'Going private': a qualitative comparison of medical specialists' job satisfaction in the public and private sectors of South Africa

Anxiety, depression, professional fulfilment and burnout: Public and private doctors' differential response to CoVID-19 pandemic

Introduction

Covid-19 pandemic has been a challenge for healthcare system; the doctors in public and private setups are at the center of this challenge. Public and private doctors differ in personality and some occupational aspects. Do these differences reflect in their response to Covid?

Aim

To study the difference in anxiety, depression, burnout, and professional fulfillment between doctors in public and private setup during Covid-19 second wave and to assess their coping strategies.

Methods

A cross-sectional Internet-based observational study was conducted using Stanford PFI, GAD-7, PHQ-2, BFI-10, and brief COPE questionnaires.

Results

A total of 114 public and 37 private doctors participated in the study. Doctors in private were older in age and deferred in personality profile. Significantly, more private doctors screened for anxiety disorder. 62.2% of private and 41.2% public doctors felt professionally fulfilled. Burnout and depression were not significantly different between groups. Active coping, acceptance, and planning coping were significantly more used by private doctors.

Conclusion

There are differences how doctors in different setups respond to Covid-19, and there is need to understand these factors.

Depression and Burnout among Health Extension Workers in Ethiopia: A Cross-Sectional Study

Background

Depression and burnout are common among healthcare workers (HCWs) and negatively affect their well-being and the quality of the service they provide. However, the burden of depression and burnout among health extension workers (HEWs) in Ethiopia and their relationship has not been documented well.The objective of this study was to estimate the prevalence of depression and burnout among HEWs in Ethiopia and to investigate the relationship between these conditions.

Materials and Methods

We used a cross-sectional study design and collected data from 584 rural and 581 urban HEWs in Ethiopia, as part of the 2019 national health extension program assessment. The Patient Health Questionnaire (PHQ-9) and Burnout Self-Test were used to screen HEWs for depression and burnout, respectively. We used descriptive statistics to estimate the magnitude of depression and burnout, and logistic regression to examine their relationship.

Result

Based on PHQ-9 cutoff scores of 10, the prevalence of major depression was 16.5% among rural and 8.9% among urban HEWs, whereas burnout risk was 39.8% among rural and 12.6% among urban HEWs. The odds of having depression among HEWs with burnout risk was relatively higher compared to those without burnout risk [For rural HEWs, the adjusted odds ratio (AOR) is 11.88 at a 95% confidence interval (CI; 5.27, 26.80), and for urban HEWs, the AOR is 11.49 at a 95% CI (5.35, 24.63)].

Conclusion

The prevalence of depression and burnout is high among HEWs in Ethiopia, with a significant rural-urban difference, and burnout is a significant predictor of depression. Mental health interventions that enable prevention, early detection, and management are needed especially for rural HEWs who are in charge of preventive health service delivery for the disadvantaged rural communities.

Absenteeism in primary health centres in Nigeria: leveraging power, politics and kinship

BACKGROUND

Primary health centres (PHCs) in Nigeria suffer critical shortages of health workers, aggravated by chronic absenteeism that has been attributed to insufficient resources to govern the system and adequately meet their welfare needs. However, the political drivers of this phenomenon are rarely considered. We have asked how political power and networks influence absenteeism in the Nigerian health sector, information that can inform the development of holistic solutions.

METHODS

Data were obtained from in-depth interviews with three health administrators, 30 health workers and 6 health facility committee chairmen in 15 PHCs in Enugu State, Nigeria. Our analysis explored how political configurations and the resulting distribution of power influence absenteeism in Nigeria's health systems.

RESULTS

We found that health workers leverage social networks with powerful and politically connected individuals to be absent from duty and escape sanctions. This reflects the dominant political settlement. Thus, the formal governance structures that are meant to regulate the operations of the health system are weak, thereby allowing powerful individuals to exert influence using informal means. As a result, health managers do not confront absentees who have a relationship with political actors for fear of repercussions, including retaliation through informal pressure. In addition, we found that while health system structures cannot effectively handle widespread absenteeism, networks of local actors, when interested and involved, could address absenteeism by enabling health managers to call politically connected staff to order.

CONCLUSION

The formal governance mechanisms to reduce absenteeism are insufficient, and building alliances (often informal) with local elites interested in improving service delivery locally may help to reduce interference by other powerful actors.

Gender composition and wage gaps in the Canadian health policy research workforce in comparative perspective

BACKGROUND

Gendered challenges have been shown to persist among health practitioners in countries at all levels of development. Less is known about non-clinical professionals, that is, those who do not deliver services directly but are essential to health systems performance, such as health policy researchers. This national observational study examined gender occupational segregation and wage gaps in the Canadian health policy research workforce using a cross-domain comparative labour market analysis approach.

METHODS

Sourcing data from the 2016 population census, we applied linear regression and Oaxaca-Blinder decomposition techniques to assess wage differentials by sex, traditional human capital measures (e.g., age, education, place of work), and social identity variables intersecting with gender (household head, childcare, migrant status) among health policy researchers aged 25-54. We compared the gender composition and wage gap with seven non-health policy and programme domains, as mapped under the national occupational classification by similarity in the types of work performed.

RESULTS

The health policy research workforce (N = 19 955) was characterized by gender segregation: 74% women, compared with 58% women among non-health policy research occupations (N = 102 555). Women health policy researchers earned on average 4.8% (95% CI 1.5‒8.0%) less than men after adjusting for other professional and personal variables. This gap was wider than among education policy researchers with similar gender composition (75% women; adjusted wage gap of 2.6%). Wages among health policy researchers were 21.1% (95% CI 19.4‒22.8%) lower than their counterparts in the male-dominated economics policy domain, all else being equal. Overall, women's earnings averaged 3.2% lower than men's due to factors that remained unexplained by policy domain or other measured predictors.

CONCLUSIONS

This investigation found that the gender inequalities already widely seen among clinical practitioners are replicated among health policy researchers, potentially hindering the competitiveness of the health sector for attracting and retaining talent. Our findings suggest intersectoral actions are necessary to tackle wage gaps and devaluation of female-dominated health professions. Accountability for gender equity in health must extend to the professionals tasked with conducting equity-informative health policy research.

Beyond monitoring functionality to results evaluation of eHealth interventions: Development and validation of an eHealth evaluation framework

Evidencing eHealth interventions, benefits generates data as a basis for assessing whether observed changes in behavior, processes or healthcare outcomes can be attributed to the eHealth interventions. Generating such evidence requires the use of frameworks or some other type of organizing schemes to help in guiding the process and making sense of eHealth systems and the findings. The frameworks available in literature do not clearly guide on how to monitor eHealth implementation and evaluate eHealth implementation results. This study aimed to develop and validate an eHealth evaluation framework to guide the process of monitoring eHealth implementations and evaluation of eHealth results in terms of outcomes and impact on healthcare in developing countries. The Design Science Research Methodology was followed to conduct this study. Recommendations from an eHealth evaluation exploratory study in Uganda and other eHealth evaluation literature formed key inputs into the design and development of the framework. The framework consists of a generic reference model with eHealth monitoring and evaluation dimensions, performance indicators, and guidelines on how to conduct eHealth monitoring and evaluation. The eHealth evaluation framework received high acceptance (>80%) as regards its fitness for purpose during its validation.

Observations of community-based multidisciplinary team meetings in health and social care for older people with long term conditions in England

Background

Community-based multi-disciplinary teams (MDTs) are the most common means to encourage health and social care service integration in England yet are rarely studied or directly observed. This paper reports on two rounds of non-participant observations of community-based multi-disciplinary team (MDT) meetings in two localities, as part of an evaluation of the Integrated Care and Support Pioneers Programme. We sought to understand how MDT meetings coordinate care and identify their ‘added value’ over bilateral discussions.

Methods

Two rounds of structured non-participant observations of 11 MDTs (28 meetings) in an inner city and mixed urban–rural area in England (June 2019-February 2020), using a group analysis approach.

Results

Despite diverse settings, attendance and caseloads, MDTs adopted similar processes of case management: presentation; information seeking/sharing; narrative construction; solution seeking; decision-making and task allocation. Patient-centredness was evident but scope to strengthen ‘patient-voice’ exists. MDTs were hampered by information governance rules and lack of interoperability between patient databases. Meetings were characterised by mutual respect and collegiality with little challenge. Decision-making appeared non-hierarchical, often involving dyads or triads of professionals. ‘Added value’ lay in: rapid patient information sharing; better understanding of contributing agencies’ services; planning strategies for patients that providers had struggled to find the right way to engage satisfactorily; and managing risk and providing mutual support in stressful cases.

Conclusions

More attention needs to be given to removing barriers to information sharing, creating scope for constructive challenge between staff and deciding when to remove cases from the caseload.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07971-x.

The health workforce status in the WHO African Region: findings of a cross-sectional study

Introduction

Several efforts have been made globally to strengthen the health workforce (HWF); however, significant challenges still persist especially in the African Region. This study was conducted by the WHO Regional Office for Africa to present the status of the HWF in 47 countries as a baseline in measuring countries’ progress in implementing the Global Strategy for HWF by 2030.

Methods

This was a cross-sectional survey of 47 countries in the African Region using a semistructured questionnaire. Data were collected from January 2018 to April 2019. Before data collection, a tool was developed and piloted in four countries. The completed tools were validated in the countries by relevant stakeholders in the 47 countries. Data were collated and analysed in Epi Info and Microsoft Excel.

Results

The total stock of health workers was approximately 3.6 million across 47 countries. Among these, 37% of the health workers were nurses and midwives, 9% were medical doctors, 10% were laboratory personnel, 14% were community health workers, 14% were other health workers, and 12% were administrative and support staff. Results show uneven distribution of health workers within the African Region. Most health workers (85%) are in the public sector. Regional density of physicians, nurses and midwives per 1000 population was 1.55, only 4 countries had densities of more than 4.45 physicians, nurses and midwives per 1000 population.

Conclusion

This survey has demonstrated that the shortage and maldistribution of health workers in the WHO African Region remain a big challenge towards the attainment of universal access to health services. This calls for the need to substantially increase investment in the HWF based on contextual evidence in line with the current and future health needs.

Public Service Motivation and Determining Factors to Attract and Retain Health Professionals in the Public Sector: A Systematic Review

(1) Background: The motivational determinants of health professionals to choose and remain in the public sector have been increasingly addressed, including the customized approach of Public Service Motivation (PSM). However, to date, no systematic research overview has been performed in this domain, leaving the body of literature unstructured. This article fills this gap by assessing the motivational factors of choice for the public sector in the health field, and the conceptual and methodological trends of this research stream. (2) Methods: This study follows the PRISMA protocol to ascertain patterns in past research and inform researchers, practitioners, and policymakers. Eighty-nine documents published between 1998 and 2021 were retained after selecting them according to their theme and outlined goals. (3) Results: Common motivational determinants are remuneration, available resources, work conditions, and frequency of contact and interaction with patients. The PSM construct and scale are often employed as main frameworks, but there is also a concern in assessing motivation drawing on psychological constructs that reflect the challenging line of work and environment that is health care, such as presenteeism, stress, and perception of hindrances. (4) Conclusions: By focusing on health professionals’ motivation, this study contributes to a timely systematization in challenging times for health institutions and their human resources.

Understanding Online Dual Practice of Public Hospital Doctors in China: A Mixed-Methods Study

Telemedicine and telehealth hold promise for reducing access barriers, improving quality, and containing medical costs. As Internet companies enter the healthcare market, a rising number of online healthcare platforms have emerged worldwide. In some countries like China, public hospital doctors are providing direct-to-consumer telemedicine services on these commercial platforms as independent providers. Such online service provision creates a new form of dual practice, which we refer to as “online dual practice” in this study. Using a mixed-methods design, this study aims to investigate the prevalence of online dual practice, doctors’ time allocation and motivations for engaging in it, and its potential impacts on the health system in China. We use the web-crawled data from four leading online health platforms to examine the prevalence of online dual practice in China. Then we conduct in-depth interviews with 38 active doctors on these platforms to investigate their time allocation, motivations, and perception regarding online service provision. We find that the nationwide prevalence of online dual practice in China reaches at least 16.5% in 2020, and that it is more common among senior public hospital doctors. Public hospital doctors mainly use small pockets of time during working hours and after-hours to render services on the platforms. The five most commonly cited motivations for their engagement in online dual practice are efficiency improvement, personal control, career development, financial rewards, and serving the patients. Interviewed doctors believe that their online service provision is conducive to increasing healthcare access and improving efficiency, but some also express their concerns about the quality of care. Further analysis shows that the impact of online dual practice on health system performance remains an open question and regulatory policies on it should be health-system specific.

Community health workers' job satisfaction in Ebola-stricken areas of Sierra Leone and its implication for COVID-19 containment: a cross-sectional mixed-methods study

OBJECTIVES

Community health workers (CHWs) played important roles in supplementing scarce healthcare workforce in Sierra Leone during the Ebola outbreak, causing the government to launch the National Community Health Worker Policy 2016-2020. This study evaluated this ambitious policy and examined CHWs' sustainability through their job satisfaction and the underlying factors to inform new policy recommendations, especially the implication for COVID-19 containment.

DESIGN

A mixed-methods approach applying structured questionnaires and semistructured interviews.

SETTING AND PARTICIPANTS

188 CHWs in Bombali District (key Ebola-stricken areas) of Sierra Leone, 184 of them participated in follow-up interviews.

PRIMARY AND SECONDARY OUTCOME MEASURES

Quantitative and qualitative elements were triangulated to improve robustness of investigation: job satisfaction was measured by the Minnesota Satisfaction Questionnaire (MSQ), and factors associated with job satisfaction were identified through thematic analysis and multivariable logistic regression.

RESULTS

The MSQ score of CHWs in Sierra Leone was 65.09, extremely low even among low-income and middle-income countries. Five themes (grouped from 16 subthemes) emerged through the semistructured interviews and were tested quantitatively. Payment was CHWs' top concern. Low stipend and payment tardiness were significantly associated with dissatisfaction. Those with Ebola experience were 5.20 times (95% CI 1.51 to 17.95, p=0.009) more likely to be dissatisfied. This study also found that working conditions, medical material supplies and career development were far from what the CHW policy promised. CHWs' commitment was the only 'positive' theme, and their intrinsic job satisfaction (mean=3.61) was much higher than the extrinsic job satisfaction (mean=2.72).

CONCLUSIONS

Some critical components of the 2016 National Community Health Worker Policy, aiming to promote CHWs and strengthen primary healthcare, have severe shortfalls in practice. The Sierra Leone government should address the underlying factors that have impaired CHWs' job satisfaction to ensure sustainability of its CHW network, especially during the combat against COVID-19.

Global accreditation practices for accelerated medically trained clinicians: a view of five countries

BACKGROUND

Shortages and maldistribution of healthcare workers persist despite efforts to increase the number of practitioners. Evidence to support policy planning and decisions is essential. The World Health Organization has proposed National Health Workforce Accounts (NHWA) to facilitate human resource information systems for effective health workforce planning and monitoring. In this study, we report on the accreditation practices for accelerated medically trained clinicians in five countries: Ethiopia, Ghana, Kenya, Malaysia, and Mongolia.

METHOD

Using open-ended survey responses and document review, information about accreditation practices was classified using NHWA indicators. We examined practices using this framework and further examined the extent to which the indicators were appropriate for this cadre of healthcare providers. We developed a data extraction tool and noted any indicators that were difficult to interpret in the local context.

RESULTS

Accreditation practices in the five countries are generally aligned with the WHO indicators with some exceptions. All countries had standards for pre-service and in-service training. It was difficult to determine the extent to which social accountability and social determinants of health were explicitly part of accreditation practices as this cadre of practitioners evolved out of community health needs. Other areas of discrepancy were interprofessional education and continuing professional development.

DISCUSSION

While it is possible to use NHWA module 3 indicators there are disadvantages as well, at least for accelerated medically trained clinicians. There are aspects of accreditation practices that are not readily coded in the standard definitions used for the indicators. While the indicators provide detailed definitions, some invite social desirability bias and others are not as easily understood by practitioners whose roles continue to evolve and adapt to their health systems.

CONCLUSION

Regular review and revision of indicators are essential to facilitate uptake of the NHWA for planning and monitoring healthcare providers.

Provider perspectives in implementing the Postpartum Intrauterine Device Initiative in Sri Lanka: a qualitative study

BACKGROUND

Integration of maternal care and family planning services has the potential to reduce unintended pregnancies and closely spaced births, leading to reductions in maternal mortality and morbidity. However, few models exist detailing how to implement/integrate such services. This study explored the implementation of the Postpartum Intrauterine Device (PPIUD) Initiative in Sri Lanka, which trained healthcare providers on how to counsel women about contraception during routine antenatal care and insert PPIUD immediately following delivery.

METHODS

We applied a qualitative design to ascertain the perspectives of maternal health service providers who participated in the PPIUD Initiative. We conducted 12 in-depth interviews with providers. We used thematic analysis to analyse the data and the results were interpreted within the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

RESULTS

Findings indicated that providers were willing to adopt the intervention and reiterated the importance of postpartum family planning. However, the intervention was not consistently implemented as intended, including provider bias in counselling and lack of attention to women's preferences. Organisational barriers to implementation included time constraints and inadequate training. Providers suggested that a range of paramedical staff be trained in counselling and PPIUD insertion to mitigate barriers and to facilitate scaling up the intervention.

CONCLUSIONS

To improve and scale up the PPIUD Initiative, training efforts should be expanded to primary and secondary care facilities and implementation strategies better utilised (eg, on-the-job training). The training can be strengthened by improving providers' knowledge of all types of methods and interpersonal communication skills, and emphasising the importance of unbiased, evidence-based contraceptive counselling techniques.

Assessment of training and mentoring for DR-TB care decentralization in Tanzania

INTRODUCTION

Drug-resistant TB (DR-TB) care shifted from centralized to decentralized care in Tanzania in 2015. This study explored whether DR-TB training and mentoring supported healthcare workers' (HCWs) DR-TB care performance.

METHODS

This mixed study assessed HCWs' DR-TB care knowledge, the training quality, and the mentoring around 454 HCWs who were trained across 55 DR-TB sites between January 2016 and December 2017. Pre- and post-training tests, end-of-training evaluation, supervisor's interviews, DR-TB team self-assessment and team focus group discussion were conducted among trained HCWs. Interim and final treatment results of the national central site and the decentralized sites were compared.

RESULTS

HCW's knowledge increased for 15-20% between pre-training and post-training. HCWs and supervisors perceived mentoring as most appropriate to further develop their DR-TB competencies. Culture negativity after 6 months of treatment was similar for the decentralized sites compared to the national central site, 81% vs 79%, respectively, whereas decentralized sites had less loss to follow-up (0% versus 3%) and fewer deaths (3% versus 12%). Delays in laboratory results, stigma, and HCWs shortage were reported the main challenges of decentralized care.

CONCLUSIONS

Training and mentoring to provide DR-TB care at decentralized sites in Tanzania improved HCWs' knowledge and skills in DR-TB care and supported observed good interim and final patient treatment outcomes despite health system challenges.

The influence of electronic health record use on collaboration among medical specialties

Background

One of the main objectives of Electronic Health Records (EHRs) is to enhance collaboration among healthcare professionals. However, our knowledge of how EHRs actually affect collaborative practices is limited. This study examines how an EHR facilitates and constrains collaboration in five outpatient clinics.

Methods

We conducted an embedded case study at five outpatient clinics of a Dutch hospital that had implemented an organization-wide EHR. Data were collected through interviews with representatives of medical specialties, administration, nursing, and management. Documents were analyzed to contextualize these data. We examined the following collaborative affordances of EHRs: (1) portability, (2) co-located access, (3) shared overviews, (4) mutual awareness, (5) messaging, and (6) orchestrating.

Results

Our findings demonstrate how an EHR will both facilitate and constrain collaboration among specialties and disciplines. Affordances that were inscribed in the system for collaboration purposes were not fully actualized in the hospital because:

(a) The EHR helps health professionals coordinate patient care on an informed basis at any time and in any place but only allows asynchronous patient record use.

(b) The comprehensive patient file affords joint clinical decision-making based on shared data, but specialty- and discipline-specific user-interfaces constrain mutual understanding of that data. Moreover, not all relevant information can be easily shared across specialties and outside the hospital.

(c) The reduced necessity for face-to-face communication saves time but is experienced as hindering collective responsibility for a smooth workflow.

(d) The EHR affords registration at the source and registration of activities through orders, but the heightened administrative burden for physicians and the strict authorization rules on inputting data constrain the flexible, multidisciplinary collaboration.

(e) While the EHR affords a complete overview, information overload occurs due to the parallel generation of individually owned notes and the high frequency of asynchronous communication through messages of varying clinical priority.

Conclusions

For the optimal actualization of EHRs’ collaborative affordances in hospitals, coordinated use of these affordances by health professionals is a prerequisite. Such coordinated use requires organizational, technical, and behavioral adaptations. Suggestions for hospital-wide policies to enhance trust in both the EHR and in its coordinated use for effective collaboration are offered.

The Albertina Sisulu Executive Leadership Programme enhancing the competencies and performance of public health service managers in South Africa

Purpose

The purpose of this paper is to evaluate the effect of the Albertina Sisulu Executive Leadership Programme in Health (ASELPH) in improving the competencies and performance of public healthcare managers in South Africa (SA).

Design/methodology/approach

This study used a quasi-experimental study design, with pre-post assessments to assess the performance and competencies of students participating in a public health leadership programme. Students were assessed using a 360° assessment of 14 competencies and 56 performance indicators.

Findings

Students improved significantly in 11 competencies and 44 performance indicators; they perceived improvements in their own performance. The assessors observed the same improvements, which confirmed performance change at the students’ workplaces. The study showed the positive effect of the ASELPH Fellowship in improving the competencies and performance of public healthcare managers in SA.

Originality/value

The ASELPH Fellowship enhanced the leadership competencies and the performance of South African public healthcare managers. South African public healthcare managers face significant challenges and concerns have been raised regarding the competencies of healthcare managers to deal with these challenges. This study shows that leadership programmes can improve competencies and performance of managers to have an impact on the South African healthcare system

Job morale of physicians in low-income and middle-income countries: a systematic literature review of qualitative studies

OBJECTIVES

To systematically review the available literature on physicians' and dentists' experiences influencing job motivation, job satisfaction, burnout, well-being and symptoms of depression as indicators of job morale in low-income and middle-income countries.

DESIGN

The review was reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for studies evaluating outcomes of interest using qualitative methods. The framework method was used to analyse and integrate review findings.

DATA SOURCES

A primary search of electronic databases was performed by using a combination of search terms related to the following areas of interest: 'morale', 'physicians and dentists' and 'low-income and middle-income countries'. A secondary search of the grey literature was conducted in addition to checking the reference list of included studies and review papers.

RESULTS

Ten papers representing 10 different studies and involving 581 participants across seven low-income and middle-income countries met the inclusion criteria for the review. However, none of the studies focused on dentists' experiences was included. An analytical framework including four main categories was developed: work environment (physical and social), rewards (financial, non-financial and social respect), work content (workload, nature of work, job security/stability and safety), managerial context (staffing levels, protocols and guidelines consistency and political interference). The job morale of physicians working in low-income and middle-income countries was mainly influenced by negative experiences. Increasing salaries, offering opportunities for career and professional development, improving the physical and social working environment, implementing clear professional guidelines and protocols and tackling healthcare staff shortage may influence physicians' job morale positively.

CONCLUSIONS

There were a limited number of studies and a great degree of heterogeneity of evidence. Further research is recommended to assist in scrutinising context-specific issues and ways of addressing them to maximise their utility.

PROSPERO REGISTRATION NUMBER

CRD42017082579.

Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa

INTRODUCTION

In 2011, in line with principles for Universal Health Coverage, South Africa formalised community health workers (CHWs) into the national health system in order to strengthen primary healthcare. The national policy proposed that teams of CHWs, called Ward-based Primary Healthcare Outreach Teams (WBPHCOTs), supervised by a professional nurse were implemented. This paper explores WBPHCOTs' and managers' perspectives on the implementation of the CHW programme in one district in South Africa at the early stages of implementation guided by the Implementation Stages Framework.

METHODS

We conducted a qualitative study consisting of five focus group discussions and 14 in-depth interviews with CHWs, team leaders and managers. A content analysis of data was conducted.

RESULTS

There were significant weaknesses in early implementation resulting from a vague national policy and a rushed implementation plan. During the installation stage, adaptations were made to address gaps including the appointment of subdistrict managers and enrolled nurses as team leaders. Staff preparation of CHWs and team leaders to perform their roles was inadequate. To compensate, team members supported each another and assisted with technical skills where they could. Structural issues, such as CHWs receiving a stipend rather than being employed, were an ongoing implementation challenge. Another challenge was that facility managers were employed by the local government authority while the CHW programme was perceived to be a provincial programme.

CONCLUSION

The implementation of complex programmes requires a shared vision held by all stakeholders. Adaptations occur at different implementation stages, which require a feedback mechanism to inform the implementation in other settings. The CHW programme represented a policy advance but lacked detail with respect to human resources, budget, supervision, training and sustainability, which made it a difficult furrow to plough. This study points to how progressive reform remains fraught without due attention to the minutiae of practice.

Perceptions of Iranian emergency department directors of interprofessional leadership: an interview study

The aim of this study was to explore the viewpoints of Iranian health-care team directors regarding factors that are influential in leading an interprofessional team in the emergency department. The study was conducted using in-depth individual interviews and inductive content analysis. The study took place in the emergency departments of three teaching hospitals in Tehran. We used purposeful criterion sampling and interviewed 15 health-care team directors including 12 emergency medicine specialists and 3 nursing directors. Each interview lasted 60 to 90 minutes. All interviews were recorded and transcribed verbatim. Participants' statements were used to freely generate the initial data codes (open coding). Then, the initial codes were arranged into subcategories, which were later grouped together into categories. Finally, by comparing and contrasting categories, three main categories were identified: (a) effectiveness of the team-based leadership, (b) strategies of advancing interprofessional collaboration, and (c) weakness in overcoming team challenges. In the present study, the main factors that affected developing interprofessional collaboration in the Iranian emergency department were the development and support of leadership at the team and organizational levels, and implementation of staff development strategies at the individual and team levels.

Intensive care nurses in South Africa: Expectations and experiences in a public sector hospital

AIM

To explore the content, fulfilment and potential breach of nurses' psychological contracts and provide a nuanced understanding of the expectations and lived experiences of intensive care unit (ICU) nurses.

BACKGROUND

The challenges presented by the South African healthcare system have implications for the motivation and retention levels of ICU nurses. In an environment such as the ICU, personnel dynamics and nursing management's role are crucial to success.

METHOD

A qualitative study of 44 ICU nurses from a South African tertiary hospital. Template analysis was used to identify themes. Manifest content analysis established the frequency of those themes.

RESULTS

Psychological content elements were predominantly relational in nature. Nurses' contracts were fulfilled by nursing managers, peers and patients. Examples of breach included unfairness, abuse of trust and public reprimands.

CONCLUSIONS

The nature of the work, the emphasis on professional and caring values, as well as the relational and intrinsic aspects associated with these, provide important indicators for the composition of nurses' psychological contracts.

IMPLICATIONS FOR NURSING MANAGEMENT

Understanding ICU nurses' expectations can ensure that their psychological contracts remain positive and fulfilled. Practical suggestions include public and private appreciation, autonomy, and management visibility and discretion.

Clinical psychology service distribution and integration into primary health care in KwaZulu-Natal, South Africa

Inadequate investment in mental health care by the governments of both high- and low-income countries contributes to recurrent challenges of uneven distribution of and access to mental health services between urban and non-urban communities. While recent research has acknowledged the role of mental health in well-being and the cost of failure to invest in the sector, prioritising mental health to the same degree as physical health remains a challenge. This article highlights the unequal distribution of mental health services, and psychological services in particular, in KwaZulu-Natal. This is achieved by considering the background of psychology in South Africa and KwaZulu-Natal and then examining the ratio of clinical psychologists to the KwaZulu-Natal population. Furthermore, the article explores the geographical distribution of psychological services in KwaZulu-Natal and concludes with a discussion of the impact of uneven mental health service distribution on service provision and utilisation in non-urban areas of KwaZulu-Natal.

The effect of human resource management on performance in hospitals in Sub-Saharan Africa: a systematic literature review

Hospitals in Sub-Saharan Africa (SSA) face major workforce challenges while having to deal with extraordinary high burdens of disease. The effectiveness of human resource management (HRM) is therefore of particular interest for these SSA hospitals. While, in general, the relationship between HRM and hospital performance is extensively investigated, most of the underlying empirical evidence is from western countries and may have limited validity in SSA. Evidence on this relationship for SSA hospitals is scarce and scattered. We present a systematic review of empirical studies investigating the relationship between HRM and performance in SSA hospitals.Following the PRISMA protocol, searching in seven databases (i.e., Embase, MEDLINE, Web of Science, Cochrane, PubMed, CINAHL, Google Scholar) yielded 2252 hits and a total of 111 included studies that represent 19 out of 48 SSA countries.From a HRM perspective, most studies researched HRM bundles that combined practices from motivation-enhancing, skills-enhancing, and empowerment-enhancing domains. Motivation-enhancing practices were most frequently researched, followed by skills-enhancing practices and empowerment-enhancing practices. Few studies focused on single HRM practices (instead of bundles). Training and education were the most researched single practices, followed by task shifting.From a performance perspective, our review reveals that employee outcomes and organizational outcomes are frequently researched, whereas team outcomes and patient outcomes are significantly less researched. Most studies report HRM interventions to have positively impacted performance in one way or another. As researchers have studied a wide variety of (bundled) interventions and outcomes, our analysis does not allow to present a structured set of effective one-to-one relationships between specific HRM interventions and performance measures. Instead, we find that specific outcome improvements can be accomplished by different HRM interventions and conversely that similar HRM interventions are reported to affect different outcome measures.In view of the high burden of disease, our review identified remarkable little evidence on the relationship between HRM and patient outcomes. Moreover, the presented evidence often fails to provide contextual characteristics which are likely to induce variety in the performance effects of HRM interventions. Coordinated research efforts to advance the evidence base are called for.

Ethics of task shifting in the health workforce: exploring the role of community health workers in HIV service delivery in low- and middle-income countries

Background

Task shifting is increasingly used to address human resource shortages impacting HIV service delivery in low- and middle-income countries. By shifting basic tasks from higher- to lower-trained cadres, such as Community Health Workers (CHWs), task shifting can reduce overhead costs, improve community outreach, and provide efficient scale-up of essential treatments like antiretroviral therapies. Although there is rich evidence outlining positive outcomes that CHWs bring into HIV programs, important questions remain over their place in service delivery. These challenges often reflect concerns over whether CHWs can mitigate HIV through a means that does not overlook the ethical and practical constraints that undergird their work. Ethical and practical guidance thus needs to become the cornerstone of CHW deployment. This paper analyzes such challenges through the lens of Ethical Principlism.

Methods

We examined papers identifying substantive and ethical challenges impacting CHWs as they provide HIV services in low- and middle-income contexts. To do this, we analyzed papers written in English and published from year 2000 or later. These articles were identified using MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar databases. In total, 465 articles were identified, 78 of which met our inclusion criteria. Article reference lists and grey literature were also examined.

Results

CHWs experience specific challenges while carrying out their duties, such as conducting emotionally- and physically-demanding tasks with often inadequate training, supervision and compensation. CHWs have also been poorly integrated into health systems, which not only impacts quality of care, but can hinder their prospects for promotion and lead to CHW disempowerment. As we argue, these challenges can be addressed if a set of ethical principles is prioritized, which specifically entail the principles of respect for persons, justice, beneficence, proportionality and cultural humility.

Conclusions

CHWs play a crucial role in HIV service delivery, yet the ethical challenges that can accompany their work cannot be overlooked. By prioritizing ethical principles, policymakers and program implementers can better ensure that CHWs are combatting HIV through a means that does not exploit or take their critical role within service delivery for granted.

Harnessing the private health sector by using prices as a policy instrument: Lessons learned from South Africa

Governments frequently draw upon the private health care sector to promote sustainability, optimal use of resources, and increased choice. In doing so, policy-makers face the challenge of harnessing resources while grappling with the market failures and equity concerns associated with private financing of health care. The growth of the private health sector in South Africa has fundamentally changed the structure of health care delivery. A mutually reinforcing ecosystem of private health insurers, private hospitals and specialists has grown to account for almost half of the country's spending on health care, despite only serving 16% of the population with the capacity to pay. Following years of consolidation among private hospital groups and insurance schemes, and after successive failures at establishing credible price benchmarks, South Africa's private hospitals charge prices comparable with countries that are considerably richer. This compromises the affordability of a broad-based expansion in health care for the population. The South African example demonstrates that prices can be part of a structure that perpetuates inequalities in access to health care resources. The lesson for other countries is the importance of norms and institutions that uphold price schedules in high-income countries. Efforts to compromise or liberalize price setting should be undertaken with a healthy degree of caution.

Nursing education challenges and solutions in Sub Saharan Africa: an integrative review

BACKGROUND

The Lancet Commission and the Global Health Workforce Alliance reported that professional education has generally not kept up the pace of health care challenges. Sub Saharan Africa needs an effective and efficient nursing education system to build an adequate, competent and relevant nursing workforce necessary for the achievement of Sustainable Development Goals. The Plan of Action for Scaling up Quality Nursing and Midwifery Education and Practice for the African Region 2012 - 2022 provided a framework for scale up of nurses and midwives. This integrative review examined literature on nursing education challenges and solutions in Sub Saharan Africa to inform development of a model for improving the quality, quantity and relevance of nursing education at local level.

METHODS

A search of PubMed, Medline on EBCSOhost and Google Scholar was conducted using key words: nursing education, challenges, solutions and/ or Africa. Published works from 2012 to 2016 were reviewed to explore reports about challenges and solution in nursing education in Sub Saharan Africa. Full texts of relevant studies were retrieved after reading the tittles and abstracts. Critical appraisal was undertaken and the findings of the relevant studies were analysed using thematic analysis.

RESULTS

Twenty articles and five grey sources were included. Findings of the review generally supports World Health Organisation framework for transformative and scale up of health professions education. Six themes emerged; curriculum reforms, profession regulation, transformative teaching strategies, collaboration and partnership, capacity building and infrastructure and resources. Challenges and solutions in nursing education are common within countries. The review shows that massive investment by development partners is resulting in positive development of nursing education in Sub Saharan Africa. However, strategic leadership, networking and partnership to share expertise and best practices are critical.

CONCLUSION

Sub Saharan Africa needs more reforms to increase capacity of educators and mentors, responsiveness of curricula, strongly regulatory frameworks, and availability of infrastructure and resources. The review adds to the body of knowledge to enhance efforts of stakeholders in the improvement of the quality, quantity and relevance of nursing education in Sub Saharan Africa.

Factors deterring dentistry, medical, pharmacy, and social science undergraduates from pursuing nursing as a healthcare career: a cross-sectional study in an Asian university

BACKGROUND

Globally more registered nurses need to be recruited to meet the needs of aging populations and increased co-morbidity. Nursing recruitment remains challenging when compared to other healthcare programs. Despite healthcare students having similar motivation in joining the healthcare industry, many did not consider nursing as a career choice. This study aims to identify the deterrents to choosing nursing among healthcare undergraduates by examining the differences in the factors influencing healthcare career choices and nursing as a career choice.

METHODS

A cross sectional study was conducted using a 35-parallel items instrument known as Healthcare Career Choice and Nursing Career Choice scale. Six hundred and four (n = 604) first year medical, pharmacy, dentistry and social science students from a university in Singapore completed the survey.

RESULTS

Nursing as a career was perceived by healthcare students to be more likely influenced by prior healthcare exposure, the nature of the work, job prospects, and social influences. Lack of autonomous decision making, perceived lower ability to make diagnosis, having to attend to patients' hygiene needs, engendered stigma, and lack of parental support were identified as deterring factors to choosing nursing as a career.

CONCLUSION

An understanding of the deterrents to choosing nursing as career allows policy makers and educational leaders to focus on recruitment strategies. These include providing more exposure to nurses' roles in early school years, helping young people to overcome the fear of providing personal hygiene care, promoting nurses' autonomous nursing practice, addressing gender stigma, and overcoming parental objection.

Exploring knowledge and attitudes toward non-communicable diseases among village health teams in Eastern Uganda: a cross-sectional study

BACKGROUND

Community health workers are essential personnel in resource-limited settings. In Uganda, they are organized into Village Health Teams (VHTs) and are focused on infectious diseases and maternal-child health; however, their skills could potentially be utilized in national efforts to reduce the growing burden of non-communicable diseases (NCDs). We sought to assess the knowledge of, and attitudes toward NCDs and NCD care among VHTs in Uganda as a step toward identifying their potential role in community NCD prevention and management.

METHODS

We administered a knowledge, attitudes and practices questionnaire to 68 VHT members from Iganga and Mayuge districts in Eastern Uganda. In addition, we conducted four focus group discussions with 33 VHT members. Discussions focused on NCD knowledge and facilitators of and barriers to incorporating NCD prevention and care into their role. A thematic qualitative analysis was conducted to identify salient themes in the data.

RESULTS

VHT members possessed some knowledge and awareness of NCDs but identified a lack of knowledge about NCDs in the communities they served. They were enthusiastic about incorporating NCD care into their role and thought that they could serve as effective conduits of knowledge about NCDs to their communities if empowered through NCD education, the availability of proper reporting and referral tools, and visible collaborations with medical personnel. The lack of financial remuneration for their role did not emerge as a major barrier to providing NCD services.

CONCLUSIONS

Ugandan VHTs saw themselves as having the potential to play an important role in improving community awareness of NCDs as well as monitoring and referral of community members for NCD-related health issues. In order to accomplish this, they anticipated requiring context-specific and culturally adapted training as well as strong partnerships with facility-based medical personnel. A lack of financial incentivization was not identified to be a major barrier to such role expansion. Developing a role for VHTs in NCD prevention and management should be a key consideration as local and national NCD initiatives are developed.

Opportunities for human resources for health and rehabilitation: a response to Jesus et al

We welcome Jesus et al.'s paper, which makes an important contribution to the under-researched area of the physical rehabilitation workforce. The authors present recommendations to "advance a policy and research agenda for ensuring that an adequate rehabilitation workforce can meet the current and future rehabilitation health needs" (p. 1). We argue that their perspective could however be strengthened by adopting a stronger global perspective, including consideration of the needs of low-resource settings. In particular, we highlight the integral role of more effective sector and inter-sectoral governance, the opportunity to support the development of community-based rehabilitation (CBR), the lessons that can be learnt from human resources for health (HRH) research and practice more generally, and the recent developments in the global provision of assistive technologies. Each of these issues has important implications and contributions to make to advance the policy and research agenda for the global rehabilitation workforce.

Geographical distribution and profile of medical doctors in public sector hospitals of the Limpopo Province, South Africa

Background

The shortage and unequal distribution of medical doctors in low- and middle-income countries continues to be a public health concern.

Objective

To establish the geographical distribution and demographic profile of medical doctors in public sector hospitals of the Limpopo Province, South Africa.

Method

The PERSAL system was used to obtain information on the number of medical doctors employed in public sector hospitals of the Limpopo Province. Data were exported from PERSAL’s database and then analysed using STATA version 9.0.

Result

The mean age of the 887 medical doctors was 40.1 ± 11.2 years (range 24–79 years). Sixty per cent of the doctors were male, 66% were aged ≤ 45 years and 84% were African. Most of the doctors (86%) were medical officers, of which 55% had < 5 years working experience. Overall, the doctor-to-population ratio for the five districts in the province was 16.4/100 000, with Capricorn (33.7/100 000) and Waterberg (20.2/100 000) recording the highest ratios. A large proportion (43%) of medical officers are employed in the Capricorn District, of which 71% were practising at the tertiary hospital.

Conclusion

This study demonstrated a shortage and maldistribution of medical doctors in the public sector hospitals of the Limpopo Province. This has a potentially negative effect on the delivery of an appropriate and efficient healthcare service to the population and requires urgent attention.

Knowledge, attitudes, and values among physicians working with clinical genomics: a survey of medical oncologists

BACKGROUND

It has been over a decade since the completion of the Human Genome Project (HGP), genomic sequencing technologies have yet to become parts of standard of care in Canada. This study investigates medical oncologists' (MOs) genomic literacy and their experiences based on their participation in a cancer genomics trial in British Columbia, Canada.

METHODS

The authors conducted a survey of MOs from British Columbia, Canada (n = 31, 52.5% response rate), who are actively involved in a clinical genomics trial called Personalized Onco-Genomics (POG). The authors also measured MOs' level of genomic knowledge and attitudes about clinical genomics in cancer medicine.

RESULTS

The findings show a low to moderate level of genomic literacy among MOs. MOs located outside the Vancouver area (the major urban center) reported less knowledge about new genetics technologies compared to those located in the major metropolitan area (26.7 vs 73.3%, P < 0.07, Fisher exact test). Forty-two percent of all MOs thought medical training programs do not offer enough genomic training. The majority of the respondents thought genomics will have major impact on drug discovery (67.7%), and treatment selection (58%) in the next 5 years. They also thought the major challenges are cost (61.3%), patient genomic literacy (48.3%), and clinical utility of genomics (42%).

CONCLUSIONS

The data suggest a high need to increase genomic literacy among MOs and other doctors in medical school training programs and beyond, especially to physicians in regional areas who may need more educational interventions. Initiatives like POG play a critical role in the education of MOs and the integration of big data clinical genomics into cancer care.

The collaboration of general practitioners and nurses in primary care: a comparative analysis of concepts and practices in Slovenia and Spain

Aim A comparative analysis of concepts and practices of GP-nurse collaborations in primary health centres in Slovenia and Spain.

BACKGROUND

Cross-professional collaboration is considered a key element for providing high-quality comprehensive care by combining the expertise of various professions. In many countries, nurses are also being given new and more extensive responsibilities. Implemented concepts of collaborative care need to be analysed within the context of care concepts, organisational structures, and effective collaboration.

METHODS

Background review of primary care concepts (literature analysis, expert interviews), and evaluation of collaboration in 'best practice' health centres in certain regions of Slovenia and Spain. Qualitative content analysis of expert interviews, presentations, observations, and group discussions with professionals and health centre managers. Findings In Slovenian health centres, the collaboration between GPs and nurses has been strongly shaped by their organisation in separate care units and predominantly case-oriented functions. Conventional power structures between professions hinder effective collaboration. The introduction of a new cross-professional primary care concept has integrated advanced practice nurses into general practice. Conventional hierarchies still exist, but a shared vision of preventive care is gradually strengthening attitudes towards team-oriented care. Formal regulations or incentives for teamwork have yet to be implemented. In Spain, health centres were established along with a team-based care concept that encompasses close physician-nurse collaboration and an autonomous role for nurses in the care process. Nurses collaborate with GPs on more equal terms with conflicts centring on professional disagreements. Team development structures and financial incentives for team achievements have been implemented, encouraging teams to generate their own strategies to improve teamwork.

CONCLUSION

Clearly defined structures, shared visions of care and team development are important for implementing and maintaining a good collaboration. Central prerequisites are advanced nursing education and greater acceptance of advanced nursing practice.

Out of control: profit-seeking behaviour, unnecessary medical procedures and rising costs of private medical care in South Africa

The World Health Assembly passed a resolution on the importance of engaging with the private health sector. However, the reality is that universal health coverage aspirations are particularly challenging when there is a significant private health sector. This sector in South Africa suffers from rapidly increasing costs, inflation and volume of services (unnecessary medical tests or treatments). This commentary draws on the international literature, particularly the Japanese model of healthcare, to illustrate that it is necessary and possible to curtail costs and volume in the private sector in South Africa, and possibly in other low-income and middle-income settings.

Factors influencing physicians' choice of workplace: systematic review of drivers of attrition and policy interventions to address them

Objectives

The movement of skilled physicians from the public to the private sector is a key constraint to achieving universal health coverage and is currently affecting health systems worldwide. This systematic review aims to assess factors influencing physicians’ choice of workplace, and policy interventions for retaining physicians in the public sector.

Methods

Five literature databases were searched. Studies were included in the review if they focused on at least one of the following criteria: (i) incentives or motivators for retaining physicians in the public sector, (ii) pull factors that encouraged physicians to move to the private sector, (iii) push factors that forced physicians to leave the public sector, (iv) policy interventions or case studies that addressed physician retention in the public sector, and (v) qualitative reviews of policy interventions that were implemented in different health system settings.

Results

Nineteen articles met the inclusion criteria. Six major themes that affected physicians’ choice of workplace were identified including: financial incentives, career development, infrastructure and staffing, professional work environment, workload and autonomy. The majority of the studies suggested that the use of financial incentives was a motivator in retaining physicians in the public sector. The review also identified policy interventions including: regulatory controls, incentives and management reforms. Regulatory controls and incentives were the two most frequently reported policy interventions.

Conclusion

While factors affecting physicians’ choice of workplace are country specific, financial incentives and professional development are core factors. Other factors are highly influenced by context, and thus, it would be useful for future cross–country research to use standardized data collection tools, allowing comparison of contextual factors as well as the examination of how context affects physician retention in the public sector.

Predictors of job satisfaction among nurses working in Ethiopian public hospitals, 2014: institution-based cross-sectional study

BACKGROUND

Nurses play a pivotal role in determining the efficiency, effectiveness, and sustainability of health care systems. Nurses' job satisfaction plays an important role in the delivery of quality health care. There is paucity of studies addressing job satisfaction among nurses in the public hospital setting in Ethiopia. Thus, this study aimed to assess job satisfaction and factors influencing it among nurses in Jimma zone public hospitals, southwestern Ethiopia.

METHODS

An institution-based census was conducted among 316 nurses working in Jimma zone public hospitals from March to April, 2014. A structured self-administered questionnaire based on a modified version of the McCloskey/Mueller Satisfaction Scale was used. Data were entered using Epi Info version 3.5.3 statistical software and analyzed using SPSS version 20 statistical package. Mean satisfaction scores were compared by independent variables using an independent sample t test and ANOVA. Bivariate and multivariable linear regressions were done.

RESULTS

A total of 316 nurses were included, yielding a response rate of 92.67%. The overall mean job satisfaction was (67.43 ± 13.85). One third (33.5%) of the study participants had a low level of job satisfaction. Mutual understandings at work and professional commitment showed significant and positive relationship with overall job satisfaction, while working at an inpatient unit and work load were negatively associated.

CONCLUSIONS

One third of nurses had a low level of job satisfaction. Professional commitment, workload, working unit, and mutual understanding at work predicted the outcome variable.

Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: recommendations of the Simnovate Global Health Domain Group

Background

Quality of medical care in low income and middle income countries (LMICs) is variable, resulting in significant medical errors and adverse patient outcomes. Integration of simulation-based training and assessment may be considered to enhance quality of patient care in LMICs. The aim of this study was to consider the role of simulation in LMICs, to directly impact health professions education, measurement and assessment.

Methods

The Simnovate Global Health Domain Group undertook three teleconferences and a direct face-to-face meeting. A scoping review of published studies using simulation in LMICs was performed and, in addition, a detailed survey was sent to the World Directory of Medical Schools and selected known simulation centres in LMICs.

Results

Studies in LMICs employed low-tech manikins, standardised patients and procedural simulation methods. Low-technology manikins were the majority simulation method used in medical education (42%), and focused on knowledge and skills outcomes. Compared to HICs, the majority of studies evaluated baseline adherence to guidelines rather than focusing on improving medical knowledge through educational intervention. There were 46 respondents from the survey, representing 21 countries and 28 simulation centres. Within the 28 simulation centres, teachers and trainees were from across all healthcare professions.

Discussion

Broad use of simulation is low in LMICs, and the full potential of simulation-based interventions for improved quality of care has yet to be realised. The use of simulation in LMICs could be a potentially untapped area that, if increased and/or improved, could positively impact patient safety and the quality of care.

Implications of Dual Practice among Health Workers: A Systematic Review

BACKGROUND

Mixed health care systems to work simultaneously on both public and private facilities, is common today. This phenomenon referred to as dual practice (DP), has potential implications for access, quality, cost and equity of health services. This paper aimed to review systematically studies that assess the implications of DP among health workers.

METHODS

MEDLINE, EMBASE, and The Cochrane library were searched for obtaining published literature between Feb 1990 and May 2014. Google and Google Scholars, organizational websites, and reference lists of relevant papers searched to get grey literature. Only studies concentrated on consequences and impacts of DP among health professionals and conducted using "randomized controlled trials", "non-randomized controlled trials", "controlled before and after studies", or "interrupted time series" were eligible for inclusion.

RESULTS

From 3242 records, we focused on 19 studies, which aimed to assess effects and impacts of dual practice. After that, the current understanding of DP positive and negative implications was categorized and discussed based on two perspectives.

CONCLUSION

There has been a propensity to over-reliance on theoretical methods in predicting the implications of this phenomenon. Almost all of the mentioned implications are based on theoretical predictions undermined in the broader literature. Furthermore, assessing the current literature showed positive and negative impacts of DP on different parts of the health system and various dimensions of service delivery. These implications are contexted specific and may vary from system to system.

Achieving universal health coverage in South Africa through a district health system approach: conflicting ideologies of health care provision

Background

Universal Health Coverage (UHC) has emerged as a major goal for health care delivery in the post-2015 development agenda. It is viewed as a solution to health care needs in low and middle countries with growing enthusiasm at both national and global levels. Throughout the world, however, the paths of countries to UHC have differed. South Africa is currently reforming its health system with UHC through developing a national health insurance (NHI) program. This will be practically achieved through a decentralized approach, the district health system, the main vehicle for delivering services since democracy.

Methods

We utilize a review of relevant documents, conducted between September 2014 and December 2015 of district health systems (DHS) and UHC and their ideological underpinnings, to explore the opportunities and challenges, of the district health system in achieving UHC in South Africa.

Results

Review of data from the NHI pilot districts suggests that as South Africa embarks on reforms toward UHC, there is a need for a minimal universal coverage and emphasis on district particularity and positive discrimination so as to bridge health inequities. The disparities across districts in relation to health profiles/demographics, health delivery performance, management of health institutions or district management capacity, income levels/socio-economic status and social determinants of health, compliance with quality standards and above all the burden of disease can only be minimised through positive discrimination by paying more attention to underserved and disadavantaged communities.

Conclusions

We conclude that in South Africa the DHS is pivotal to health reform and UHC may be best achieved through minimal universal coverage with positive discrimination to ensure disparities across districts in relation to disease burden, human resources, financing and investment, administration and management capacity, service readiness and availability and the health access inequalities are consciously implicated. Yet ideological and practical issues make its achievement problematic.

'Your health our concern, our health whose concern?': perceptions of injustice in organizational relationships and processes and frontline health worker motivation in Ghana

Taking a perspective of frontline health workers as internal clients within health systems, this study explored how perceived injustice in policy and organizational matters influence frontline health worker motivation and the consequent effect on workers’ attitudes and performance in delivering maternal and neonatal health care in public hospitals. It consisted of an ethnographic study in two public hospitals in Southern Ghana. Participant observation, conversation and in-depth interviews were conducted over a 16-month period. Ethical approval and consent were obtained from relevant persons and authorities. Qualitative analysis software Nvivo 8 was used for coding and analysis of data. Main themes identified in the analysis form the basis for interpreting and reporting study findings. Findings showed that most workers perceived injustice in distributive, procedural and interactional dimensions at various levels in the health system. At the national policy level this included poor conditions of service. At the hospital level, it included perceived inequity in distribution of incentives, lack of protection and respect for workers. These influenced frontline worker motivation negatively and sometimes led to poor response to client needs. However, intrinsically motivated workers overcame these challenges and responded positively to clients’ health care needs. It is important to recognize and conceptualize frontline workers in health systems as internal clients of the facilities and organizations within which they work. Their quality needs must be adequately met if they are to be highly motivated and supported to provide quality and responsive care to their clients. Meeting these quality needs of internal clients and creating a sense of fairness in governance arrangements between frontline workers, facilities and health system managers is crucial. Consequently, intervention measures such as creating more open door policies, involving frontline workers in decision making, recognizing their needs and challenges and working together to address them are critical.

Models of public-private engagement for health services delivery and financing in Southern Africa: a systematic review

In low- and middle-income countries (LMICs), the private sector-including international donors, non-governmental organizations, for-profit providers and traditional healers-plays a significant role in health financing and delivery. The use of the private sector in furthering public health goals is increasingly common. By working with the private sector through public -: private engagement (PPE), states can harness private sector resources to further public health goals. PPE initiatives can take a variety of forms and understanding of these models is limited. This paper presents the results of a Campbell systematic literature review conducted to establish the types and the prevalence of PPE projects for health service delivery and financing in Southern Africa. PPE initiatives identified through the review were categorized according to a PPE typology. The review reveals that the full range of PPE models, eight distinct models, are utilized in the Southern African context. The distribution of the available evidence-including significant gaps in the literature-is discussed, and key considerations for researchers, implementers, and current and potential PPE partners are presented. It was found that the literature is disproportionately representative of PPE initiatives located in South Africa, and of those that involve for-profit partners and international donors. A significant gap in the literature identified through the study is the scarcity of information regarding the relationship between international donors and national governments. This information is key to strengthening these partnerships, improving partnership outcomes and capacitating recipient countries. The need for research that disaggregates PPE models and investigates PPE functioning in context is demonstrated.

Predictors of activity level and retention among African American lay health advisors (LHAs) from The National Witness Project: Implications for the implementation and sustainability of community-based LHA programs from a longitudinal study

BACKGROUND

Lay health advisor (LHA) programs are increasingly being implemented in the USA and globally in the context of health promotion and disease prevention. LHAs are effective in addressing health disparities when used to reach medically underserved populations, with strong evidence among African American and Hispanic women. Despite their success and the evidence supporting implementation of LHA programs in community settings, there are tremendous barriers to sustaining LHA programs and little is understood about their implementation and sustainability in "real-world" settings. The purpose of this study was to (1) propose a conceptual framework to investigate factors at individual, social, and organizational levels that impact LHA activity and retention; and (2) use prospective data to investigate the individual, social, and organizational factors that predict activity level and retention among a community-based sample of African American LHAs participating in an effective, evidence-based LHA program (National Witness Project; NWP).

METHODS

Seventy-six LHAs were recruited from eight NWP sites across the USA. Baseline predictor data was collected from LHAs during a telephone questionnaire administered between 2010 and 2011. Outcome data on LHA participation and program activity levels were collected in the fall of 2012 from NWP program directors. Chi-square and ANOVA tests were used to identify differences between retained and completely inactive LHAs, and LHAs with high/moderate vs. low/no activity levels. Multivariable logistic regression models were conducted to identify variables that predicted LHA retention and activity levels.

RESULTS

In multivariable models, LHAs based at sites with academic partnerships had increased odds of retention and high/moderate activity levels, even after adjusting for baseline LHA activity level. Higher religiosity among LHAs was associated with decreased odds of being highly/moderately active. LHA role clarity and self-efficacy were associated with retention and high/moderate activity in multivariable models unadjusted for baseline LHA activity level.

CONCLUSIONS

Organizational and role-related factors are critical in influencing the retention and activity levels of LHAs. Developing and fostering partnerships with academic institutions will be important strategies to promote successful implementation and sustainability of LHA programs. Clarifying role expectations and building self-efficacy during LHA recruitment and training should be further explored to promote LHA retention and participation.

Physician Dual Practice: A Descriptive Mapping Review of Literature

BACKGROUND

Physician dual practice is a common phenomenon in almost all countries throughout the world, which could potential impacts on access, equity and quality of services. This paper aims to review studies in physician dual practice and categorize them in order to their main objectives and purposes.

METHODS

Comprehensive literature searches were undertaken in order to obtain main papers and documents in the field of physician dual practice. Systematic searches in Medline and Embase from 1960 to 2013, and general searches in some popular search engines were carried out in this way. After that, descriptive mapping review methods were utilized to categorize eligible studies in this area.

RESULTS

The searches obtained 404 titles, of which 81 full texts were assessed. Finally, 24 studies were eligible for inclusion in our review. These studies were categorized into four groups - "motivation and forces behind dual practice", "consequences of dual practice", "dual practice Policies and their impacts", and "other studies" - based on their main objectives. Our findings showed a dearth of scientifically reliable literature in some areas of dual practice, like the prevalence of the phenomenon, the real consequences of it, and the impacts of the implemented policy measures.

CONCLUSION

Rigorous empirical and evaluative studies should be designed to detect the real consequences of DP and assess the effects of interventions and regulations, which governments have implemented in this field.

Provision of Services in Perinatal Palliative Care: A Multicenter Survey in the United States

BACKGROUND

Congenital anomalies account for 20% of neonatal and infant deaths in the United States. Perinatal palliative care is a recent addition to palliative care and is meant to meet the needs of families who choose to continue a pregnancy affected by a life-limiting diagnosis.

OBJECTIVE

To examine characteristics of programs and services provided, assess alignment with the National Consensus Project domains of care, and identify providers and disciplines involved in programs.

DESIGN

A cross-sectional survey design included 48 items addressing funding and domains of quality care.

SUBJECTS

Program representatives from 30 states (n = 75).

PRINCIPAL RESULTS

Perinatal palliative care programs are housed in academic medical centers, regional or community hospitals, local hospices, or community-based organizations. Significant differences by program setting were observed for type of fetal diagnoses seen, formal training in communicating bad news to parents, mechanisms to ensure continuity of care, and reimbursement mechanisms. One hundred percent of programs provided attention to spiritual needs and bereavement services; 70% of programs are less than 10 years old. Follow-up with parents to assess whether goals were met occurs at 43% of the perinatal palliative care programs. Formal measures of quality assessment were articulated in 38% of programs.

CONCLUSION

This study dramatically adds to the literature available on perinatal palliative care program settings, types, and domains of care. It is clear that there are a variety of types of programs and that the field is still developing. More work is needed to determine which quality measures are needed to address perinatal care needs in this population.

What motivates doctors to leave the UK NHS for a "life in the sun" in New Zealand; and, once there, why don't they stay?

BACKGROUND

At 44%, New Zealand has the highest proportion of international medical graduates (IMGs) in its workforce amongst OECD member countries. Around half of New Zealand's IMGs come from the UK NHS, yet only around 50% stay longer than 1 year post-registration with significant costs to the New Zealand health care system. Why these doctors go to New Zealand and do not stay for long is an important question.

METHODS

UK-trained doctors who had gained registration with the Medical Council of New Zealand and currently practising in New Zealand were surveyed (n = 1357) on the motivation for their move to New Zealand, experiences once there and what was prompting any intentions to move away from New Zealand. Multivariate proportional odds models (POM) were used to quantify various associations.

RESULTS

The survey had a 47% response (n = 632). Quality of life considerations motivated 96% of respondents to move to New Zealand, although 65% indicated they were pushed by a desire to leave the NHS. POM analyses revealed older respondents were significantly less likely than younger respondents to be motivated by quality of life considerations. Younger doctors were significantly more likely to be seeking to leave the NHS. Seventy-six per cent of respondents signalling an intention to leave New Zealand indicated that the desire to return to the UK was the primary reason for this.

CONCLUSION

There is a long history of medical migration from the UK to New Zealand. However, the 65% of respondents in this study seeking to leave the NHS was much higher than found elsewhere, perhaps reflecting increasing workplace and funding pressures in recent years. Of concern to policy makers were the higher odds of seeking to leave the NHS motivating younger doctors. Various changes "down under", in New Zealand as well as Australia, mean their IMG markets may well be tightening up.

Six principles to enhance health workforce flexibility

This paper proposes approaches to break down the boundaries that reduce the ability of the health workforce to respond to population needs, or workforce flexibility. Accessible health services require sufficient numbers and types of skilled workers to meet population needs. However, there are several reasons that the health workforce cannot or does not meet population needs. These primarily stem from workforce shortages. However, the health workforce can also be prevented from responding appropriately and efficiently because of restrictions imposed by professional boundaries, funding models or therapeutic partitions. These boundaries limit the ability of practitioners to effectively diagnose and treat patients by restricting access to specific skills, technologies and services. In some cases, these boundaries not only reduce workforce flexibility, but they introduce inefficiencies in the form of additional clinical transactions and costs, further detracting from workforce responsiveness. Several new models of care are being developed to enhance workforce flexibility by enabling existing staff to work to their full scope of practice, extend their roles or by introducing new workers. Expanding on these concepts, this theoretical paper proposes six principles that have the potential to enhance health workforce flexibility, specifically: 1. Measure health system performance from the perspective of the patient. 2. Minimise training times. 3. Regulate tasks (competencies), not professions. 4. Match rewards and indemnity to the levels of skill and risk required to perform a particular task, not professional title. 5. Ensure that practitioners have all the skills they need to perform the tasks required to work in the environment in which they work 6. Enable practitioners to work to their full scope of practice delegate tasks where required These proposed principles will challenge some of the existing social norms around health-care delivery; however, many of these principles are already being applied, albeit on a small scale. This paper discusses the implications of these reforms.

PROPOSED DISCUSSION POINTS

1. Is person-centred care at odds with professional monopolies? 2. Should the state regulate professions and, by doing so, protect professional monopolies or, instead, regulate tasks or competencies? 3. Can health-care efficiency be enhanced by reducing the number of clinical transactions required to meet patient needs?

Authentic leadership as a source of optimism, trust in the organisation and work engagement in the public health care sector

Orientation: The orientation of this study is towards authentic leadership (AL) and its influence on optimism, trust in the organisation and work engagement of employees in the public health care sector.Research purpose: The objectives of this study were to determine whether the leadership style of AL could predict optimism, trust in the organisation and work engagement amongst a large sample of employees from various functions in public hospitals and clinics in Gauteng and to establish whether optimism and trust in the organisation could mediate the relationship between AL and work engagement.Research approach, design and method: A convenience sample of 633 public health employees from various functions within 27 public hospitals and clinics in the province was used in this research. A cross-sectional research design was implemented. Structural equation modelling was utilised to investigate the Authentic Leadership Inventory (ALI), and the validity and fit of the measurement model, to position AL as a job resource within the nomological net and to test its mediating effects.Main findings: The statistical analysis revealed that AL was a significant predictor of optimism and trust in the organisation and that optimism and trust in the organisation mediated the relationship between AL and work engagement.Practical/managerial implications: The research results suggested that organisations in the public health care sector should encourage their managers to adopt a more authentic leadership style. This will lead to higher levels of optimism, trust in the organisation and eventually work engagement. This will greatly assist employees in the domain of public health care to manage their demanding working environment.Contribution: This study provides evidence that the ALI can be used reliably within the South African context and specifically within the public health care sector. It further substantiates for the implementation of AL as a leadership style in the South African public health care sector, supporting work that has been done internationally in health care where AL has been associated with a number of positive outcomes. Finally, the study puts forward two practical suggestions, on both an individual and an organisational level, to facilitate a culture in which AL can be translated more effectively into an engaged workforce.

Conceptualizing the impacts of dual practice on the retention of public sector specialists - evidence from South Africa

BACKGROUND

'Dual practice', or multiple job holding, generally involves public sector-based health workers taking additional work in the private sector. This form of the practice is purported to help retain public health care workers in low and middle-income countries' public sectors through additional wage incentives. There has been little conceptual or empirical development of the relationship between dual practice and retention.

METHODS

This article helps begin to fill this gap, drawing on empirical evidence from a qualitative study focusing on South African specialists. Fifty-one repeat, in-depth interviews were carried out with 28 doctors (predominantly specialists) with more than one job, in one public and one private urban hospital.

RESULTS

Findings suggest dual practice can impact both positively and negatively on specialists' intention to stay in the public sector. This is through multiple conceptual channels including those previously identified in the literature such as dual practice acting as a 'stepping stone' to private practice by reducing migration costs. Dual practice can also lead specialists to re-evaluate how they compare public and private jobs, and to overworking which can expedite decisions on whether to stay in the public sector or leave. Numerous respondents undertook dual practice without official permission.

CONCLUSIONS

The idea that dual practice helps retain public specialists in South Africa may be overstated. Yet banning the practice may be ineffective, given many undertake it without permission in any case. Regulation should be better enforced to ensure dual practice is not abused. The conceptual framework developed in this article could form a basis for further qualitative and quantitative inquiry.

Needs-based human resources for health planning in Jamaica: using simulation modelling to inform policy options for pharmacists in the public sector

BACKGROUND

Planning for human resources for health (HRH) is central to health systems strengthening around the world, including in the Caribbean and Jamaica. In an effort to align Jamaica's health workforce with the changing health needs of its people, a partnership was established between Jamaican and Canadian partners. The purpose of the work described in this paper is to describe the development and application of a needs-based HRH simulation model for pharmacists in Jamaica's largest health region.

METHODS

Guided by a Steering Committee of Jamaican stakeholders, a simulation modelling approach originally developed in Canada was adapted for the Jamaican context. The purpose of this approach is to promote understanding of how various factors affect the supply of and/or requirements for HRH in different scenarios, and to identify policy levers for influencing each of these under different future scenarios. This is done by integrating knowledge of different components of the health care system into a single tool that shows how changes to different parameters affect HRH supply or requirements. Data to populate the model were obtained from multiple administrative databases and key informants. Findings were validated with the Steering Committee.

RESULTS

The model estimated an initial shortage of 110 full-time equivalent (FTE) pharmacists in the South East Region that, without intervention, would increase to a shortage of about 150 FTEs over a 15-year period. In contrast to the relatively small impact of a large enrollment increase in Jamaica's pharmacy training programme, interventions to increase recruitment of pharmacists to the public sector, or improve productivity - through, for example, the use of support staff and/or new technologies - may have much greater impact on reducing this shortage.

CONCLUSIONS

The model represents an improvement on the HRH planning tools previously used in Jamaica in that it supports the estimation of HRH requirements based directly on measures of population health need. Both the profession (pharmacists) and country (Jamaica) considered here are under-studied. Further investments by Jamaica's MoH in continuing to build capacity to use such models, in combination with their efforts to enhance health information systems, will support better informed HRH planning in Jamaica.

Why do some physicians in Portuguese-speaking African countries work exclusively for the private sector? Findings from a mixed-methods study

BACKGROUND

Despite the growing interest in the private health sector in low- and middle-income countries, little is known about physicians working outside the public sector. The present work adopts a mixed-methods approach to explore characteristics, working patterns, choices, and motivations of the physicians working exclusively for the private sector in the capital cities of Cape Verde, Guinea Bissau, and Mozambique. The paper's objective is to contribute to the understanding of such physicians, ultimately informing the policies regulating the medical profession in low- and middle-income countries.

METHODS

The qualitative part of the study involved 48 interviews with physicians and health policy-makers and aimed at understanding the practice in the three locations. The quantitative study included a survey of 329 physicians, and multivariate analysis was conducted to analyse characteristics, time allocation, earnings, and motivations of those physicians working only for the private sector, in comparison to their public sector-only and dual practice peers.

RESULTS

Our findings showed that only a limited proportion of physicians in the three locations work exclusively for the private sector (11.2%), with members of this group being older than those practicing only in the public or in both sectors. They were found to work fewer hours per week (49 hours) than their public (56 hours) and dual practice peers (62 hours) (P <0.001 and P = 0.011, respectively). Their median earnings were USD 4,405 per month, with substantial variations across the three locations. Statistically significant differences were found with the earnings of public-only physicians (P <0.001), but not with those of the dual practice group (P = 0.340). The qualitative data from the interviews showed private-only physicians' preference for an independent and more flexible work modality, and this was quoted as a determining factor for their choice of sector. This group appears to include those working in the more informal sector, and those who decided to leave the civil service following a disagreement with the public employer.

CONCLUSIONS

The study shows the importance of understanding the relation between health professionals' characteristics, motivations, and their engagement with the private sector to develop effective policies to regulate the profession. This may ultimately contribute to achieving universal access to medical services in low- and middle-income countries.