Flexibility of deployment: challenges and policy options for retaining health workers during crisis in Zimbabwe

Health System Resilience in the Eastern Mediterranean Region: Perspective on the Recent Lessons Learned

BACKGROUND

Public health has a pivotal role in strengthening resilience at individual, community, and system levels as well as building healthy communities. During crises, resilient health systems can effectively adapt in response to evolving situations and reduce vulnerability across and beyond the systems. To engage national, regional, and international public health entities and experts in a discussion of challenges hindering achievement of health system resilience (HSR) in the Eastern Mediterranean Region, the Eastern Mediterranean Public Health Network (EMPHNET) held its seventh regional conference in Amman, Jordan, between November 15 and 18, 2021, under the theme "Towards Resilient Health Systems in the Eastern Mediterranean: Breaking Barriers." This viewpoint paper portrays the roundtable discussion of experts on the core themes of that conference.

OBJECTIVE

Our aim was to provide insights on lessons learned from the past and explore new opportunities to attain more resilient health systems to break current barriers.

METHODS

The roundtable brought together a panel of public health experts representing Field Epidemiology Training Programs (FETPs), Centers for Disease Control and Prevention in Atlanta, World Health Organization, EMPHNET, universities or academia, and research institutions at regional and global levels. To set the ground, the session began with four 10-12-minute presentations introducing the concept of HSR and its link to workforce development with an overall reflection on the matter and lessons learned through collective experiences. The presentations were followed by an open question and answer session to allow for an interactive debate among panel members and the roundtable audience.

RESULTS

The panel discussed challenges faced by health systems and lessons learned in times of the new public health threats to move toward more resilient health systems, overcome current barriers, and explore new opportunities to enhance the HSR. They presented field experiences in building resilient health systems and the role of FETPs with an example from Yemen FETP. Furthermore, they debated the lessons learned from COVID-19 response and how it can reshape our thinking and strategies for approaching HSR. Finally, the panel discussed how health systems can effectively adapt and prosper in the face of challenges and barriers to recover from extreme disruptions while maintaining the core functions of the health systems.

CONCLUSIONS

Considering the current situation in the region, there is a need to strengthen both pandemic preparedness and health systems, through investing in essential public health functions including those required for all-hazards emergency risk management. Institutionalized mechanisms for whole-of-society engagement, strengthening primary health care approaches for health security and universal health coverage, as well as promoting enabling environments for research, innovation, and learning should be ensured. Investing in building epidemiological capacity through continuous support to FETPs to work toward strengthening surveillance systems and participating in regional and global efforts in early response to outbreaks is crucial.

Health-care worker retention in post-conflict settings: a systematic literature review

Conflicts affect health-care systems not only during but also well beyond periods of violence and immediate crises by draining resources, destroying infrastructure and perpetrating human resource shortages. Improving health-care worker (HCW) retention is critical to limiting the strain placed on health systems already facing infrastructure and financial challenges. We reviewed the evidence on the retention of HCWs in fragile, conflict-affected and post-conflict settings and evaluated strategies and their likely success in improving retention and reducing attrition. We conducted a systematic review of studies, following PRISMA guidelines. Included studies (1) described a context that is post-conflict, conflict-affected or was transformed by war or a crisis; (2) examined the retention of HCWs; (3) were available in English, Spanish or French and (4) were published between 1 January 2000 and 25 April 2021. We identified 410 articles, of which 25 studies, representing 17 countries, met the inclusion criteria. Most of the studies (22 out of 25) used observational study designs and qualitative methods to conduct research. Three studies were literature reviews. This review observed four main themes: migration intention, return migration, work experiences and conditions of service and deployment policies. Using these themes, we identify a consolidated list of six push and pull factors contributing to HCW attrition in fragile, conflict-affected and post-conflict settings. The findings suggest that adopting policies that focus on improving financial incentives, providing professional development opportunities, establishing flexibility and identifying staff with strong community links may ameliorate workforce attrition.

Participation of women in the health workforce in the fragile and conflict-affected countries: a scoping review

INTRODUCTION AND BACKGROUND

The full participation of women as healthcare providers is recognized globally as critical to favorable outcomes at all levels, including the healthcare system, to achieving universal health coverage and sustainable development goals (SDGs) by 2030. However, systemic challenges, gender biases, and inequities exist for women in the global healthcare workforce. Fragile and conflict-affected states/countries (FCASs) experience additional pressures that require specific attention to overcome challenges and disparities for sustainable development. FCASs account for 42% of global deaths due to communicable, maternal, perinatal, and nutritional conditions, requiring an appropriate health workforce. Consequently, there is a need to understand the impact of gender on workforce participation, particularly women in FCASs.

METHODS

This scoping review examined the extent and nature of existing literature, as well as identified factors affecting women's participation in the health workforce in FCASs. Following Arksey and O'Malley's scoping review methodology framework, a systematic search was conducted of published literature in five health sciences databases and grey literature. Two reviewers independently screened the title and abstract, followed by a full-text review for shortlisted sources against set criteria.

RESULTS

Of 4284, 34 sources were reviewed for full text, including 18 primary studies, five review papers, and 11 grey literature sources. In most FCASs, women predominate in the health workforce, concentrated in nursing and midwifery professions; medicine, and the decision-making and leadership positions, however, are occupied by men. The review identified several constraints for women, related to professional hierarchies, gendered socio-cultural norms, and security conditions. Several sources highlight the post-conflict period as a window of opportunity to break down gender biases and stereotypes, while others highlight drawbacks, including influences by consultants, donors, and non-governmental organizations. Consultants and donors focus narrowly on programs and interventions solely serving women's reproductive health rather than taking a comprehensive approach to gender mainstreaming in planning human resources during the healthcare system's restructuring.

CONCLUSION

The review identified multiple challenges and constraints facing efforts to create gender equity in the health workforce of FCASs. However, without equal participation of women in the health workforce, it will be difficult for FCASs to make progress towards achieving the SDG on gender equality.

Social exclusion and the perspectives of health care providers on migrants in Gauteng public health facilities, South Africa

BACKGROUND

Universal health coverage (UHC) for all people, regardless of citizenship, is a global priority. Health care providers are central to the achievement of UHC, and their attitudes and behaviour could either advance or impede UHC for migrants. Using a social exclusion conceptual framework, this study examined the perspectives of health care providers on delivering health services to migrants in public health facilities in Gauteng Province, South Africa.

METHODS

We used stratified, random sampling to select 13 public health facilities. All health care providers working in ambulatory care were invited to complete a self-administered questionnaire. In addition to socio-demographic information, the questionnaire asked health care providers if they had witnessed discrimination against migrants at work, and measured their perspectives on social exclusionary views and practices. Multiple regression analysis was used to identify predictors of more exclusionary perspectives for each item.

RESULTS

277 of 308 health care providers participated in the study-a response rate of 90%. The participants were predominantly female (77.6%) and nurses (51.9%), and had worked for an average of 6.8 years in their facilities. 19.2% of health care providers reported that they had witnessed discrimination against migrants, while 20.0% reported differential treatment of migrant patients. Exclusionary perspectives varied across the different items, and for different provider groups. Enrolled nurses and nursing assistants were significantly more exclusionary on a number of items, while the opposite was found for providers born outside South Africa. For some questions, female providers held more exclusionary perspectives and this was also the case for providers from higher levels of care.

CONCLUSION

Health care providers are critical to inclusive UHC. Social exclusionary views or practices must be addressed through enabling health policies; training in culture-sensitivity, ethics and human rights; and advocacy to ensure that health care providers uphold their professional obligations to all patients.

Developing strategies to attract, retain and support midwives in rural fragile settings: participatory workshops with health system stakeholders in Ituri Province, Democratic Republic of Congo

BACKGROUND

Midwifery plays a vital role in the quality of care as well as rapid and sustained reductions in maternal and newborn mortality. Like most other sub-Saharan African countries, the Democratic Republic of Congo experiences shortages and inequitable distribution of health workers, particularly in rural areas and fragile settings. The aim of this study was to identify strategies that can help to attract, support and retain midwives in the fragile and rural Ituri province.

METHODS

A qualitative participatory research design, through a workshop methodology, was used in this study. Participatory workshops were held in Bunia, Aru and Adja health districts in Ituri Province with provincial, district and facility managers, midwives and nurses, and non-governmental organisation, church medical coordination and nursing school representatives. In these workshops, data on the availability and distribution of midwives as well as their experiences in providing midwifery services were presented and discussed, followed by the development of strategies to attract, retain and support midwives. The workshops were digitally recorded, transcribed and thematically analysed using NVivo 12.

RESULTS

The study revealed that participants acknowledged that most of the policies in relation to rural attraction and retention of health workers were not implemented, whilst a few have been partially put in place. Key strategies embedded in the realities of the rural fragile Ituri province were proposed, including organising midwifery training in nursing schools located in rural areas; recruiting students from rural areas; encouraging communities to use health services and thus generate more income; lobbying non-governmental organisations and churches to support the improvement of midwives' living and working conditions; and integrating traditional birth attendants in health facilities. Contextual solutions were proposed to overcome challenges.

CONCLUSION

Midwives are key skilled birth attendants managing maternal and newborn healthcare in rural areas. Ensuring their availability through effective attraction and retention strategies is essential in fragile and rural settings. This participatory approach through a workshop methodology that engages different stakeholders and builds on available data, can promote learning health systems and develop pragmatic strategies for the attraction and retention of health workers in fragile remote and rural settings.

Mapping the role of health professionals in peace promotion within an urban complex emergency: the case of Chegutu, Zimbabwe

The study sought to establish the role of health professionals in promoting peace through health care using a case study of Chegutu Urban District in Zimbabwe. The participants were drawn from health professionals employed in three council clinics and were interviewed on their views on programmes that promote peace and end violence. Their narratives were thematically presented. Results revealed that although the participants had ideas on how to promote peace through health care, did health education and assisted victims of violence, their programmes were inhibited by several challenges, predominantly related to the state of the Zimbabwean economy. The study recommended a systematic focus on these challenges so that the health professionals can realize their potential. The study also recommended further research into the impact of village health workers in community peace and the use of a multisectoral approach to managing artisanal violence.