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Pestana J, Frutuoso J, Costa E, Fonseca F. Heterogeneity in physician's job preferences in a dual practice context - Evidence from a DCE. Soc Sci Med 2024; 343:116551. [PMID: 38242030 DOI: 10.1016/j.socscimed.2023.116551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/26/2023] [Accepted: 12/21/2023] [Indexed: 01/21/2024]
Abstract
Many countries are facing challenges in recruiting and retaining physicians, particularly in regions where the public and private sectors compete for doctors. Understanding the factors influencing physicians' job choices can help inform policies aimed at attracting and retaining this valuable workforce. This study aims to elicit the strength of physicians' preferences regarding various job-related aspects, including earnings, time flexibility, discussion of clinical cases, frequency of facilities and equipment updates, training opportunities and autonomy in decision making. To achieve this, a Discrete Choice Experiment (DCE) was administered to 697 physicians. Each participant completed a series of eight choice tasks, where they had to choose between two hypothetical jobs differing in these attributes with levels mirroring positions in the public and private sectors in Portugal. The resulting choices were analysed using mixed logit, generalized multinomial logit and latent classes models to account for diverse unobserved variations in physicians' preferences and to explore preference heterogeneity across different observable characteristics. Jobs that offered more autonomy and training opportunities were strongly preferred, as physicians would require additional compensation to work with reduced autonomy (equivalent to 28.62% of gross income) or less frequent training (equivalent to 22.75%). This study also shows that the ranking of the job characteristics is similar between physicians working exclusively in the public sector and those engaged in dual practice. Nevertheless, public sector physicians place more emphasis on the availability of frequent training possibilities and frequent updates of facilities and equipment compared to their counterparts in dual practice. These findings contribute to existing knowledge by highlighting the significance of non-monetary attributes and shedding light on the preferences of physicians across various employment scenarios. They offer valuable insights for policy development aimed at influencing physicians' allocation of time between sectors.
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Affiliation(s)
- Joana Pestana
- Nova School of Business and Economics, Lisbon, Portugal.
| | - João Frutuoso
- Serviço de Medicina Intensiva do Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Eduardo Costa
- Nova School of Business and Economics, Lisbon, Portugal
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Fernandes A, Santinha G, Forte T. Public Service Motivation and Determining Factors to Attract and Retain Health Professionals in the Public Sector: A Systematic Review. Behav Sci (Basel) 2022; 12:95. [PMID: 35447667 PMCID: PMC9028512 DOI: 10.3390/bs12040095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 02/07/2023] Open
Abstract
(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.
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Affiliation(s)
- Alexandre Fernandes
- Governance, Competitiveness and Public Policies (GOVCOPP), Department of Social, Political and Territorial Sciences, University of Aveiro, 3810-193 Aveiro, Portugal; (G.S.); (T.F.)
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Munyangaju I, Langa MAS, Clemens SAC, Marchetti E. Evaluation of the partnership between international non-governmental organizations and the State in the health sector in Mozambique. Pan Afr Med J 2021; 39:91. [PMID: 34466193 PMCID: PMC8379398 DOI: 10.11604/pamj.2021.39.91.25970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 05/18/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Mozambique is one of the poorest nations in the world and its health budget is heavily dependent on external funding. Increasingly, donors prefer to direct their funds through international non-governmental organizations instead of direct donations to the State budget. In the current climate of increased emphasis on health system strengthening, a strong and stable partnership between government and international non-governmental organizations is pivotal for health system strengthening in Mozambique. Methods the study evaluates the current partnership through a standardized survey to healthcare workers employed by international non-governmental organizations in health (INGO, private) and the ministry of health (MOH, public). Results of the survey have been analyzed only descriptively and no statistical evaluations have been performed. Results out of the valid 109 responses obtained 55.1% were from MOH cadres and 45.0% from INGO cadres. Most have been in the health sector for more than 5 years. Most of the respondents recognize that INGOs assist the government in strengthening the health system (71.6%), see the internal brain drain to INGOs and salary scale difference as major problems (70.6% and 78.0%); 87.2% reported that the coordination between INGOs and government needs to be improved. MOH cadres perceived the migration of cadres to INGOs and the need for improving coordination as major issues more acutely than their INGO counterparts (80.0% vs. 59.2% and 88.3% vs. 85.7% respectively). INGOs were perceived to offer better quality health services by 51.4% of respondents (of these 69.4% were INGO respondents). The quality of health services was alike between INGOs and MOH for 33% of the respondents. Conclusion through the various efforts outlined the MOH and INGOs are moving towards an environment of mutual accountability, joint planning and coordination as well as harmonization of activities; but there are still challenges to be addressed. Prioritization and increased funding of the planning unit and planning and cooperation directorate as well as strategies for workforce retention are urgently needed.
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Affiliation(s)
- Isabelle Munyangaju
- Tinpswalo Association, Vicentian Association to Fight AIDS and Tuberculosis, Gaza, Mozambique
| | | | | | - Elisa Marchetti
- GlaxoSmithKline (GSK) Vaccines Institute for Global Health, Siena, Italy
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Silva CA, Trindade VC, Abel RCD, Silva MO, Santos JFV, Koch VHK, Ferrer APS, Brentani A, Odone-Filho V, Tannuri U, Carvalho WB, Carneiro-Sampaio M, Grisi SJFE. PEDIATRICIANS AFTER RESIDENCY: A SURVEY OF PERSONAL/PROFESSIONAL DATA AND ISSUES. REVISTA PAULISTA DE PEDIATRIA 2020; 39:e2019190. [PMID: 32756760 PMCID: PMC7401498 DOI: 10.1590/1984-0462/2021/39/2019190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/02/2019] [Indexed: 05/30/2023]
Abstract
Objective: To assess personal, professional, medical, and scientific educational
characteristics and issues reported by pediatricians. Methods: Cross-sectional study based on an online survey including 614 pediatricians
who graduated in the last 15 years at a University Pediatric Department in
Brazil. Results: The response rate was 331/614(54%). The majority were females (82%), the
median age was 33 years (27-40) and median years of pediatric practice was 5
(1-13). High workload (>60 hours/week) occurred in 25% and 47% earned ≥15
minimum wages/month. The most work-related issues reported were long working
hours, poor social life and a sedentary lifestyle (>50%). Pediatricians
were further divided into two groups, according to years of pediatric
clinical practice: group 1 (≤5 years) and group 2 (>5 years). The median
of overall satisfaction with pediatric residency [8(0-10) vs. 9 (4-10);
p=0.002] was significantly reduced in group 1. The frequencies of workload
>60 hours, work on pediatric ward and pediatric intensive care were
significantly higher in the first group (p<0.05). Regarding main issues
related to clinical practice in the last year, long working hours (73 vs.
53%; p<0.001), poor social life (75 vs. 62%; p=0.018) and harassment (23
vs. 4%; p=0.003) were significantly higher in the first group. Conclusions: Very early career pediatricians (≤5 years) reported higher workload, lower
income, work-related issues and different location of pediatric practice
compared to early career pediatricians (>5 years). The overall
satisfaction with pediatric residency was good, however, reduced in very
early career pediatricians.
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Miotto BA, Guilloux AGA, Cassenote AJF, Mainardi GM, Russo G, Scheffer MC. Physician's sociodemographic profile and distribution across public and private health care: an insight into physicians' dual practice in Brazil. BMC Health Serv Res 2018; 18:299. [PMID: 29688856 PMCID: PMC5914025 DOI: 10.1186/s12913-018-3076-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 03/28/2018] [Indexed: 11/16/2022] Open
Abstract
Background The intertwined relation between public and private care in Brazil is reshaping the medical profession, possibly affecting the distribution and profile of the country’s medical workforce. Physicians’ simultaneous engagement in public and private services is a common and unregulated practice in Brazil, but the influence played by contextual factors and personal characteristics over dual practice engagement are still poorly understood. This study aimed at exploring the sociodemographic profile of Brazilian physicians to shed light on the links between their personal characteristics and their distribution across public and private services. Methods A nation-wide cross-sectional study using primary data was conducted in 2014. A representative sample size of 2400 physicians was calculated based on the National Council of Medicine database registries; telephone interviews were conducted to explore physicians’ sociodemographic characteristics and their engagement with public and private services. Results From the 2400 physicians included, 51.45% were currently working in both the public and private services, while 26.95% and 21.58% were working exclusively in the private and public sectors, respectively. Public sector physicians were found to be younger (PR 0.84 [0.68–0.89]; PR 0.47 [0.38–0.56]), less experienced (PR 0.78 [0.73–0.94]; PR 0.44 [0.36–0.53]) and predominantly female (PR 0.79 [0.71–0.88]; PR 0.68 [0.6–0.78]) when compared to dual and private practitioners; their income was substantially lower than those working exclusively for the private (PR 0.58 [0.48–0.69]) and mixed sectors (PR 0.31 [0.25–0.37]). Conversely, physicians from the private sector were found to be typically senior (PR 1.96 [1.58–2.43]), specialized (PR 1.29 [1.17–1.42]) and male (PR 1.35 [1.21–1.51]), often working less than 20 h per week (PR 2.04 [1.4–2.96]). Dual practitioners were mostly middle-aged (PR 1.3 [1.16–1.45]), male specialists with 10 to 30 years of medical practice (PR 1.23 [1.11–1.37]). Conclusion The study shows that more than half of Brazilian physicians currently engage with dual practice, while only one fifth dedicate exclusively to public services, highlighting also substantial differences in socio-demographic and work-related characteristics between public, private and dual-practitioners. These results are consistent with the international literature suggesting that physicians’ sociodemographic characteristics can help predict dual practice forms and prevalence in a country. Electronic supplementary material The online version of this article (10.1186/s12913-018-3076-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bruno Alonso Miotto
- Department of Preventive Medicine, Faculdade de Medicina, Universidade de São Paulo, Doutor Arnaldo Avenue, nº 455, São Paulo, SP, 01246-903, Brazil.
| | - Aline Gil Alves Guilloux
- Department of Preventive Medicine, Faculdade de Medicina, Universidade de São Paulo, Doutor Arnaldo Avenue, nº 455, São Paulo, SP, 01246-903, Brazil
| | - Alex Jones Flores Cassenote
- Department of Preventive Medicine, Faculdade de Medicina, Universidade de São Paulo, Doutor Arnaldo Avenue, nº 455, São Paulo, SP, 01246-903, Brazil
| | - Giulia Marcelino Mainardi
- Department of Preventive Medicine, Faculdade de Medicina, Universidade de São Paulo, Doutor Arnaldo Avenue, nº 455, São Paulo, SP, 01246-903, Brazil
| | - Giuliano Russo
- Centre for Primary Care and Public Health, Queen Mary University of London, 58 Turner Street, London, E1 2AB, UK
| | - Mário César Scheffer
- Department of Preventive Medicine, Faculdade de Medicina, Universidade de São Paulo, Doutor Arnaldo Avenue, nº 455, São Paulo, SP, 01246-903, Brazil
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El Koussa M, Atun R, Bowser D, Kruk ME. Factors influencing physicians' choice of workplace: systematic review of drivers of attrition and policy interventions to address them. J Glob Health 2017; 6:020403. [PMID: 27648254 PMCID: PMC5017032 DOI: 10.7189/jogh.06.020403] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Maria El Koussa
- Harvard T.H. Chan School of Public Health, Harvard University, Boston MA, USA
| | - Rifat Atun
- Harvard T.H. Chan School of Public Health, Harvard University, Boston MA, USA
| | - Diana Bowser
- Harvard T.H. Chan School of Public Health, Harvard University, Boston MA, USA; The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Margaret E Kruk
- Harvard T.H. Chan School of Public Health, Harvard University, Boston MA, USA
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Njuguna F, Martijn H, Langat S, Musimbi J, Muliro H, Skiles J, Vik T, Sitaresmi MN, van de Ven PM, Kaspers GJL, Mostert S. Factors influencing time to diagnosis and treatment among pediatric oncology patients in Kenya. Pediatr Hematol Oncol 2016; 33:186-99. [PMID: 27184775 DOI: 10.3109/08880018.2016.1169566] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Early diagnosis and start of treatment are fundamental goals in cancer care. This study determines the time lag and the factors that influence the time to diagnosis and start of treatment. Study participants were parents of childhood cancer patients diagnosed between August 2013 and July 2014 in a hospital in Kenya. Patient, physician, diagnosis, treatment, health care system, and total delay were explored using a questionnaire. Demographic and medical data were collected from the patients' medical records. Parents of 99 childhood cancer patients were interviewed (response rate: 80%). Median total delay was 102 (9-1021) days. Median patient delay (4 days) was significantly shorter than health care system delay (median 87 days; P < .001). Diagnosis delay (median 94 days) was significantly longer than treatment delay (median 6 days; P < .001). days. Lack of health insurance at diagnosis and use of alternative medicine before attending conventional health services were associated with a significantly longer patient delay (P = .041 and P = .017, respectively). The type of cancer had a significant effect on treatment delay (P = .020). The type of health facility attended affected only patient delay (P = .03). Gender, age at diagnosis, stage of disease, parents' education level or income, and distance from hospital did not have a significant effect on the length of any type of delay. Training on childhood cancer should be included in the curricula for medical training institutes. In-service workshops should be held for the health workers already working. Families must be obligated to get health insurance. Families should be encourage to attend conventional health facilities and informed on symptoms of cancer through mass media.
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Affiliation(s)
- F Njuguna
- a Department of Child Health and Pediatrics , Moi University , Eldoret , Kenya
| | - H Martijn
- b Department of Pediatric Oncology-Hematology, Doctor 2 Doctor Program , VU University Medical Center , Amsterdam , The Netherlands
| | - S Langat
- a Department of Child Health and Pediatrics , Moi University , Eldoret , Kenya
| | - J Musimbi
- a Department of Child Health and Pediatrics , Moi University , Eldoret , Kenya
| | - H Muliro
- a Department of Child Health and Pediatrics , Moi University , Eldoret , Kenya
| | - J Skiles
- c Division of Hemato-Oncology , Department of Pediatrics , Indiana University School of Medicine , Indianapolis , IN , USA
| | - T Vik
- c Division of Hemato-Oncology , Department of Pediatrics , Indiana University School of Medicine , Indianapolis , IN , USA
| | - M N Sitaresmi
- d Department of Pediatrics , Dr. Sardjito Hospital , Yogyakarta , Indonesia
| | - P M van de Ven
- e Department of Epidemiology and Biostatistics , VU University Medical Center , Amsterdam , The Netherlands
| | - G J L Kaspers
- b Department of Pediatric Oncology-Hematology, Doctor 2 Doctor Program , VU University Medical Center , Amsterdam , The Netherlands
| | - S Mostert
- b Department of Pediatric Oncology-Hematology, Doctor 2 Doctor Program , VU University Medical Center , Amsterdam , The Netherlands
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McPake B, Russo G, Hipgrave D, Hort K, Campbell J. Implications of dual practice for universal health coverage. Bull World Health Organ 2015; 94:142-6. [PMID: 26908963 PMCID: PMC4750430 DOI: 10.2471/blt.14.151894] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 11/04/2015] [Accepted: 11/04/2015] [Indexed: 11/02/2022] Open
Abstract
Making progress towards universal health coverage (UHC) requires that health workers are adequate in numbers, prepared for their jobs and motivated to perform. In establishing the best ways to develop the health workforce, relatively little attention has been paid to the trends and implications of dual practice - concurrent employment in public and private sectors. We review recent research on dual practice for its potential to guide staffing policies in relation to UHC. Many studies describe the characteristics and correlates of dual practice and speculate about impacts, but there is very little evidence that is directly relevant to policy-makers. No studies have evaluated the impact of policies on the characteristics of dual practice or implications for UHC. We address this lack and call for case studies of policy interventions on dual practice in different contexts. Such research requires investment in better data collection and greater determination on the part of researchers, research funding bodies and national research councils to overcome the difficulties of researching sensitive topics of health systems functions.
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Affiliation(s)
- Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - Giuliano Russo
- Instituto de Higiene e Medicina Tropical, Nova University of Lisbon, Rua da Junqueira 100, Lisbon, 1349-008, Portugal
| | | | - Krishna Hort
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
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Mukolo A, Cooil B, Victor B. The effects of utility evaluations, biomedical knowledge and modernization on intention to exclusively use biomedical health facilities among rural households in Mozambique. Soc Sci Med 2015; 138:225-33. [PMID: 26123881 DOI: 10.1016/j.socscimed.2015.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In resource-limited settings, the choice between utilizing biomedical health services and/or traditional healers is critical to the success of the public health mission. In the literature, this choice has been predicted to be influenced by three major factors: knowledge about biomedical etiologies; cultural modernization; and rational choice. The current study investigated all three of these predicted determinants, applying data from a general household survey conducted in 2010 in Zambézia Province of Mozambique involving 1045 randomly sampled rural households. Overall, more respondents (N = 802) intended to continue to supplement their biomedical healthcare with traditional healer services in comparison with those intending to utilize biomedical care exclusively (N = 243). The findings strongly supported the predicted association between rational utility (measured as satisfaction with the quality of service and results from past care) with the future intention to continue to supplement or utilize biomedical care exclusively. Odds of moving away from supplementation increase by a factor of 2.5 if the respondent reported seeing their condition improve under government/private biomedical care. Odds of staying with supplementation increase by a factor 3.1 if the respondent was satisfied with traditional care and a factor of 16 if the condition had improved under traditional care. Modernization variables (education, income, religion, and Portuguese language skills) were relevant and provided a significant component of the best scientific model. Amount of biomedical knowledge was not a significant predictor of choice. There was a small effect on choice from knowing the limitations of biomedical care. The findings have implications for public healthcare promotion activities in areas where biomedical care is introduced as an alternative to traditional healing.
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Affiliation(s)
- Abraham Mukolo
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, 2525 West End Avenue, Nashville, TN 37203, USA; Mental Health America of Middle Tennessee, 295 Plus Park Boulevard, Nashville, TN 37217, USA.
| | - Bruce Cooil
- Owen Graduate School of Management, Vanderbilt University, Nashville, TN 37201, USA
| | - Bart Victor
- Owen Graduate School of Management, Vanderbilt University, Nashville, TN 37201, USA
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Bonenberger M, Aikins M, Akweongo P, Bosch-Capblanch X, Wyss K. What Do District Health Managers in Ghana Use Their Working Time for? A Case Study of Three Districts. PLoS One 2015; 10:e0130633. [PMID: 26068907 PMCID: PMC4465977 DOI: 10.1371/journal.pone.0130633] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 05/21/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Ineffective district health management potentially impacts on health system performance and service delivery. However, little is known about district health managing practices and time allocation in resource-constrained health systems. Therefore, a time use study was conducted in order to understand current time use practices of district health managers in Ghana. METHODS All 21 district health managers working in three districts of the Eastern Region were included in the study and followed for a period of three months. Daily retrospective interviews about their time use were conducted, covering 1182 person-days of observation. Total time use of the sample population was assessed as well as time use stratified by managerial position. Differences of time use over time were also evaluated. RESULTS District health managers used most of their working time for data management (16.6%), attending workshops (12.3%), financial management (8.7%), training of staff (7.1%), drug and supply management (5.0%), and travelling (9.6%). The study found significant variations of time use across the managerial cadres as well as high weekly variations of time use impulsed mainly by a national vertical program. CONCLUSIONS District health managers in Ghana use substantial amounts of their working time in only few activities and vertical programs greatly influence their time use. Our findings suggest that efficiency gains are possible for district health managers. However, these are unlikely to be achieved without improvements within the general health system, as inefficiencies seem to be largely caused by external factors.
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Affiliation(s)
- Marc Bonenberger
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- * E-mail:
| | - Moses Aikins
- School of Public Health, University of Ghana, Legon, Ghana
| | | | - Xavier Bosch-Capblanch
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Kaspar Wyss
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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