Skilled Health Workers Research Articles

Analysis of the measured medical waste generation rate in Tanzanian district hospitals using statistical methods

In this study the medical waste generation rates at Amana and Ligula hospitals were measured and analyzed. The rate of medical waste generation is high; about 2,250 kg/day in Amana and 2,500 kg/day in Ligula hospital. The waste generation rate per patient per day is also high about 1.8 (Amana) and 2.0 (Ligula) kg/patient.day. The daily medical waste generation rate is not constant, and fluctuates randomly. About 6 to 10% of waste generated is left uncollected. Eight medical waste categories were measured and compared: general waste, pathological waste, radioactive waste, chemical waste, infectious waste, sharps waste, pharmaceutical waste, and pressurized containers. The results indicated general waste to have high generation rate while others waste types such as chemical and radioactive wastes have low generation rates. Due to differences in generation rates, the data was normalized in order to compare statistical parameters used to assess medical waste generation rates. The statistical parameters used include: range, skewness, kurtosis, probability density functions and histograms. The study revealed that management of medical waste is still facing critical problems and requires skilled health workers, appropriate technologies and suitable equipment for collection, storage and transportation. The study will enable hospitals to understand trends in variations of medical waste generation and accommodate fluctuations in their plans and budgets. Key words: Measured medical waste in selected Tanzania district hospitals, variations of waste generation, average waste generation, waste collection efficiency; range of waste generation, normalized waste generation

Determinants of apparent rural-urban differentials in measles vaccination uptake in Indonesia

Regional differences in vaccination uptake are common in both developed and developing countries, and are often linked to the availability of healthcare services and socioeconomic factors. In 2007, 0.9 million eligible Indonesian children missed measles vaccination, and 19 456 cases of measles were documented among Indonesian children. The authors investigated rural-urban differentials in measles vaccination coverage among young Indonesian children, and sought to identify key factors influencing the probability of a child receiving the first dose of measles vaccination in Indonesia. Data used in the analyses were sourced from the nationally representative Indonesia Demographic and Health Survey 2007. The influence of location of residence, household wealth, maternal and paternal education, total children ever born and use of skilled birth attendants on measles vaccination coverage was investigated using bivariate analysis and chi-square tests. The independent effects of these variables were established using binomial logistic regression analysis. Indonesia's 2007 first-dose measles national vaccination coverage was, at 72.8%, lower than the 2008 global first-dose measles vaccination average coverage of 82%. Bivariate analysis revealed that the first-dose measles vaccination coverage in rural areas of Indonesia was 68.5%, compared with 80.1% in urban regions (p < 0.001). The apparent significance of rural residence in impairing vaccination coverage was marginal after controlling for the sex of the child, maternal age, maternal and paternal education, wealth, and access to skilled health workers. Apart from sustainable initiatives to increase measles vaccination coverage globally, it is important to close the rural-urban gap in Indonesia's measles vaccination uptake. Addressing critical determinants of inferior measles vaccination coverage in Indonesia's rural regions will facilitate major improvements in Indonesia's child health trends. This article suggests initiatives for addressing three of such determinants in Indonesia's rural areas: poverty, parental education and access to skilled health workers.

The Impossible Dream? Codes of Practice and the International Migration of Skilled Health Workers

AbstractThe international migration of skilled health workers has increased significantly from the 1990s. Many source countries have expressed concern over losses of health workers, resulting in regional Codes of Practice and bilateral Memoranda of Understanding being established since 1999 to achieve more effective, equitable and ethical international migration. The finalisation of a Global Code in 2010 drew attention to continued migration concerns. Codes have three key objectives — protecting rights of migrant workers, adequate workplace support for migrant workers and ensuring that migration flows do not disrupt health services in source countries. There is no agreed definition of ethical international recruitment, and no consensus on the significance and location of harmful recruitment practices. Most codes have covered relatively few regions and exhibit a high degree of generality. Several source countries encourage rather than discourage migration. Migration is a right and occurs in contexts that do not necessarily involve health issues. There are no incentives for recipient countries and agencies to be involved in ethical international recruitment. All codes are voluntary which has restricted their impact. Substantial migration and recruitment have occurred outside their scope, and codes have diverted skilled health workers beyond regulation. The private sector is effectively excluded from codes. Bilateral agreements and memoranda have a greater chance of success, enabling managed migration and return migration, but are more geographically limiting. The most effective constraints to the unregulated flow of skilled health workers are the production of adequate numbers in present recipient countries and provision of improved employment conditions in source countries.

USING QUALITATIVE DATA TO DEVELOP LOCALLY RELEVANT AND VALID QUANTITATIVE MEASUREMENT TOOLS: A CASE EXAMPLE OF TRUST IN ETHIOPIA

Purpose: To build a new measure of trust from the ground up that is valid and locally relevant. Background: Little is known about the influence of trust among health workers in low‐resource settings. Trust may be particularly salient among health workers in developing countries such as Ethiopia where skilled health worker shortages have led to reliance on lower‐skilled community‐level health workers to provide services. Methods: Ethnographic data on the conceptualization of trust were collected through semi‐structured interviews with 30 health workers in Amhara region, Ethiopia. Transcripts underwent thematic analysis to identify characteristics of trustworthiness. Respondents’ own words were used to build a 25‐item trust scale which was subsequently pilot tested with 92 health workers. Cultural consensus analysis and Quadratic Assignment Procedure (QAP) assessed the level of shared cultural knowledge within and between cadres of health workers. Results: Psychometric testing of the trust scale reveals strong internal consistency. Cultural consensus analysis and QAP provide preliminary evidence for the existence of divergent models of trust among health worker cadres. Conclusions: This represents a case example of how rapid formative work can lead to the development of a scale that is both valid and locally relevant. Next steps in the research involve assessing the association between trust and teamwork, and linking trust and teamwork with delivery of health services and outcomes. Funding: Bill and Melinda Gates Foundation

John Connell: Migration and the globalisation of health care: the health worker exodus?

This book addresses a major current topic and attempts to cover the trends, arguments and dilemmas. The author is eminently qualified to tackle such an exercise as he has a long history of migration and other research, especially in the Pacific region. The book provides a comprehensive overview of the major issues together with detailed analysis and debate. Chapter 2 on ‘the geography of need’ outlines the factors that influence disease patterns and the provision of health care services, at the global, national and regional levels. In this context, the provision of health workers is only one factor but it is a crucial one. Connell states that the presence of health workers is crucial to positive health outcomes, and the association between ‘health workforce density’ and health outcomes has been clearly demonstrated (p. 13). This chapter contains a good mix of developed and developing-country examples and demonstrates the complex interplay of factors (including the availability of finance, politics, culture) that are at work to determine shortages or surpluses of skilled health workers. In developing countries the disease burden is greatest and least well served by workers and facilities. The migration of skilled workers has grown in recent decades and the trends and patterns are outlined in Chap. 3, ‘Phases of globalisation’. Connell identifies three major periods: (1) Early Days, Colonial Years, (2) The First Brain Drain? and (3) Globalization. The first period is hardly ever written about so this provides a timely reminder of the early flows and the place of expatriates in establishing the first Western-style services, and training Indigenous workers. Connell reminds us of the role of these movements in setting the scene for later flows in the opposite direction. The second phase ‘accompanied the recognition of widespread brain drain’ (p. 63) and he provides plenty of evidence for the validity of the concept at that time, in

Are traditional birth attendants good for improving maternal and perinatal health? Yes

Joseph Ana argues that the shortage of skilled health workers means traditional birth attendants have a valuable place, but Kelsey A Harrison (doi:10.1136/bmj.d3308) believes they do more harm than good

Are traditional birth attendants good for improving maternal and perinatal health? No

<b>Joseph Ana</b> (doi:10.1136/bmj.d3310) argues that the shortage of skilled health workers means traditional birth attendants have a valuable place, but <b>Kelsey A Harrison</b> believes they do more harm than good

Understanding the impact of conflict on health services in Iraq: information from 401 Iraqi refugee doctors in Jordan

This study aims to assess how conflict has affected the function of Iraqi health services and its doctors. Interviews were conducted in person or by mobile phone with 401 Iraqi doctors entering Jordan since 2003, using respondent-driven sampling methods. Of the Iraqi doctors interviewed in 2008, 94% came from Baghdad, although 25% had moved within Iraq in the past year. They reported a steady year-by-year decline in Iraqi health services from 2003 through 2006, with perhaps some improvement in 2007. By 2006, 67% of doctors said essential drugs were present less than half of the time (95% confidence interval [CI] 54-81), and 69% (95% CI 56-84) said essential equipment was available or working half the time or less. By 2006, 95% said their facilities lacked skilled health workers, and 90% noted reduced quality of care. Violent death rates among doctors in Baghdad reached 47.6/1000/yr (95% CI 42.0-53.7) in 2006. In the same year, migration rates for Baghdad doctors moving elsewhere in Iraq were 143.8/1000/yr (95% CI 134.0-154.1), and departure from Iraq was 299.5/1000/yr (95% CI 285.3-314.3). Deterioration of health services quality, staffing levels and violence against doctors continued from 2003 through 2006, although these may have improved slightly in 2007. In 2009 and 2010, reports suggest that assassinations of doctors and out-migration have continued. Few have returned.

The Global Health Care Chain: From the Pacific to the World (review)

Reviewed by: The Global Health Care Chain: From the Pacific to the World Penelope Schoeffel The Global Health Care Chain: From the Pacific to the World, by John Connell. Routledge Research in Population and Migration Series 12. New York: Routledge, 2008. ISBN cloth, 978-0-415-95622-2; eBook, 978-0-203-88511-6; 197 pages, maps, preface, bibliography, index. Cloth, US$105.00; eBook US$105.00. John Connell's finely researched and informative book is a Pacific regional companion to his 2008 edited volume The International Migration of Health Workers. The Global Health Care Chain: From the Pacific to the World draws on a survey of more than five hundred health workers in nine island states—Kiribati, Marshall Islands, and Palau in Micronesia; Fiji and Vanuatu in Melanesia; and Cook Islands, Niue, Sāmoa, and Tonga in Polynesia-and three destination states—Australia, Canada, and New Zealand. He also pulls together a large literature including academic studies and technical reports by international agencies. Beginning with an overview of globalization of skilled migration as it affects the Pacific, the book contextualizes the rise of Pacific migration, examines various health care systems in the Pacific, describes how skilled health workers are trained in the various Island states, considers why these workers decide to migrate or stay at home, and analyzes the impacts of their migration choices on Island health services. Globalization draws the highly skilled from every corner of the world to the metropolitan centers that offer the best working conditions and pay—a negative trend for the health systems of less-developed countries and especially for the small Island states of the Pacific. Health professionals are among the most expensive to train and have the easiest access to overseas job markets, not only in Australia and New Zealand but also in the Arabian Gulf states and Canada. Some Pacific Island states recruit from within the Pacific, as well as from other developing countries. For example, Fijian nurses work in the Marshall Islands and Palau, and Samoan doctors work in American Samoa. Men and women from Pacific Island communities where nursing was once seen as demeaning or unmanly now regard it much more positively because of the overseas employment opportunities it offers. Higher wages are not the only reason for leaving, or for not returning after training. Returning graduates are often as frustrated by their working conditions as they are by their salaries. Small, poor countries lack the medical equipment and other resources that encourage professional development, and few can support highly specialized staff. Migration-prone Pacific Island states also have the problem of meeting rising expectations, knowing the life-extending technologies available to their relatives overseas and wanting them at home. But providing specialized facilities for renal or cardiothoracic or oncology care is likely to mean fewer basic services in rural [End Page 252] areas, and overseas treatment schemes, unless donor funded, eat up health-sector budgets. Keeping professionally qualified health staff in remote rural areas is a challenge for all Pacific Island states, where not only nationals may refuse to serve but also doctors recruited from other developing countries. In some states this is related to poor governance, where health centers and rural hospitals have been allowed to become dilapidated, lacking drugs and equipment, with staff salaries sporadically paid. The book explores in detail how skilled health workers make decisions to migrate or remain at home and provides a number of illustrative case studies from the survey on the options and dilemmas of skilled health workers. Family considerations are prominent in many of these accounts, particularly among Islander nurses; by staying they may directly care for their families but by going they may provide them with material support. Some choose both options, alternately working abroad and at home. Connell critically examines the various policy options open to Pacific Islands governments, such as the rationing of training by offering less internationally marketable credentials, offering salary supplements, improving workplaces, and bonding graduates trained in health sciences abroad. Should small Island states train more intermediate paramedical staff than doctors, even when paramedics are unwelcome among local people who want "real" doctors? Should they change the rules to allow nurse practitioners and...

Care of the newborn: Community perceptions and health seeking behavior

Background: Every year, 120,000 newborns die in Ethiopia. In 2005 a national Safe Motherhood Community-Based Survey was carried out on behalf of the Family Health Department to explore community practices surrounding newborn health and care seeking behavior.Objective: To explore and understand health seeking behavior, and identify the positive practices surrounding care of the newborn.Methods: In-depth interviews and focus group discussions regarding newborn care practices were conducted with mothers, older women, men with young children, health providers, religious leaders and elders across Ethiopia’s 11 regions.Important findings: Tradition recommends mothers and their newborns to stay at home for 40 days. The principle behind the practice, facilitates the period of rest and repair, establishes breastfeeding and is justified on the grounds that the mother and newborn are vulnerable to malevolent spirits. Perceptions of the causes of newborn mortality and morbidity are consistent with those relating to biomedical causes. Many complained of lack of accessible health care that in event of emergencies. Therefore they have to rely on traditional medicine as it is easily accessed, readily acceptable.Conclusions: When families seek care for their newborns, remedies from traditional healers are often preferred to skilled health workers because of cultural and religious beliefs, poor access to health facilities, (including distance and terrain) and financial barriers. [Ethiop. J. Health Dev. 2010;24 Special Issue 1:110-114]

Taking advantage of the 2010 population census round to strengthen the global evidence base on the health workforce

There is an increasing body of evidence of a strong correlation between the density of trained health workers in a country and improved population health outcomes. Yet many countries lack sufficient numbers and equitable distribution of skilled health workers to deliver essential health interventions, such as immunization and skilled attendance at delivery. The World Health Organization estimates that there are 57 countries, mostly located in sub-Saharan Africa, with crisislevel shortages of doctors, nurses, midwives and other health workers (WHO, 2006). An increasing number of stakeholders – including international and national agencies, non-governmental organizations and the general public – have become sensitive to the importance of planning, developing and strengthening the health workforce in order to meet national and global health and development goals, including the healthrelated Millennium Development Goals. With only five years left until the 2015 deadline to achieve the Millennium Development Goals, 2010 presents a critical opportunity for action to increase investment and support to countries to strengthen their health systems, including their health workforce, to deliver primary health services. Despite the undoubted importance of monitoring the health workforce and impacts on population health outcomes, the empirical evidence to support policy formulation is often fragmented. Many sources can potentially produce information relevant to this issue but remain underused in health research, especially among lowand middleincome countries. Falling into this category are national population censuses. Population censuses with questions on labour force activity and occupation can be a key source for statistics describing the health workforce, providing a comprehensive snapshot of the stock and distribution of health workers in a country (GUPTA et al., 2003; LAVALLEE, et al., 2009). However there are few (if any) documented experiences of health sector planners, managers and policy-makers capitalizing on this resource to inform decision making. In most cases, ministries of health rely exclusively on administrative data sources such as facility staffing records and registries of professional regulatory bodies. While these sources offer many advantages compared to populationbased sources, including being locally available and generally easy to use among non-specialist audiences, having and using a range of data from different sources can help present a fuller picture and minimize the risk of making decisions based on statistics that are incomplete or biased (ABOUZAHR et al., 2007). In Brazil, like many other countries, population censuses are conducted about once every ten years. The last census for which data are currently available, conducted in the year 2000, included questions on occupation among household members of age of economic activity. The coding of responses, as mapped to the national classification of occupations, allowed for statistical delineation and analysis of those with a health-related occupation, such as medical doctors, nutritionists and nursing auxiliaries. As in many other countries, the national classification holds as reference the International Standard Classification of Occupations (ISCO).

A New Measurement for Optimal Antenatal Care: Determinants and Outcomes in Cameroon

A combined measure of optimal antenatal care can provide more information on the role it plays in maternal health. Our objectives were to investigate the determinants of a measure of optimal antenatal care and the associated pregnancy outcomes. Data on 7,557 women taken from the 2004 Demographic and Health Survey in Cameroon were used to develop a new measurement of optimal antenatal care based on four indicators: at least four visits, first visit in first trimester, last visit in third trimester and a professional provider of antenatal care. We studied the relationship of this new variable with other related variables in a multivariate analysis, taking into account the complex study design. Almost sixty six percent of the women had optimal antenatal care. Secondary or higher education (OR 1.74; 95% CI 1.28-2.36), greater wealth (OR 2.31; 95% CI 1.73-3.1), urban residence (OR 1.42; 95% CI 1.12-1.82) and parity of 3-4 (OR 0.79; 95% CI 0.62-0.99) were independently associated with optimal antenatal care. Women with optimal antenatal care were more likely to deliver in a health unit (OR 2.91; 95% CI 2.42-3.49), to be assisted by a skilled health worker during delivery (OR 1.88; 95% CI 1.49-2.37) and to have a baby with a normal birthweight (OR 1.62; 95% CI 1.11-2.38). Obtaining and using a new measure for ANC is feasible. The association of optimal antenatal care to education, wealth and residence in this study, consistent with others, highlights the role of the country's development in maternal health.

Indian approaches to retaining skilled health workers in rural areas

The lack of skilled service providers in rural areas of India has emerged as the most important constraint in achieving universal health care. India has about 1.4 million medical practitioners, 74% of whom live in urban areas where they serve only 28% of the population, while the rural population remains largely underserved. The National Rural Health Mission, launched by the Government of India in 2005, promoted various state and national initiatives to address this issue. Under India's federal constitution, the states are responsible for implementing the health system with financial support from the national government. The availability of doctors and nurses is limited by a lack of training colleges in states with the greatest need as well as the reluctance of professionals from urban areas to work in rural areas. Before 2005, the most common strategy was compulsory rural service bonds and mandatory rural service for preferential admission into post-graduate programmes. Initiatives under the National Rural Health Mission include an increase in sanctioned posts for public health facilities, incentives, workforce management policies, locality-specific recruitment and the creation of a new service cadre specifically for public sector employment. As a result, the National Rural Health Mission has added more than 82,343 skilled health workers to the public health workforce. The problem of uneven distribution of skilled health workers can be solved. Educational strategies and community health worker programmes have shown promising results. Most of these strategies are too recent for outcome evaluation, although this would help optimize and develop an ideal mix of strategies for different contexts.

Women’s and children’s health: from pledges to action

It has been a landmark year for the health of women and children. The world is making important progress in reducing the number of children dying from preventable causes. After six decades of little progress in reducing under-five mortality to less than 10 million, this past decade has seen a steady decline in child deaths.1,2 The publication of new maternal mortality data confirmed that since 1990 there has been a decline of one-third in the numbers of women dying in childbirth,3,4 showing that progress on Millennium Development Goal 5 is being made. For the first time – through the Muskoka Initiative led by the Canadian Government – heads of state of the group of 8 countries (G8) committed US$ 5 billion to improving maternal, child and newborn health. The African Union summit focused on “Maternal and Child Health and Development in Africa” and committed to action in their countries through a coordinated campaign to be delivered by the African Union Commission and a new task force that will review progress every year until 2015. The United Nations General Assembly discussed the theme in a special event at which the Secretary-General launched a Global Strategy for Women's and Children's Health, developed with the support and facilitation of the Partnership for Maternal, Newborn and Child Health.5 The main objective of this strategy is to save 16 million lives by 2015 by integrating service delivery and funding platforms, involving a wide range of stakeholders, research and innovation, and tracking progress through an accountability framework. Planned outcomes include: 43 million new users having access to comprehensive family planning and 19 million more women giving birth attended by a skilled health worker with access to necessary infrastructure, drugs, equipment and regulations. The strategy is designed to ensure that 2.2 million additional neonatal infections are treated, 21.9 million additional infants are breastfed, 15.2 million more children are fully immunized in the first year of life and that 117 million more children aged less than five years receive vitamin A supplements. To deliver these interventions, 85 000 more health facilities and up to 3.5 million additional health workers are needed. Success will mean saving the lives of more than 15 million children aged less than five years and of 570 000 women endangered by complications of pregnancy and childbirth, including unsafe abortion. The strategy will prevent 33 million unwanted pregnancies, protect 88 million children aged less than five years from stunting and protect 120 million children from pneumonia. To reach these objectives, governments from developing and developed countries, foundations, civil society organizations, academics, health-care professionals and the private sector pledged more than US$ 40 billion and made policy and service delivery commitments at the United Nations special event. To begin the process of transforming pledges to action, all these groups will participate in this month's Forum of The Partnership for Maternal, Newborn and Child Health, hosted by the Government of India. The lives of women and children depend on the choices that are available to them to determine their health and to realize their rights. Only if women are fully empowered with the knowledge and means to take action for themselves and their children will this transformation succeed. At the global level, these actions depend on the availability of effective, efficient and equitable mechanisms for funding and service delivery. One of the key outcomes of the Forum will be agreement on the principles and actions required to ensure mutual accountability for realizing the results to which all stakeholders committed themselves in the Global Strategy. Tracking commitments and ensuring accountability will require actions at many different levels – community, national, agency and international. The World Health Organization has been tasked to chair a process to determine the most effective arrangements for global reporting, oversight and accountability on women's and children's health.5 The Partnership for Maternal, Newborn and Child Health brings together many of the key global institutions and actors – governments, United Nations organizations, donor agencies, professional associations, academics and civil society – who will need to carry out the work. We see the Forum as an opportunity for all partners to take inspiration from the landmark events of 2010 for women’s and children’s health. We then need to reinvigorate our efforts and hold each other accountable if we are to realize our shared global commitments to health, development and human rights.

Five years to go and counting: progress towards the Millennium Development Goals

Five years to go and counting: progress towards the Millennium Development Goals

Competence and Performance of the Skilled Birth Attendants to undertake Normal Delivery and Emergency Obstetric Care in Eritrea.

Objective: to determine the competence and performance of the skilled birth attendants and the quality of normal delivery and emergency obstetric services in Eritrea. Methods: All of the 17 hospitals that provide maternity services and all of the 46 health centers in the country were included in this study. Quality or Quality gap was assessed through measuring the percentage of clients who got a service in compliance with the standards described in the national safe motherhood protocol. Findings: The study revealed gaps in the competence and performance of the skilled health workers as well as in the quality of normal delivery and emergency obstetric services in the country. Among the quality gaps identified were poor monitoring of normal and complicated labor and lack of use of partographs. Conclusion: The study concluded that in order to reduce maternal morality in developing countries like Eritrea; it is not adequate to just increase the percentage of women who are attended by health professionals, it is also at least equally important to improve the skills and performance of the available birth attendants.

Improving health workforce recruitment and retention in rural and remote regions of Nigeria

As highlighted by the 2006 World Health Report, Nigeria is one of 36 sub-Saharan African countries in the midst of a health workforce crisis. Inadequacy of optimal numbers of health workers with the appropriate skills-set is most pronounced in the rural and remote regions of Nigeria where 52% of the population live. Mortality and morbidity data from limited surveys of Nigeria indicate greater unmet health needs in rural and remote regions than in urban areas. Spartan living conditions, non-existent rural workforce policies and strategies, and an inadequate number of health staff with skills appropriate to the health priorities of rural areas are several of the many factors attributable to the steady decline in Nigeria's rural and remote health system. Based on 7 years' experience as a public health physician in rural and remote northern Nigeria, the author provides a perspective on factors hindering health workforce recruitment and retention, and proposes approaches to sustainably improving the current unsatisfactory health workforce situation in Africa's most populous nation. This article posits that out-migration of health workers is not a critical contributor to health workforce shortages in Nigeria's rural and remote areas. More important factors include contraction of government health spending as a percentage of GDP despite deteriorating health conditions, public health management systems that operate by default rather than by design, spartan living conditions outside urban areas, inadequate training of appropriate cadres of health staff, limited facilities and medications for effective delivery of clinical services, and burnout of overworked and underpaid rural-based clinicians. Most current health policy and strategy documents in Nigeria do not adequately account for the unique demographic features and health issues which vary according to remoteness from major cities. Addressing rural and remote health workforce shortages in Nigeria should begin with the development of a well-researched national rural and remote health strategy. Sub-optimal leadership and management at all levels of the public health sector, poverty, low motivation, inadequacy of health facilities and medications for effective delivery of health care, inadequacy of funding to employ qualified health staff, and primitive living conditions constitute major disincentives for skilled health workers to work in the rural and remote regions of Nigeria, and for declining productivity among existing health workers. Practical interventions to encourage recruitment and retention, and to assure improvements in the quality and popularity of appropriately designed training programs for health professionals needed in rural and remote regions of Nigeria are discussed. A need is highlighted for adequate planning and resource allocation to enable a systematic overhaul of encumbrances currently impacting on Nigeria's rural and remote health system. Lessons that may be adapted from successful rural and remote health workforce training and recruitment strategies in Tanzania are discussed.

Limited Progress in Increasing Coverage of Neonatal and Child-health Interventions in Africa and Asia

The study was conducted to analyze recent trends in the coverage of selected child-survival interventions. A systematic analysis of the coverage of six key child-health interventions in 29 African and Asian countries that had two recent demographic and health surveys--the latest one carried out in 2001 onwards and the immediately preceding survey conducted after 1990--was undertaken. A regression model was used for examining the relationship between the changes in the coverage of interventions and the changes in rates of mortality among children aged less than five years (under-five mortality). A limited increase in the coverage of key child-health interventions occurred in the past 5-10 years in these 29 countries in sub-Saharan Africa and Asia. More than half of the countries had no significant improvement or a significant reduction in the coverage of oral rehydration therapy (ORT) for diarrhoea (17/29) and care-seeking for acute respiratory infection (ARI) (16/29). Results of multivariate analysis revealed that increases in the coverage of early initiation of breastfeeding, ORT for diarrhoea, and care-seeking for ARI were significantly associated with reductions in under-five mortality. The results of this analysis should serve as a wake-up call for policymakers and programme managers in countries, donors, and international agencies to accelerate efforts to increase the coverage of key child-survival interventions. The following three main actions are proposed: setting of the clear target; mobilization of resources for increasing skilled birth attendants and health workers trained in integrated management of childhood illness; and implementation of community-based approaches.

Safe Motherhood Case Studies: Learning from South Asia

Safe Motherhood Case Studies: Learning from South Asia

The International Migration of Health Workers

The International Migration of Health Workers: A Global Health System? By John Connell. New York: Routledge Research in Population and Migration Series, 2008. 228 pp., $95.00 hardcover (ISBN-13: 978-0415956239). Published in the Routledge research in population and migration series, The International Migration of Health Workers addresses one of the most controversial yet important issues of our time—the migration of skilled health workers (SHW). John Connell's (editor) book offers an innovative analysis of the dynamics of the migration of SHW, presented in accessible and engaging manner drawing from various case studies. It is organized in thirteen chapters, with the editor giving a summative account of the rest of the chapters in chapter one which also forms the analytical grounding of the book. Chapter one captures the debate in the book by providing a picture of where human resources in health are most needed or what the author has termed “the geography of need” (p. 3). Regions such as Sub-Saharan Africa, Latin America, India, and China, where disease burden is high, are also the areas where human resources are most needed. The author then engages with the main subject of the book—migration of SHW—providing a lucid account of the main “losers” and “beneficiaries” of this migration. The reader is given an illuminating account of the main reasons behind SHW migration, the players …