Measuring inequalities in the distribution of the Fiji Health Workforce

'First of all, I need training': a qualitative study evaluating the Fiji community health worker training program

BACKGROUND

Fiji faces a growing burden of diseases and a significant emigration of health workers, heightening the role of community health workers (CHWs) in healthcare delivery. Effective training is crucial for CHWs to enhance their capacity and service quality. This study evaluates CHW training in Fiji, aiming to identify areas for improvement.

METHODS

A qualitative study was conducted, encompassing a review of national policies on CHW training, six focus group discussions, and interviews with CHWs and their supervisors across Fijian subdivisions. This study was collaboratively designed with Fiji's Ministry of Health and Medical Services (MOHMS). Data was transcribed, coded, and thematically analysed using the Community Health Workers Assessment and Improvement Matrix (CHW-AIM).

FINDINGS

While CHW training policies in Fiji are well-established, discrepancies exist between the policy and its implementation. Challenges include inconsistent training for new recruits, limited resources, and variability in training content and frequency of training across divisions, especially concerning noncommunicable disease (NCD) training.

INTERPRETATION

To enhance the CHW training program in Fiji, a restructuring and standardisation of both pre-service and in-service training is necessary, tailored to the needs of each division. Investment in ongoing capacity building, alongside the development and revision of training guidelines, particularly for managing NCD complications in the community, is crucial. Implementing these changes will enable CHWs in Fiji to be better equipped for providing essential community-based care.

Differences in regional distribution and inequality in health workforce allocation in hospitals and primary health centers in China: A longitudinal study

BACKGROUND

In 2009, China launched a new round of healthcare reform to provide households with secure, efficient, convenient, equitable and affordable healthcare services. Healthcare reform is underpinned by three critical pillars: the health workforce, funding, and infrastructure, with reform of the health workforce being particularly significant.

OBJECTIVE

This study analyses the disparities in regional distribution and the inequity of healthcare workforce allocation across hospitals and primary health centers in China over twelve years.

DESIGN

Retrospective longitudinal data from the National Health Statistics Yearbook 2011-2022 and National Statistical Yearbook in China from 2011 to 2022 were collected for analysis.

PARTICIPANTS

The focus was on hospitals and primary health centers, explicitly examining their health technician and nursing workforce.

METHODS

The research utilized four key indicators of the healthcare workforce to evaluate the distribution of health resources between hospitals and primary health centers. Furthermore, the Gini coefficient and Theil index were employed to assess the inequality in allocating the health workforce.

RESULTS

Between 2010 and 2021, there was a nationwide increase in the ratio of health workers per 1000 population in hospitals and primary health centers. It is noted that rural districts had higher ratios than urban districts in terms of the number of health technicians and nurses per 1000 population, whether in hospitals or primary health centers; western districts had higher ratios than eastern and central districts did. In the same year, at different levels of medical institutions, the Theil indices of health technicians and nurses in hospitals were lower than those in primary health centers in terms of both demographic and geographical dimensions. Regarding the allocation of the health workforce by population, the Gini coefficient remained below 0.3, while for geographical allocation, it exceeded 0.4.

CONCLUSIONS

This study analyzed the temporal trends and inequality of health-resource allocation at the hospital and primary health center levels in China, noting trends of improvements in the quantity and inequality in health workforce allocation from 2010 to 2021, suggesting the success of the government's efforts to advance healthcare reform since 2009. The allocation of health workforce based on population exhibits greater fairness compared to geographical distribution.

Are Doctors Equally Distributed Throughout the World?

Background

As the vital and scarce resource of the health system, physicians are responsible for treating patients and saving lives and the equitable distribution of physicians among the whole population is a prerequisite to achieving health for all. We aimed to investigate inequality in physician distribution in the world using the Gini coefficient.

Methods

This descriptive-analytical study was conducted in 2021. The number of physicians and the population of countries were obtained from the WHO and United Nations (UN) databases. The Gini coefficient was calculated in three different modes and the distribution of physicians among countries in various Human Development Index (HDI) groups was determined using the physician ratio per 10,000 population.

Results

There were generally more than 13 million doctors in the world. About 43% of the world's physicians were available to 20% of the world's population in very high HDI countries, and 12% of the population had access to about 1% of physicians in low HDI countries. An average of 19.5 physicians are distributed per 10,000 population worldwide. The Gini coefficient between the four groups of HDI countries was 0.55, and that of all countries in the world was 0.640.

Conclusion

There was a shortage and inequality in the distribution of physicians worldwide. Governments should eliminate inequality in the distribution of the medical workforce, in particular physicians, by redoubling their efforts and accurate planning.

Distribution of nursing workforce in the world using Gini coefficient

INTRODUCTION

Unequal Access to human resources for health, reduces access to healthcare services, worsens the quality of services and reduces health outcomes. This study aims to investigate the distribution of the nursing workforce around the world.

METHODS

This is a descriptive-analytical study, which was conducted in 2021. The number of nurses and world populations was gathered from World Health Organization (WHO) and The United Nations (UN) databases. The UN has divided world countries based on the Human Development Index (HDI) into four categories of very high, high, medium and low HDI. To investigate the distribution of the nurses around the world, we used the nurse population ratio (per 10,000 population), Gini coefficient, Lorenz curve and Pareto curve.

FINDINGS

On average, there were 38.6 nurses for every 10,000 people in the world. Nations with the very high HDI, had the highest nurse/population ratio (95/10,000), while the low HDI nations had the lowest nurse/population ratio (7/10,000). Most nurses around the world were females (76.91%) who were in the age group of 35-44 (29.1%). The Gini coefficient of nations in the each four HDI categories varied from 0.217 to 0.283. The Gini coefficient of the nations between the four HDI categories was 0.467, and the Gini coefficient of the whole world was 0.667.

CONCLUSION

There were inequalities between countries all over the world. Policymakers should focus on the equitable distribution of the nursing workforce across all local, national and regional levels.

"We are the ones who will have to make the change": Cuban health cooperation and the integration of Cuban medical graduates into practice in the Pacific

BACKGROUND

This paper responds to Asante et al. (in Hum Resour Health, 2014), providing an updated picture of the impacts of Cuban medical training in the Pacific region based on research carried out in 2019-2021, which focused on the experiences of Pacific Island doctors trained in Cuba and their integration into practice in their home countries.

METHODS

The research focussed on two case studies-Solomon Islands and Kiribati. Study methods for this research included multi-sited ethnographic methods and semi-structured interviews as well as qualitative analysis of policy documents, reports, and media sources.

RESULTS

The Cuban health assistance programme has had a significant impact on the medical workforce in the Pacific region increasing the number of doctors employed by Pacific Ministries of Health between 2012 and 2019. Qualitatively, there have been some notable improvements in the medical workforce and health delivery over this period. However, the integration of the Cuban-trained doctors into practise has been challenging, with criticisms of their clinical, procedural and communication skills, and the need for the rapid development of bridging and internship training programmes (ITPs) which were inadequately planned for at the outset of the programme.

CONCLUSIONS

The Cuban programme in the Pacific is an important model of development assistance for health in the region. While Cuba's offer of scholarships was the trigger for a range of positive outcomes, the success of the programme has relied on input from a range of actors including support from other governments and institutions, and much hard work by the graduates themselves, often in the face of considerable criticism. Key impacts of the programme to date include the raw increase in the number of doctors and the development of the ITPs and career pathways for the graduates, although this has also led to the reorientation of Cuban graduates from preventative to curative health. There is considerable potential for these graduates to contribute to improved health outcomes across the region, particularly if their primary and preventative health care skills are utilised.

Understanding the relationship between the public sector healthcare workers and NGO-based HIV counsellors while providing HIV counselling and testing services to pregnant women: A Qualitative Study in Suva, Fiji

Human immunodeficiency virus (HIV) counselling and testing plays a significant role in the prevention of mother-to-child transmission of HIV. HIV counselling and testing during pregnancy is an essential gateway for HIV prevention, timely treatment, and care services. Lack of proper counselling could jeopardise the quality of services. This paper aims to understand the relationship between the government employed hospital healthcare workers and the Non-Governmental Organisation based counsellors while providing HIV counselling and testing services to pregnant women attending antenatal clinic in one of the main hospitals in Suva, Fiji. Data were collected via individual, in-depth, interviews held in a single hospital and an associated reproductive health centre in Suva in April-May 2013. A total of 15 healthcare providers including doctors (n = 4), midwives (n = 5), nurses (n = 4), and counsellors (n = 2) were interviewed. The data were analysed using thematic analysis. Ethical approvals were obtained. We found that there was tension between the government employed hospital healthcare workers and the Non-Governmental Organisation based counsellors involved in the provision of HIV counselling and testing services to pregnant women. The predominant causes of tension were poor referral for HIV test counselling, long counselling time, lack of cooperation and conflict due to the differences in counselling approaches. Tension between the government employed hospital healthcare workers and the Non- Governmental Organisation based HIV counsellors appear to be the main challenge to effective provision of HIV test counselling services in the hospital. Ongoing tension between both groups could restrict healthcare workers abilities to provide quality HIV counselling services. Our findings would be useful in developing strategies to overcome tension amongst healthcare workers as it would be an imperative step in providing streamlined HIV counselling services to women attending antenatal clinic in Fiji.

Community Dynamics and Engagement Strategies in Establishing Demographic Development and Environmental Surveillance Systems: A Multi-Site Report from India

BACKGROUND

Six diverse Demographic Development and Environmental Surveillance System (DDESS) sites were established in urban slum, urban resettlement, peri-urban, rural, and tribal areas located in Northern, North-East, Eastern, and Southern regions of India from June 2020 to March 2022. Understanding the community dynamics and engaging people in the community is critically important in the process of establishing DDESS. We ascertained the barriers, challenges, and facilitators during the establishment of multiple DDESS sites across India.

METHODS

This was a cross-sectional descriptive mixed-methods study.

RESULTS

Multiple barriers and challenges encountered were reported in the process of community engagement (CE), such as geographical inaccessibility, language barriers, adverse weather, non-responsiveness due to perceived lack of individual benefit or financial gain, fear of contracting COVID-19, COVID-19 vaccine hesitancy, etc. Facilitators in the CE process were pre-existing links with the community, constitution of community advisory boards, community need assessment, concomitant delivery of outreach health services, and skill-building facilities.

CONCLUSION

Most community barriers in the development of DDESS sites in resource-limited settings can be overcome through a multipronged approach, including effective community engagement by focusing on demonstrating trust at the local level, enlisting community mobilization and support, utilizing pre-existing community linkages, initiating community diagnosis, and meeting perceived community health needs.

Measuring the Inequalities in the Distribution of Public Healthcare Resources by the HRDI (Health Resources Density Index): Data Analysis from 2010 to 2019

Background: In China, a developing country, the imbalance of development exists in different fields, and the inequalities in the distribution of healthcare services have garnered increasing attention. This study aimed to assess the healthcare services allocation and compare the latest distribution ratios of the essential healthcare indicators with the national requirement values announced by the government to research the level of healthcare development in China. Methods: Data were extracted from the Chinese Statistical Yearbook (2010–2019). The Healthcare Resource Density Index (HRDI) was used to evaluate equity in the demographic and geographical dimensions. The requirement values related to the ratio of doctors, nurses, and institution beds per thousand people were drawn from government documents. The data of healthcare serviceability indicators were compared with those requirements to check the situation of each province’s medical development. Results: From 2010 to 2018, there was a sustainable upward trend in government investment, however, a noticeable drop in the investment in northeast areas was seen. Although the HRDI of the institutions, beds, doctors, and nurses experienced some small fluctuations over the years, the developing areas in the middle-west areas had almost approached the level of developed east areas. There were only four provinces that met the requirements of the government in all three indicators (the ratio of institution beds, doctors, and nurses per thousand people). Conclusion: The equality of the distribution of healthcare services in China was unfair between the eastern and middle-western areas. The government launched the developing requirements and paid additional attention to narrowing the imbalance among different economic level regions to meet the needs of the local people. Although many provinces did not meet the requirements for medical resources in 2019, the distribution of healthcare services was approached relatively equitably countrywide.

Research on the Equity and Influencing Factors of Medical and Health Resources Allocation in the Context of COVID-19: A Case of Taiyuan, China

COVID-19 has killed millions of people worldwide. As a result, medical and health resources continue to be strained, posing a great threat to people’s safety and economic and social development. This paper built the index system of influencing factors of medical and health resources containing the economy, population and society, and then classified Taiyuan into three types of regions by cluster analysis. The Gini coefficient, Theil index and agglomeration degree were then used to analyze the spatial distribution of medical and health resources allocation, and its influencing factors were studied by grey relational analysis. It was found that the population allocation of medical and health resources in Taiyuan was better than area allocation. Population has the greatest influence on the allocation of medical and health resources, followed by society and the economy. The more developed the regional economy, the more diversified the main influencing factors, and the more adjustment and control choices of medical and health resources allocation. Suggestions for optimal allocation were put forward in order to fully utilize the limited medical and health resources, effectively respond to the epidemic needs, promote the sustainable development of resources, protect the health of residents, and improve social benefits.

Inequity in the Access to eHealth and Its Decomposition Case of Poland

The aim of this research is to analyze the disparities in the distribution of information and communication technologies and skills across geographically determined population groups and to identify the source of the inequity. Literature showed that the nature of e-Health has the potential to resolve health inequalities. However, its successful implementation depends on such factors as the accessibility of required technologies to all people, the existence of technical infrastructure as well as people having the necessary information and communication skills. Employment of the Theil index allowed us to measure and decompose the national inequality into both: between and within macro-regions differences. Data was collected from Statistics Poland. The results showed the existence of inequity and its drivers. The novelty of this research results from application of the Theil index in the field of eHealth and identification of the barrier in access to e-Health, which can be a basis for improvement in government policy.

Inequality trends in the distribution of healthcare human resources in eastern Iran

Background

Inequitable distribution of human resources in healthcare is one of the main obstacles to improve any health system. This study aimed to evaluate inequalities in the distribution of human resources in healthcare in South Khorasan Province, Iran.

Methods

We have investigated three types of health staff (i.e. nurses, general practitioners, and specialists) from 2013 to 2018. Data were collected from the annual reports of the Statistical Centre of Iran. The Gini coefficient and time trend regression were applied to measure the inequality.

Results

The distribution of specialists and general practitioners were the highest and lowest inequality, respectively. Inequalities in the distribution of nurses and specialists have decreased from 2013 to 2018, while the Gini coefficients of the general practitioners have increased from 0.31 to 0.38. According to the regression analysis, inequality in the distribution of nurses and specialists was decreasing over the time; however, the decline was only significant for specialists. While the coefficient B for general practitioners is positive, this indicates raised inequality, but the observed increase was not significant.

Conclusions

This study revealed that Iran, similar to several other low- and middle-income countries, is with faced the challenge of inequitable distribution of human resources in healthcare, which in turn indicates the necessity of reforms at national and regional levels to address inequalities in the distribution of healthcare human resources, particularly in South Khorasan Province. Hence, the main policy recommendation is to focus on continuous monitoring and evaluation of resource allocation in South Khorasan Province to reduce inequalities.

Regional inequalities and substitutability of health resources in the Czech Republic: a five methods of evaluation

BACKGROUND

An analysis of the regional distribution of health resources is one of the tools for evaluating equal geographic access to health care. The usual analytical approach to an assessment of regional differences is to evaluate each health resource separately. This is a sensible approach, because there may be systematic reasons for any differences, for example, higher salaries in urban areas. However, a separate evaluation of the regional distribution of health resource capacities may be misleading. We should evaluate all health resource capacities as a whole and consider the substitutability of resources.

OBJECTIVE

This study aims to measure regional inequalities in the Czech Republic with the help of alternative approaches to the evaluation of regional inequalities in the case of several substitutable health resources.

METHODS

Five alternative evaluation methods (models) are described and applied: the separate evaluation, expert model, market model, common weights model, and production frontier model.

RESULTS

The regional distribution of physicians and nurses in the Czech Republic in 2017 was evaluated. In spite of many regulations at the national and regional levels, we have found inequalities in regional resource distribution. The models that consider all health resources and the possibility of a resource substitution show lower inequalities between regional health resource capacities.

CONCLUSION

Both researchers and policy-makers should always consider the possibility of resource substitutions in the assessment of regional inequalities.

Trends in mortality and life expectancy in Fiji over 20 years

BACKGROUND

Fiji, a Pacific Island nation of 884,887 (2017 census), has experienced a prolonged epidemiological transition. This study examines trends in mortality and life expectancy (LE) in Fiji by sex and ethnicity over 1996-2017, with comparisons to published estimates.

METHODS

Trends in infant mortality rates (IMR), under-5 mortality (U5M), adult mortality (probability of dying), LE (at birth) and directly age-standardised death rates (DASRs) by sex and ethnicity, are calculated (with 95% confidence limits) using unit death records from the Fiji Ministry of Health and Medical Services. The LE gap between populations, or within populations over time, is examined using decomposition by age. Period trends are assessed for statistical significance using linear regression.

RESULTS

Over 1996-98 to 2014-17: IMR and U5M for i-Taukei and Fijians of Indian descent declined; U5M decline for i-Taukei (24.6 to 20.1/1000 live births) was significant (p = 0.016). Mortality (15-59 years) for i-Taukei males was unchanged at 27% but declined for Indians 33 to 30% (p = 0.101). Mortality for i-Taukei females increased 22 to 24% (p = 0.011) but declined for Indians 20 to 18% (p = 0.240). DASRs 1996-2017 were lower for i-Taukei (9.3 to 8.2/1000 population) than Indian males (10.6 to 9.8/1000). DASRs declined for i-Taukei (both sexes, p < 0.05), and for Indians (both sexes, p > 0.05). Over 22 years, LE at birth increased by 1 year or less (p = 0.030 in male i-Taukei). In 2014-17, LE (years) for males was: i-Taukei 64.9, Indians 63.5; and females: i-Taukei 67.0 and Indians 68.2. Mortality changes in most 5-year age groups increased or decreased the LE gap less than 10 weeks over 22 years. Compared to international agency reports, 2014-17 empirical LE estimates (males 64.7, females 67.8) were lower, as was IMR.

CONCLUSIONS

Based on empirical data, LE in Fiji has minimally improved over 1996-2017, and is lower than some international agencies report. Adult mortality was higher in Indian than i-Taukei men, and higher in i-Taukei than Indian women. Exclusion of stillbirths resulted in IMRs lower than previously reported. Differing mortality trends in subgroups highlight the need to collect census and health data by ethnicity and sex, to monitor health outcomes and inform resource allocation.

From the Frontline: Strengthening Surveillance and Response Capacities of the Rural Workforce in the Asia-Pacific Region. How Can Grass-Roots Implementation Research Help?

Health systems in the Asia-Pacific region are poorly prepared for pandemic threats, particularly in rural/provincial areas. Yet future emerging infectious diseases are highly likely to emerge in these rural/provincial areas, due to high levels of contact between animals and humans (domestically and through agricultural activities), over-stretched and under-resourced health systems, notably within the health workforce, and a diverse array of socio-cultural determinants of health. In order to optimally implement health security measures at the frontline of health services where the people are served, it is vital to build capacity at the local district and facility level to adapt national and global guidelines to local contexts, including health systems, and community and socio-cultural realities. During 2017/18 James Cook University (JCU) facilitated an implementation research training program (funded by Australian Department of Foreign Affairs and Trade) for rural/provincial and regional health and biosecurity workers and managers from Fiji, Indonesia, Papua New Guinea (PNG), Solomon Islands and Timor-Leste. This training was designed so frontline health workers could learn research in their workplace, with no funding other than workplace resources, on topics relevant to health security in their local setting. The program, based upon the WHO-TDR Structured Operational Research and Training IniTiative (SORT-IT) consists of three blocks of teaching and a small, workplace-based research project. Over 50 projects by health workers including surveillance staff, laboratory managers, disease control officers, and border security staff included: analysis and mapping of surveillance data, infection control, IHR readiness, prevention/response and outbreak investigation. Policy briefs written by participants have informed local, provincial and national health managers, policy makers and development partners and provided on-the-ground recommendations for improved practice and training. These policy briefs reflected the socio-cultural, health system and disease-specific realities of each context. The information in the policy briefs can be used collectively to assess and strengthen health workforce capacity in rural/provincial areas. The capacity to use robust but simple research tools for formative and evaluative purposes provides sustainable capacity in the health system, particularly the rural health workforce. This capacity improves responses to infectious diseases threats and builds resilience into fragile health systems.

Community Orientation Scale among Community Health Nurses in Fiji: Scale development and psychometric evaluation

Aim

To develop and evaluate the reliability and validity of the COSCHN, a scale that aims to measure community orientation among community health nurses in Fiji.

Design

Descriptive cross-sectional design.

Methods

A self-administered questionnaire that included the 51 items in the preliminary COSCHN was distributed to community health nurses in Fiji from April-July 2016.

Results

Exploratory factor analysis of 226 responses (77.4% response rate) to the COSCHN revealed 30 items loading on four factors: Community Initiative Promotion, Consensus Building for Community Needs and Activity Goal, Commitment towards Work and Community Members and Mutually Trusting Relationships with Community Members towards Empowerment. Confirmatory factor analysis with high-order factor modelling revealed a reasonable fit to the data. Cronbach's α values for the COSCHN and the four factors ranged from 0.78-0.94. Weak correlations were noted for concurrent validity, while known-groups validity and time stability were generally satisfactory.

Inequality in the Distribution of Healthcare Human Resources in Poland

Human resources are the major input in health systems. Therefore, their equitable distribution remains critical in making progress towards the goal of sustainable development. The purpose of this study is to evaluate equity in the distribution of healthcare human resources across regions of Poland from 2010 to 2017. This research by applying specifically to Polish conditions will allow the existing gap in the literature to be closed. Data were derived from the Database of Statistics Poland, and the Lorenz Curve/Gini coefficient was engaged as well as the Theil index to measure the extent and drivers of inequality in the distribution of healthcare human resources in macro-regions. Population size along with crude death rates are employed as proxies for healthcare need/demand. This research has several major findings. Mainly, it was found, that the geographical distribution of all types of human resources is less equitable than is the case with population distribution. Relatively lower equity in the access to oncologists, family doctors, and cardiologists was found. There are some noticeable differences between macro-regions in the equity level of healthcare human resources distribution. This research provides various implications for policy and practice and will allow for improved planning and more efficient use of these resources.

Spatio-temporal variations of licensed doctor distribution in China: measuring and mapping disparities

BACKGROUND

The licensed doctor misdistribution is one of the major challenges faced by China. However, this subject remains underexplored as spatial distribution characteristics (such as spatial clustering patterns) have not been fully mapped out by existing studies. To fill the void, this study aims to explore the spatio-temporal dynamics and spatial clustering patterns of different subtypes of licensed doctors (i.e., clinicians, traditional Chinese medicine doctors, dentists, public health doctors, general practitioners) in China.

METHODS

Data on the licensed doctor quantity and population during 2012-2016 was obtained from the National Health (and Family Planning) Yearbook. Functional boxplots were used to visualize and compare the temporal trends of densities of different subtypes of licensed doctors. This study adopted two complementary spatial statistics (space-time scan statistics and Moran's I statistics) to explore the spatio-temporal dynamics and spatial clustering patterns of licensed doctor distribution in China. The former was used to explore the spatial variations in the temporal trends of licensed doctor density during 2012-2016, and the latter was adopted to explore the spatial changing patterns of licensed doctor distribution during the research period.

RESULTS

The results show that the densities of almost all subtypes of licensed doctors displayed upward trends during 2012-2016, though some provincial units were left behind. Besides, spatial distribution characteristics varied across different subtypes of licensed doctors, with the low-low cluster area of general practitioners being the largest.

CONCLUSIONS

The misdistribution of licensed doctors is a global problem and China is no exception. In order to achieve a balanced distribution of licensed doctors, the government is suggested to introduce a series of measures, such as deliberative policy design and effective human resource management initiatives to educate, recruit, and retain licensed doctors and prevent a brain drain of licensed doctors from disadvantaged units.

Comparing Regional Distribution Equity among Doctors in China before and after the 2009 Medical Reform Policy: A Data Analysis from 2002 to 2017

Background: Although China began implementing medical reforms in 2009 aimed at fair allocation of the regional distribution of doctors, little is known of their impact. This study analyzed the geographic distribution of doctors from 2002 to 2017. Methods: This study calculated the Gini coefficient and Theil index among doctors in the eastern, central, and western regions (Category 1) of China, and in urban and rural areas (Category 2). The statistical significance of fairness changes was analyzed using the Mann–Whitney U test. Results: The annual growth rates of the number of doctors for the periods from 2002 to 2009 and 2010 to 2017 were 2.38% and 4.44%. The Gini coefficients among Category 1 were lower than those in Category 2, and statistically decreased after the medical reforms (P < 0.01) but continued to increase in Category 2 (P = 0.463). In 2017, the Theil decomposition result of Category 1 was 74.33% for the between-group, and in Category 2, it was 95.22% for the within-group. Conclusions: The fairness among the regional distribution of doctors in Category 1 is now at a high level and is better than that before the reforms. While the fairness in Category 2 is worse than that before the reforms, it causes moderate inequality and is continually decreasing. Overall unfairness was found to be derived from the between-group.

End-stage kidney disease in Fiji

BACKGROUND

Chronic kidney disease is now a leading cause of death in Fiji. The country lacks even basic statistics about the incidence of end-stage kidney disease (ESKD) and presents significant challenges to conducting clinical research.

AIM

To estimate the incidence and characteristics of ESKD in Fijian adults.

METHODS

A retrospective cohort study was conducted of patients admitted to Colonial War Memorial Hospital in Suva, Fiji, in 2012. Suspected ESKD cases were identified from laboratory registers of renal function tests and confirmed through medical record review. Population data were from the Fijian Bureau of Statistics.

RESULTS

Screening identified 1474 suspected ESKD cases. Following removal of 763 duplicates and cases with discrepant identifiers, 711 unique cases remained. An additional 552 cases met exclusion criteria, including acute kidney injury (247), failure to be admitted (131) and pre-existing ESKD diagnosis (103), leaving 159 cases of confirmed ESKD. Median age was 57 years (interquartile range 47-65). Crude and age-adjusted ESKD incidence rates were 753 per million population (pmp) (95% confidence interval (CI) 636-870) and 793 pmp (95% CI 669-916), respectively, rising to 938 pmp (95% CI 804-1072) if African-American correction was removed. Diabetic nephropathy was the most common cause of ESKD (65.4%).

CONCLUSION

The incidence of ESKD in Fiji is high. This is a substantial public health problem that is likely impacting life expectancy and quality of life. Improving screening, detection and management of kidney disease should be given more prominence in programmes to address non-communicable diseases in Fiji and the Western Pacific.

Measuring inequalities in the public health workforce at county-level Centers for Disease Control and Prevention in China

Background

The public health workforce (PHW) is a key component of a country’s public health system. Since the outbreak of SARS (severe acute respiratory syndrome) in 2003, the scale of PHW in China has been continuously expanding, but policymakers and researchers still focus on the distribution of public health personnel, especially the regional inequality in such distribution. We aimed to identify the root cause of PHW inequality by decomposing different geographical units in China.

Methods

This study was based on data from a nationwide survey, which included 2712 county-level data. The distribution of the PHW in geographical units was evaluated by the Gini coefficient and Theil T index, and inequalities at regional, provincial, and municipal levels were decomposed to identify the root causes of inequalities in the PHW. Additionally, the contextual factors affecting the distribution of the PHW were determined through regression analysis.

Results

The overall inequality results show that health professional and field epidemiological investigators faced worse inequality than the staff. In particular, field epidemiological investigators had a Gini coefficient close to 0.4. Step decomposition showed that within-region inequalities accounted for 98.5% or more of overall inter-county inequality in the distribution of all PHW categories; provincial decomposition showed that at least 74% of inequality is still distributed within provinces; the overall contribution of within-municipal inequality and between-municipal inequality was basically the same. Further, the contextual factor that influenced between-municipality and within-municipality inequality for all three categories of PHWs was the agency building area per employee. Per capita GDP had a similar effect, except for between-municipality inequality of professionals and within-municipality inequality of field epidemiological investigators.

Conclusions

The successive decomposition showed that inequality is mainly concentrated in counties at the within-province and within-municipal levels. This study clearly suggests that the government, especially the municipal government at the provincial level, should increase financial investment in Centers for Disease Control and Prevention (CDCs) with worse resource allocation in their jurisdiction through various ways of compensation and incentives, enhance their infrastructure, and improve the salary of personnel in these institutions, to attract more public health professionals to these institutions.

Identifying characteristic features of community orientation among community health nurses in Fiji

AIM

The present study aimed to identify detailed characteristics of community orientation among community health nurses in Fiji.

DESIGN

Qualitative descriptive design using semi-structured individual interviews.

METHODS

Twenty participants including expert nurses, novice nurses, policymakers and representatives from communities were interviewed between July-August 2015 in Fiji. Data were analysed using descriptive qualitative methods.

RESULTS

Three main themes described in detail characteristics of community orientation among community health nurses in Fiji: Trusting Relationships, Commitment and Activity Management. Trusting Relationships and Commitment were interrelated and served as foundations for community orientation that promoted and facilitated Activity Management. Reflection and a sense of self-accomplishment in the CHN experiences during Activity Management further strengthened Commitment and Trusting Relationships. Community orientation leads to superior understanding of community health needs, effective use of resources and increased community participation in activities. Such activity management will contribute to promote health beyond the individual, extending to entire communities.

Availability and inequality in accessibility of health centre-based primary healthcare in Ethiopia

Background

Achieving fair access to healthcare and improving population health are crucial in all settings. Properly staffed and fairly distributed primary health care (PHC) facilities are prerequisites to ensure accessible healthcare services. Nevertheless, availability and accessibility issues are common public health concerns, especially in under-resourced countries including Ethiopia. Measuring inequalities in accessibility of healthcare resources guide policy decisions to improve PHC services and ultimately achieving universal health coverage (UHC).

Purpose

To assess availability and measure magnitude and trend of inequalities in accessibility of health centre-based PHC resources in Ethiopia during 2015 to 2017.

Methods

We conducted a cross-sectional population-based analysis of district-level data collected from 16^th December 2017 until 24^th May 2018. Afar, Dire-Dawa, and Tigray regions were purposefully included in the study to represent the four pastoralist/semi-pastoralist, three urban and four agrarian regions in Ethiopia, respectively. We used ratios, different inequality indices and Gini decomposition techniques to characterise the inequalities.

Results

In 2017, median of health centres (HCs) per 15,000 inhabitants and their Gini indices (GIs) for Afar, Dire-Dawa, and Tigray were 0.781, 0.566, 0.591 vs. 0.237, 0.280, 0.216 respectively. Median overall skilled health workers (SHWs) per 10,000 inhabitants were 5.250, 7.539, and 6.246, respectively. These accounted for 11.80%, 16.94% and 14.04% of the WHO target of 44.5 to achieve SDGs. The corresponding GIs for the regions were 0.347, 0.186 and 0.175. Despite a higher overall SHWs inequality in the urban districts of Tigray (GI = 0.301), only Tigray showed significant inequality reductions in GHE (p < 0.001) and in all categories of SHWs (p < 0.05).

Conclusions

Our analysis provided a clear picture of availability and inequalities in PHC resources across three regions in Ethiopia. Identifying contributing factors to low densities and high inequalities of SHWs may help improve PHC services nationwide, along with pathway towards UHC.

Inequalities in healthcare resources and outcomes threatening sustainable health development in Ethiopia: panel data analysis

OBJECTIVE

To measure inequalities in the distributions of selected healthcare resources and outcomes in Ethiopia from 2000 to 2015.

DESIGN

A panel data analysis was performed to measure inequalities in distribution of healthcare workforce, infrastructure, outcomes and finance, using secondary data.

SETTING

The study was conducted across 11 regions in Ethiopia.

PARTICIPANTS

Regional population and selected healthcare workforce.

OUTCOMES MEASURED

Aggregate Theil and Gini indices, changes in inequalities and elasticity of healthcare resources.

RESULTS

Despite marked inequality reductions over a 16 year period, the Theil and Gini indices for the healthcare resources distributions remained high. Among the healthcare workforce distributions, the Gini index (GI) was lowest for nurses plus midwives (GI=0.428, 95% CI 0.393 to 0.463) and highest for specialist doctors (SPDs) (GI=0.704, 95% CI 0.652 to 0.756). Inter-region inequality was the highest for SPDs (95.0%) and the lowest for health officers (53.8%). The GIs for hospital beds, hospitals and health centres (HCs) were 0.592(95% CI 0.563 to 0.621), 0.460(95% CI 0.404 to 0.517) and 0.409(95% CI 0.380 to 0.439), respectively. The interaction term was highest for HC distributions (47.7%). Outpatient department visit per capita (GI=0.349, 95% CI 0.321 to 0.377) and fully immunised children (GI=0.307, 95% CI 0.269 to 0.345) showed inequalities; inequality in the under 5 years of age mortality rate increased overtime (P=0.048). Overall, GI for government health expenditure (GHE) was 0.596(95% CI 0.544 to 0.648), and the estimated relative GHE share of the healthcare workforce and infrastructure distributions were 46.5% and 53.5%, respectively. The marginal changes in the healthcare resources distributions were towards the advantaged populations.

CONCLUSION

This study revealed high inequalities in healthcare resources in favour of the advantaged populations which can hinder equal access to healthcare and the achievements of healthcare outcomes. The government should strengthen monitoring mechanisms to address inequalities based on the national healthcare standards.

Inequality trends in the demographic and geographic distribution of health care professionals in China: Data from 2002 to 2016

China has long been negatively affected by a shortage and maldistribution of health workers. This study aimed to examine the national and regional trends in the demographic and geographic distribution inequality of health care professionals in China from 2002 to 2016. Based on data from the China Health and Family Planning Statistical and China Statistical Yearbooks, we calculated the Gini coefficient and the Theil T and Theil L indices based on the number of health care professionals per capita and per geographic area to measure the inequalities in their demographic and geographic distribution, respectively. The contributions by intra-regional and inter-regional differences on total inequality were explored within and among East, Central, and West China via Theil index decomposition. We found that the national demographic distribution of health care professionals maintained in an absolute equality level, and the inequality indices decreased gradually, whereas the corresponding geographic inequalities were severe and presented a worsening trend. Compared with nurses, physicians not only maintained higher densities but also maintained a more equal distribution. Intra-regional disparities within the east, central, and western regions were the main cause for overall demographic inequality, whereas both intra-regional and inter-regional disparities significantly contributed to overall geographic inequality. To conclude, the distribution equality of health care professionals by population was satisfactory, whereas the corresponding distribution inequality by area was severe. Different types of distribution inequality of health care professionals existed regionally and nationally despite their increasing quantities and densities. Factors beyond population size should be considered when the government introduces health workforce allocation policies.

Measuring inequalities in the demographical and geographical distribution of physicians in China: Generalist versus specialist

OBJECTIVE

The equitable distribution of both generalist and specialist physicians is vital in establishing a fair and efficient health care system. The presents study aims at comparatively measuring the demographical and geographical distribution of generalist and specialist physicians in China from 2012 to 2016.

METHODS

The data were obtained from China Health and Family Planning Statistics and China Statistical Yearbooks 2013 to 2017. Descriptive statistical methods were used to address the quantity and density of physicians, and Gini coefficient was adopted as inequality indicator to trace their distribution inequalities.

RESULTS

The quantity and density of total physicians, generalist, and specialist physicians increased during the last 5 years. The demographic distribution inequalities of total physicians, generalist, and specialist physicians are decent with Gini coefficients of approximately 0.3, whereas the corresponding geographical distribution inequalities are severe with Gini coefficients higher than 0.6. Compared with generalist physicians, specialist physicians not only had a higher geographical and geographical density but also maintained a more equitable distribution.

CONCLUSION

The present study compares the distribution inequalities between generalist and specialist physicians in China for the first time. Despite the rapid increase in quantity and density of these physicians, the whole nation faces a severe shortage and maldistribution of generalist physicians. The increase in the number of physicians has not necessarily eliminated the geographical distribution inequalities. The government should consider all influencing factors when allocating health workers and continue promoting the development of primary health care to alleviate these inequalities in physician distribution.