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Patient experiences and preferences for antiretroviral therapy service provision: implications for differentiated service delivery in Northwest Ethiopia

Lun, 27/06/2022 - 00:00
Abstract Background

Understanding the experiences, needs, preferences, and behaviors of people living with HIV (PLHIV) are critical to tailor HIV treatment. However, there is limited empirical evidence in Ethiopia on the views of PLHIV regarding their experiences with current antiretroviral therapy (ART) services and preferred models of HIV treatment. Hence, this study aimed to explore the patients’ experiences of taking medications and preferences for ART service provision in Northwest Ethiopia.

Methods

A phenomenological study design was employed. In this study, stable and 18 years old and above PLHIVs, who had been using ART service at four public hospitals and two health centers in East Gojjam, West Gojjam and Awi zones, and Bahir Dar city administration of Amhara National Regional State, Northwest Ethiopia, were purposively selected. Fifteen in-depth interviews were conducted from July 2021 to September 2021 to collect data. ATLAS.ti version 9 software was used for coding translated transcripts. A thematic analysis approach was employed.

Findings

Participants in this study had reported positive and negative experiences in receiving ART services and also varied preferences toward ART service features. The study identified five themes on experiences for ART service and 15 attributes of ART service characteristics. The identified themes were stigma, time, availability of drugs and providers, costs for clinic visits, and provider-patient interaction. The fifteen attributes were buddy system, ART refill (individualized or group), ART packaging and labeling, drug formulation and administration, ART room labeling, distance, location of service, preferences on involvement in treatment decision-making, the person providing ART refills, provider’s attitude, spatial arrangement of ART room, time of health facility operation, time spent at clinics, and total cost of the visit.

Conclusions

The results raise awareness for the positive and negative experiences of patients informing us about barriers and supporting factors in ART service provision. They open up the potential for HIV treatment service improvement. The preferences of PLHIVs toward ART service delivery features were heterogeneous. Policy and program efforts should tailor ART services that suit patients’ needs and priorities in Ethiopia. Future research should further assess the reasons for patients’ distrust of the community ART delivery models.

Categorías: Investigaciones

“Not shifting, but sharing”: stakeholders' perspectives on mental health task-shifting in Indonesia

Vie, 24/06/2022 - 00:00
Abstract Background

Task-shifting, the distribution of tasks among health workers to address health workforce shortage, has been widely used to tackle mental health treatment gaps. However, its implementation in Indonesia has still been rarely explored. This study aimed to explore stakeholders’ perspectives on the implementation of mental health task-shifting to nurses in Indonesia's primary health care.

Methods

An exploratory descriptive approach using in-depth interviews and focused group discussions (FGDs) was used. The study involved 19 stakeholders from the government's ministry directorates, professional organisations, and mental health practitioners. Thematic analysis was used to analyse the data.

Results

Three themes emerged namely, task-shifting feasibility and acceptability, shared task implementation, and nurse role enhancement issues, with 14 sub-themes.

Conclusions

Task-shifting on mental health issues in the eye of Indonesian stakeholders is viewed as a matter of sharing and collaboration. Implementation of task-shifting in Indonesia may require policies in place and political will across stakeholders. Further scrutiny on task-shifting implementation is needed by considering the local context and national environment.

Categorías: Investigaciones

‘You say you are a TB doctor, but actually, you do not have any power’: health worker (de)motivation in the context of integrated, hospital-based tuberculosis care in eastern China

Jue, 23/06/2022 - 00:00
Abstract Background

In China, tuberculosis (TB) care, traditionally provided through the Centre for Disease Control (CDC), has been integrated into ‘designated’ public hospitals at County level, with hospital staff taking on delivery of TB services supported by CDC staff. Little is known about the impact of this initiative on the hospital-based health workers who were delegated to manage TB. Drawing on a case study of two TB ‘designated’ hospitals in Zhejiang province, we explored factors influencing hospital-based health workers’ motivation in the context of integrated TB service delivery.

Methods

We conducted 47 in-depth interviews with health officials, TB/hospital managers, clinicians, radiologists, laboratory staff and nurses involved in the integrated model of hospital-based TB care. Thematic analysis was used to develop and refine themes, code the data and assist in interpretation.

Results

Health workers tasked with TB care in ‘designated’ hospitals perceived their professional status to be low, related to their assessment of TB treatment as lacking need for professional skills, their limited opportunities for professional development, and the social stigma surrounding TB. In both sites, the integrated TB clinics were under-staffed: health workers providing TB care reported heavy workloads, and expressed dissatisfaction with a perceived gap in their salaries compared with other clinical staff. In both sites, health workers were concerned about poor infection control and weak risk management assessment systems.

Conclusions

Inadequate attention to workforce issues for TB control in China, specifically the professional status, welfare, and development as well as incentivization of infectious disease control workers has contributed to dissatisfaction and consequently poor motivation to serve TB patients within the integrated model of TB care. It is important to address the failure to motivate health workers and maximize public good-oriented TB service provision through improved government funding and attention to the professional welfare of health workers providing TB care in hospitals.

Categorías: Investigaciones

Work-related factors affecting the retention of medical officers in the preventive health sector in Sri Lanka

Jue, 23/06/2022 - 00:00
Abstract Background

Retention of human resources in the healthcare system, particularly doctors at district level is a great challenge faced by the decentralized health systems in poorly resourced countries. Medical Officers of Health (MOH), medical doctors who provide preventive health services, are a particularly important human resource in the preventive health sector in Sri Lanka. This study explores the relative importance of different factors affecting the retention of MOHs in the preventive health sector of Sri Lanka.

Methods

A descriptive cross-sectional study was carried out among Medical Officers of Health in the Colombo district with 18 MOH Offices with 74 medical officers. A pre-tested self-administered questionnaire was used as the study instrument. Data were analyzed using descriptive statistics, correlation and regression analyses.

Results

Of the 74 medical officers 64 responded with a response rate of response rate of 86.5%. Regression analysis showed that all four variables; recognition, work schedule, remuneration and responsibility are positively and significantly correlated with retention of Medical Officers of Health in the preventive health sector. The variable ‘work schedule’ showed the highest impact on the retention of Medical Officers of Health.

Conclusions

In order to retain trained Medical Officers of Health in the Sri Lankan preventive health sector, health authorities should address the factors identified in this study. If policymakers fail to address these factors, preventive health services will face negative implications due to the shortage of key service providers.

Categorías: Investigaciones

Community Health Workers and Stigma Associated with Mental Illness: An Integrative Literature Review

Lun, 20/06/2022 - 00:00
Abstract

Community health workers (CHWs) are facilitators between health services and service users, providing essential and effective support to those seeking health care. However, stigmatizing attitudes towards people with mental illness also exist among CHWs and are based on prejudicial and biasedopinions. This integrative review critically assessed evidence regarding CHWs approaches for addressing mental health issues. In total, 19 studies were included in this review. The results revealed that CHWs have limited knowledge about mental illness and also stigmatizing attitudes towards people with mental illness or substance use problems. Despite feeling unprepared, CHWs are favorable resources for mental health care and can contribute to reducing stigma due to the similarities they share with the communities that they serve. Task-sharing between health professionals and CHWs is an important strategy to improve access to health services and reducing stigma towards people with mental illness, provided that receive adequate training to perform the duties.

Categorías: Investigaciones

The impact of training on self-reported performance in reproductive, maternal, and newborn health service delivery among healthcare workers in Tanzania: a baseline- and endline-survey

Lun, 20/06/2022 - 00:00
Abstract Background

Delivery of quality reproductive health services has been documented to depend on the availability of healthcare workers who are adequately supported with appropriate training. However, unmet training needs among healthcare workers in reproductive, maternal, and newborn health (RMNH) in low-income countries remain disproportionately high. This study investigated the effectiveness of training with onsite clinical mentorship towards self-reported performance in RMNH among healthcare workers in Mwanza Region, Tanzania.

Methods

The study used a quasi-experimental design with pre-and post-intervention evaluation strategy. The baseline was compared with two endline groups: those with intervention (training and onsite mentorship) and those without. The differences among the three groups in the sociodemographic characteristics were analyzed by using chi-square test for categorical variables, independent-sample t-test for continuous variables and Mann–Whitney U test for ordinal or skewed continuous data. The independent sample t-test was used to determine the effect of the intervention by comparing the computed self-reported performance on RMNH services between the intervention and control groups. The paired-samples t-test was used to measure the differences between before and after intervention groups. Significance was set at a 95% confidence interval with p ≤ 0.05.

Results

The study included a sample of 216 participants with before and after intervention groups comprising of 95 (44.0%) and 121 (56.0%) in the control group. The comparison between before and after intervention groups revealed a statistically significant difference (p ≤ 0.05) in all the dimensions of the self-reported performance scores. However, the comparison between intervention groups and controls indicated a statistical significant difference on intra-operative care (t = 3.10, df = 216, p = 0.002), leadership skills (t = 1.85, df = 216, p = 0.050), Comprehensive emergency obstetric and newborn care (CEMONC) (t = 34.35, df = 216, p ≤ 0.001), and overall self-reported performance in RMNH (t = 3.15, df = 216, p = 0.002).

Conclusions

This study revealed that the training and onsite clinical mentorship to have significant positive changes in self-reported performance in a wide range of RMNH services especially on intra-operative care, leadership skills and CEMONC. However, further studies with rigorous designs are warranted to evaluate the long-term effect of such training programs on RMNH outcomes.

Categorías: Investigaciones

Lessons learned from the history of postgraduate medical training in Japan: from disease-centred care to patient-centred care in an aging society

Sáb, 18/06/2022 - 00:00
Abstract Background

Health workers, the core of health service delivery and a key driver of progress towards universal health coverage, must be available in sufficient numbers and distributed fairly to serve the entire population. In addition, the planning and management of the health workforce must be responsive to the changing needs of society, including changes in age structure and epidemiology. Considering these issues, this paper examines in historical perspective the evolution of postgraduate medical training and practice in Japan, from the late nineteenth century to the present.

Main text

When the first medical schools were established in the country towards the end of the nineteenth century, Japan was a largely agrarian society, with a population of about 30 million and an average life expectancy of 30–40 years. During the twentieth century, life expectancy and the national population continued to increase in a context of rapid economic growth. Since the 1980s, another demographic transition has occurred: low fertility rates and an aging society. As a result, the inputs and skills required from health professionals have changed considerably over time, posing new challenges to the national health sector and the management of human resources for health.

Conclusions

The case of Japan offers valuable lessons for other countries experiencing a rapid epidemiological and demographic transition. To provide medical care that meets health priorities in the communities, we must consider not only the training of specialists, but also ensure the availability of a large cadre of physicians who possess basic skills and can provide patient-centred care. Furthermore, the Japanese experience shows that a highly hierarchical system and organisational culture are ill-suited to respond quickly to the changing demands of society.

Categorías: Investigaciones

Clinical ethical practice and associated factors in healthcare facilities in Ethiopia: a cross-sectional study

Sáb, 18/06/2022 - 00:00
Abstract Background

Clinical ethical practice (CEP) is required for healthcare workers (HCWs) to improve health-care delivery. However, there are gaps between accepted ethical standards and CEP in Ethiopia. There have been limited studies conducted on CEP in the country. Therefore, this study aimed to determine the magnitude and associated factors of CEP among healthcare workers in healthcare facilities in Ethiopia.

Method

From February to April 2021, a mixed-method study was conducted in 24 health facilities, combining quantitative and qualitative methods. Quantitative (survey questionnaire) and qualitative (semi-structured interviews) data were collected. For quantitative and qualitative data analysis, Stata version 14 and Atlas.ti version 7 were utilized. Multiple logistic regression and thematic analysis for quantative and qualitative respectively used.

Results

From a total of 432 study participants, 407 HCWs were involved in the quantitative analysis, 36 participants were involved in five focus group discussions (FGDs), and eleven key informant interviews (KIIs) were involved in the qualitative analysis. The score of good CEP was 32.68%. Similarly, the scores of good knowledge and attitude were 33.50% and 25.31%, respectively. In the multiple logistic regression models, satisfaction with the current profession, availability of functional CECs, compassionate leaders, previously thought clinical ethics in pre-service education and good attitude were significant factors associated with CEP. Among these significant factors, knowledge, compassionate leaders, poor infrastructure, a conducive environment and positive attitudes were also determinants of CEP according to qualitative findings.

Conclusions

The CEP in health care services in Ethiopia is low. Satisfaction with the current profession, functional CECs, positive attitude, compassionate leaders and previously thought clinical ethics were significant factors associated with CEP. The Ministry of Health (MoH) should integrate interventions by considering CECs, compassionate leadership, and positive attitudes and enhance the knowledge of health professionals. Additionally, digitalization, intersectoral collaboration and institutionalization are important for promoting CEP.

Categorías: Investigaciones

Assessing the contribution of immigrants to Canada’s nursing and health care support occupations: a multi-scalar analysis

Lun, 13/06/2022 - 00:00
Abstract Background

The World Health Organization adopted the Global Strategy on Human Resources for Health Workforce 2030 in May 2016. It sets specific milestones for improving health workforce planning in member countries, such as developing a health workforce registry by 2020 and ensuring workforce self-sufficiency by halving dependency on foreign-trained health professionals. Canada falls short in achieving these milestones due to the absence of such a registry and a poor understanding of immigrants in the health workforce, particularly nursing and healthcare support occupations. This paper provides a multiscale (Canada, Ontario, and Ontario’s Local Health Integration Networks) overview of immigrant participation in nursing and health care support occupations, discusses associated enumeration challenges, and the implications for health workforce planning focusing on immigrants.

Methods

Descriptive data analysis was performed on Canadian Institute for Health Information dataset for 2010 to 2020, and 2016 Canadian Census and other relevant data sources.

Results

The distribution of nurses in Canada, Ontario, and Ontario’s Local Health Integration Networks reveal a growth in Nurse Practitioners and Registered/Licensed Practical Nurses, and contraction in the share of Registered Nurses. Immigrant entry into the profession was primarily through the practical nurse cadre. Mid-sized communities registered the highest growth in the share of internationally educated nurses. Data also pointed towards the underutilization of immigrants in regulated nursing and health occupations.

Conclusion

Immigrants comprise an important share of Canada’s nursing and health care support workforce. Immigrant pathways for entering nursing occupations are complex and difficult to accurately enumerate. This paper recommends the creation of an integrated health workforce dataset, including information about immigrant health workers, for both effective national workforce planning and for assessing Canada’s role in global health workforce distribution and utilization.

Categorías: Investigaciones

Teamwork quality and health workers burnout nexus: a new insight from canonical correlation analysis

Lun, 13/06/2022 - 00:00
Abstract Background

Burnout is evidenced to have  adverse effect on the well-being of health workers. Although several risk factors of burnout have been found, only a hand full of studies have examined the role of teamwork quality. This study therefore sought to explore the relationship between the sub-dimensions of burnout and teamwork quality.

Method

This is an empirical study involving health workers who have practising certificate from the National Health Commission of the People’s Republic of China. Relying on the study’s target population, a sample of 939 healthworkers complied to partake in the survey. Data were obtained from the administration of a well-structured electronic questionnaire containing the Maslach Burnout Inventory together with Healthy and Resilient Organization (HERO) scales correspondingly. The scales were then analysed using the canonical correlation approach (CCA).

Results

The results unveiled a statistically significant correlation between teamwork quality and health worker burnout indicating that teamwork quality and burnout are canonically correlated. Further, examination on the relationship existing between the dimensions of teamwork quality and burnout unveiled that with the exception of personal accomplishment and teamwork dedication, teamwork quality sub-scales (teamwork vigour and teamwork absorption) were negatively related to emotional exhaustion and depersonalization as sub-scales of burnout, respectively.

Conclusion

The study concluded that, surge in teamwork quality leads to reduced emotional exhaustion and reduced depersonalization while simultaneously increasing professional accomplishment. Therefore, this study presents a solid foundation for decreasing burnout syndrome in healthcare that can be implemented by successfully increasing levels of teamwork quality.

Categorías: Investigaciones

Getting Closer or Falling Apart? Euro Area Countries After the Sovereign Debt Crisis

Lun, 13/06/2022 - 00:00
Abstract

We study convergence and divergence dynamics in a sample of euro area countries by assembling an extensive dataset that contains information on public spending and policy outcomes in a variety of areas of government intervention including education, health, and civil justice from the early 1990s. We also focus on other important determinants of a country’s economic performance such as the level of regulation of product and labor markets, as well as the trust in political institutions, quality of governance, and inequality. Results show that despite divergent economic growth in the euro periphery countries after the 2010–2012 sovereign debt crisis, the quality of services and level of regulation did not deteriorate or indeed improved, increasing convergence with the core euro countries. However, the euro area sovereign debt crisis dramatically worsened citizens’ perceptions of quality of governance, as well as the level of social trust. This calls in question the future political viability of the EMU project and asks for reform.

Categorías: Investigaciones

Development assistance for human resources for health, 1990–2020

Vie, 10/06/2022 - 00:00
Abstract Background

Investing in the health workforce is key to achieving the health-related Sustainable Development Goals. However, achieving these Goals requires addressing a projected global shortage of 18 million health workers (mostly in low- and middle-income countries). Within that context, in 2016, the World Health Assembly adopted the WHO Global Strategy on Human Resources for Health: Workforce 2030. In the Strategy, the role of official development assistance to support the health workforce is an area of interest. The objective of this study is to examine progress on implementing the Global Strategy by updating previous analyses that estimated and examined official development assistance targeted towards human resources for health.

Methods

We leveraged data from IHME’s Development Assistance for Health database, COVID development assistance database and the OECD’s Creditor Reporting System online database. We utilized an updated keyword list to identify the relevant human resources for health-related activities from the project databases. When possible, we also estimated the fraction of human resources for health projects that considered and/or focused on gender as a key factor. We described trends, examined changes in the availability of human resources for health-related development assistance since the adoption of the Global Strategy and compared disease burden and availability of donor resources.

Results

Since 2016, development assistance for human resources for health has increased with a slight dip in 2019. In 2020, fueled by the onset of the COVID-19 pandemic, it reached an all-time high of $4.1 billion, more than double its value in 2016 and a 116.5% increase over 2019. The highest share (42.4%) of support for human resources for health-related activities has been directed towards training. Since the adoption of the Global Strategy, donor resources for health workforce-related activities have on average increased by 13.3% compared to 16.0% from 2000 through 2015. For 47 countries identified by the WHO as having severe workforce shortages, the availability of donor resources remains modest.

Conclusions

Since 2016, donor support for health workforce-related activities has increased. However, there are lingering concerns related to the short-term nature of activities that donor funding supports and its viability for creating sustainable health systems.

Categorías: Investigaciones

Human resource management in Ethiopian public hospitals

Vie, 10/06/2022 - 00:00
Abstract Background

In Ethiopia, public hospitals deal with a persistent human resource crisis, even by Sub-Saharan Africa (SSA) standards. Policy and hospital reforms, however, have thus far resulted in limited progress towards addressing the strategic human resource management (SHRM) challenges Ethiopia’s public hospitals face.

Methods

To explore the contextual factors influencing these SHRM challenges of Ethiopian public hospitals, we conducted a qualitative study based on the Contextual SHRM framework of Paauwe. A total of 19 structured interviews were conducted with Chief Executive Officers (CEOs) and HR managers from a purposive sample of 15 hospitals across Ethiopia. An additional four focus groups were held with professionals and managers.

Results

The study found that hospitals compete on the supply side for scarce resources, including skilled professionals. There was little reporting on demand-side competition for health services provided, service quality, and service innovation. Governmental regulations were the main institutional mechanism in place. These regulations also emphasized human resources and were perceived to tightly regulate employee numbers, salaries, and employment arrangements at detailed levels. These regulations were perceived to restrict the autonomy of hospitals regarding SHRM. Regulation-induced differences in allowances and external employment arrangements were among the concerns that decreased motivation and job satisfaction and caused employees to leave. The mismatch between regulation and workforce demands posed challenges for leadership and caused leaders to be perceived as incompetent and unable when they could not successfully address workforce needs.

Conclusions

Bottom-up involvement in SHRM may help resolve the aforementioned persistent problems. The Ethiopian government might better loosen regulations and provide more autonomy to hospitals to develop SHRM and implement mechanisms that emphasize the quality of the health services demanded rather than the quantity of human resources supplied.

Categorías: Investigaciones

Factors influencing attraction and retention of frontline health workers in remote and rural areas in Nigeria: a discrete choice experiment

Mié, 08/06/2022 - 00:00
Abstract

The policy thrust in Nigeria is to ensure qualified, skilled, and adequate health workforce to achieve universal health coverage. We designed a discrete choice experiment to determine the combinations of incentives that may increase the attraction and retention of frontline health workers. We conducted the study in Bauchi State amongst 145 students and health workers. Health workers are 14.6 and 14.4 times more likely to take up a rural posting or continue to stay in their present rural posts if there was basic housing and improvement of the quality of the facilities respectively. The preference for rural job location increased 6.17 times when good schools for children's education were provided. Ensuring availability of basic housing, improving the quality of health facilities, and ensuring good schools for children’s educations are essential factors that may support attraction and retention of health workers. These strategies will support health care services in rural areas and achieving universal health coverage.

Categorías: Investigaciones

A qualitative exploration of the contributions of Polio Eradication Initiative to the Nigerian health system: policy implications for polio transition planning

Lun, 06/06/2022 - 00:00
Abstract Background

The Nigerian health care system is weak due to lack of coordination, fragmentation of services by donor funding of vertical services, dearth and poor distribution of resources, and inadequate infrastructures. The Global Polio Eradication Initiative has supported the country’s health system and provided strategies and skills which need to be documented for use by other health programs attempting disease control or eradication. This study, therefore, explored the contributions of the Polio Eradication Initiative (PEI) activities to the operations of other health programs within the Nigerian health system from the perspectives of frontline workers and managers.

Methods

This cross-sectional qualitative study used key informant interviews (KIIs) and inductive thematic analysis. Twenty-nine KIIs were conducted with individuals who have been involved continuously in PEI activities for at least 12 months since the program's inception. This research was part of a more extensive study, the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE), conducted in 2018. The KII tool focused on four major themes: work experience in other health programs, similarities and differences between polio programs and other health programs, contributions of polio programs, and missed opportunities for implementing polio lessons. All interviews were transcribed verbatim and analyzed using a thematic framework.

Results

The implementation of the PEI has increased health promotion activities and coverage of maternal and child health interventions through the development of tangible and intangible resources, building the capacities of health workers and discovering innovations. The presence of a robust PEI program within a weakened health system of similar programs lacking such extensive support led to a shift in health workers' primary roles. This was perceived to reduce human resources efforts in rural areas with a limited workforce, and to affect other programs' service delivery.

Conclusion

The PEI has made a notable impact on the Nigerian health system. There should be hastened efforts to transition these resources from the PEI into other programs where there are missed opportunities and future control programs. The primary health care managers should continue integration efforts to ensure that programs leverage opportunities within successful programs to improve the health of the community members.

Categorías: Investigaciones

Implementing a health labour market analysis to address health workforce gaps in a rural region of India

Sáb, 04/06/2022 - 00:00
Abstract Background

Human Resources for Health (HRH) are essential for making meaningful progress towards universal health coverage (UHC), but health systems in most of the developing countries continue to suffer from serious gaps in health workforce. The Global Strategy on Human Resources for Health—Workforce 2030, adopted in 2016, includes Health Labor Market Analysis (HLMA) as a tool for evidence based health workforce improvements. HLMA offers certain advantages over the traditional approach of workforce planning. In 2018, WHO supported a HLMA exercise in Chhattisgarh, one of the predominantly rural states of India.

Methods

The HLMA included a stakeholder consultation for identifying policy questions relevant to the context. The HLMA focused on state HRH at district-level and below. Mixed methods were used for data collection and analysis. Detailed district-wise data on HRH availability were collected from state’s health department. Data were also collected on policies implemented on HRH during the 3 year period after the start of HLMA and changes in health workforce.

Results

The state had increased the production of doctors but vacancies persisted until 2018. The availability of doctors and other qualified health workers was uneven with severe shortages of private as well as public HRH in rural areas. In case of nurses, there was a substantial production of nurses, particularly from private schools, however there was a lack of trusted accreditation mechanism and vacancies in public sector persisted alongside unemployment among nurses. Based on the HLMA, pragmatic recommendations were decided and followed up. Over the past 3 years since the HLMA began an additional 4547 health workers including 1141 doctors have been absorbed by the public sector. The vacancies in most of the clinical cadres were brought below 20%.

Conclusion

The HLMA played an important role in identifying the key HRH gaps and clarifying the underlying issues. The HLMA and the pursuant recommendations were instrumental in development and implementation of appropriate policies to improve rural HRH in Chhattisgarh. This demonstrates important progress on key 2030 Global Strategy milestones of reducing inequalities in access to health workers and improving financing, retention and training of HRH.

Categorías: Investigaciones

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