medical licentiates are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use non-physician clinicians to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.
Human Resources
Uganda’s national community health worker program involves volunteer Village Health Teams (VHTs) delivering basic health services and education. Evidence demonstrates their positive impact on health outcomes, particularly for Ugandans who would otherwise lack access to health services. Despite their impact, VHTs are not optimally supported and attrition is a growing problem. In this study, the authors examined the support needs and existing challenges of VHTs in two Ugandan districts and evaluated specific factors associated with long-term retention. The authors reported on findings from a standardised survey of VHTs and exploratory interviews with key stakeholders and draw conclusions that inform efforts to strengthen and sustain community health care delivery in Uganda. A mixed-methods approach was employed through a survey of 134 individual VHT members and semi-structured interviews with six key stakeholders. Descriptive and bivariate regression analysis of quantitative survey data was performed along with thematic analysis of qualitative data from surveys and interviews. In the regression analysis, the dependent variable is 10-year anticipated longevity among VHTs, which asked respondents if they anticipate continuing to volunteer as VHTs for at least 10 more years if their current situation remains unchanged. VHTs desire additional support primarily in the forms of money (for example transportation allowance) and material supplies (for example rubber boots). VHTs commonly report difficult working conditions and describe a lack of respect from their communities and other health workers. If their current situation remains unchanged, 57% of VHTs anticipate remaining in their posts for at least 10 years. Anticipated 10-year longevity was positively associated with stronger partnerships with local health centre staff and greater ease in home visiting. The authors note that supporting and retaining Uganda’s VHTs would be enhanced by building stronger partnerships between VHTs and other health workers and regularly providing supplies and transportation allowances. Pursuing such measures would likely improve equity in access to healthcare for all Ugandans.
Studies have shown the contribution that supportive supervision can make to improving job satisfaction amongst over-stretched health workers in in resource-constrained settings. The Support, Train and Empower Managers study designed and implemented a supportive supervision intervention and measured its’ impact on health workers using a controlled trial design with a three-arm pre- and post-study in Niassa Province in Mozambique. Post-intervention interviews with a small sample of health workers were also conducted. The quantitative measurements of job satisfaction, emotional exhaustion and work engagement showed no statistically significant differences between end-line and baseline. The qualitative data collected from health workers post the intervention showed many positive impacts on health workers not captured by this quantitative survey. Health workers perceived an improvement in their performance and attributed this to the supportive supervision they had received from their supervisors following the intervention. Reports of increased motivation were also common. An unexpected, yet important consequence of the intervention, which participants directly attributed to the supervision intervention, was the increase in participation and voice amongst health workers in intervention facilities.
Many countries have created community-based health worker (CHW) programs for HIV, often through national and non-governmental initiatives, raising questions of how well these different approaches co-ordinate. The authors conducted a literature review on the harmonisation of CHW programs, defining harmonisation, and identifying and describing the major issues and relationships surrounding the harmonisation of CHW programs, including key characteristics, facilitators, and barriers for each of the priority areas of harmonisation. The authors found a large number and immense diversity of CHW programs for HIV. This includes integration of HIV components into countries’ existing national programs along with the development of multiple, stand-alone CHW programs. While harmonisation is likely a complex political process, with in many cases incremental steps toward improvement, a wide range of facilitators are available to decision-makers. They can be categorised into those involved in the intervention itself, in relation to stakeholders, health systems, and the broad context.
Tanzania faces a critical shortage of skilled health workers. While training, deployment, and retention are important, motivation is also necessary for all health workers, particularly those who serve in rural areas. This study measured the motivation of health workers who were posted at government-run rural primary health facilities. The authors sought to measure three aspects of motivation—management, performance, and individual aspects—among health workers deployed in rural primary level government health facilities. In addition, they also sought to identify the job-related attributes associated with each of these three aspects. Two regions in Tanzania were selected for the research. In each region, the authors further selected two rural districts in each in which they carried out their investigation. Motivation was associated with marital status, having a job description and number of years in the current profession for management aspects; having a job description for performance aspects; and salary scale for individual aspects. The authors conclude that having a clear job description motivates health workers, and that the existing Open Performance Review and Appraisal System, of which job descriptions are the foundation, needs to be institutionalised in order to effectively manage the health workforce in resource-limited settings.
This time and motion study in Dar es Salaam, Tanzania estimated the potential of task-shifting in services for prevention of mother to child transmission (PMTCT) to reduce nurses’ workload and health system costs. The time used by nurses to accomplish PMTCT activities during antenatal care (ANC) and postnatal care (PNC) visits was measured. These data were then used to estimate the costs that could be saved by shifting tasks from nurses to community health workers in the Tanzanian public-sector health system. A total of 1121 PMTCT-related tasks carried out by nurses involving 179 patients at ANC and PNC visits were observed at 26 health facilities. The average time of the first ANC visit was the longest, 54 min, followed by the first PNC visit which took 29 minutes on average. ANC and PNC follow-up visits were substantially shorter, 15 and 13 minutes, respectively. During both the first and the follow-up ANC visits, 94% of nurses’ time could be shifted to community health workers, while 84% spent on the first PNC visit and 100% of the time spent on the follow-up PNC visit could be task-shifted. Depending on community health workers salary estimates, the cost savings due to task-shifting in PMTCT ranged from US$ 1.3 to 2.0 (first ANC visit), US$ 0.4 to 0.6 (ANC follow-up visit), US$ 0.7 to 1.0 (first PNC visit), and US$ 0.4 to 0.5 (PNC follow-up visit). Nurses working in PMTCT spend large proportions of their time on tasks that could be shifted to community health workers, giving them more time for specialised PMTCT tasks and reducing the average cost per PMTCT patient.
Community health workers (CHWs) play key roles in delivering health programmes in many countries worldwide. CHW programmes can improve coverage of maternal and child health services for the most disadvantaged and remote communities, leading to substantial benefits for mothers and children. However, there is limited evidence of effective mentoring and supervision approaches for CHWs. This cluster randomised controlled trial investigated the effectiveness of a continuous quality improvement intervention amongst CHWs providing home-based education and support to pregnant women and mothers. Thirty CHW supervisors were randomly allocated to intervention (n = 15) and control (n = 15) arms. Intervention CHWs received a 2-week training in WHO Community Case Management followed by mentoring for 12 months. Baseline and follow-up surveys were conducted with mothers of infants <12 months old living in households served by participating CHWs. At follow-up, compared to mothers served by control CHWs, mothers served by intervention CHWs were more likely to have received a CHW visit during pregnancy and the postnatal period. Intervention mothers had higher maternal and child health knowledge scores and reported higher exclusive breastfeeding rates to 6 weeks. HIV-positive mothers served by intervention CHWs were more likely to have disclosed their HIV status to the CHW. Uptake of facility-based interventions was not significantly different. Improved training and mentoring of CHWs can, it is thus argued, improve quantity and quality of CHW-mother interactions at household level, leading to improvements in mothers’ knowledge and infant feeding practices.
This paper highlights current issues and challenges in public health nutrition in low- and middle-income countries and shares recommendations for the development of this workforce. Several factors are argued to contribute to a scarcity of nutrition professionals in low- and middle-income countries, including: a lack of understanding of the role of public health nutrition in the prevention and management of the various forms of malnutrition; a low-income country priority for doctors and nurses (and sometimes also frontline workers) within meagre health workforce expenditures; a higher priority for undernutrition interventions than for those for nutrition-related chronic diseases, despite their escalation in these countries. Both food system changes, at the level of production, processing and distribution, and behaviour change communication are argued to be needed to reorient the nutrition transition, and nutritionists have a major role to play in this regard. Although it requires sustained efforts, training can be regarded as the easy part of nutrition workforce development in low- and middle-income countries. More challenging steps are recognition of the nutrition profession and its regulation, opening up government jobs for nutrition graduates and financing local training programmes and nutritionists’ salaries in the public sector. The underlying causes of malnutrition, and hence sustained solutions to the problem, lie to a large extent in the non-health sectors. The authors argue that nutrition has to be addressed not only by other health professionals, but also by agriculture and education professionals and field workers, who need to integrate relevant nutrition tasks into their professional activities (such as orienting food production towards meeting the population’s nutrition requirements or teaching healthy eating to schoolchildren).
In Nigeria, several challenges have been reported within the health sector, especially in training, funding, employment, and deployment of the health workforce. The authors reviewed the recent health workforce crises in the Nigerian health sector to identify key underlying causes and provide recommendations toward preventing and/or managing potential future crises in Nigeria. The authors observe that the Nigerian health system is relatively weak, and there is yet a coordinated response across the country. A number of health workforce crises have been reported in recent times due to several months’ salaries owed, poor welfare, lack of appropriate health facilities and emerging factions among health workers. Poor administration and response across different levels of government were found to have played contributory roles to further internal crises among health workers, with different factions engaged in protracted supremacy challenge. These crises have consequently prevented optimal healthcare delivery to the Nigerian population. The authors argue for various measures, including an inclusive stakeholders’ forum in the health sector; and a solid administrative policy foundation that allows coordination of priorities and partnerships in the health workforce and among various stakeholders.
Community Health Workers feel unrecognised and undervalued by community leaders and health professionals. This was the central message from a major thematic discussion held on the HIFA forums and sponsored by The Lancet, Reachout Project/Liverpool School of Tropical Medicine, World Vision International and USAID Assist Project. More than 60 HIFA members contributed their experience and expertise to the discussion, including CHW programme managers, researchers and policymakers, as well as a large number of CHWs and ASHAs from India and Uganda. Countries represented included Burundi, Cameroon, Canada, Ethiopia, France, Ghana, India, Iran, Japan, Kenya, Malaysia, Netherlands, New Zealand, Nigeria, Pakistan, Rwanda, Switzerland, Tanzania, Uganda, UK, and USA. Other major concerns were lack of training and supervision; access to healthcare information; remuneration; equipment, medicines, and need for mobile phones/computers. CHWs said they are asked to carry out a wide range and ever increasing number of tasks, but often without the appropriate facilities to enable this. CHWs feel unrecognised and undervalued by official health care providers which not only reduces morale but also creates a disjoint between perceived influence by community, and their actual influence, reducing their respect from the community. Furthermore, this lack of respect is reflected in their lack of training and supervision, and results in a paucity of avenues for them to voice their needs and concerns.