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The Global Code of Practice on the International Recruitment of Health Personnel focuses particularly on migration of doctors from low- and middle-income countries. Less is understood about migration from high-income countries. Recession has impacted several European countries in recent years, and in some cases emigration has reached unprecedented levels. This study measures and explores the predictors of trainee doctor emigration from Ireland.Methods
Using a partially mixed sequential dominant (quantitative) study design, a nationally representative sample of 893 trainee doctors was invited to complete an online survey. Of the 523 who responded (58.6% response rate), 423 were still in Ireland and responded to questions on factors influencing intention to practice medicine abroad and are the subjects of this study. Explanatory factors for intention to practice medicine in Ireland in the foreseeable future, the primary outcome, included demographic variables and experiences of working within the Irish health system. Associations were examined using univariable and multivariable logistic regression to estimate odds ratios for factors influencing the primary outcome. Qualitative interviews were conducted with 50 trainee doctors and analysed thematically, exploring issues associated with intention to practice medicine abroad.Results
There were high levels of dissatisfaction among trainee doctors around working conditions, training and career progression opportunities in Ireland. However, most factors did not discriminate between intention to leave or stay. Factors that did predict intention to leave included dissatisfaction with one’s work-life balance (odds ratio (OR) 2.51; 95% confidence interval (CI) 1.53–4.10; P < 0.001); feeling that the quality of training in Ireland was poor (OR 1.82; 95% CI 1.09–3.05; P = 0.002) and leaving for family or personal reasons (OR 1.85; 95% CI 1.08–3.17; P = 0.027). Qualitative findings illustrated the stress of doing postgraduate training with inadequate supervision, lack of ring-fenced training time and pressures on personal and family life.Conclusions
Large-scale dissatisfaction with working, training and career opportunities point to systemic factors that need to be addressed by health workforce planners if Ireland is to retain and benefit from a motivated medical workforce, given trainees’ perceptions that there are better opportunities abroad.
Author(s): Andrea Baumann, Mabel Hunsberger, Mary Crea-Arsenio, Noori Akhtar-Danesh, Mohamad Alameddine
Purpose To evaluate the impact of a government full-time employment policy targeting new graduate nurses in the province of Ontario, Canada, by comparing participants with non-participants. Methods The Policy Impact on Nurse Employment (PINEP) survey was administered in 2014 to nurses who graduated between 2007 and 2012. Backward multiple logistic regression analysis was conducted to determine the effect of participation in the policy on key outcomes: full-time employment, retention and perceptions of clinical proficiency. Results A total of 2369 nurses responded to the survey. Policy participants were 1.5 times more likely to be employed full-time and 2.3 times more likely to be retained in their initial position at the time of survey compared to non-participants. Participants also perceived their clinical proficiency to be higher. Conclusions The evidence is converging around the importance of providing full-time employment to nurses to sustain the workforce, increase clinical proficiency and improve patient outcomes. In Ontario, the government created a policy to stimulate full-time employment for nurses. Results demonstrate that nursing employment has become more stable. Yet more needs to be done particularly in relation to the precarious employment trend.
Author(s): Scott L. Greer, Nikolai Vasev, Matthias Wismar
A study of human resource competencies required to implement community rehabilitation in less resourced settings
It is estimated that over one billion persons worldwide have some form of disability. However, there is lack of knowledge and prioritisation of how to serve the needs and provide opportunities for people with disabilities. The community-based rehabilitation (CBR) guidelines, with sufficient and sustained support, can assist in providing access to rehabilitation services, especially in less resourced settings with low resources for rehabilitation. In line with strengthening the implementation of the health-related CBR guidelines, this study aimed to determine what workforce characteristics at the community level enable quality rehabilitation services, with a focus primarily on less resourced settings.Methodology
This was a two-phase review study using (1) a relevant literature review informed by realist synthesis methodology and (2) Delphi survey of the opinions of relevant stakeholders regarding the findings of the review. It focused on individuals (health professionals, lay health workers, community rehabilitation workers) providing services for persons with disabilities in less resourced settings.Results
Thirty-three articles were included in this review. Three Delphi iterations with 19 participants were completed. Taken together, these produced 33 recommendations for developing health-related rehabilitation services. Several general principles for configuring the community rehabilitation workforce emerged: community-based initiatives can allow services to reach more vulnerable populations; the need for supportive and structured supervision at the facility level; core skills likely include case management, social protection, monitoring and record keeping, counselling skills and mechanisms for referral; community ownership; training in CBR matrix and advocacy; a tiered/teamwork system of service delivery; and training should take a rights-based approach, include practical components, and involve persons with disabilities in the delivery and planning.Conclusion
This research can contribute to implementing the WHO guidelines on the interaction between the health sector and CBR, particularly in the context of the Framework for Action for Strengthening Health Systems, in which human resources is one of six components. Realist syntheses can provide policy makers with detailed and practical information regarding complex health interventions, which may be valuable when planning and implementing programmes.
Digital technologies in health care are expected to increase in scope and to affect ever more parts of the health care system. It is important to enhance the knowledge of whether new digital methods and innovations provide value for money compared with traditional models of care.Objective
The objective of the study was to evaluate whether a digital health care model for primary care is a less costly alternative compared with traditional in-office primary care in Sweden.Methods
Cost data for the two care models were collected and analyzed to obtain a measure in local currency per care contact.Results
The comparison showed that the total economic cost of a digital consultation is 1960 Swedish krona (SEK) (SEK100 = US$11.29; February 2017) compared with SEK3348 for a traditional consultation at a health care clinic. Cost differences arose on both the provider side and on the user side.Conclusion
The digital health care model may be a less costly alternative to the traditional health care model. Depending on the rate of digital substitution, gross economic cost savings of between SEK1 billion and SEK10 billion per year could be realized if more digital consultations were made. Further studies are needed to validate the findings, assess the types of care most suitable for digital care, and also to obtain various quality-adjusted outcome measures.
Desde el mes de enero de 2017, se inicia la formación de nuevos 70 profesionales y técnicos de la Región Metropolitana de Salud, procedentes de los Ecos F y E, es la segunda generación del curso de Atención Primaria de Salud Integral, cuyos facilitadores son profesionales graduados del primer Diplomado de APS, que están acreditados como tal, con una duración de 28 sesiones presenciales y sesiones virtuales en la plataforma web del MINSAL, desarrolladas durante ocho meses, este día, 1 de septiembre se finaliza con la entrega de Diplomas por parte de las autoridades del MINSAL y de la Agencia Internacional de Cooperación de Corea( KOICA):Dr Eduardo Espinoza, Viceministro de Politicas de Salud, Sr. Yi Jongsu, Director de País de Cooperación Koica, Dra. Nadia Rodríguez, Directora Región de Salud y la Maestra María Angela Elías Marroquín, Directora de Desarrollo de Recursos Humanos.
Este curso en Atención Primaria en Salud Integral (APSI), ha sido implementado como una de las estrategias para mejorar las competencias del personal de salud de la Región Metropolitna de Salud, tanto de nivel Regional, SIBASI como a nivel de las UCSF, fortaleciendo con ello la capacidad de respuesta en los establecimientos de la región de salud.
Este curso ha sido desarrollado gracias a la experiencia acumulada en el primer Diplomado APS, ya que egresados del mismo fueron los facilitadores de este curso, generando nuevas capacidades regionales y nacionales para sub siguientes procesos similares, además ha sido financiado por la Agencia de Cooperación Internacional de Corea ( KOICA).
El modelo de formación, ha estado basado en la pedagogía de la problematicación, siendo su objeto de aprendizaje el proceso de trabajo que cada uno desarrolla en los territorios asignados, transformando paulatinamente su realidad y mejorando la salud de su población. El proceso formativo ha sido acompañado por personal de ambas instituciones, en un primer momento profesionales del nivel central y de las Regiones de Salud coordinados por el Dirección de Desarrollo de Recursos Humanos y la Región Metropolitana de Salud.
La ejecución del curso se realizó en la región metrolitana de salud, cuyos participantes procedian de los cuatro SIBASI, durante el mismo han vivido experiencias de formación que esta mejorando el acceso a la salud de la población.
El curso ha logrado que cada unos de los participantes, desarrolle competencias para búsqueda y uso de la información en salud, comprension de la gestión en redes, herramientas para la promoción de la salud, salud familiar y comunitaria, las bases conceptuales y los fundamentos del modelo de atención, gestión en salud y diseño de estudios de salud (ASSI), desarrollando habilidades para la recolección de la información y el analisis de la situacion de salud, con enfoque de derechos, género, intersectorialidad, integralidad de la atención y participación social.
En cada módulo desarrollaron trabajos prácticos que les permitieron reforzar conocimientos y habilidades para resolver situaciones concretas de su realidad, fortalecer el trabajo en equipos y multidisciplinaro y a trabajar con actores locales, especialmente con el FNS.
Es de felicitar la dedicación, empeño y responsabilidad demostrada por la mayoría de los participantes en cada uno de los encuestros presenciales y el trabajo en la plataforma del curso y la dedicación y competencias tanto metodologicas como de contenido demostrado por los facilitadores. A partir de su finalización se dara seguimiento a los becarios así como programas de fortalecimiento y acompañamiento por la Regiones de Salud y la Dirección de Desarrollo de Recursos Humanos.
Retention of qualified healthcare workers in rural Senegal: lessons learned from a qualitative study [...]
Rural Remote Health;17(3): 4149, 2017 Jul-Sep. . [Artigo]
The impact of austerity on the health workforce and the achievement of human resources for health po [...]
Hum Resour Health;15(1): 62, 2017 Sep 11. . [Artigo]
Health worker attrition at a rural district hospital in Rwanda: a need for improved placement and re [...]
Pan Afr Med J;27: 168, 2017. . [Artigo]
Devolution and its effects on health workforce and commodities management - early implementation exp [...]
Int J Equity Health;16(1): 169, 2017 Sep 15. . [Artigo]
J Nurs Manag;2017 Sep 10. . [Artigo]
Human resources for health in Peru: recent trends (2007–2013) in the labour market for physicians, nurses and midwives
Most analyses of gaps in human resources for health (HRH) do not consider training and the transition of graduates into the labour market. This study aims to explore the labour market for Peru’s recent medical, nursing, and midwifery graduates as well as their transition into employment in the Ministry of Health’s (MOH) system.Methods
Data from four different datasets, covering 2007–2013, was used to characterize the patterns of recently trained physicians, nurses, midwives, and postgraduate-trained physicians that enter employment in the MOH system, and scenario analyses were used to describe how this rate of entry needs to adapt in order to fill current HRH shortages.Results
HRH graduates have been increasing from 2007 to 2011, but the proportions that enter employment in the MOH system 2 years later range from 8 to 45% and less than 10% of newly trained medical specialists. Scenario analyses indicate that the gap for physicians and nurses will be met in 2027 and 2024, respectively, while midwives in 2017. However, if the number of HRH graduates entering the MOH system doubles, these gaps could be filled as early as 2020 for physicians and 2019 for nurses. In this latter scenario, the MOH system would still only utilize 56% of newly qualified physicians, 74% of nurses, and 66% of midwives available in the labour market.Conclusion
At 2013 training rates, Peru has the number of physicians, nurses, and midwives it needs to address HRH shortages and meet estimated HRH gaps in the national MOH system during the next decade. However, a significant number of newly qualified health professionals do not work for the MOH system within 2 years of graduation. These analyses highlight the importance of building adequate incentive structures to improve the entry and retention of HRH into the public sector.
Implementation considerations when expanding health worker roles to include safe abortion care: a five-country case study synthesis
Allowing a broader range of trained health workers to deliver services can be an important way of improving access to safe abortion care. However, the expansion of health worker roles may be challenging to implement. This study aimed to explore factors influencing the implementation of role expansion strategies for non-physician providers to include the delivery of abortion care.Methods
We conducted a multi-country case study synthesis in Bangladesh, Ethiopia, Nepal, South Africa and Uruguay, where the roles of non-physician providers have been formally expanded to include the provision of abortion care. We searched for documentation from each country related to non-physician providers, abortion care services and role expansion through general internet searches, Google Scholar and PubMed, and gathered feedback from 12 key informants. We carried out a thematic analysis of the data, drawing on categories from the SURE Framework of factors affecting the implementation of policy options.Results
Several factors appeared to affect the successful implementation of including non-physician providers to provide abortion care services. These included health workers’ knowledge about abortion legislation and services; and health workers’ willingness to provide abortion care. Health workers’ willingness appeared to be influenced by their personal views about abortion, the method of abortion and stage of pregnancy and their perceptions of their professional roles. While managers’ and co-workers’ attitudes towards the use of non-physician providers varied, the synthesis suggests that female clients focused less on the type of health worker and more on factors such as trust, privacy, cost, and closeness to home. Health systems factors also played a role, including workloads and incentives, training, supervision and support, supplies, referral systems, and monitoring and evaluation. Strategies used, with varying success, to address some of these issues in the study countries included values clarification workshops, health worker rotation, access to emotional support for health workers, the incorporation of abortion care services into pre-service curricula, and in-service training strategies.Conclusions
To increase the likelihood of success for role expansion strategies in the area of safe abortion, programme planners must consider how to ensure motivation, support and reasonable working conditions for affected health workers.
Author(s): Ingrid Wolfe, Kate Mandeville, Katherine Harrison, Raghu Lingam
The United Kingdom, like all European countries, is struggling to strengthen health systems and improve conditions for child health and survival. Child mortality in the UK has failed to improve in line with other countries. Securing optimal conditions for child health requires a healthy society, strong health system, and effective health care. We examine inter-sectoral and intra-sectoral policy and governance for child health and survival in England. Literature reviews and universally applicable clinical scenarios were used to examine child health problems and English policy and governance responses for improving child health through integrating care and strengthening health systems, over the past 15 years. We applied the TAPIC framework for analyzing policy governance: transparency, accountability, participation, integrity, and capacity. We identified strengths and weaknesses in child health governance in all the five domains. However there remain policy failures that are not fully explained by the TAPIC framework. Other problems with successfully translating policy to improved health that we identified include policy flux; policies insufficiently supported by delivery mechanisms measurable targets, and sufficient budgets; and policies with unintended or contradictory aspects. We make recommendations for inter-sectoral and intra-sectoral child health governance, policy, and action to improve child health in England with relevant lessons for other countries.
El día miercoles 16 de Agosto de 2017 se realizó la entrega de diplomas a los participantes del Diplomado de Gerencia Pública que tuvo una duración total de 112 horas, contando con una fase inicial de 3 módulos respectivamente, dicho diplomado fue orgranizado por la Secretaría Técnica y de Planificación de la Presidencia y realizado en las instalaciones de la Universidad Dr. José Matías Delgado (UJMD); la entrega de diplomas fue realizada por Dr. Eduardo Espinoza Viceministro de Políticas de Salud, Licda. María Ángela Elías Marroquín Directora de Desarrollo de Recursos Humanos y Licda. Aurora Cubías Directora de ENAFOP, en las instalaciones de la Dirección de Vigilancia Sanitaria del MINSAL.
Improving the performance of community health workers in Swaziland: findings from a qualitative study
The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre.Methods
The CHW cadres studied were the rural health motivators, mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV. We conducted semi-structured, face-to-face qualitative interviews with all (15) CHW program managers and a purposive sample of 54 CHWs. Interview transcripts were analyzed using conventional content analysis to identify categories of changes to the program that participants perceived would result in improved CHW performance.Results
Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: (i) increased monetary compensation of CHWs, (ii) a more reliable supply of equipment and consumables, (iii) additional training, and (iv) an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as requiring improvement to increase CHW performance.Conclusions
While this study is unable to provide evidence on whether the suggested changes would indeed lead to improved CHW performance, these views should nonetheless inform program reforms in Swaziland because CHWs and CHW program managers are familiar with the day-to-day operations of the program and the needs of the target population. In addition, program reforms that agree with their views would likely experience a higher degree of buy-in from these frontline health workers.
Physicians’ perceptions on the impact of telemedicine on recruitment and retention in underserved areas: a descriptive study in Senegal
Similar to many places, physicians in Senegal are unevenly distributed. Telemedicine is considered a potential solution to this problem. This study investigated the perceptions of Senegal’s physicians of the impact of telemedicine on their recruitment to and retention in underserved areas.Methods
We conducted individual interviews with a random sample of 60 physicians in Senegal, including 30 physicians working in public hospitals and 30 physicians working in district health centres between January and June 2014, as part of a mixed methods study. Data were collected using a semi-structured interview guide comprising both open- and close-ended questions. Interviews were recorded, transcribed and coded thematically using NVivo 10 software using a priori and emergent codes. Participants’ characteristics were analyzed descriptively using SPSS 23.Results
The impact of telemedicine on physicians’ recruitment and retention in underserved areas was perceived with some variability. Among the physicians who were interviewed, most (36) thought that telemedicine could have a positive impact on their recruitment and retention but many (24) believed the opposite. The advantages noted by the first included telemedicine’s ability to break their professional isolation and reduce the stress related to this, facilitate their distance learning and improve their working conditions. They did acknowledge that it is not sufficient in itself, an opinion also shared by physicians who did not believe that telemedicine could affect their recruitment and retention. Both identified contextual, economic, educational, family, individual, organizational and professional factors as influential.Conclusion
Based on these opinions of physicians, telemedicine promotion is one intervention that, alongside others, could be promoted to assist in addressing the multiple factors that influence physicians’ recruitment and retention in underserved areas.
Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016
Source:The Lancet, Volume 390, Issue 10100
Author(s): GBD 2016 DALYs and HALE CollaboratorsAmanuel AlemuAbajobirKalkidan HassenAbateCristianaAbbafatiKaja MAbbasFoadAbd-AllahRizwan SuliankatchiAbdulkaderAbdishakur MAbdulleTeshome AbukaAbeboSemaw FeredeAberaVictorAboyansLaith JAbu-RaddadIlana NAckermanIsaac AAdedejiOlatunjiAdetokunbohAshkanAfshinRakeshAggarwalSutapaAgrawalAnuragAgrawalMuktar BeshirAhmedMiloud Taki EddineAichourAmani NidhalAichourIbtihelAichourSnehaAiyarTomi FAkinyemijuNadiaAkseerFaris HasanAl LamiFaresAlahdabZiyadAl-AlyKhurshidAlamNooreAlamTahiyaAlamDeenaAlasfoorKefyalew AddisAleneRaghibAliRezaAlizadeh-NavaeiJuma MAlkaabiAla'aAlkerwiFrançoisAllaPeterAllebeckChristineAllenFatmaAl-MaskariMohammad AbdulAzizAlMazroaRajaaAl-RaddadiUbaiAlsharifShirinaAlsowaidiBenjamin MAlthouseKhalid AAltirkawiNelsonAlvis-GuzmanAzmeraw TAmareErfanAminiWalidAmmarYaw AmpemAmoakoMustafa GeletoAnshaCarl Abelardo TAntonioPalwashaAnwariJohanÄrnlövMeghaAroraAlArtamanKrishna KumarAryalSolomon WAsgedomTesfay MehariAteyNiguse 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Background Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI). Methods We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate. Findings The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9–78·6) for females and 72·0 years (68·8–75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0–49·5]) and for males was in Lesotho (41·5 years [39·0–44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97–6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74–6·27) for males and 6·49 years (6·08–6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61–1·93) for males and 1·96 years (1·69–2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (–2·3% [–5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally. Interpretation At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support. Funding Bill & Melinda Gates Foundation.
Professional fulfillment and parenting work-life balance in female physicians in Basic Sciences and medical research: a nationwide cross-sectional survey of all 80 medical schools in Japan
In Japan, the field of Basic Sciences encompasses clinical, academic, and translational research, as well as the teaching of medical sciences, with both an MD and PhD typically required. In this study, it was hypothesized that the characteristics of a Basic Sciences career path could offer the professional advancement and personal fulfillment that many female medical doctors would find advantageous. Moreover, encouraging interest in Basic Sciences could help stem shortages that Japan is experiencing in medical fields, as noted in the three principal contributing factors: premature resignation of female clinicians, an imbalance of female physicians engaged in research, and a shortage of medical doctors in the Basic Sciences. This study examines the professional and personal fulfillment expressed by Japanese female medical doctors who hold positions in Basic Sciences. Topics include career advancement, interest in medical research, and greater flexibility for parenting.Methods
A cross-sectional questionnaire survey was distributed at all 80 medical schools in Japan, directed to 228 female medical doctors whose academic rank was assistant professor or higher in departments of Basic Sciences in 2012. Chi-square tests and the binary logistic regression model were used to investigate the impact of parenthood on career satisfaction, academic rank, salary, etc.Results
The survey response rate of female physicians in Basic Sciences was 54.0%. Regardless of parental status, one in three respondents cited research interest as their rationale for entering Basic Sciences, well over twice other motivations. A majority had clinical experience, with clinical duties maintained part-time by about half of respondents and particularly parents. Only one third expressed afterthoughts about relinquishing full-time clinical practice, with physicians who were parents expressing stronger regrets. Parental status had little effect on academic rank and income within the Basic Sciences,Conclusion
Scientific curiosity and a desire to improve community health are hallmarks of those choosing a challenging career in medicine. Therefore, it is unsurprising that interest in research is the primary motivation for a female medical doctor to choose a career in Basic Sciences. Additionally, as with many young professionals with families, female doctors seek balance in professional and private lives. Although many expressed afterthoughts relinquishing a full-time clinical practice, mothers generally benefited from greater job flexibility, with little significant effect on career development and income as Basic Scientists.
Devolution and its effects on health workforce and commodities management – early implementation experiences in Kilifi County, Kenya
Decentralisation is argued to promote community participation, accountability, technical efficiency, and equity in the management of resources, and has been a recurring theme in health system reforms for several decades. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous county governments, with substantial transfer of responsibility for health service delivery from the central government to these counties. Focusing on two key elements of the health system, Human Resources for Health (HRH) and Essential Medicines and Medical Supplies (EMMS) management, we analysed the early implementation experiences of this major governance reform at county level.Methods
We employed a qualitative case study design, focusing on Kilifi County, and adapted the decision space framework developed by Bossert et al., to guide our inquiry and analysis. Data were collected through document reviews, key informant interviews, and participant and non-participant observations between December 2012 and December 2014.Results
As with other county level functions, HRH and EMMS management functions were rapidly transferred to counties before appropriate county-level structures and adequate capacity to undertake these functions were in place. For HRH, this led to major disruptions in staff salary payments, political interference with HRH management functions and confusion over HRH management roles. There was also lack of clarity over specific roles and responsibilities at county and national government, and of key players at each level. Subsequently health worker strikes and mass resignations were witnessed. With EMMS, significant delays in procurement led to long stock-outs of essential drugs in health facilities. However, when the county finally managed to procure drugs, health facilities reported a better order fill-rate compared to the period prior to devolution.Conclusion
The devolved government system in Kenya has significantly increased county level decision-space for HRH and EMMS management functions. However, harnessing the full potential benefits of this increased autonomy requires targeted interventions to clarify the roles and responsibilities of different actors at all levels of the new system, and to build capacity of the counties to undertake certain specific HRH and EMMS management tasks. Capacity considerations should always be central when designing health sector decentralisation policies.