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Appropriate training and retention of community doctors in rural areas: a case study from Mali
Background:
While attraction of doctors to rural settings is increasing in Mali, there is concern for their retention. An orientation course for young practicing rural doctors was set up in 2003 by a professional association and a NGO. The underlying assumption was that rurally relevant training would strengthen doctors' competences and self- confidence, improve job satisfaction, and consequently contribute to retention.
Methods:
Programme evaluation distinguished trainees' opinions, competences and behaviour. Data were collected through participant observation, group discussions, satisfaction questionnaires, a monitoring tool of learning progress, and follow up visits. Retention was assessed for all 65 trainees between 2003 and 2007.Results and discussionThe programme consisted of four classroom modules - clinical skills, community health, practice management and communication skills - and a practicum supervised by an experienced rural doctor. Out of the 65 trained doctors between 2003 and 2007, 55 were still engaged in rural practice end of 2007, suggesting high retention for the Malian context. Participants viewed the training as crucial to face technical and social problems related to rural practice. Discussing professional experience with senior rural doctors contributed to socialisation to novel professional roles. Mechanisms underlying training effects on retention include increased self confidence, self esteem as rural doctor, and sense of belonging to a professional group sharing a common professional identity. Retention can however not be attributed solely to the training intervention, as rural doctors benefit from other incentives and support mechanisms (follow up visits, continuing training, mentoring...) affecting job satisfaction.
Conclusions:
Training increasing self confidence and self esteem of rural practitioners may contribute to retention of skilled professionals in rural areas. While reorientations of curricula in training institutions are necessary, other types of professional support are needed. This experience suggests that professional associations dedicated to strengthening quality of care can contribute significantly to rural practitioners' morale.
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Strategies to overcome physician shortages in northern Ontario: A study of policy implementation over 35 years
Background:
Shortages and maldistibution of physicians in northern Ontario, Canada, have been a long-standing issue. This study seeks to document, in a chronological manner, the introduction of programmes intended to help solve the problem by the provincial government over a 35-year period and to examine several aspects of policy implementation, using these programmes as a case study.
Methods:
A programme analysis approach was adopted to examine each of a broad range of programmes to determine its year of introduction, strategic category, complexity, time frame, and expected outcome. A chronology of programme initiation was constructed, on the basis of which an analysis was done to examine changes in strategies used by the provincial government from 1969 to 2004.
Results:
Many programmes were introduced during the study period, which could be grouped into nine strategic categories. The range of policy instruments used became broader in later years. But conspicuous by their absence were programmes of a directive nature. Programmes introduced in more recent years tended to be more complex and were more likely to have a longer time perspective and pay more attention to physician retention. The study also discusses the choice of policy instruments and use of multiple strategies.
Conclusion:
The findings suggest that an examination of a policy is incomplete if implementation has not been taken into consideration. The study has revealed a process of trial-and-error experimentation and an accumulation of past experience. The study sheds light on the intricate relationships between policy, policy implementation and use of policy instruments and programmes.
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The role of leadership in HRH development in challenging public health settings
As part of the special feature on leadership and human resources (HR), Management Sciences for Health profiles three leaders who have made a significance difference in the HR situation in their countries. By taking a comprehensive approach and working in partnership with stakeholders, these leaders demonstrate that strengthening health workforce planning, management, and training can have a positive effect on the performance of the health sector.
Three profiles are presented, from Afghanistan, South Africa, and Southern Sudan, revealing common approaches and leadership traits while demonstrating the specificity of local contexts.
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Is satisfaction a direct predictor of nursing turnover? Modelling the relationship between satisfaction, expressed intention and behaviour in a longitudinal cohort study
Background:
The theory of planned behaviour states that attitudinal variables (e.g. job satisfaction) only have an indirect effect on retention, whereas intentions have a direct effect. This study uses secondary data from a longitudinal cohort of newly qualified nurses to test for the direct and indirect effects of job satisfaction (client care, staffing, development, relationships, education, work-life interface, resources, pay) and intentions to nurse on working as a nurse during the three years after qualification.
Methods:
A national sample (England) of newly qualified (1997/98) nurses (n=3669) were surveyed at six months, eighteen months and three years . ANOVA and MANOVA were used for comparison of mean job satisfaction scores between groups; intentions to nurse (very likely, likely vs. unlikely, very unlikely and unable to say at this stage); working (or not working as a nurse) at each time-point. Indirect and direct effects were tested using structural equation and logistic regression models.
Results:
Intentions expressed at six months to nurse at eighteen months were associated with higher scores on pay and relationships, and intentions at three years were associated with higher scores on care, development, relationships, work-life interface, resources, and pay respectively. Intentions expressed at eighteen months to nurse at three years were associated with higher scores on development, relationships, education and work-life interface. Associations with actual nursing were fewer. Those working as a nurse had higher satisfaction scores for development (eighteen months) and relationships (three years). Regression models found significant associations between the pay and staffing factors and intentions expressed at six months to nurse at eighteen months, and between pay and intentions to nurse at three years. Many of the associations between intentions and working as a nurse were significant. Development was the only job satisfaction factor significantly associated with working as a nurse and just at eighteen months.
Conclusions:
Results partially support the theory of planned behaviour. Intentions expressed by nurses are stronger predictors of working as a nurse than job satisfaction. Retention strategies should focus on identifying nurses showing early signs of departure with emphasis on developmental aspects, mentoring and support.
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Human resources for maternal health: multi-purpose or specialists?
A crucial question in the aim to attain MDG5 is whether it can be achieved faster with the scaling up of multi-purpose health workers operating in the community or with the scaling up of professional skilled birth attendants working in health facilities. Most advisers concerned with maternal mortality reduction concur to promote births in facilities with professional attendants as the ultimate strategy. The evidence, however, is scarce on what it takes to progress in this path, and on the 'interim solutions' for situations where the majority of women still deliver at home. These questions are particularly relevant as we have reached the twentieth anniversary of the safe motherhood initiative without much progress made.In this paper we review the current situation of human resources for maternal health as well as the problems that they face. We propose seven key areas of work that must be addressed when planning for scaling up human resources for maternal health in light of MDG5, and finally we indicate some advances recently made in selected countries and the lessons learned from these experiences. Whilst the focus of this paper is on maternal health, it is acknowledged that the interventions to reduce maternal mortality will also contribute to significantly reducing newborn mortality.Addressing each of the seven key areas of work – recommended by the first International Forum on 'Midwifery in the Community', Tunis, December 2006 – is essential for the success of any MDG5 programme.We hypothesize that a great deal of the stagnation of maternal health programmes has been the result of confusion and careless choices in scaling up between a limited number of truly skilled birth attendants and large quantities of multi-purpose workers with short training, fewer skills, limited authority and no career pathways. We conclude from the lessons learnt that no significant progress in maternal mortality reduction can be achieved without a strong political decision to empower midwives and others with midwifery skills, and a substantial strengthening of health systems with a focus on quality of care rather than on numbers, to give them the means to respond to the challenge.
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Training of front-line health workers for tuberculosis control: Lessons from Nigeria and Kyrgyzstan
Efficient human resources development is vital for facilitating tuberculosis control in developing countries, and appropriate training of front-line staff is an important component of this process. Africa and Central Asia are over-represented in global tuberculosis statistics. Although the African region contributes only about 11% of the world population, it accounts for at least 25% of annual TB notifications, a proportion that continues to increase due to poor case management and the adverse impact of HIV/AIDS. Central Asia's estimated current average tuberculosis prevalence rate of 240/100 000 is significantly higher than the global average of 217/100 000. With increased resources currently becoming available for countries in Africa and Central Asia to improve tuberculosis control, it is important to highlight context-specific training benchmarks, and propose how human resources deficiencies may be addressed, in part, through efficient (re)training of frontline tuberculosis workers. This article compares the quality, quantity and distribution of tuberculosis physicians, laboratory staff, community health workers and nurses in Nigeria and Kyrgyzstan, and highlights implications for (re)training tuberculosis workers in developing countries.
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The health worker recruitment and deployment process in Kenya: an emergency hiring program
Despite a pool of unemployed health staff available in Kenya, staffing levels at most facilities were only 50%, and maldistribution of staff left many people without access to antiretroviral therapy (ART). Because in the current system it takes one to two years to fill vacant positions, even when funding is available, an emergency approach was needed to fast-track the hiring and deployment process.A stakeholder group was formed to bring together leaders from several sectors to design and implement a fast-track hiring and deployment model that would mobilize 830 additional health workers. This model used the private sector to recruit and deploy new health workers and manage the payroll and employment contracts, with an agreement from the government to transfer these staff to the government payroll after three years.The recruitment process was shortened to less than three months. By providing job orientation and on-time pay checks, the program increased employee retention and satisfaction.Most of the active roadblocks to changes in the health workforce policies and systems are 'human' and not technical, stemming from a lack of leadership, a problem-solving mindset and the alignment of stakeholders from several sectors.It is essential to establish partnerships and foster commitment and collaboration to create needed change in human resource management (HRM).Strengthening appointment on merit is one of the most powerful, yet simplest ways in which the health sector and governments that seek to tackle the challenges of corruption and poor governance can improve their image and efficiency.The quality and integrity of the public health sector can be improved only through professionalizing HRM, reformulating and consolidating the currently fragmented HR functions, and bringing all the pieces together under the authority and influence of HR departments and units with expanded scopes. HR staff must be specialists with strategic HR functions and not generalists who are confined to playing a restricted and bureaucratic role.
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Incentives for retaining and motivating health workers in Pacific and Asian countries
This paper was initiated by the Australian Agency for International Development (AusAID) after identifying the need for an in-depth synthesis and analysis of available literature and information on incentives for retaining health workers in the Asia-Pacific region. The objectives of this paper are to:1. Highlight the situation of health workers in Pacific and Asian countries to gain a better understanding of the contributing factors to health worker motivation, dissatisfaction and migration.2. Examine the regional and global evidence on initiatives to retain a competent and motivated health workforce, especially in rural and remote areas.3. Suggest ways to address the shortages of health workers in Pacific and Asian countries by using incentives.The review draws on literature and information gathered through a targeted search of websites and databases. Additional reports were gathered through AusAID country offices, UN agencies, and non-government organizations.The severe shortage of health workers in Pacific and Asian countries is a critical issue that must be addressed through policy, planning and implementation of innovative strategies – such as incentives – for retaining and motivating health workers. While economic factors play a significant role in the decisions of workers to remain in the health sector, evidence demonstrates that they are not the only factors. Research findings from the Asia-Pacific region indicate that salaries and benefits, together with working conditions, supervision and management, and education and training opportunities are important. The literature highlights the importance of packaging financial and non-financial incentives.Each country facing shortages of health workers needs to identify the underlying reasons for the shortages, determine what motivates health workers to remain in the health sector, and evaluate the incentives required for maintaining a competent and motivated health workforce. Decision-making factors and responses to financial and non-financial incentives have not been adequately monitored and evaluated in the Asia-Pacific region. Efforts must be made to build the evidence base so that countries can develop appropriate workforce strategies and incentive packages.
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Developing a competency-based curriculum in HIV for nursing schools in Haiti
Background:
Preparing health workers to confront the HIV/AIDS epidemic is an urgent challenge in Haiti, where the HIV prevalence rate is 2.2% and approximately 10 100 people are taking antiretroviral treatment. There is a critical shortage of doctors in Haiti, leaving nurses as the primary care providers for much of the population. Haiti's approximately 1000 nurses play a leading role in HIV/AIDS prevention, care and treatment. However, nurses do not receive sufficient training at the pre-service level to carry out this important work.
Methods:
To address this issue, the Ministry of Health and Population collaborated with the International Training and Education Center on HIV over a period of 12 months to create a competency-based HIV/AIDS curriculum to be integrated into the 4-year baccalaureate programme of the four national schools of nursing.
Results:
Using a review of the international health and education literature on HIV/AIDS competencies and various models of curriculum development, a Haiti-based curriculum committee developed expected HIV/AIDS competencies for graduating nurses and then drafted related learning objectives. The committee then mapped these learning objectives to current courses in the nursing curriculum and created an 'HIV/AIDS Teaching Guide' for faculty on how to integrate and achieve these objectives within their current courses. The curriculum committee also created an 'HIV/AIDS Reference Manual' that detailed the relevant HIV/AIDS content that should be taught for each course.
Conclusion:
All nursing students will now need to demonstrate competency in HIV/AIDS-related knowledge, skills and attitudes during periodic assessment with direct observation of the student performing authentic tasks. Faculty will have the responsibility of developing exercises to address the required objectives and creating assessment tools to demonstrate that their graduates have met the objectives. This activity brought different administrators, nurse leaders and faculty from four geographically dispersed nursing schools to collaborate on a shared goal using a process that could be easily replicated to integrate any new topic in a resource-constrained pre-service institution. It is hoped that this experience provided stakeholders with the experience, skills and motivation to strengthen other domains of the pre-service nursing curriculum, improve the synchronization of didactic and practical training and develop standardized, competency-based examinations for nursing licensure in Haiti.
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The double burden of human resource and HIV crises: a case study of Malawi
Two crises dominate the health sectors of sub-Saharan African countries: those of human resources and of HIV. Nevertheless, there is considerable variation in the extent to which these two phenomena affect sub-Saharan countries, with a few facing extreme levels of both: Lesotho, Zimbabwe, Zambia, Mozambique, the Central African Republic and Malawi.This paper reviews the continent-wide situation with respect to this double burden before considering the case of Malawi in more detail. In Malawi, there has been significant concurrent investment in both an Emergency Human Resource Programme and an antiretroviral therapy programme which was treating 60,000 people by the end of 2006. Both areas of synergy and conflict have arisen, as the two programmes have been implemented. These highlight important issues for programme planners and managers to address and emphasize that planning for the scale-up of antiretroviral therapy while simultaneously strengthening health systems and the human resource situation requires prioritization among compelling cases for support, and time (not just resources).
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