Coordinating health workforce management in a devolved context: lessons from Kenya

Abstract Introduction

In 2013, Kenya fully and rapidly devolved health services to 47 county governments under its new constitution. It soon became evident that the coordination mechanism to manage the health workforce at a county level was inadequate. This case study describes how Kenya created an inter-county, multi-stakeholder human resources for health (HRH) coordination framework that promotes consensus, commitment, and cooperation in devolved HR management.

Case presentation

Through USAID funding, IntraHealth International built the health workforce management capacity of county governments by strengthening coordination mechanisms at the national and county levels. Informed by stakeholder mapping, Kenya’s 47 counties were grouped into nine clusters with similar geographic contexts and HRH challenges. Inter-county cluster HRH stakeholder coordination forums are hosted by a rotating county-led secretariat and meet quarterly to address gaps, share successes and challenges, and track implementation of action plans. They link to the national level for capacity building, policy formulation, HRH regulation, and provision of standards. Counties have assumed ownership of the forums and contributed about US$85000 to date toward expenses.

Conclusions

As a mechanism for transforming Kenya’s national HRH agenda into action at the county level, the HRH coordination framework has been instrumental in (1) expediting development, customization, and dissemination of policies, (2) enabling national HRH officers to mentor their county counterparts, and (3) providing collaborative platforms for multiple stakeholders to resolve HRH challenges and harmonize HR practices nationwide. Successes catalyzed through the inter-county forums include hiring over 20 000 health workers to address shortages; expanding the national HR information system to all 47 counties; developing guidelines for sharing specialist providers; and establishing professionalized HRH units in all 47 counties.

Kenya has made great strides in strengthening its health system through the HRH coordination framework, which supports standardization of county health operations with national goals while enabling national policy to address HRH gaps in the counties. Transitioning to fully local funding of inter-county forums is important for sustaining progress.

Categorías: Investigaciones

Supervision as a tool for building surgical capacity of district hospitals: the case of Zambia

Abstract Introduction

Many countries in sub-Saharan Africa have adopted task shifting of surgical responsibilities to non-physician clinicians (NPCs) as a solution to address workforce shortages. There is resistance to delegating surgical procedures to NPCs due to concerns about their surgical skills and lack of supervision systems to ensure safety and quality of care provided. This study aimed to explore the effects of a new supervision model implemented in Zambia to improve the delivery of health services by surgical NPCs working at district hospitals.

Methods

Twenty-eight semi-structured interviews were conducted with NPCs and medical doctors at nine district hospitals and with the surgical specialists who provided in-person and remote supervision over an average period of 15 months. Data were analysed using ‘top-down’ and ‘bottom-up’ thematic coding.

Results

Interviewees reported an improvement in the surgical skills and confidence of NPCs, as well as better teamwork. At the facility level, supervision led to an increase in the volume and range of surgical procedures done and helped to reduce unnecessary surgical referrals. The supervision also improved communication links by facilitating the establishment of a remote consultation network, which enabled specialists to provide real-time support to district NPCs in how to undertake particular surgical procedures and expert guidance on referral decisions. Despite these benefits, shortages of operating theatre support staff, lack of equipment and unreliable power supply impeded maximum utilisation of supervision.

Conclusion

This supervision model demonstrated the additional role that specialist surgeons can play, bringing their expertise to rural populations, where such surgical competence would otherwise be unobtainable. Further research is needed to establish the cost-effectiveness of the supervision model; the opportunity costs from surgical specialists being away from referral hospitals, providing supervision in districts; and the steps needed for regular district surgical supervision to become part of sustainable national programmes.

Categorías: Investigaciones

Can traditional bonesetters become trained technicians? Feasibility study among a cohort of Nigerian traditional bonesetters

Abstract Background

Traditional bonesetters (TBS) provide the majority of primary fracture care in Nigeria and other low- and middle-income countries (LMICs). They are widely patronized and their services are commonly associated with complications. The aim of the study was to establish the feasibility of formal training of TBS and subsequent integration into the healthcare system.

Methods

Two focus group discussions were conducted involving five TBS and eight orthopaedic surgeons in Enugu Nigeria. Audio-recordings made during the focus groups were transcribed verbatim and analysed using a thematic analysis method.

Results

Four themes were identified: Training of TBS, their experiences and challenges; perception of traditional bonesetting by orthopaedic surgeons; need for formal training TBS and willingness to offer and accept formal training to improve TBS practice. Participants (TBS group) acquired their skills through informal training by apprenticeship from relatives and family members. They recognized the need to formalize their training and were willing to accept training support from orthopaedists. The orthopaedists recognized that the TBS play a vital role in filling the gap created by shortage of orthopaedic surgeons and are willing to provide training support to them.

Conclusion

This study demonstrates the feasibility of providing formal training to TBS by orthopaedic surgeons to improve the quality of services and outcomes of TBS treatment. This is critical for integration of TBS into the primary healthcare system as orthopaedic technicians. Undoubtedly, this will transform the trauma system in Nigeria and other LMICs where TBS are widely patronized.

Categorías: Investigaciones

Changing demographic trends among South African occupational therapists: 2002 to 2018

Abstract Background

South Africa’s quadruple burden of disease, coupled with health system challenges and other factors, predicts a high burden of disability within the population. Human Resources for Health policy and planning need to take account of this challenge. Occupational therapists are part of the health rehabilitation team, and their supply and status in the workforce need to be better understood.

Methods

The study was a retrospective record-based review of the Health Professions Council of South Africa database from 2002 to 2018. The data obtained from the Health Professions Council of South Africa was analysed for the following variables: geographical location, population groups, age, practice type and sex. Data was entered on a Microsoft Excel spreadsheet and analysed using the Statistical Package for the Social Sciences (SPSS version 22.0).

Results

In 2018, there were 5180 occupational therapists registered with the Health Professions Council of South Africa with a ratio of 0.9 occupational therapists per 10 000 population. There has been an average annual increase of 7.1% over the time period of 2002–2018. The majority of occupational therapists are located in the more densely populated and urbanised provinces, namely Gauteng, Western Cape and KwaZulu-Natal. Most of the registered occupational therapists are under the age of 40 years (67.7%). The majority (66%) are classified as white followed by those classified as black and coloured. Females make up 95% of the registered occupational therapists. Nationally, 74.8% of occupational therapists are deployed in the private sector catering for 16% of the population while approximately 25.2% are employed in the public sector catering for 84% of the population.

Conclusions

Under-resourcing and disparities in the profile and distribution of occupational therapy human resources remain an abiding concern which negatively impacts on rehabilitation service provision and equitable health and rehabilitation outcomes.

Categorías: Investigaciones

Gender imbalance in executive management positions at the Mexican National Institutes of Health

Abstract Background

Around the world, there is a significant difference in the proportion of women with access to leadership in healthcare with respect to men. This article studies gender imbalance and wage gap in managerial, executive, and directive job positions at the Mexican National Institutes of Health.

Methods

Cohort data were described using a visual circular representation and modeled using a generalized linear model. Analysis of variance was used to assess model significance, and posterior Fisher’s least significant differences were analyzed when appropriate.

Results

This study demonstrated that there is a gender imbalance distribution among the hierarchical position at the Mexican National Health Institutes and also exposed that the wage gap exists mainly in the (highest or lowest) ranks in hierarchical order.

Conclusions

Since the majority of the healthcare workforce is female, Mexican women are still underrepresented in executive and directive management positions at national healthcare organizations.

Categorías: Investigaciones

Understanding implementation barriers in the national scale-up of differentiated ART delivery in Uganda

Abstract Background

Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)‘s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perspectives on barriers to implementation of Differentiated ART service delivery in Uganda.

Methods

We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context.

Results

Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Context: Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups.

Conclusion

This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

Categorías: Investigaciones

Development and upgrading of public primary healthcare facilities with essential surgical services infrastructure: a strategy towards achieving universal health coverage in Tanzania

Abstract Background

Infrastructure development and upgrading to support safe surgical services in primary health care facilities is an important step in the journey towards achieving Universal Health Coverage (UHC). Quality health service provision together with equitable geographic access and service delivery are important components that constitute UHC. Tanzania has been investing in infrastructure development to offer essential safe surgery close to communities at affordable costs while ensuring better outcomes. This study aimed to understand the public sector’s efforts to improve the infrastructure of primary health facilities between 2005 and 2019. We assessed the construction rates, geographic coverage, and physical status of each facility, surgical safety and services rendered in public primary health facilities.

Methods

Data was collected from existing policy reports, the Services Availability and Readiness Assessment (SARA) tool (physical status), the Health Facility Registry (HFR), implementation reports on infrastructure development from the 26 regions and 185 district councils across the country (covering assessment of physical infrastructure, waste management systems and inventories for ambulances) and Comprehensive Emergence Obstetric Care (CEMONC) signal functions assessment tool. Data was descriptively analyzed so as to understand the distribution of primary health care facilities and their status (old, new, upgraded, under construction, renovated and equipped), and the service provided, including essential surgical services.

Results

Of 5072 (518 are Health Centers and 4554 are Dispensaries) existing public primary health care facilities, the majority (46%) had a physical status of A (good state), 33% (1693) had physical status of B (minor renovation needed) and the remaining facilities had physical status of C up to F (needing major renovation). About 33% (1673) of all health facilities had piped water and 5.1% had landline telecommunication system. Between 2015 and August 2019, a total of 419 (8.3%) health facilities (Consisting of 350 health centers and 69 District Council Hospitals) were either renovated or constructed and equipped to offer safe surgery services. Of all Health Centers only 115 (22.2%) were offering the CEMONC services. Of these 115 health facilities, only 20 (17.4%) were offering the CEMONC services with all 9 - signal functions and only 17.4% had facilities that are offering safe blood transfusion services.

Conclusion

This study indicates that between 2015 and 2019 there has been improvement in physical status of primary health facilities as a result constructions, upgrading and equipping the facilities to offer safe surgery and related diagnostic services. Despite the achievements, still there is a high demand for good physical statuses and functioning of primary health facilities with capacity to offer essential and safe surgical services in the country also as an important strategy towards achieving UHC. This is also inline with the National Surgical, Obstetrics and Anesthesia plan (NSOAP).

Categorías: Investigaciones

Attitudes of anesthetists towards an anesthesia-led nurse practitioner model for low-risk colonoscopy procedures: a cross-sectional survey

Abstract Background

The mounting pressure on the Australian healthcare system is driving a continual exploration of areas to improve patient care and access and to maximize utilization of our workforce. We hypothesized that there would be support by anesthetists employed at our hospital for the design, development, and potential implementation of an anesthesia-led nurse practitioner (NP) model for low-risk colonoscopy patients.

Methods

We conducted a cross-sectional, mixed methods study to ascertain the attitudes and acceptability of anesthetists towards a proposed anesthesia-led NP model for low-risk colonoscopy patients. An online survey using commercial software and theoretical questions pertaining to participants’ attitudes towards an anesthesia-led NP model was e-mailed to consultant anesthetists. Participants were also invited to participate in a voluntary 20-min face-to-face interview.

Results

A total of 60 survey responses were received from a pool of 100 anesthetists (response rate = 60%, accounting for 8.04% margin of error). Despite the theoretical benefits of improved patient access to colonoscopy services, most anesthetists were not willing to participate in the supervision and training of NPs. The predominant themes underlying their lack of support for the program were a perception that patient safety would be compromised compared to the current model of anesthesia-led care, the model does not meet the Australian and New Zealand College of Anesthetists guidelines for procedural sedation and analgesia, and the program may be a public liability prone to litigation in the event of an adverse outcome. Concerns about consumer acceptance and cost-effectiveness were also raised. Finally, participants thought the model should be pilot tested to better understand consumer attitudes, logistical feasibility, patient and proceduralist attitudes, clinical governance, and, importantly, patient safety.

Conclusions

Most anesthetists working in a single-center university hospital did not support an anesthesia-led NP model for low-risk colonoscopy patients. Patient safety, violations of the current Australian and New Zealand College of Anesthetists guidelines on procedural sedation, and logistical feasibility were significant barriers to the acceptance of the model.

Trial registration

Australian and New Zealand Clinical Trials Registry, 12619001036101

Categorías: Investigaciones

Assessment of dual practice among physicians in Cambodia.

Hum Resour Health;18(1): 18, 2020 Mar 12. . [Artigo]

Categorías: Investigaciones

Caribbean nurse migration—a scoping review

Abstract Background

The migration of Caribbean nurses, particularly to developed countries such as Canada, the United States, and the United Kingdom, remains a matter of concern for most countries of the region. With nursing vacancy rates averaging 40%, individual countries and the region collectively are challenged to address this issue through the development and implementation of sustainable, feasible strategies. The aim of this scoping review is to examine the amount, type, sources, distribution, and focus of the conceptual and empirical literature on the migration of Caribbean nurses, and to identify gaps in the literature.

Methods

Identified records were selected and reviewed using Arksey and O’Malley’s scoping framework. A comprehensive search was conducted of eight electronic databases and the Google search engine. Findings were summarized numerically and thematically, with themes emerging through an iterative, inductive process.

Results

Much of the literature included in our study (N = 6, 33%) originated in the United States. Publications steadily increased between 2003 and 2016, and half of them (N = 9) were journal articles. Many (N = 6, 33%) of the records used quantitative methods. The themes identified were as follows: (1) migration patterns and trends; (2) post-migration experiences; (3) past and present, policies, programs, and practices; and (4) consequences of migration to donor countries. More than half (N = 11, 56%) of the literature addressed nurse migration policies, programs, or practices, either solely or in part. Several gaps were identified including the need for evaluation of the effectiveness of current nurse migration management strategies and to study policies, trends, and impacts in understudied Caribbean countries.

Conclusion

This review demonstrates the need for future research in key areas such as the impact of nurse migration on health systems and population health. The literature tends to focus on Caribbean countries with higher levels of nurse migration. However, data regarding this phenomenon in other Caribbean countries is needed for a more comprehensive understanding of the plight of the Caribbean region and would answer the call from the International Organization for Migration to study policies, trends, and impacts in understudied Caribbean countries.

Categorías: Investigaciones

User-centred design and evaluation of a tele-operated echocardiography robot

Abstract

We present the collected findings of a user-centred approach for developing a tele-operated robot for remote echocardiography examinations. During the three-year development of the robot, we involved users in all development stages of the robot, to increase the usability of the system for the doctors. For requirement compilation, we conducted a literature review, observed two traditional examinations, arranged focus groups with doctors and patients, and conducted two online surveys. During the development of the robot, we regularly involved doctors in usability tests to receive feedback from them on the user interface for the robot and on the robot’s hardware. For evaluation of the robot, we conducted two eye tracking studies. In the first study, doctors executed a traditional echocardiography examination. In the second study, the doctors conducted a remote examination with our robot. The results of the studies show that all doctors were able to successfully complete a correct ultrasonography examination with the tele-operated robot. In comparison to a traditional examination, the doctors on average only need a short amount of additional time to successfully examine a patient when using our remote echocardiography robot. The results also show that the doctors fixate considerably more often, but with shorter fixation times, on the USG screen in the traditional examination compared to the remote examination. We found further that some of the user-centred design methods we applied had to be adjusted to the clinical context and the hectic schedule of the doctors. Overall, our experience and results suggest that the usage of user-centred design methodology is well suited for developing medical robots and leads to a usable product that meets the end users’ needs.

Categorías: Investigaciones

Assessment of dual practice among physicians in Cambodia

Abstract Background

Dual practice and multiple job holding are widespread among health workers throughout the world. Although dual practice can help the financially strained public sector retain skilled workers, there are also potential negative consequences if it is not regulated. In Cambodia, there is substantial anecdotal evidence of dual practice among physicians but there is very little data on the extent and prevalence of the practice. This study was conducted by the University of Health Sciences (UHS) to gain insight in to the employment practices of UHS alumni. Results from this survey may help to inform policymakers in rational planning for future health system development related to capacity building and regulation of human resources for health.

Methods

Data were collected from a self-administered survey of UHS graduates who graduated between 1999 and 2012. A total of 162 medical graduates were randomly sampled from a total of 1867 medical graduates between 1999 and 2012. Contacted individuals were asked to complete a written structured questionnaire regarding demographic characteristics, current employment and types of employment, compensation, and job satisfaction. The response rate of graduates sampled was 49% (79 completed questionnaires). The low response rate was primarily due to the difficulty in locating individuals.

Results

Of 79 respondents, 96% were currently employed at the time of the survey. However, only 63 of the respondents (80%) were working in the healthcare sector. The 16 respondents (20%) not working in healthcare were excluded from further analyses since they are not relevant to dual practice analysis. The vast majority (87%) of respondents are public sector employees (61.9% in public sector only and 25.4% in both public and private sector). 12.7% of respondents only work in the private sector. Almost half (47.6%) of respondents hold more than one job. For income satisfaction, physicians employed in both sectors have higher satisfaction than physicians employed in the public sector only.

Conclusions

As policymakers in Cambodia consider new approaches to regulation of the practice, it is important to know the context of the practice, the benefits to the healthcare system, and the costs. Recognizing the high prevalence of multiple job holding in Cambodia, as evidenced in our survey of UHS medical graduates, contributes to the discussion as important information that can be used toward meaningful reform.

Categorías: Investigaciones

Frameworks for health systems performance assessment: how comprehensive is Ghana’s holistic assessment tool?

Abstract Background

Measuring the performance of a health system is an essential requirement in creating systems that generate efficient, equitable, patient-focused, accessible and sustainable results. A fundamental requirement for a performance measurement system is the development of an assessment framework within which specific performance measures could be defined and applied regularly. This paper examines the comprehensiveness of Ghana’s health system assessment framework called the Holistic Assessment Tool in relation to some of the internationally recognized frameworks. The paper also analyzes trends in the performance of the health system to understand whether or not an improvement has been recorded following the adoption and implementation of the Holistic Assessment Tool.

Methods

Mainly secondary data were used in this analysis. Searches were conducted on Google Scholar, PubMed, Scopus and Science Direct between May and July, 2019 for published documents on health system performance assessment. We also obtained unpublished documents from Ghana’s Ministry of Health, Ghana Health Service website, and Ghana Statistical Service database. Descriptive statistics were used to examine trends in the performance of the Ghanaian health system.

Results

While the tool provides a national framework for evaluating the performance of the Ghana Health system in several domains, the Holistic Assessment Tool does not cover key health system domains such as information systems for health, access to essential medicines, and patient-centeredness. Also, the scope of the assessment program seems limited to the evaluation of the Ministry of Health’s annual plans, programs and projects. However, the health system has recorded improvements in population health indicators, such as life expectancy at birth, infant mortality, under-5 mortality, HIV prevalence and disease burden (in terms of disability adjusted life years).

Conclusions

The Holistic Assessment Tool is a useful framework, but needs further refinement, both in scope and in conceptual robustness. Future studies should consider exploring factors influencing performance of the Ghanaian health system. Such information will help in strategizing for better and more improvements.

Categorías: Investigaciones

Clarifying workforce flexibility from a division of labor perspective: a mixed methods study of an emergency department team

Abstract Background

The need for greater flexibility is often used to justify reforms that redistribute tasks through the workforce. However, “flexibility” is never defined or empirically examined. This study explores the nature of flexibility in a team of emergency doctors, nurse practitioners (NPs), and registered nurses (RNs), with the aim of clarifying the concept of workforce flexibility. Taking a holistic perspective on the team’s division of labor, it measures task distribution to establish the extent of multiskilling and role overlap, and explores the behaviors and organizational conditions that drive flexibly.

Methods

The explanatory sequential mixed methods study was set in the Fast Track area of a metropolitan emergency department (ED) in Sydney, Australia. In phase 1, an observational time study measured the tasks undertaken by each role (151 h), compared as a proportion of time (Kruskal Wallis, Mann-Whitney U), and frequency (Pearson chi-square). The time study was augmented with qualitative field notes. In phase 2, 19 semi-structured interviews sought to explain the phase 1 observations and were analyzed thematically.

Results

The roles were occupationally specialized: “Assessment and Diagnosis” tasks consumed the largest proportion of doctors’ (51.1%) and NPs’ (38.1%) time, and “Organization of Care” tasks for RNs (27.6%). However, all three roles were also multiskilled, which created an overlap in the tasks they performed. The team used this role overlap to work flexibly in response to patients’ needs and adapt to changing demands. Flexibility was driven by the urgent and unpredictable workload in the ED and enabled by the stability provided by a core group of experienced doctors and nurses.

Conclusion

Not every healthcare team requires the type of flexibility found in this study since that was shaped by patient needs and the specific organizational conditions of the ED. The roles, tasks, and teamwork that a team requires to “be flexible” (i.e., responsive and adaptable) are highly context dependent. Workforce flexibility therefore cannot be defined as a particular type of reform or role; rather, it should be understood as the capacity of a team to respond and adapt to patients’ needs within its organizational context. The study’s findings suggest that solutions for a more flexible workforce may lay in the organization of healthcare work.

Categorías: Investigaciones

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