Missing in action: teacher and health worker absence in developing countries

An approach to addressing governance from a health system framework perspective

As countries strive to strengthen their health systems in resource constrained contexts, policy makers need to know how best to improve the performance of their health systems. To aid these decisions, health system stewards should have a good understanding of how health systems operate in order to govern them appropriately. While a number of frameworks for assessing governance in the health sector have been proposed, their application is often hindered by unrealistic indicators or they are overly complex resulting in limited empirical work on governance in health systems. This paper reviews contemporary health sector frameworks which have focused on defining and developing indicators to assess governance in the health sector. Based on these, we propose a simplified approach to look at governance within a common health system framework which encourages stewards to take a systematic perspective when assessing governance. Although systems thinking is not unique to health, examples of its application within health systems has been limited. We also provide an example of how this approach could be applied to illuminate areas of governance weaknesses which are potentially addressable by targeted interventions and policies. This approach is built largely on prior literature, but is original in that it is problem-driven and promotes an outward application taking into consideration the major health system building blocks at various levels in order to ensure a more complete assessment of a governance issue rather than a simple input-output approach. Based on an assessment of contemporary literature we propose a practical approach which we believe will facilitate a more comprehensive assessment of governance in health systems leading to the development of governance interventions to strengthen system performance and improve health as a basic human right.

Whom do physicians work for? An analysis of dual practice in the health sector

This article presents a thorough analysis of dual practice among physicians who work in both the public and private sectors. A conceptual framework is presented to help the reader understand dual practice and the contexts where it takes place. The article reviews the existing theoretical and empirical literature on this form of dual practice among physicians. It analyzes the extent of this phenomenon, the underlying factors that motivate physicians to engage in dual practice, and the main implications of their decision to do so. It also examines and discusses current policies that address dual practice. In this regard, the article provides some qualified support for the use of "rewarding" policies to retain physicians in the public sectors of more developed countries, while "limiting" policies are recommended for developing countries - with the caveat that the policies should be accompanied by the strengthening of institutional and contracting environments. The article highlights the lack of quality evaluative evidence regarding the consequences of dual practice on the delivery of health care services. It concludes that the overall impact of dual practice remains an open question that warrants more attention from researchers and policy makers alike.

Health care and equity in India

In India, despite improvements in access to health care, inequalities are related to socioeconomic status, geography, and gender, and are compounded by high out-of-pocket expenditures, with more than three-quarters of the increasing financial burden of health care being met by households. Health-care expenditures exacerbate poverty, with about 39 million additional people falling into poverty every year as a result of such expenditures. We identify key challenges for the achievement of equity in service provision, and equity in financing and financial risk protection in India. These challenges include an imbalance in resource allocation, inadequate physical access to high-quality health services and human resources for health, high out-of-pocket health expenditures, inflation in health spending, and behavioural factors that affect the demand for appropriate health care. Use of equity metrics in monitoring, assessment, and strategic planning; investment in development of a rigorous knowledge base of health-systems research; development of a refined equity-focused process of deliberative decision making in health reform; and redefinition of the specific responsibilities and accountabilities of key actors are needed to try to achieve equity in health care in India. The implementation of these principles with strengthened public health and primary-care services will help to ensure a more equitable health care for India's population.

Primary eye care in sub-Saharan African: do we have the evidence needed to scale up training and service delivery?

The models for addressing the delivery of an eye-care service in sub-Saharan Africa have seen considerable revision in the last 30 years, and the on-going challenges, as well as the future needs, will probably require many more changes and new systems. There is a need to assess the different models that are currently employed, in order to ensure that all potential contributions to the elimination of avoidable blindness are used; the evolving concept of primary eye care (PEC) requires such assessment. For the current review, the published literature on eye care provided by general front-line healthworkers was screened for articles that provided evidence of the impact of such PEC on the general delivery of eye care in sub-Saharan Africa. Of the 103 relevant articles detected, only three provided evidence of the effectiveness of PEC and the authors of all three of these articles suggested that such eye care was not meeting the needs or expectations of the target populations, the trainers, or programmes of eye care. Among the main problems identified were a lack of a clear definition of the scope of practice for PEC, the need for clarifying the specific skills that a front-line healthworker could perform correctly, and the changing needs and expectations for the delivery of an eye-care service in Africa. If PEC is to become adequately grounded in Africa, the generation of further evidence of the effectiveness and limitations of such care would be a prudent move.

Performance-based financing: just a donor fad or a catalyst towards comprehensive health-care reform?

Performance-based financing is generating a heated debate. Some suggest that it may be a donor fad with limited potential to improve service delivery. Most of its critics view it solely as a provider payment mechanism. Our experience is that performance-based financing can catalyse comprehensive reforms and help address structural problems of public health services, such as low responsiveness, inefficiency and inequity. The emergence of a performance-based financing movement in Africa suggests that it may contribute to profoundly transforming the public sectors of low-income countries.

Knowledge Economy in India: Challenges and Opportunities

India, along with some of the other middle low income countries like Brazil, Russia, China and the Republic of Korea is competing with high income developed nations like USA and Japan in the knowledge sector. India has to its advantage a big pool of knowledge workers like scientists, engineers, and researchers available at low cost. The pertinent question is whether the flow of knowledge has resulted in inclusive growth. This research paper is a critical analysis of the challenges and opportunities on the pathway to India's journey towards becoming a global leader in knowledge economy with respect to the four pillars as defined by the Knowledge Assessment Model (KAM) of the World Bank, namely, economic and institutional regime, education, information and communication technology, and innovation.

Overworked? On the relationship between workload and health worker performance

The shortage of health workers in many low-income countries poses a threat to the quality of health services. When the number of patients per health worker grows sufficiently high, there will be insufficient time to diagnose and treat all patients adequately. This paper tests the hypothesis that high caseload reduces the level of effort per patient in the diagnostic process. We observed 159 clinicians in 2095 outpatient consultations at 126 health facilities in rural Tanzania. Surprisingly, we find no association between caseload and the level of effort per patient. Clinicians appear to have ample amounts of idle time. We conclude that health workers are not overworked and that scaling up the number of health workers is unlikely to raise the quality of health services. Training has a positive effect on quality but is not in itself sufficient to raise quality to adequate levels.

Cost-effectiveness of "golden mustard" for treating vitamin A deficiency in India

BACKGROUND

Vitamin A deficiency (VAD) is an important nutritional problem in India, resulting in an increased risk of severe morbidity and mortality. Periodic, high-dose vitamin A supplementation is the WHO-recommended method to prevent VAD, since a single dose can compensate for reduced dietary intake or increased need over a period of several months. However, in India only 34 percent of targeted children currently receive the two doses per year, and new strategies are urgently needed.

METHODOLOGY

Recent advancements in biotechnology permit alternative strategies for increasing the vitamin A content of common foods. Mustard (Brassica juncea), which is consumed widely in the form of oil by VAD populations, can be genetically modified to express high levels of beta-carotene, a precursor to vitamin A. Using estimates for consumption, we compare predicted costs and benefits of genetically modified (GM) fortification of mustard seed with high-dose vitamin A supplementation and industrial fortification of mustard oil during processing to alleviate VAD by calculating the avertable health burden in terms of disability-adjusted life years (DALY).

PRINCIPAL FINDINGS

We found that all three interventions potentially avert significant numbers of DALYs and deaths. Expanding vitamin A supplementation to all areas was the least costly intervention, at $23-$50 per DALY averted and $1,000-$6,100 per death averted, though cost-effectiveness varied with prevailing health subcenter coverage. GM fortification could avert 5 million-6 million more DALYs and 8,000-46,000 more deaths, mainly because it would benefit the entire population and not just children. However, the costs associated with GM fortification were nearly five times those of supplementation. Industrial fortification was dominated by both GM fortification and supplementation. The cost-effectiveness ratio of each intervention decreased with the prevalence of VAD and was sensitive to the efficacy rate of averted mortality.

CONCLUSIONS

Although supplementation is the least costly intervention, our findings also indicate that GM fortification could reduce the VAD disease burden to a substantially greater degree because of its wider reach. Given the difficulties in expanding supplementation to areas without health subcenters, GM fortification of mustard seed is an attractive alternative, and further exploration of this technology is warranted.

Structured Inequalities: Factors Associated with Spatial Disparities in Maternity Care in India

Research on India documents considerable heterogeneity in health and health care across states. However, while regional differences are well established, factors underlying these differences have received little attention. This paper seeks to explain disparities in delivery care across districts by focusing on three factors: (1) Marriage and kinship patterns; (2) District wealth; (3) Governance and quality of services. Using data from nationally representative India Human Development Survey 2005 (IHDS) it examines the probability that the 11,905 women who had a child between 2000 and 2005 delivered in a hospital or received care from a doctor or a nurse while delivering at home. The results suggest that 47% of the variation in delivery care in India is between districts while 53% is between women within district. Although compositional differences in education and household wealth explain some of the variation between districts, marriage and kinship patterns, district wealth and governance each has a significant impact on shaping between-district variation in maternity care.

Training needs assessment for clinicians at antiretroviral therapy clinics: evidence from a national survey in Uganda

BACKGROUND

To increase access to antiretroviral therapy in resource-limited settings, several experts recommend "task shifting" from doctors to clinical officers, nurses and midwives. This study sought to identify task shifting that has already occurred and assess the antiretroviral therapy training needs among clinicians to whom tasks have shifted.

METHODS

The Infectious Diseases Institute, in collaboration with the Ugandan Ministry of Health, surveyed health professionals and heads of antiretroviral therapy clinics at a stratified random sample of 44 health facilities accredited to provide this therapy. A sample of 265 doctors, clinical officers, nurses and midwives reported on tasks they performed, previous human immunodeficiency virus training, and self-assessment of knowledge of human immunodeficiency virus and antiretroviral therapy. Heads of the antiretroviral therapy clinics reported on clinic characteristics.

RESULTS

Thirty of 33 doctors (91%), 24 of 40 clinical officers (60%), 16 of 114 nurses (14%) and 13 of 54 midwives (24%) who worked in accredited antiretroviral therapy clinics reported that they prescribed this therapy (p<0.001). Sixty-four percent of the people who prescribed antiretroviral therapy were not doctors. Among professionals who prescribed it, 76% of doctors, 62% of clinical officers, 62% of nurses and 51% of midwives were trained in initiating patients on antiretroviral therapy (p=0.457); 73%, 46%, 50% and 23%, respectively, were trained in monitoring patients on the therapy (p=0.017). Seven percent of doctors, 42% of clinical officers, 35% of nurses and 77% of midwives assessed that their overall knowledge of antiretroviral therapy was lower than good (p=0.001).

CONCLUSION

Training initiatives should be an integral part of the support for task shifting and ensure that antiretroviral therapy is used correctly and that toxicity or drug resistance do not reverse accomplishments to date.

Health facilities at the district level in Indonesia

Background

At Independence the Government of Indonesia inherited a weak and unevenly distributed health system to which much of the population had only limited access. In response, the government decided to increase the number of facilities and to locate them closer to the people. To staff these health facilities the government introduced obligatory government service for all new graduates in medicine, nursing and midwifery. Most of these staff also established private practices in the areas in which they were located. The health information system contains little information on the health care facilities established for private practice by these staff. This article reports on the results of enumerating all health facilities in 15 districts in Java.

Methods

We enumerated all healthcare facilities, public and private, by type in each of 15 districts in Java.

Results

The enumeration showed a much higher number of healthcare facilities in each district than is shown in most reports and in the health information system which concentrates on public, multi-provider facilities. Across the 15 districts: 86% of facilities were solo-provider facilities for outpatient services; 13% were multi-provider facilities for outpatient services; and 1% were multi-provider facilities offering both outpatient and inpatient services.

Conclusion

The relatively good distribution of health facilities in Indonesia was achieved through establishing public health centers at the sub-district level and staffing them through a system of compulsory service for doctors, nurses and midwives. Subsequently, these public sector staff also established solo-provider facilities for their own private practice; these solo-provider facilities, of which those for nurses are almost half, comprise the largest category of outpatient care facilities, most are not included in official statistics. Now that Indonesia no longer has mandatory service for newly graduated doctors, nurses and midwives, it will have difficulty maintaining the distribution of facilities and providers established through the 1980s. The current challenge is to envision a new health system that responds to the changing disease patterns as well as the changes in distribution of health facilities.

Human resources for health at the district level in Indonesia: the smoke and mirrors of decentralization

BACKGROUND

In 2001 Indonesia embarked on a rapid decentralization of government finances and functions to district governments. One of the results is that government has less information about its most valuable resource, the people who provide the services. The objective of the work reported here is to determine the stock of human resources for health in 15 districts, their service status and primary place of work. It also assesses the effect of decentralization on management of human resources and the implications for the future.

METHODS

We enumerated all health care providers (doctors, nurses and midwives), including information on their employment status and primary place of work, in each of 15 districts in Java. Data were collected by three teams, one for each province.

RESULTS

Provider density (number of doctors, nurses and midwives/1000 population) was low by international standards--11 out of 15 districts had provider densities less than 1.0. Approximately half of all three professional groups were permanent public servants. Contractual employment was also important for both nurses and midwives. The private sector as the primary source of employment is most important for doctors (37% overall) and increasingly so for midwives (10%). For those employed in the public sector, two-thirds of doctors and nurses work in health centres, while most midwives are located at village-level health facilities.

CONCLUSION

In the health system established after Independence, the facilities established were staffed through a period of obligatory service for all new graduates in medicine, nursing and midwifery. The last elements of that staffing system ended in 2007 and the government has not been able to replace it. The private sector is expanding and, despite the fact that it will be of increasing importance in the coming decades, government information about providers in private practice is decreasing. Despite the promise of decentralization to increase sectoral "decision space" at the district level, the central government now has control over essentially all public sector health staff at the district level, marking a return to the situation of 20 years ago. At the same time, Indonesia has changed dramatically. The challenge now is to envision a new health system that takes account of these changes. Envisioning the new system is a crucial first step for development of a human resources policy which, in turn, will require more information about health care providers, public and private, and increased capacity for human resource planning.

Improving Education in the Developing World: What Have We Learned from Randomized Evaluations?

Across a range of contexts, reductions in education costs and provision of subsidies can boost school participation, often dramatically. Decisions to attend school seem subject to peer effects and time-inconsistent preferences. Merit scholarships, school health programs, and information about returns to education can all cost-effectively spur school participation. However, distortions in education systems, such as weak teacher incentives and elite-oriented curricula, undermine learning in school and much of the impact of increasing existing educational spending. Pedagogical innovations designed to address these distortions (such as technology-assisted instruction, remedial education, and tracking by achievement) can raise test scores at a low cost. Merely informing parents about school conditions seems insufficient to improve teacher incentives, and evidence on merit pay is mixed, but hiring teachers locally on short-term contracts can save money and improve educational outcomes. School vouchers can cost-effectively increase both school participation and learning.

Mandated empowerment: handing antipoverty policy back to the poor?

The current trend in antipoverty policy emphasizes mandated empowerment: the poor are being handed the responsibility for making things better for themselves, largely without being asked whether this is what they want. Beneficiary control is now being built into public service delivery, while microcredit and small business promotion are seen as better ways to help the poor. The clear presumption is that the poor are both able and happy to exercise these new powers. This essay uses two examples to raise questions about these strategies. The first example is about entrepreneurship among the poor. Using data from a number of countries, we argue that there is no evidence that the median poor entrepreneur is trying his best to expand his existing businesses, even if we take into account the many constraints he faces. While many poor people own businesses, this seems to be more a survival strategy than something they want to do. The second example comes from an evaluation of a program in India that aims to involve poor rural parents in improving local public schools. The data suggest that despite being informed that they now have both the right to intervene in the school and access to funds for that purpose, and despite being made aware of how little the children were learning, parents opt to not get involved. Both examples raise concerns about committing ourselves entirely to antipoverty strategies that rely on the poor doing a lot of the work.

The quality of medical advice in low-income countries

This paper documents the quality of medical advice in low-income countries. Our evidence on health care quality in low-income countries is drawn primarily from studies in four countries: Tanzania, India, Indonesia, and Paraguay. We provide an overview of recent work that uses two broad approaches: medical vignettes (in which medical providers are presented with hypothetical cases and their responses are compared to a checklist of essential procedures) and direct observation of the doctor–patient interaction These two approaches have proved quite informative. For example, doctors in Tanzania complete less than a quarter of the essential checklist for patients with classic symptoms of malaria, a disease that kills 63,000–96,000 Tanzanians each year. A public-sector doctor in India asks one (and only one) question in the average interaction: “What's wrong with you?” We present systematic evidence in this paper to show that these isolated facts represent common patterns. We find that the quality of care in low-income countries as measured by what doctors know is very low, and that the problem of low competence is compounded due to low effort—doctors provide lower standards of care for their patients than they know how to provide. We discuss how the properties and correlates of measures based on vignettes and observation may be used to evaluate policy changes. Finally, we outline the agenda in terms of further research and measurement.

What is middle class about the middle classes around the world?

We expect a lot from the middle classes. At least three distinct arguments about the special economic role of the middle class are traditionally made. In one, new entrepreneurs armed with a capacity and a tolerance for delayed gratification emerge from the middle class and create employment and productivity growth for the rest of society. In a second, perhaps more conventional view, the middle class is primarily a source of vital inputs for the entrepreneurial class: it is their “middle class values”—their emphasis on the accumulation of human capital and savings—that makes them central to the process of capitalist accumulation. The third view, a staple of the business press, emphasizes the middle class consumer, whose demand for quality consumer goods feeds investment in production and marketing, which in turn raises income levels for everyone. This essay asks what we should make of these arguments in the context of today's developing countries. We focus on two groups of households: those whose daily per capita expenditures are between $2 and $4, and those with expenditures between $6 and $10. These are the groups that we will call the middle class. Starting from survey data on patterns of consumption and investment by the middle class in thirteen developing countries, we look for what is distinct about the global middle class, especially when compared to the global poor (defined as those whose per capita daily consumption is below $2 a day). In particular, is there anything special about the way middle class people per spend their money, earn their incomes, or bring up their children?

PUTTING A BAND-AID ON A CORPSE: INCENTIVES FOR NURSES IN THE INDIAN PUBLIC HEALTH CARE SYSTEM

The public Indian health care system is plagued by high staff absence, low effort by providers, and limited use by potential beneficiaries who prefer private alternatives. This artice reports the results of an experiment carried out with a district administration and a nongovernmental organization (NGO). The presence of government nurses in government public health facilities (subcenters and aid-posts) was recorded by the NGO, and the government took steps to punish the worst delinquents. Initially, the monitoring system was extremely effective. This shows that nurses are responsive to financial incentives. But after a few months, the local health administration appears to have undermined the scheme from the inside by letting the nurses claim an increasing number of "exempt days." Eighteen months after its inception, the program had become completely ineffective.

The contribution of human resources for health to the quality of care in Indonesia

Using a representative sample of public facilities surveyed in 1993 and 1997, we took advantage of exogenous changes imposed on the Indonesian health system to evaluate the contribution of physicians, nurses, and midwives to the quality of primary care. We found that quality depends on the availability, type, and number of health workers, which, in turn, is affected by public policies about deployment. We conclude that staff deployment could be refined by analyses of the skill-mix needed to provide quality care. Professional nurses in particular could play an important role in promoting quality.