Understanding the factors affecting the attraction and retention of health professionals in rural and remote areas: a mixed-method study in Niger

Challenges in reducing maternal and neonatal mortality in Niger: an in-depth case study

INTRODUCTION

Recent modelled estimates suggest that Niger made progress in maternal mortality since 2000. However, neonatal mortality has not declined since 2012 and maternal mortality estimates were based on limited data. We researched the drivers of progress and challenges.

METHODS

We reviewed two decades of health policies, analysed mortality trends from United Nations data and six national household surveys between 1998 and 2021 and assessed coverage and inequalities of maternal and newborn health indicators. Quality of care was evaluated from health facility surveys in 2015 and 2019 and emergency obstetric assessments in 2011 and 2017. We determined the impact of intervention coverage on maternal and neonatal lives saved between 2000 and 2020. We interviewed 31 key informants to understand the factors underpinning policy implementation.

RESULTS

Empirical maternal mortality ratio declined from 709 to 520 per 100 000 live births during 2000-2011, while neonatal mortality rate declined from 46 to 23 per 1000 live births during 2000-2012 then increased to 43 in 2018. Inequalities in neonatal mortality were reduced across socioeconomic and demographic strata. Key maternal and newborn health indicators improved over 2000-2012, except for caesarean sections, although the overall levels were low. Interventions delivered during childbirth saved most maternal and newborn lives. Progress came from health centre expansion, emergency care and the 2006 fee exemptions policy. During the past decade, challenges included expansion of emergency care, continued high fertility, security issues, financing and health workforce. Social determinants saw minimal change.

CONCLUSIONS

Niger reduced maternal and neonatal mortality during 2000-2012, but progress has stalled. Further reductions require strategies targeting comprehensive care, referrals, quality of care, fertility reduction, social determinants and improved security nationwide.

Quality of antenatal care in 13 sub-Saharan African countries in the SDG era: evidence from Demographic and Health Surveys

BACKGROUND

Maternal and neonatal mortality remains high in sub-Saharan Africa (SSA) with women having 1 in 36 lifetime risk. The WHO launched the new comprehensive recommendations/guidelines on antenatal care (ANC) in 2016, which stresses the essence of quality antenatal care. Consequently, the objective of this cross-sectional study is to investigate the quality of ANC in 13 SSA countries.

METHODS

This is a cross-sectional study that is premised on pre-existing secondary data, spanning 2015 to 2021. Data for the study was obtained from the Measure DHS Programme and included a total of 79,725 women aged 15-49 were included. The outcome variable was quality ANC and it was derived as a composite variable from four main ANC services: blood pressure taken, urine taken, receipt of iron supplementation and blood sample taken. Thirteen independent variables were included and broadly categorised into individual and community-level characteristics. Descriptive statistics were used to present the proportion of women who had quality ANC across the respective countries. A two-level multilevel regression analysis was conducted to ascertain the direction of association between quality ANC and the independent variables.

RESULTS

The overall average of women who had quality ANC was 53.8% [CI = 51.2,57.5] spanning from 82.3% [CI = 80.6,85.3] in Cameroon to 11% [CI = 10.0, 11.4] in Burundi. Women with secondary/higher education had higher odds of obtaining quality ANC compared with those without formal education [aOR = 1.23, Credible Interval [Crl] = 1.10,1.37]. Poorest women were more likely to have quality ANC relative to the richest women [aOR = 1.21, Crl = 1.14,1.27]. Married women were more likely to receive quality ANC relative to those cohabiting [aOR = 2.04, Crl = 1.94,3.05]. Women who had four or more ANC visits had higher odds of quality ANC [aOR = 2.21, Crl = 2.04,2.38]. Variation existed in receipt of quality ANC at the community-level [σ2 = 0.29, Crl = 0.24,0.33]. The findings also indicated that a 36.2% variation in quality ANC is attributable to community-level factors.

CONCLUSION

To achieve significant improvement in the coverage of quality ANC, the focus of maternal health interventions ought to prioritise uneducated women, those cohabiting, and those who are unable to have at least four ANCs. Further, ample recognition should be accorded to the existing and potential facilitators and barriers to quality ANC across and within countries.

Health inequalities in the geographic distribution of dental practitioners in Costa Rica: An ecological study

OBJECTIVE

The uneven distribution of dental health services in a territory can cause an imbalance in accessibility, increasing health inequalities. This study aimed to describe the geographical distribution of dental health practitioners according to urbanicity and area-level socio-economic status in Costa Rica.

METHODS

A National Dentist Survey was developed to identify employment status, number of working hours, address and list of the working clinics. Data was completed using information from the national College of Surgeons, including all Costa Rican dentists. The Minimal Geographic Units (MGU) allowed for aggregating the population's individual level socio-economic position. Local Potential Accessibility (LPA) calculated the density of full-time hour's equivalents around each MGU using floating sectors. Clinics were geocoded using Geographic Information Systems, creating 2853 clinical points. Distance between each MGU and the nearest accessible clinics considering full-time working hours equivalents was estimated. MGU were divided into six categories: 'No accessibility', 'Very low accessibility', 'Low accessibility', 'Good accessibility' 'High accessibility' and 'Very high accessibility'.

RESULTS

Mean national LPA was 6.5 full-time equivalents per 10 000 inhabitants, 3.4% of the Costa Rican population had no access to dentist; 12.9% had very low accessibility, 22.7% had low accessibility, 35.0% had good accessibility, 16.2% had high accessibility, and 9.8% had very high accessibility. Overall, 39% of the population has a rather low accessibility. LPA was higher in urban districts compared to rural districts and in wealthiest districts compared to most disadvantaged districts. Within districts, after adjustment for district's characteristics, LPA was higher in urban MGU compared to rural MGU and in wealthiest MGU compared to most disadvantaged MGU.

CONCLUSIONS

This study found that despite having a high number of dentists, their numbers are small in many areas, increasing inequalities in access to health care. The dentist's free establishment, where they can decide to provide private services within a community, creates zones with very high densities, in particular in the wealthiest urban areas, and others with very low densities, in particular the poorest rural areas. The lack of territorial planning has been one of the reasons that has encouraged an imbalance in the availability of dental human resources. To achieve effective universal health coverage, public institutions should focus their efforts on improving access to dental services in underserved areas.

Factors associated with retention of health workers in remote public health centers in Northern Uganda: a cross-sectional study

BACKGROUND

Health worker retention in remote and hard-to-reach areas remains a threat in most low- and middle-income countries, and this negatively impacts health service delivery. The health workforce inequity is catastrophic for countries like Uganda that still has a low health worker to patient ratio, and remote areas like Lira District that is still recovering from a long-term civil war. This study explores factors associated with retention of health workers in remote public health centers in Lira district in Northern Uganda.

METHODS

A descriptive cross-sectional study with quantitative methods of data collection was used among health workers namely; doctors, clinical officers, nurses, midwives, pharmacists and, laboratory technicians. The study utilized a structured questionnaire with closed ended questions to obtain quantitative information.

RESULTS

Most of the respondents were females (62.90%), married (84.62%), with certificate level (55.74%), and nurses as qualification (36.60%) as well as attached to Health Center 3 level (61.28%). Significant individual factors associated with retention included having a certificate as highest level of education, staying with family, and working at facility for 6 or more years. The health system factors were good physical state of facility, equipment availability, availability of sundries, feeling comfortable with rotations, receiving adequate support from staff, feeling valued and respected by colleagues at workplace and access to incentives while career factors were job satisfaction, job motivation, promotion, and further training on scholarship.

CONCLUSION

The study established that indeed several individual and social demographics, health system and career-related factors are significantly associated with retention of Health workers in the rural public health facilities and these are critical policy recommendations for establishing retention guidelines in a national human resources for health manual.

Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll

BACKGROUND

Health worker (HW) retention in the public health sector in Uganda is an enduring health system constraint. Although previous studies have examined the retention of in-service HWs, there is little research focusing on donor-recruited HWs. The objective of this study was to explore drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll between 2015 and 2017.

METHODS

We conducted ten focus group discussions with HWs (n = 87) transitioned from PEPFAR support to the public sector payroll in 10 purposively selected districts across Uganda. In-depth interviews were conducted with national-level stakeholders (n = 17), district health and personnel officers (n = 15) and facility in-charges (n = 22). Data were analyzed by a hybrid approach of inductive and deductive thematic development based on the analytical framework by Schaefer and Moos regarding individual-level and organizational-context drivers.

RESULTS

At the individual level, job security in the public sector was the most compelling driver of health worker retention. Community embeddedness of HWs in the study districts, opportunities for professional development and career growth and the ability to secure salary loans due to 'permanent and pensionable' terms of employment and the opportunity to work in 'home districts', where they could serve their 'kinsmen' were identified as enablers. HWs with prior private sector backgrounds perceived public facilities as offering more desirable challenging professional work. Organizational context enablers identified include perceptions that public facilities had relaxed supervision regimes and more flexible work environments. Work environment barriers to long-term retention include frequent stock-out of essential commodities, heavy workloads, low pay and scarcity of rental accommodation, particularly in rural Northern Uganda. Compared to mid-cadres (such as nurses and midwives), higher calibre cadres, such as physicians, pharmacists and laboratory technologists, expressed a higher affinity for seeking alternative employment in the private sector in the immediate future.

CONCLUSIONS

Overall, job security was the most compelling driver of retention in public service for the health workforce transitioned from PEPFAR support to the Uganda government payroll. Monetary and non-monetary policy strategies are needed to enhance the retention of upper cadre HWs, particularly physicians, pharmacists and laboratory technologists in rural districts of Uganda.

Motivation and retention of primary healthcare workers in rural health facilities: An exploratory qualitative study of Chipata and Chadiza Districts, Zambia

Rural areas have the greatest health needs and yet they face the largest shortage of human resources for health which negatively impacts health systems capacity to deliver quality care as they struggle to motivate and retain healthcare workers in such settings. This study explored factors that shape motivation and retention of primary healthcare workers in rural health facilities in Chipata and Chadiza Districts of Zambia using a phenomenological research design. The data consisted 28 in-depth interviews with rural primary healthcare workers and were analysed using thematic analysis. Three main themes of factors shaping motivation and retention of rural primary healthcare workers were identified. Firstly, professional development with emergent themes of career advancement and opportunities for attending capacity-building workshops. Secondly, the work environment with emergent themes of challenging and stimulating tasks, availability of opportunities for promotion and co-workers' recognition and supportive relationships. Thirdly, rural community dynamics with emergent themes of reduced cost of living, community recognition and support, and easy access to farmland for economic and consumption purposes. Interventions that are contextually relavant, which can streamline career progression pathways, enhance rural working environments, offer suitable incentives, and rally community support for rural primary healthcare workers are required.

An Evaluation of Push and Pull Factors associated with the Emigration of Medical Consultants from Nigeria

Background

The health workforce of a nation is crucial to its economic productivity and development. In Nigeria, the emigration of healthcare professionals from the country has become alarming and is fueled by various factors. This study thus determined to study the push and pull factors encouraging the emigration of medical consultants from Nigeria as well as their perceptions of what can be done to retain Nigeria's health workforce in the country.

Methodology

An online survey of 238 consultants (fellows) of the West Africa College of Physicians, West Africa College of Surgeons, and the National Postgraduate Medical College of Nigeria under the auspices of the Medical and Dental Consultants Association of Nigeria (MDCAN) was conducted. A structured questionnaire was used as the instrument for data collection. The data were analyzed using the Statistical Package for Social Sciences (SPSS) version 23.

Results

Push factors promoting the emigration of doctors identified in this study included the occurrence of armed conflict (66.0%), the inadequacy of job opportunities (69.7%), poor remuneration (69.7%) as well as the need to improve professional skills (82.4%). Pull factors supporting the emigration of the doctors included the need for better prospects for their professional practice (65.1%) and their children (84.9%), better remuneration (87.4%), and the assurance of better security (76.1%). Availability of incentives (82.4%), as well as improved security (85.3%) among other factors, were identified as being effective in retaining Nigeria's health workforce.

Conclusion

The problem of doctors' emigration from Nigeria persists and is fueled by various factors that need to be addressed urgently for improving the retention of the country's health workforce. It is recommended that a holistic approach confronting issues of training, availability of an enabling environment as well as the professional progression of doctors be adopted in tackling this emigration problem.

Job Performance of Medical Graduates With Compulsory Services in Underserved Rural Areas in China: A Cohort Study

BACKGROUND

China started a national program in 2010 to train qualified general practitioners with compulsory services program (CSP) in rural and remote areas. While the program has shown positive effects on staffing primary healthcare (PHC) in rural areas, very little is known about how well they perform. This study aims to evaluate the job performance of medical graduates from this program and the influence of program design on job performance.

METHODS

A cohort study was conducted with graduates from CSP and non-CSP (NCSP) from four medical universities in central and western China. Baseline and three waves of follow-up surveys were conducted from 2015-2020. The pass rate of China National Medical Licensing Examinations (NMLE) and self-reported job performance were used as measurements. Multivariable regressions were used to identify factors affecting job performance.

RESULTS

2154 medical graduates were included, with 1586 CSP and 568 NCSP graduates. CSP (90.6%) and NCSP (87.5%) graduates showed no difference in passing the NMLE (P=.153). CSP graduates reported similar job performance with NCSP graduates (CSP, 63.7; NCSP, 64.2); in the multivariable regression, CSP graduates scored 0.32 and 1.36 points lower in the total sample and graduates of 2015-2017, respectively, but not significantly. Having formally funded positions improved the job performance of CSP (β coefficient=4.87, P<.05). After controlling for Qinghai which adopted a different contracting strategy, "working in hometown" showed significant influence on job performance (β coefficient = 1.48, P<.05).

CONCLUSION

CSP graduates have demonstrated as good job performance as NCSP, proving the competency to provide high-quality care for remote and rural areas. The contracted township health centers (THCs) should provide guidance for CSP graduates, especially in the first few years after graduation. The local government should provide formally funded positions on time and prioritize signing contracts with hometowns or places nearby.

Perceptions, Motivations, and Empowerment Strategies of Midwives in Rural and Remote Areas of Northern Morocco

The shortage of midwives is a problem in rural and remote areas. This is mainly the consequence of job insecurity and difficult living conditions. The present study aimed to identify and analyse the perceptions and motivations of midwives in rural and remote areas of northern Morocco on the quality of their working life and the motivational factors and empowerment strategies they use to maintain and develop their work. It is a qualitative study that follows Van Manen's hermeneutic phenomenology approach. Three focus groups and in-depth interviews were conducted with 15 midwives from rural and remote areas. The results indicate that midwives in rural and remote areas have a negative perception of the quality of the work and their personal life because of the scarcity of basic resources, unfavourable working conditions, and the personal sacrifices they have to make to support themselves. However, some factors favour their efforts. Therefore, there is a need to promote intersectoral policies that focus on improving material and human resources, as well as the working and personal conditions of midwives and the factors that support and empower them.

Commitments, Conditions and Corruption: An Interpretative Phenomenological Analysis of Physician Recruitment and Retention Experiences in Indonesia

Complex factors influence physicians’ decisions to remain in rural and remote (RR) practice. Indonesia, particularly, has various degrees of poor governance contributing to physicians’ decisions to stay or leave RR practice. However, there is a paucity of literature exploring the phenomenon from the perspective of Indonesian RR physicians. This study explores physicians’ lived experiences working and living in Indonesian RR areas and the motivations that underpin their decisions to remain in the RR settings. An interpretative phenomenological analysis was utilised to explore the experiences of 26 consenting voluntary participants currently working in the RR areas of Maluku Province. A focus group discussion was undertaken with post-interns (n = 7), and semi-structured interviews were undertaken with junior (n = 9) and senior physicians (n = 10) working in district hospitals and RR health centres. Corruption was identified as an overarching theme that was referred to in all of the derived themes. Corruption adversely affected physicians’ lives, work and careers and influenced their motivation to remain working in Indonesia’s RR districts. Addressing the RR workforce shortage requires political action to reduce corruptive practice in the districts’ governance. Establishing a partnership with regional medical schools could assist in implementing evidence-based strategies to improve workforce recruitment, development, and retention of the RR medical workforce.

Retention of dental practitioners in rural health services in Iran: Experiences from Kerman province

Background

In Iran, the inequitable distribution of health-care staff, especially dental practitioners between rural and urban areas has a major impact on the delivery of care for those living in rural communities. This study investigated the factors affecting the retention of dental practitioners to stay in the rural areas.

Materials and Methods

This is a cross-sectional study conducted in 2019. All dental practitioners working in health services centers covering a population lower than 20,000 people in Kerman province participated in this study (n = 81). A researcher-designed questionnaire was used for the data collection. The data were analyzed using the descriptive statistics and logistic regression through the SPSS software.

Results

The mean age of the participants was 29.2 ± 6.5 and 39.5% were female. The results showed that about two-thirds of native dentists (with local origin), 73.3% of married dentists, and all dental practitioners who had no children or had a child under the age of six were willing to continue working with their current Comprehensive centers of health services compared to other dentists. Univariate and multivariate logistic regression showed that there was a significant relationship among dentists' age, monthly salary, and facilities available in the area (place of residence, availability of vehicles, etc.), view of dental practitioners on living in a rural area, and view of dentists' families on living and working in the area (p < 0.05).

Conclusion

More than half of the dental practitioners declared their willingness to stay in rural areas, although, in practice, this amount of presence in rural areas does not meet the needs of residents. Financial issues, amenities, and facilities in the rural areas can have a positive impact on the retention of dental practitioners.

Social Disconnectedness and Career Advancement Impact on Performance: The Role of Employees’ Satisfaction in the Energy Sector

Employee performance in remote areas is a source of concern for the Saudi Arabian energy sector, which serves as the primary engine of the country’s economy. This research paper aimed to study the impact of social disconnectedness and career advancement on employees’ performance through employee satisfaction as a mediator. The targeted population was employees worked in remote areas in the energy sector. Data were collected using a web-based questionnaire and distributed electronically using social media. A total of 390 respondents participated in this study, and structural equation modeling (SEM) was employed to analyze the collected data. The study findings revealed that career advancement positively impacts employee performance; however, social disconnectedness negatively impacts employees’ performance. Both career and social factors had an indirect effect on employees’ performance through employee satisfaction. Lastly, results demonstrated a positive impact of employee satisfaction on employee performance. Important insights into theoretical and practical implications were discussed.

Impact of reliable light and electricity on job satisfaction among maternity health workers in Uganda: A cluster randomized trial

BACKGROUND

Maintaining a motivated health workforce is critical to health system effectiveness and quality of care. Scant evidence exists on whether interventions aimed to strengthen health infrastructure in low-resource settings affect health workers. This study evaluated the impact of an intervention providing solar light and electricity to rural maternity facilities in Uganda on health workers' job satisfaction.

METHODS

We used a mixed-methods design embedded in a cluster randomized trial to evaluate whether and how the We Care Solar Suitcase intervention, a solar electric system providing lighting and power, affected health workers in rural Ugandan maternity facilities with unreliable light. Facilities were randomly assigned to receive the intervention or not without blinding in a cluster-randomized controlled trial. Outcomes were assessed through two rounds of surveys with health workers. We used regression analyses to examine the intervention's impact on job satisfaction. We used an inductive approach to analyze qualitative data to understand the study context and interpret quantitative findings.

RESULTS

We interviewed 85 health workers across 30 facilities, the majority of whom were midwives or nurses. Qualitative reports indicated that unreliable light made it difficult to provide care, worsened facility conditions, and harmed health workers and patients. Before the intervention, only 4% of health workers were satisfied with their access to light and electricity. After the installation, satisfaction with light increased by 76 percentage points [95% confidence interval (CI): 61-92 percentage points], although satisfaction with electricity did not change. Experience of negative impacts of lack of overhead light also significantly decreased and the intervention modestly increased job satisfaction. Qualitative evidence illustrated how the intervention may have strengthened health workers' sense of job security and confidence in providing high-quality care while pointing towards implementation challenges and other barriers health workers faced.

CONCLUSIONS

Reliable access to light and electricity directly affects health workers' ability to provide maternal and neonatal care and modestly improves job satisfaction. Policy makers should invest in health infrastructure as part of multifaceted policy strategies to strengthen human resources for health and to improve maternal and newborn health services. Trial registration socialscienceregistry.org: AEARCTR-0003078. Registered June 12, 2018, https://www.socialscienceregistry.org/trials/3078 Additionally registered on: ClinicalTrials.gov: NCT03589625, Registered July 18, 2018, https://clinicaltrials.gov/ct2/show/NCT03589625 ).

Identifying factors affecting dentists retention in deprived areas in Iran

BACKGROUND

One of the concerns of health managers in regard to improving the oral health of residents in deprived areas is to increase the tendency of dentists to stay in those areas. The purpose of this study was to explore factors affecting the intention of dentists to stay in deprived areas.

METHODS

The present qualitative study was carried out using semi-structured interviews. We interviewed 22 informants (4 oral health managers and 18 dentists) who were identified purposefully. Informants were asked what factors affecting retention in remote and deprived areas. Content analysis through the 7-step Colaizzi approach was used for data analysis.

RESULTS

Fifteen subthemes under five themes of individual factors, the development level of the region, social and cultural factors, financial issues, and managerial and organizational factors were identified as factors affecting tendency of dentist to stay and work in deprived areas.

CONCLUSION

According to the results of our study, health policymakers and managers should focus on culture and attitudes of the residents, Provision of financial incentives, structural problems and underdevelopment of the region, and high workload to increase the tendency of dentists to stay in remote and deprived areas.

Factors affecting retention in the Philippine National Rural Physician Deployment Program from 2012 to 2019: a mixed methods study

BACKGROUND

To address the maldistribution of healthcare providers and the shortage of physicians in geographically isolated and disadvantaged areas of the Philippines, the Philippine National Rural Physician Deployment Program, or more commonly known as the Doctors to the Barrios (DTTB) program was established in 1993. However, as of 2011, only 18% of the DTTBs chose to stay in their assigned municipalities after their two-year deployment, termed retention. This study aims to identify the individual, local, work, national, and international factors affecting the retention of DTTBs in their assigned communities after their two-year deployment.

METHODS

A descriptive, mixed-methods, explanatory design was used. For the quantitative part, the modified and updated Stayers Questionnaire was given to all current DTTBs present in a Continuing Medical Education session in the Development Academy of the Philippines. Descriptive statistics were then presented. For the qualitative part, individual, semi-structured key informant interviews were conducted in-person or via phone with current and alumni DTTBs from 2012 to 2019. Proceedings of the interviews were transcribed, translated, and analyzed thematically.

RESULTS

102 current DTTBs participated in the quantitative part of our study, while 10 current and former DTTBs participated in the interviews. Demographic factors and location, personal beliefs, well-being, friends and family dynamics, and perceptions about work were the individual factors identified to affect retention. Social working conditions, career development, and infrastructure, medical equipment, and supplies were among the work factors identified to affect retention. Geography, living conditions, local social needs, and technology were among the local factors identified to affect retention. Compensation, the recently signed Universal Healthcare Law, and Safety and Security were identified as national factors that could affect retention. International factors did not seem to discourage DTTBs from staying in their communities.

CONCLUSIONS

A host of individual, work-related, local, national, and international factors influence the DTTB's decision to be retained in different, complex, interconnected, and dynamic ways. We also identified implementation issues in the DTTB program and suggested interventions to encourage retention.

Retention of healthcare workers 1 year after recruitment and deployment in rural settings: an experience post-Ebola in five health districts in Guinea

BACKGROUND

Guinea undertook health workforce reform in 2016 following the Ebola outbreak to overcome decades-long shortages and maldistribution of healthcare workers (HCWs). Specifically, over 5000 HCWs were recruited and deployed to rural health districts and with a signed 5-year commitment for rural medical practice. Governance structures were also established to improve the supervision of these HCWs. This study assessed the effects of this programme on local health systems and its influence on HCWs turnover in rural Guinea.

METHODS

An exploratory study design using a mixed-method approach was conducted in five rural health districts. Data were collected through semi-structured questionnaires, in-depth interview guides, and documentary reviews.

RESULTS

Of the 611 HCWs officially deployed to the selected districts, 600 (98%) took up duties. Female HCWs (64%), assistant nurses (39%), nurses (26%), and medical doctors (20%) represented the majority. Findings showed that 69% of HCWs were posted in health centres and the remaining in district hospitals and the health office (directorate); the majority of which were medical doctors, nurses, and midwives. The deployment has reportedly enhanced quality and timely data reporting. However, challenges were faced by local health authorities in the posting of HCWs including the unfamiliarity of some with primary healthcare delivery, collaboration conflicts between HCWs, and high feminization of the recruitment. One year after their deployment, 31% of the HCWs were absent from their posts. This included 59% nurses, 29% medical doctors, and 11% midwives. The main reasons for absenteeism were unknown (51%), continuing training (12%), illness (10%), and maternity leave (9%). Findings showed a confusion of roles and responsibilities between national and local actors in the management of HCWs, which was accentuated by a lack of policy documents.

CONCLUSION

The post-Ebola healthcare workers policy appears to have been successfully positive in the redistribution of HCWs, quality improvement of staffing levels in peripheral healthcare facilities, and enhancement of district health office capacities. However, greater attention should be given to the development of policy guidance documents with the full participation of all actors and a clear distinction of their roles and responsibilities for improved implementation and efficacy of this programme.

From twisting to settling down as a nurse in China: a qualitative study of the commitment to nursing as a career

Background

The nurse workforce shortage, partially caused by high work turnover, is an important factor influencing the quality of patient care. Because previous studies concerning Chinese nurse work turnover were predominantly quantitative, they lacked insight into the challenges faced by nurses as they transition from university to their career. A successful transition can result in new nurses' commitment to the career. As such, this study sought to understand how new nurses commit to the career, and focused on identifying facilitators and barriers to such commitment.

Methods

This was a qualitative study using a grounded theory design. Through purposive sampling, clinical nurses were recruited from hospitals in Western China to participate in semi-structured interviews. The data was analyzed through coding to develop categories and themes.

Results

Theoretical saturation was achieved after interviewing 25 participants. The data revealed the 'zigzag journey' of committing to the nursing career. The emerging core theme was "getting settled", indicating that new nurses needed to acclimate to the work reality in the nursing career. By analyzing the data provided by the participants, the researchers concluded that the journey to getting settled in nursing compassed four stages:1) "sailing out with mixed feelings", 2) "contemplating to leave", 3) "struggling to stay", and 4) "accepting the role". For most participants, nursing was described as a way to earn a living for their family, not as a career about which they felt passionate.

Conclusions

Committing to the nursing career is a complicated long-term process. There seems to be a lack of passion for nursing among the Chinese clinical nurses participating in this study. Thus, the nurses may need continued support at different career stages to enhance their ability to remain a nurse for more than economic reasons.

Policies and Challenges on the Distribution of Specialists and Subspecialists in Rural Areas of Iran

Background and objectives: Having fair access to medical services may probably be a standard feature and indisputable right of all health policies. The health policy of Iran enunciates this right. Unfortunately, as may happen in many countries, the execution of this policy depends on different factors. Among these parameters, the suitable distribution of professionals, hospitals, and medical facilities should be quoted. On the other hand, in Iran, there are many other problems linked to accessing areas with natural hindrances. Materials and methods: A literature search was conducted in PubMed and CINAHL libraries, specifically studies from 2010 to 2019. A Boolean operated medical subject headings (MeSH) term was used for the search. Newcastle–Ottawa Scale (NOS) scoring was adopted to assess the quality of each study. Results: A total of 118 studies were displayed, and among them, 102 were excluded due to duplication and study relevance. Study selection was made based on content classified into two groups: (1) shortage and unsuitable distribution of specialist and subspecialist physicians in Iran and (2) studies that explained the status of degradation in different areas of Iran. Outcomes demonstrated that Iran is generally suffering a shortage and unsuitable distribution of specialists and subspecialists. This lack is particularly crucial in deprived and areas far away from the cities. Conclusions: The present study analyzed in detail research studies regarding policies and challenges that reflect on the provision of specialists and subspecialists in Iranian rural areas.

The effects of maternity waiting homes on the health workforce and maternal health service delivery in rural Zambia: a qualitative analysis

BACKGROUND

Maternity waiting homes (MWHs) are a potential strategy to address low facility delivery rates resulting from access-associated barriers in resource-limited settings. Within a cluster-randomized controlled trial testing a community-generated MWH model in rural Zambia, we qualitatively assessed how MWHs affect the health workforce and maternal health service delivery at their associated rural health centers.

METHODS

Four rounds of in-depth interviews with district health staff (n = 21) and health center staff (n = 73) were conducted at intervention and control sites over 24 months. We conducted a content analysis using a mixed inductive-deductive approach. Data were interpreted through the lens of the World Health Organzation Health Systems Framework.

RESULTS

Nearly all respondents expressed challenges with understaffing and overwork and reported that increasing numbers of facility-based deliveries driven by MWHs contributed substantively to their workload. Women waiting at MWHs allow staff to monitor a woman's final stage of pregnancy and labor onset, detect complications earlier, and either more confidently manage those complications at the health center or refer to higher level care. District, intervention, and control site respondents passionately discussed this benefit over all time points, describing it as outweighing challenges of additional work associated with MWHs. Intervention site staff repeatedly discussed the benefit of MWHs in providing a space for postpartum women to wait after the first few hours of clinical observation through the first 48 h after delivery. Additionally, intervention site staff perceived the ability to observe women for longer before and after delivery allowed them to better anticipate and plan their own work, adjust their workloads and mindset accordingly, and provide better and more timely care. When understaffing and overwork were frequently discussed, this satisfaction in providing better care was a meaningful departure.

CONCLUSIONS

MWHs may benefit staff at rural health centers and the health system more broadly, allowing for the provision of more timely and comprehensive obstetric care. We recommend future studies consider how MWHs impact the workforce, operations, and service delivery at their associated health facilities. Considering the limited numbers of skilled birth attendants available in rural Zambia, it is important to strategically select locations for new MWHs.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02620436. Registered December 3, 2015, https://clinicaltrials.gov/ct2/show/NCT02620436.

[Motivations of obstetric healthcare personnel to work in rural areas in Niger.]

OBJECTIVES

The objective of this study was to determine the individual motivations influencing health professionals' decisions to work in rural areas. This study was conducted in three of the six districts of the Tillabery region in Niger (Tillabéry, Téra and Ouallam).

METHODS

We conducted 102 in-depth interviews with health professionals (physicians, nurses and midwives), which were analysed according to thematic analysis with a mixed approach (inductive and deductive).

RESULTS

Multiple individual motivations influence the choice to work in rural areas: the health professional's rural origin, the low cost of living, development of the professional career (to acquire a position of responsibility and to gain experience, working in the public health system) and social relations (superiors and communities).

CONCLUSION

This study highlighted the complexity of individual motivation, which depends on a multitude of factors and is expressed differently according to individual trajectories. Improving access to public health service status, and a position of responsibility providing support to health personnel by district managers through positive and formative supervision could be initiatives to support the retention of health personnel in rural areas.

[Health Labour Market dynamics in Niger and perspectives for universal health coverage.]

OBJECTIVE

To analyse Health Labour Market dynamics (2010-2014) in Niger in the light of the processes and interrelations between training, recruitment, deployment and retention of health workers, and to estimate additional health workforce needs to achieve universal health coverage in 2030.

METHOD

This was a descriptive study based on data collected from health training institutions from the capital city (training dynamics), the Ministry of Public Health (labour market dynamics) and international institutions (health workforce dynamics and demographic dynamics).

RESULTS

Between 2010 and 2014, approximately 8,570 health graduates were trained in Niger and 3,780 to 3,924 were recruited, representing less than 4% of the permanent jobs created at the national level. Between 14,300 to 15,070 graduates were unemployed or occupied precarious jobs, including 300 to 370 doctors. Health workers' remuneration, which is 13 to 25 times higher than the average national income, makes the public sector particularly attractive.The achievement of universal health coverage (UHC) in 2030 and population growth induce additional annual needs of: 23 to 30 midwives, 139 to 174 nurses and 169 to 186 physicians. The threshold of 23 health workers per 10,000 inhabitants increases these needs by 50%. The country is facing an underproduction of doctors and an overproduction of paramedical agents.Training, recruitment, deployment and retention of health workers policies are not effective, threatening achievement of UHC.

CONCLUSION

Urgent actions are required to develop a health human resources information system, to better regulate the training sector, to operationalize the regionalization of budget centres and to strengthen the Ministry of Public Health leadership.

Performance-based financing in low-income and middle-income countries: isn't it time for a rethink?

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.