Skilled Health Workers Research Articles

The decentralisation-centralisation dilemma: recruitment and distribution of health workers in remote districts of Tanzania.

BackgroundThe implementation of decentralisation reforms in the health sector of Tanzania started in the 1980s. These reforms were intended to relinquish substantial powers and resources to districts to improve the development of the health sector. Little is known about the impact of decentralisation on recruitment and distribution of health workers at the district level. Reported difficulties in recruiting health workers to remote districts led the Government of Tanzania to partly re-instate central recruitment of health workers in 2006. The effects of this policy change are not yet documented. This study highlights the experiences and challenges associated with decentralisation and the partial re-centralisation in relation to the recruitment and distribution of health workers.MethodsAn exploratory qualitative study was conducted among informants recruited from five underserved, remote districts of mainland Tanzania. Additional informants were recruited from the central government, the NGO sector, international organisations and academia. A comparison of decentralised and the reinstated centralised systems was carried out in order to draw lessons necessary for improving recruitment, distribution and retention of health workers.ResultsThe study has shown that recruitment of health workers under a decentralised arrangement has not only been characterised by complex bureaucratic procedures, but by severe delays and sometimes failure to get the required health workers. The study also revealed that recruitment of highly skilled health workers under decentralised arrangements may be both very difficult and expensive. Decentralised recruitment was perceived to be more effective in improving retention of the lower cadre health workers within the districts. In contrast, the centralised arrangement was perceived to be more effective both in recruiting qualified staff and balancing their distribution across districts, but poor in ensuring the retention of employees.ConclusionA combination of centralised and decentralised recruitment represents a promising hybrid form of health sector organisation in managing human resources by bringing the benefits of two worlds together. In order to ensure that the potential benefits of the two approaches are effectively integrated, careful balancing defining the local-central relationships in the management of human resources needs to be worked out.

Health Worker Migration: Time for the Global Justice Approach

We applaud the efforts of Dr. Snyder (2009) to draw attention to the elements of individual responsibility in the ethical discussions of skilled health worker migration, as it has been an underrepr...

Health workers, quality of care, and child health: simulating the relationships between increases in health staffing and child length.

One in three children globally is stunted in growth. Many of the conditions that promote child stunting are amenable to quality care provided by skilled health workers. The study uses household and facility data from the Indonesian Family Life Surveys in 1993 and 1997. The first set of multivariate regression models evaluate whether the number of medical doctors (MDs), nurses, and midwives predict quality of care as measured by adherence to clinical guidelines. The second set explains the relationships between quality and length among children less than 36 months. Using the information generated from these two sets of regressions, we simulate the effect of increasing the number of MDs, nurses, and midwives on child length and stunting. Increases in the number of MDs and nurses predict increases in the quality of care. Higher quality care is associated with child length in centimeters and stunting. Simulations suggest that large health gains among children under 24 months of age result by placing MDs where none are available. Improvements in child health could be made by increasing the number of qualified health staff. The returns to investing in improvements in human resources for health are high.

Doctors and romance: Not only of interest ot Mills and Boon readers

Internationally there is a growing demand for health services. Skilled health workers, including doctors, have a high degree of international mobility and New Zealand (NZ) stands out internationally in terms of the significant flows of doctors in and out of the country. Through changes in training of doctors in NZ and migration flows, there have been major shifts in the composition of the medical workforce in NZ since the mid-1980s. Studies of the changing nature of the medical workforce often focus on gender and migration separately as well as only considering doctors as individuals. The aim of this exploratory study is to examine the living arrangements of doctors, the composition of migrant doctors who are coming to NZ, and to understand the educational and employment status of the partners of doctors. This study is a descriptive analysis primarily using census data from 1986 through to 2006 and immigration data collected by the Department of Labour. Half of the female medical doctors approved for residence through the Skilled/Business stream migrated independently, while for male doctors less than athird came to NZ independently. Male migrant doctors were more likely to be partnered. Census data showed that people with medical backgrounds tend to partner with each other. However, these relationships are changing, as more women become doctors. In 1986 about 14% of male doctors had a nurse or midwife as a partner and nearly 9% had a doctor partner. By 2006 the proportion of partners of male doctors who were also doctors had risen to 16%, higher than the 9% who were nurses. For female doctors the changes are more dramatic. In 1986, 42% of female doctors in relationships had a doctor as a partner. By 2006, female doctors had increased substantially, but the percentage with a doctor partner had dropped to under athird. Well-qualified couples where one or both are doctors, have a greater propensityto live in main urban areas. Through official reports and extensive media coverage, the NZ public is well aware of local and national doctor shortages. There is also awareness, often through personal visits to a GP or hospital, of the significant rise in number of female and of foreign-born doctors. The choices doctors are making in living arrangements need to be taken into account when considering both national and international recruitment of medical staff. Researchers and policy makers may need to consider family migration issues more than they have in the past for doctors as well as for other migrant groups.

Care-seeking practices in South Asia: using formative research to design program interventions to save newborn lives

The purpose of this paper is to summarize the formative research findings of newborn care practices in poor and rural districts of Bangladesh, Nepal, and Pakistan and to explain how these findings were used to design behavior change communication elements of newborn care programs. In-depth interviews and focus group discussions regarding newborn care practices were conducted with mothers, mothers-in-law, delivery attendants, health care providers, husbands/fathers, male and female community leaders, religious leaders and elderly influential persons between 2002-2003 in three countries supported by Save the Children's Saving Newborn Lives program. Key findings from each country are summarized according to time periods and care-seeking practices: antenatal care, birth and emergency preparedness/care-seeking, postnatal care and care-seeking for newborn illness. All country reports indicated cultural and religious barriers to seeking care as well as limited societal knowledge about the importance of care-seeking and recognition of maternal and newborn danger signs. Routine care-seeking, especially during the postnatal period, was universally low. When families did seek care, they preferred remedies from traditional healers rather than skilled health workers because of cultural and religious beliefs, poor access to health facilities, and financial barriers. Findings from the country reports were used to design behavior change communication strategies that addressed the underlying reasons why newborn care practices were sub-optimal. Cultural and religious barriers, though strong, were not insurmountable in implementing effective behavior change communication strategies. Formative research from South Asian countries has proved crucial to program approaches to improve care-seeking for maternal and newborn care, increasing availability and access of key services, and expanding family and community knowledge and demand for these services.

Dissemination of the safe motherhood advocacy package in Tanzania

The White Ribbon Alliance Tanzania, which is a coalition of 102 organizations and 800 individuals interested in making childbirth safe, has advocated for the reduction of maternal and newborn mortality ratios (MMR/MNR) since its inception in 2004. In August 2007 the alliance conducted a baseline assessment followed by advocacy with district authorities and community mobilization for skilled health workers in Sumbawanga and Monduli Districts. A follow-up assessment was carried out six months after the advocacy activity. Advocacy and mobilization resulted in an increase of three skilled workers and a 50% increase in facility deliveries at 17 dispensaries in Sumbawanga. Seven dispensaries in Monduli had an increase of five skilled workers and 18 deliveries compared to 0 deliveries before the advocacy. This assessment concludes that advocacy contributed to changes in employment/deployment policy, and that community mobilization changed behavior, for example, the villagers opted to give birth at dispensaries, something they did not do before the mobilization.

A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context

Two decades after the Safe Motherhood campaigns 1987 launch in India, half a million women continue to die from pregnancy-related causes every year. Key health-care interventions can largely prevent these deaths, but their use is limited in developing countries, and is reported to vary between population groups. We reviewed the use of maternal health-care interventions in developing countries to assess the extent, strength and implications of evidence for variations according to women's place of residence and socioeconomic status. Studies with data on use of a skilled health worker at delivery, antenatal care in the first trimester of pregnancy and medical settings for delivery were assessed. We identified 30 eligible studies, 12 of which were of high or moderate quality, from 23 countries. Results of these studies showed wide variation in use of maternal health care. Methodological factors (e.g. inaccurate identification of population in need or range of potential confounders controlled for) played a part in this variation. Differences were also caused by factors related to health-care users (e.g. age, education, medical insurance, clinical risk factors) or to supply of health care (e.g. clinic availability, distance to facility), or by an interaction between such factors (e.g. perceived quality of care). Variation was usually framed by contextual issues relating to funding and organization of health care or social and cultural issues. These findings emphasize the need to investigate and assess context-specific causes of varying use of maternal health care, if safe motherhood is to become a reality in developing countries.

Sub-Saharan Africa: Beyond the health worker migration crisis?

Migration of skilled health workers from sub-Saharan African countries has significantly increased in this century, with most countries becoming sources of migrants. Despite the growing problem of health worker migration for the effective functioning of health care systems there is a remarkable paucity and incompleteness of data. Hence, it is difficult to determine the real extent of migration from, and within, Africa, and thus develop effective forecasting or remedial policies. This global overview and the most comprehensive data indicate that the key destinations remain the USA and the UK, and that major sources are South Africa and Nigeria, but in both contexts there is now greater diversity. Migrants move primarily for economic reasons, and increasingly choose health careers because they offer migration prospects. Migration has been at considerable economic cost, it has depleted workforces, diminished the effectiveness of health care delivery and reduced the morale of the remaining workforce. Countries have sought to implement national policies to manage migration, mitigate its harmful impacts and strengthen African health care systems. Recipient countries have been reluctant to establish effective ethical codes of recruitment practice, or other forms of compensation or technology transfer, hence migration is likely to increase further in the future, diminishing the possibility of achieving the United Nations millennium development goals and exacerbating existing inequalities in access to adequate health care.

Forecasting the Global Shortages of Physicians: An Economic- and Needs-Based Approach

Objectives: An adequate supply of physicians is a key component for any health system. We assess the current global supply of physicians and estimate the future supply of, demand for, and need for physicians by WHO region to determine where likely shortages and surpluses will occur by 2015. Methods: Using World Bank data on physicians per capita from 1980-2001 for 158 countries of the world, we employ two different modelling approaches to estimating the future global supply of physicians. A needs-based model assesses the number of physicians per capita required to achieve 80% coverage of live births by skilled health care attendants in any given country. These estimates are then compared to those of an economic model which identifies the number of physicians likely to be demanded, based on the notion from previous research that economic growth is the best single predictor in growth in health care spending, and subsequently physician demand. Results: By 2015, the world supply of physicians appears to be in balance with projected demand. Because our measure of need — 80% of live births attended by a skilled health worker — reflects a relatively low level of health service provision that is met in all but the least developed countries, the needs-based estimate predicts a global surplus of physicians. However, on a regional basis, both our needs-based and demand-based estimates project shortages for many countries in Africa in 2015. In particular, some African countries will experience both a need and demand shortage, suggesting that these economies may not be able to support larger supplies despite the need for a larger workforce, possibly contributing to out-migration. Conclusion: Achievements in global health will entail policies geared toward increasing physician supplies in identified shortage regions, as well as addressing physician migration.

Situational assessment and strategies for strengthening nursing and midwifery in the Western Pacific region

AbstractA situational assessment of the World Health Organization’s (WHO) Western Pacific region illustrates the area’s geographical, topographical, political, socioeconomic, and cultural diversity, as well as its human resource and health system challenges, including limited capacities in evidence‐based policies, planning and management. The poor repair of facilities, lack of essential drugs and equipment, low salaries, and lack of ongoing supervision are linked to lowered productivity and morale and deficient service delivery to vulnerable populations, particularly those in rural and remote areas. The situation analysis lays the foundation for the Regional Human Resources for Health strategy. The core strategies and activities of the WHO Western Pacific regional human resources for health and nursing area of work are highlighted, with attention given to workforce planning tools and guidelines and policy option support in relation to: the migration of skilled health workers; poverty, gender, and health publications; building workforce capacity in relation to priority health problems; and strengthening networking and partnerships to support leadership capacity‐building and good governance in relation to health service planning and policy‐making. Future WHO support to member states emphasizes workforce planning and management, leadership development, networking, and partnerships.

Health Systems and Access to Antiretroviral Drugs for HIV in Southern Africa: Service Delivery and Human Resources Challenges

Without strengthened health systems, significant access to antiretroviral (ARV) therapy in many developing countries is unlikely to be achieved. This paper reflects on systemic challenges to scaling up ARV access in countries with both massive epidemics and weak health systems. It draws on the authors' experience in southern Africa and the World Health Organization's framework on health system performance. Whilst acknowledging the still significant gap in financing, the paper focuses on the challenges of reorienting service delivery towards chronic disease care and the human resource crisis in health systems. Inadequate supply, poor distribution, low remuneration and accelerated migration of skilled health workers are increasingly regarded as key systems constraints to scaling up of HIV treatment. Problems, however, go beyond the issue of numbers to include productivity and cultures of service delivery. As more countries receive funds for antiretroviral access programmes, strong national stewardship of these programmes becomes increasingly necessary. The paper proposes a set of short- and long-term stewardship tasks, which include resisting the verticalisation of HIV treatment, the evaluation of community health workers and their potential role in HIV treatment access, international action on the brain drain, and greater investment in national human resource functions of planning, production, remuneration and management.

Kaqchikel midwives, home births, and emergency obstetric referrals in Guatemala: Contextualizing the choice to stay at home

Maternal mortality is highest in those countries whose health budgets are restricted. Practical strategies employed in the International Safe Motherhood Initiative, therefore, must be both effective and economical. Investing in emergency obstetric care resources has been touted as one such strategy. This investment aims to insure significant improvements are made in regional health centers, and a chain of referral is put into place so that only problem cases are attended by the most skilled health workers. This article examines how this model of referral functions in Sololá, Guatemala, where most Kaqchikel Mayan women give birth at home with a traditional midwife, and no skilled biomedical attendant is available at the birth to make a referral. Ethnographic data is used to explore reasons why women do not go to the hospital at the first sign of difficulty. I argue that the problem frequently is not that Mayan midwives, their clients and families fail to understand the biomedical information about dangers in birth, but rather that this information fails to fit into an already existing social system of understanding birth and birth-related knowledge.

A baseline survey of the Primary Healthcare System in South Eastern Nigeria

A baseline survey to audit the PHC operations and determine community perception and expectations of PHC service delivery was conducted in 72 communities in Enugu state, southeastern Nigeria. The study was intended to facilitate the development of intermediate performance indicators for monitoring the progress of an ongoing health sector reform and to gather baseline data for planning and policy formulation. The tools used for the operations audit assessed indicators for evaluating: (a) Stewardship, (b) Service Provision and (c) Administrative and financial management; while the community survey was assessed by, (a) utilization of health services, (b) perception of service delivery and (c) health care financing. One hundred and sixteen respondents from each of the facilities in the sample frame were interviewed using a structured self-assessment questionnaire and a qualitative assessment was undertaken in 53 of the facilities using an audit guide. Focus group discussions (FGD) were conducted with the policy makers and planners in each of the 17 LGAs in the state. A total of 832 respondents were interviewed in the communities (using a structured questionnaire) and 42 community FGDs were conducted. The results indicate a lack of operational efficiency in the majority of the facilities audited. It was also observed that majority of the facilities do not provide all services required of it, are poorly maintained, do not have enough skilled health workers and operate without a budget. There appears to be no formal financial management system in place and no policy on financial resource generation. The community survey identified two major problems; low utilization of PHCs and poor service provision. The key indicator identified by the community for evaluating performance of the PHCs remains “access to essential drugs”. The major prospect was the willingness of an appreciable number of respondents to invest in health financing through insurance schemes and payment of health tax among others. It was evident that poor funding, bad management practices and infrastructural decay is the bane of efficient PHC delivery. Consequently, we propose that cost determination studies, to establish the financial implication of the minimum package for provision of primary healthcare services, should be an essential prerequisite to the reform process. Some critical cross-cutting issues identified from the data obtained which could form the basis for major policy thrust include, development of strategies for sustainable promotion of public–private–partnership for enhanced community involvement in healthcare management, ensuring that interventional investment is proportional to the felt health needs of the populace and funding of healthcare through equitable integration of user fees/charges.

What is required to retain registered nurses in the public health sector in Malawi?

Western recruiting agencies and countries has been blamed for the \'brain drain\' of medical doctors and nurses from developing countries. The increasing demand for skilled human resources and better remuneration of the developed countries coupled with the poor work environment and low remuneration of the developing countries militate against the retention of skilled human resources in the developing countries. Health professionals in the developing countries are also leaving the public sector in search for better remuneration in the private sector including non-governmental organizations within their countries. The massive loss of health professionals from the developing countries to developed countries has sometimes resulted in the developed countries of the world being blamed for the phenomenon. This questionnaire study was carried out in order to deter mine factors that may facilitate the poor retention of registered nurses in the Malawian public health sector. The results indicate that poor salaries, heavy workloads, lack of promotional opportunities and poorly resourced and equipped health facilities are a de-motivating factor for registered nurses and could resulting loss from the public sector. We argue that while western nations have a role to play in ensuring retention of skilled health workers in developing countries, developing country governments also have a part to play in improving the work environment and remuneration of their employees. Malawi Medical Journal Vol.16(2) 2005: 30-32

Learning to manage leprosy after 2005: preserving critical knowledge and exploiting new technology

Amidst the many challenges currently facing leprosy services, two key training issues stand out. Firstly, the struggle to maintain an adequate pool of appropriately knowledgeable and skilled health workers in endemic areas, in order to sustain leprosy services in an integrated setting. The second major challenge is to utilize technology in the fields of training, communication and informatics, in a cost-effective manner. During the next few years, we face the loss of knowledge and experience in the management of leprosy. Many experienced clinicians, from clinic level health workers to district supervisors, medical officers and specialists, will no longer be working with leprosy patients, for a variety of reasons. Many are retiring, or they are being re-assigned to other work; others are leaving to advance their careers elsewhere, either within the same country or abroad. Thus it will become more difficult for people with leprosy to access expert and timely care – both for the initial diagnosis and for the management of complications. Furthermore, these experienced clinicians have, until now, been responsible for the training and supervision of junior staff, who see and manage most cases. Thus over time, one may predict that the quality of care for most new leprosy cases will deteriorate. While this may be inevitable in low endemic areas, it may also become a problem in areas where large numbers of new cases are still presenting. A similar problem is occurring in the commercial world as large numbers of senior staff are expected to retire in the next five to ten years. This has led to further thinking about the kind of knowledge that is particularly at risk of being lost and how it can be preserved. The converse of the problem of the loss of senior staff is the need to enable the many new health staff in integrated health units to learn the clinical and counseling skills necessary to suspect and manage leprosy. There are large numbers of such staff and each one will see at most only a few cases of leprosy throughout their career. Nevertheless, appropriate training at each level (both the primary clinics and the referral centers) will be essential if people affected by leprosy are to be given the treatment they need.

Mantombazana Tshabalala-Msimang: South Africa's controversial health minister

Mantombazana Tshabalala-Msimang: South Africa's controversial health minister

The remittances of migrant Tongan and Samoan nurses from Australia.

BackgroundMigration and remittances are of considerable importance in the small Pacific island states. There has been a significant migration of skilled health workers in recent decades to metropolitan fringe states, including Australia and New Zealand. This paper reports the findings of a re-analysis of survey of Samoan and Tongan migrants in Australia where the sample is split between nurse households and others.MethodsThe study analyzes the survey data with a view to comparing the remittance behaviour and determinants of remittances for nurses and other migrant households, using both descriptive, cross-tabulations and appropriate econometric methods.ResultsIt is found that a significantly higher proportion of nurse households sent remittances home, and, on average remitted more. Remittances of nurse households did not decline significantly over time contrary to what has generally been predicted. This was in contrast to other migrant households in the sample, for whom remittances showed a sharp decline after 15 years absence. Remittances contribute much more to the income of migrant sending countries, than the cost of the additional human capital in nurse training.ConclusionsGiven the shortage of nurses in Australia and New Zealand, and therefore the high demand for immigrant nurses, investment by Pacific island governments and families in nurse training constitutes a rational use of economic resources. Policies encouraging investment in home countries may be more effective than policies directly discouraging brain drain in contributing to national development.

Interpretation of hospital-specific outcome measures based on routine data.

Hospital-specific outcome measures based on routine data are useful for stimulating interest in quality of care and for suggesting avenues for more in-depth analyses. They might also identify serious, once-in-a-lifetime failures of health care. However, such analyses are not definitive. They are a way of screening large amounts of routine data and, like all screening tools, they can generate false positives and false negatives. This is because differences in outcome measures across hospitals can be due to differences in types of patients seen (casemix), differences in data quality, and the play of chance; rather than differences in the quality of care. End-users of such analyses should be aware of these technical difficulties, otherwise skilled health workers in high-quality hospitals might be subjected to unwarranted criticism.

Mobile Health Services

The techniques of cost-effectiveness are employed to simplify resource allocation decisions concerned with the use of land and air transport systems in the health services of a developing country. Outcome classifications are produced for patients seen by mobile and fixed primary care units. The mobile services examined were far more costly (8 to 14 times greater) per likely-effective-patient-contact than comparable care delivered from permanently staffed fixed clinics. This was particularly so for the air-delivered service. The disparity in cost-effectiveness was due mainly to the small proportion of patients seen by the mobile services who could be treated effectively in contrast to a far larger proportion at fixed clinics. This was a consequence of the periodic availability of care from the mobile services as against the continuing provision of care at fixed clinics. The main justification for the use of mechanical transport in connection with primary health care is regular supportive (not policing) visits by skilled health workers to rural clinics. Land vehicles are cheaper than aircraft for visiting the more accessible facilities; for the more distant clinics, the cost of journeys by land vehicle are similar to those by aircraft.

International Health Planning

Scrimshawin a paper published in 1974 correctly emphasizes that socioeconomic development; of which improved health and nutrition standards are integral components can only be a holistic process. This axiom is now receiving the attention it deserves and there are repeated requests on the part of developing countries leaders and planners that technical assistance resources be not allocated disproportionately according to priorities demanded by Western experts. The focus of the last decades on a systems approach to planning should promote adequate consideration of the influence on nonhealth factors on health conditions and health services. Most of the ills of public health importance in developing countries are basically socioenvironmental in nature and the following are examples of major health problems in these countries: malnutrition decreasing practice of breast-feeding the effects of socioenvironmental conditions on communicable diseases anemia and health problems related to human reproduction. In that high fertility in developing countries is promoted by very high infant and child morality and since it is recognized that this excessive morality is overwhelmingly due to socioenvironmental factors the population problem itself is to a certian extent environmental in its causation. An obvious corollary of great importance is that health workers must be very knowledgeable about this environment. No matter how skilled health workers are they will not be of much help if there is a gap between them and those they are supposed to be serving. The real challenge in international health planning might well be the effective involvement of the community the bridging of the gap between the common person and the health services the government makes available. Additionally all planners should be wary of avoiding overplanning and underimplementing.