Missing in action: teacher and health worker absence in developing countries

Absenteeism of Healthcare Workers in Primary Healthcare in Sub-Saharan Africa: A Scoping Review

INTRODUCTION

Sub-Saharan Africa is facing a severe crisis in human resources for health. Primary healthcare is the most affected. This problem is aggravated by absenteeism, implying that healthcare workers are absent on duty during scheduled working hours. This scoping review maps existing literature on absenteeism among primary healthcare workers in Sub-Saharan Africa.

METHODS

This scoping review complies with the Population Concept Context guidelines of Arksey and O'Malley and the PRISMA 2020 checklist. A literature search (Medline, Embase, Scopus, Africa Index Medicus) was performed from inception until December 2023 in collaboration with a medical information specialist. Peer-reviewed English-published literature was considered. Two independent reviewers screened titles, abstracts, and full-texts.

RESULTS

Twenty-four studies were included from 7 of 46 Sub-Saharan countries (15%). Prevalence of absenteeism varied from 14% to 49%. Causes at individual and health-system levels were explored in 16 studies (67%) and included physician dual practices (75%), low wages (69%), and insufficient supervision (56%). Consequences at the healthcare worker and patient level were described in 14 studies (58%) and included hindered/delayed access to care (64%), high workload (29%), and increased treatment costs when patients are forced to attend private facilities (22%). Recommendations to address absenteeism were provided in 18 studies (75%) and included regular supervision (33%), performance-based rewards/punishments (33%), and augmented salaries (33%).

CONCLUSION

Absenteeism is highly prevalent among primary healthcare workers in Sub-Sahara Africa. Its adverse impact on both healthcare workers and patients is profound. The complexity of different individual and health system causal factors shows that a multifactorial approach to address absenteeism is warranted.

Childhood Cancer Awareness Program in Bungoma County, Kenya

BACKGROUND

Awareness could play a key role in reducing underdiagnosis and accelerating referral of childhood cancer in low- and middle-income countries and ultimately improve outcomes. This study describes the implementation of a childhood cancer awareness program in Bungoma County in Kenya, containing five components: (1) baseline data collection of primary healthcare facilities; (2) live training session for healthcare providers (HCP); (3) early warning signs posters; (4) online SMS course for HCP; and (5) radio campaign.

METHODS

This study was conducted between January and June 2023. All 144 primary healthcare facilities (level 2 and 3 health facilities) within Bungoma County were visited by the field team.

RESULTS

All 125 level 2 (87%) and 19 level 3 (13%) facilities participated in the study. National Health Insurance Fund (NHIF) failed to cover services in 37 (26%) facilities. HCP were more often reported absent at level 3 (89%) than level 2 (64%) facilities (P = 0.034). The 144 live training sessions were attended by over 2000 HCP. Distribution of 144 early warning signs posters resulted in 50 phone calls about suspected childhood cancer cases. Sixteen children were later confirmed with childhood cancer and treated. Online SMS learning was completed by 890 HCP. Knowledge mean scores improved between pre-test (7.1) and post-test (8.1; P < 0.001). Finally, 540 radio messages about childhood cancer and a live question-and-answer session were broadcasted.

CONCLUSION

This study described the implementation of a childhood cancer awareness program in Kenya involving both HCP and the general public. The program improved HCP's knowledge and increased the number of referrals for children with cancer.

Impact of private practice of public health workers on public health provision: Evidence from a natural experiment

This paper analyzes the effects of private practice on public health provision in Indonesia among doctor heads of primary public health clinics known as puskesmas. We exploit the exogenous variation in the initiation of private practice after the 1997 Ministry of Health regulation 916 that mandated health professionals to apply for a license for private practice after at least three years of compulsory public service after graduation. Instrumental variable estimates, built around this threshold experience of 3 years after 1997 regulation, suggest that dual practitioners (relative to those only engaged in puskesmas) work significantly fewer hours per week at their public posts at the puskesmas but see significantly more public patients. These observed effects become more pronounced when the private practice is held away from the puskesmas.

Community perceptions of health accountability meetings with local politicians to improve healthcare quality: a qualitative study in Western Uganda

BACKGROUND

Lack of accountability within healthcare systems contributes to suboptimal healthcare quality and ultimately poor health outcomes, especially in low-income countries. In Uganda, our research team implemented a pilot project of quarterly health accountability meetings between community members and their local political leaders to discuss healthcare needs and strategies for quality improvement. In this study, we examine the community members' understanding and perceptions of the health accountability meetings, as well as the perceived impact of the meetings on local healthcare services and community life.

METHODS

We conducted a total of 12 focus group discussions (FGDs), half with men and half with women, in November 2022 across six randomly chosen communities out of the ten communities where health accountability meetings were held. We audio taped, transcribed, and translated all FGDs into English. We collected data on demographics, understanding of the meetings, and perceived changes within healthcare services and the community from 111 participants. Two researchers analyzed the data using an inductive thematic approach, generating five themes.

RESULTS

We found the following themes: (1) increased inclusivity and promotion of bidirectional communication; (2) increased understanding of patient rights and practicing of collective empowerment by the community; (3) improved provider behavior; (4) enhanced relationships among politicians, community members, and healthcare providers; and (5) identified needs for future improvements.

CONCLUSION

Through this qualitative study, we found that the community members perceived the accountability meetings as beneficial in improving the local healthcare services and community life. The study demonstrates the need to prioritize the voices of local communities in efforts to address the accountability gaps, as well as the potential for utilizing the relationship between community members and politicians to address accountability shortfalls in other governmental functions beyond healthcare.

TRIAL REGISTRATION

N/A.

How much could health worker absenteeism impact health outcomes? A modeling study of malaria in Kenya

When health workers are not at their posts, health care does not happen. Health worker absenteeism in Kenya was 53.8% in 2018 according to the World Bank Service Delivery Indicators Survey. Absenteeism is especially impactful for treatment of malaria where delays in treatment can lead to deadly consequences especially among the most vulnerable. Human resources management and development strengthening interventions using digital tools like iHRIS, IntraHealth International's open-source, human resource information system, can enable data-driven decision making to plan and budget for health workers and dynamically redistribute them. These promising approaches can reduce systemic absenteeism, but little is known how much impact reduced absenteeism can have on health outcomes. In this study, the Spectrum Malaria tool, a dynamic malaria transmission model developed by Avenir Health, was used to test three scenarios of reduced absenteeism (5, 10 and 15%) to quantify the potential impact of absenteeism on malaria cases and deaths averted and Plasmodium falciparum (P. falciparum) prevalence among children ages 2-9 years in Kenya between 2023 and 2030. A small, 5% increase in effective coverage of treatment of uncomplicated cases of malaria with artemisinin combination therapy could result in a 12% decrease in uncomplicated cases, a 15% reduction in severe cases, and a 13% reduction in deaths among the population and a 24% reduction in P. falciparum prevalence among children aged 2-9 years. Stemming health worker absenteeism is a critical intervention in the fight against malaria and digital tools like iHRIS for health workforce planning can help reduce absenteeism.

RESUMEN

Cuando los prestadores de salud no están en sus puestos, el cuidado de la salud no ocurre. El ausentismo entre los prestadores de salud en Kenia fue de 53.8% en 2018, según las encuestas de los Indicadores de Prestación de Servicios (IPS) del Banco Mundial. Ausentismo como este entraña un impacto especialmente fuerte en el tratamiento de la malaria, donde la demora puede tener consecuencias letales, especialmente entre los más vulnerables. Intervenciones con herramientas digitales que fortalecen la gestión y desarrollo de recursos humanos, como iHRIS (el sistema de información de recursos humanos de código abierto de IntraHealth International), hacen posible tomar decisiones basadas en datos en torno a la planificación y presupuestación de la fuerza laboral de prestadores de salud y a cómo distribuirla de forma dinámica. Estos prometedores enfoques pueden reducir el ausentismo sistémico, pero se sabe poco acerca del tamaño del impacto que esta reducción puede tener en los resultados de salud. En este estudio usamos Spectrum-Malaria (un modelo dinámico de transmisión de la malaria, desarrollado por Avenir Health) como herramienta para examinar tres escenarios de ausentismo reducido (del 5, 10, y 15%) a fin de cuantificar el impacto potencial del ausentismo sobre el número de casos y fallecimientos evitados, y la prevalencia de Plasmodium falciparum (P. falciparum) en niños de 2-9 años de edad en Kenia entre 2023 y 2030. Un incremento pequeño, de 5%, en la cobertura efectiva de casos de malaria con tratamientos combinados con artemisinina (TCA), podría resultar en una reducción de 12% en el número de casos sin complicaciones, una reducción de 15% en los casos severos, y una reducción de 13% en el número de muertes entre la población, además de suponer una reducción de 24% en la prevalencia de P. falciparum en niños de 2-9 años de edad. Restringir el ausentismo de los prestadores de salud es una intervención crítica en la lucha contra la malaria, y el uso de herramientas digitales de planificación de la fuerza laboral, como iHRIS, puede ayudar a reducir este ausentismo.

RESUMO

Quando os profissionais de saúde não estão nos seus postos, os cuidados de saúde não são prestados O absentismo dos profissionais de saúde no Quénia foi de 53,8% em 2018, de acordo com o Inquérito de Indicadores de Prestação de Serviços do Banco Mundial. O absentismo tem um impacto especial no tratamento da malária, onde os atrasos no tratamento podem ter consequências mortais, especialmente entre os mais vulneráveis. As intervenções de gestão de recursos humanos e de reforço do desenvolvimento que utilizam ferramentas digitais como o iHRIS, o sistema de informação de recursos humanos de fonte aberta da IntraHealth International, podem permitir a tomada de decisões baseadas em dados para planear e orçamentar os profissionais de saúde e redistribuí-los dinamicamente. Estas abordagens promissoras podem reduzir o absentismo sistémico, mas pouco se sabe sobre o impacto que a redução do absentismo pode ter nos resultados sanitários. Neste estudo, a ferramenta Spectrum Malaria, um modelo dinâmico de transmissão da malária desenvolvido pela Avenir Health, foi utilizada para testar três cenários de redução do absentismo (5, 10 e 15%), para quantificar o impacto potencial do absentismo nos casos de malária e mortes evitadas e na prevalência de Plasmodium falciparum (p falciparum) entre crianças dos 2 aos 9 anos de idade no Quénia entre 2023 e 2030. Um pequeno aumento de 5% na cobertura efectiva do tratamento de casos não complicados de malária com ACT poderia resultar numa diminuição de 12% nos casos não complicados, numa redução de 15% nos casos graves e numa redução de 13% nas mortes entre a população, bem como numa redução de 24% na prevalência de p falciparum entre crianças dos 2 aos 9 anos de idade. Travar o absentismo dos profissionais de saúde é uma intervenção fundamental na luta contra a malária e ferramentas digitais como o iHRIS para o planeamento da força de trabalho no sector da saúde podem ajudar a reduzir o absentismo.

RÉSUMÉ

Lorsque les agents de santé ne sont pas à leur poste, les soins de santé ne sont pas dispensés. L'absentéisme des agents de santé au Kenya était de 53,8% en 2018, selon l'enquête sur les Indicateurs de prestation de services de la Banque mondiale. L'absentéisme a un impact particulièrement important pour le traitement du paludisme, où les retards dans le traitement peuvent avoir des conséquences mortelles, en particulier parmi les plus vulnérables. Les interventions de renforcement de la gestion et du développement des ressources humaines utilisant des outils numériques comme iHRIS, le système d'information sur les ressources humaines open source d'IntraHealth International, peuvent permettre une prise de décision fondée sur les données pour planifier et budgétiser la gestion des agents de santé et les redistribuer de manière dynamique. Ces approches prometteuses peuvent réduire l'absentéisme systémique, mais on sait peu de choses sur l'impact qu'une réduction de l'absentéisme peut avoir sur les résultats de santé. Dans cette étude, l'outil Spectrum Malaria, un modèle dynamique de transmission du paludisme développé par Avenir Health, a été utilisé pour tester trois scénarios de réduction de l'absentéisme (5, 10 et 15%) afin de quantifier l'impact potentiel de l'absentéisme sur les cas de paludisme et les décès évités. et sur la prévalence de Plasmodium falciparum (P. falciparum) chez les enfants âgés de 2 à 9 ans au Kenya entre 2023 et 2030. Une légère augmentation de 5% de la couverture efficace du traitement des cas de paludisme non compliqués par l'ACT pourrait entraîner une diminution de 12% de ceux-ci, une réduction de 15% des cas graves et une réduction de 13% des décès au sein de la population, ainsi qu'une réduction de 24% de la prévalence de P. falciparum chez les enfants âgés de 2 à 9 ans. Réduire l'absentéisme des agents de santé est une intervention essentielle dans la lutte contre le paludisme et les outils numériques comme iHRIS pour la planification des personnels de santé peuvent contribuer à réduire l'absentéisme.

Promoting healthy practices among schools and children in rural bangladesh: a randomised controlled trial of skill-based health education

BACKGROUND

Poor child health and hygiene practices are persistent issues in resource-constrained settings, particularly in low-income countries. This study assessed the impact of skill-based health education (SBHE) on school and child hygiene practices in rural Bangladesh.

METHODS

A cluster-randomised-controlled intervention with cross-cutting/factorial design was conducted in 180 randomly selected primary schools, stratified by school type, in Jhenaidah District, Bangladesh. Weekly SBHE sessions were delivered to half of the schools by locally recruited para-teachers for one year. A cross-cutting soap provision treatment was given monthly to half of the SBHE-treatment schools and half of the SBHE-control schools. Treatment assignment was masked to all baseline and endline surveyors. Data were collected at both the school and child levels, with child-level data aggregated at the school level. Outcome measures were grouped into five thematic families. The primary outcome families were school hygiene practice & maintenance, school-aggregated child handwashing and school-aggregated child dentalcare. Utilising the difference-in-differences estimator with seemingly unrelated regression, we estimated the average treatment effect for each family of multiple outcomes. The intervention spillover effect to neighbouring schools along with the time-period effect were also evaluated. The project's cost-effectiveness was additionally assessed.

RESULTS

Our findings revealed that SBHE had a positive impact on primary outcomes related to healthy practices and behavioural changes, resulting in a 0.32SD improvement in school hygiene practices and maintenance (p < 0.001), a 0.47SD increase in child handwashing (p < 0.001), and a 0.43SD enhancement in child dentalcare (p < 0.01). Despite its imperfect implementation, the provision of soap itself showed no significant effect. Furthermore, significant spillover effects of healthy practices were observed in neighbouring non-treatment schools. The cost-effectiveness analysis indicated that our SBHE program was cost-effective.

CONCLUSIONS

Our study provides compelling evidence of the positive impact of SBHE on school hygiene and child health practices in rural Bangladesh, with notable spillover effects. The cost-effectiveness analysis underscores the value of SBHE, affirming its potential as an effective intervention method in improving school health and hygiene practices in primary schools and beyond.

Teacher vaccinations enhance student achievement in Pakistan: The role of role models and theory of mind

We provide experimental evidence that role models can galvanize prosocial actions amid global crises, exemplified by the COVID-19 pandemic. In a randomized control trial comparing role models, cash incentives, and celebrity endorsements, only role models successfully mitigated vaccine reluctance and ameliorated pandemic-induced educational setbacks. Monthly tracking of vaccination status was achieved via QR-code-verified certificates. Theory-of-mind behavioral data on the mentalizing of others shed light on the mechanism underlying the role model effect. This research, from Pakistan, suggests how role models and theory of mind have the potential to play a role in tackling global challenges.

Exploring health worker absenteeism at public healthcare facilities in Chhattisgarh, India

AIM

This study aims to assess the health worker absenteeism and factors associated with it in a high-focus district in Chhattisgarh, India.

BACKGROUND

Human resources for health are among the key foundations to build resilient healthcare systems. Chhattisgarh is a high-focus Indian state with a severe shortage of health care workers, and absenteeism further aggravates the shortage.

METHODS

This study was conducted as a mixed-methods study employing sequential explanatory design. Absenteeism was defined as the absence of health worker in the designated position without a formal leave or official reason in two different unannounced visits. A facility survey across all the public healthcare facilities in Jashpur district, Chhattisgarh, was conducted through random, unannounced visits employing a checklist developed based on Indian Public Health Standards. Twelve participants were purposively sampled and interviewed from healthcare facilities to explore factors associated with absenteeism. Survey data were analysed descriptively, and thematic analysis was employed to analyse qualitative interviews.

FINDINGS

Among all the positions filled at primary health centre level (n = 339), close to 8% (n = 27) were absent, whereas among the positions filled at community health centre level (n = 285), only 1.14% (n = 4) were absent. Absenteeism was not found in the district hospital. Qualitative interviews reveal that macro-level (geographical location and lack of connectivity), meso-level (lack of equipment and amenities, makeshift health facilities, doctor shortage, and poor patient turnover), and micro-level (unmet expectations) factors contribute to health worker absenteeism.

CONCLUSION

Health worker absenteeism was more at PHC level. Systemic challenges, human resource shortages, and infrastructural shortcomings contributed to health worker absenteeism.

How useful do communities find the health and wellness centres? A qualitative assessment of India's new policy for primary health care

BACKGROUND

The policy attention to primary health care has seen a global upswing in recent years, including in India. Earlier assessments had shown that a very small proportion of Indian population used the government primary health facilities. Starting in 2018, Indian government has established more than 100,000 Health and Wellness Centres (HWCs) to increase rural population's access to primary health care. It is crucial to know how useful people find the services of HWCs.

METHODS

A qualitative inquiry was made to understand the perceptions, experiences and expectations of the rural communities regarding HWCs in Chhattisgarh state. Fourteen focus group discussions were conducted with community members. The study areas were chosen to include both the central and remote districts of the state. The study used accessibility, availability, acceptability and quality (AAAQ) framework to assess HWCs.

RESULTS

Community members felt that the most important change brought about by HWCs was to offer a wider range of curative services than previously available. Services for noncommunicable diseases such as hypertension and diabetes were seen as a key value addition of HWCs. People felt improvements in services for acute ailments also. The services people found missing in HWCs were for injuries, dental care and mental health. In people's experience, the availability of essential medicines and point-of-care tests at HWCs was satisfactory and the treatment was effective. People appreciated the supportive behaviour of health workers in HWCs. They did not find the referrals from HWCs as excessive but often faced difficulties in receiving necessary services at higher facilities.

CONCLUSIONS

The assessment based on community perceptions showed that the services of HWCs matched well with people's needs of curative primary care. It shows that people are willing to use the government facilities for primary health care if the services are relevant, adequately functional and accessible.

Is household shock a boon or bane to the utilisation of preventive healthcare for children? Evidence from Uganda

This paper investigates how poor households in low-income countries trade off time investment in their children's preventive healthcare vis-à-vis labour force participation during household-level health shocks. By using the reported illness or death of any household member as the indicator for an adverse health shock, I examine its effect on the intake of Vitamin A Supplementation (VAS) by children. Using four waves of the Uganda National Panel Survey, I find that children between 12-24 months are significantly more likely to get VAS when the household is under a health shock. I argue that this effect works through an economies of scale mechanism, by which the household adult(s) utilise the released time from the labour force during the shock to access remedial care from the healthcare facility and simultaneously obtain VAS for their children during the same visit. This arguably results from the high opportunity cost of time-constrained households, which is exacerbated by a mediocre service delivery side. To distinguish the unique mechanism of the health shock in this context, the effect and channels of an income shock are also explored. By proxying a negative income shock with the household-reported incidence of flood or drought, the study cautiously hints that VAS adoption may increase among the relatively wealthy who experience a dominating substitution effect of the income shock.

Is the quality of public health facilities always worse compared to private health facilities: Association between birthplace on neonatal deaths in the Indian states

BACKGROUND

The role of place of delivery on the neonatal health outcomes are very crucial. Although the quality of care is being improved, there is no consensus about who is the better healthcare provider in low and middle-income countries (LMICs), public or private facilities. The aim of this study is to assess the differentials in neonatal mortality by the type of healthcare providers in India and its states.

METHODS

We used the data from the fourth wave of the National Family Health Survey 2015-16 (NFHS-4). Information on 259,627 live births to women within the five years preceding the survey was examined. Neonatal mortality rates for state and national levels were calculated using DHS methodology. Multi-variate logistics regression was performed to find the effect of birthplace on neonatal deaths. Propensity score matching (PSM) was used to evaluate the relationship between place of delivery and neonatal deaths to account for the bias attributable to observable covariates.

RESULTS

The rise in parity of the women and purchasing power influences the choice of healthcare providers. Increased neonatal mortality was found in private hospital delivery compared to public hospitals in Punjab, Rajasthan, Chhattisgarh, Madhya Pradesh, Bihar, Jharkhand, Odisha, Goa, Maharashtra, Andhra Pradesh and Karnataka states using propensity score matching analysis. However, analysis on the standard of pre-natal and post-natal care indicates that private hospitals generally outperformed public hospitals.

CONCLUSIONS

The study observed a significant variation in neonatal mortality among public and private health care systems in India. Findings of the study urges that more attention be paid to the improve care at the place of delivery to improve neonatal health. There is a need of strengthened national health policy and public-private partnerships in order to improve maternal and child health care in both private and public health facilities.

In search of a fix to the primary health care chasm in India: can institutionalizing a public health cadre and inducting family physicians be the answer?

India's woes with an underprioritized and hence underfunded and understaffed public health system continue to plague public healthcare delivery. Though the need for appropriately qualified public health cadre to lead public health programmes is well established, a well-meaning conducive approach to implementing this is lacking. As the COVID-19 pandemic brought back the focus on India's fragmented health system and primary healthcare deficiencies, we discuss the primary healthcare conundrum in India in search of a quintessential fix. We argue for instituting a well-thought and inclusive public health cadre to lead preventive and promotive public health programmes and manage public health delivery. With the aim being to increase community confidence in primary health care, along with the need to augment primary healthcare infrastructure, we argue for a need to augment primary healthcare with physicians trained in family medicine. Provisioning medical officers and general practitioners trained in family medicine can salvage community's confidence in primary care, increase primary healthcare utilization, stymie over-specialization of care, channelize and prioritize referrals, and guarantee competence in healthcare quality for rural communities.

Does information improve service delivery? A randomized trial in education in India

From a cluster randomized control trial in 610 villages, the study evaluates the impact of a community-based information campaign on school outcomes in three Indian states. The campaign consisted of eleven to fourteen public meetings over two rounds in treatment villages to disseminate information to the community about its state-mandated roles and responsibilities in school management. No intervention took place in control villages. The paper reports on the final follow up survey two and half years after the campaign. Providing information improved teacher effort and learning outcomes in schools. Bigger gains were seen in the two states, Madhya Pradesh (MP) and Uttar Pradesh (UP), where baseline level of outcomes was lower than in the third state, Karnataka. The impact on teacher effort, primarily for civil-service teachers with permanent jobs and therefore lower accountability, was between 16%-43% in MP and UP. The shares of children able to do basic mathematics competencies improved. Due to low baseline learning levels, the magnitudes of the percentage increases were much larger compared to the absolute increases in shares. Fewer improvements occurred in language. This can be because of low teaching effectiveness as well as more time needed for larger and wider impacts on learning. School councils became more active after the campaign. Focus group discussions indicated discussions within communities and communities actively bringing up issues with teachers and school councils. Impacts were generally larger or broader than those at midline survey 2-4 months after one round of intervention. Overall providing information holds promise in improving public services via worker accountability.

Factors influencing the motivation of maternal health workers in conflict setting of Mogadishu, Somalia

Motivated health workers play an important role in delivering high-quality maternal health services, especially in low-income countries where maternal mortality rates are high, and shortages of human resource for health is prevalent. The aim of this study is to investigate maternal health workers' motivation in three tertiary hospitals in Mogadishu Somalia. We used a semi-structured questionnaire that was validated and widely used in Sub-Saharan Africa to collect data from 220 health workers across three tertiary hospitals in Mogadishu between February and April 2020. Health worker motivation was measured using seven constructs: general motivation, burnout, job satisfaction, intrinsic job satisfaction, organizational commitment, conscientiousness, timeliness and attendance. A multiple linear regression analysis was performed to determine the predictors of health worker motivation. The results show that male health workers have a higher work motivation, with a mean score of 92.75 (SD 21.31) versus 90.43 (SD 21.61) in women. As regards to profession, significant correlation was found between health workers' motivation and being an assistant (coeff, 6.873, p = 0.001), nurse (coeff, 5.111, p = 0.000), physicians (coeff, 2.898 p = 0.042), pediatric assistants (coeff, 2.878, p = 0.048), midwife (coeff, 3.822, P = 0.01), and others (supervisor and pharmacist) (coeff, 5.623, P = 0.001). Unexpectedly, the gynecologists and midwives were the least motivated groups among the different professions, with mean scores of 83.63, (SD: 27.41) and 86.95 (SD: 21.08), respectively. Of the aforementioned seven motivation constructs, the highest mean motivation scores (from 1-5) were observed in conscientiousness and intrinsic job satisfaction. These results highlight the importance of targeted interventions that increase female health workers' motivation, particularly gynecologists and midwives. This can be done by providing non-financial incentives, in addition to encouraging their participation in the decision-making process. Further research is needed to investigate the effect of a lack of motivation among gynecologists and midwives on maternal health in Somalia.

Institutional Quality and Education Quality in Developing Countries: Effects and Transmission Channels

The main objective of this study is to analyze the effect of institutional quality on education quality in developing countries. The literature review explores the channels through which institutional quality transits to affect education quality. The empirical analyses cover a sample of 82 developing countries. The main results obtained using ordinary least squares and two-stage least squares estimators show that institutional quality has a positive effect on student achievement and school completion, and a negative effect on educational failure. Concerning the role of transmission channels, the results show that a deterioration in institutional quality, characterized in particular by the presence of corruption, political instability, or the deterioration of government effectiveness, reduces the effectiveness of public spending on education and the quality of teaching through unethical behavior of teachers and the recruitment of untrained or less trained persons to carry out teaching tasks.

Monetary Incentives and Early Initiation of Antenatal Care: A Matched-Pair, Parallel Cluster-Randomized Trial in Zambia

Monetary incentives are often used to increase the motivation and output of health service providers. However, the focus has generally been on frontline health service providers. Using a cluster randomized trial, we evaluate the effect of monetary incentives provided to community-based volunteers on early initiation of antenatal care (ANC) visits and deliveries in health facilities in communities in Zambia. Monetary incentives were assigned to community-based volunteers in treatment sites, and payments were made for every woman referred or accompanied in the first trimester of pregnancy during January-June 2020. We find a significant increase of about 32 percent in the number of women completing ANC visits in the first trimester but no effect on service coverage rates. The number of women accompanied by community-based volunteers for ANC in the first trimester increased by 33 percent. The number of deliveries in health facilities also increased by 22 percent. These findings suggest that the use of health facilities during the first trimester of pregnancy can be improved by providing community-based volunteers with monetary incentives and that such incentives can also increase deliveries in health facilities, which are key to improving the survival of women and newborns.

Disruptions to healthcare quality and early child health outcomes: Evidence from health-worker strikes in Kenya

This paper measures the effects of disruptions to healthcare quality at birth on early child health outcomes in Kenya. To identify impacts, we exploit variation in the timing and location of health-worker strikes at individual hospitals across the country between 1999 and 2014. Using data from Demographic Health Surveys, we find that children born during strikes are more likely to suffer a neonatal death. We find similar results using separate data collected in two informal settlements in Nairobi located near hospitals with frequent strikes. These results show that interruptions to healthcare quality can have large immediate health impacts, and suggests that status quo hospital care provides positive benefits. We also find suggestive evidence of reductions in later health investments, measured by vaccine take-up, among those who survive. This study provides the first rigorous evidence on the consequences of health-worker strikes, a frequent but understudied phenomenon in Sub-Saharan Africa.

The ethics of talent development: frameworks and identities

Purpose

This paper aims to examine the ethics of authentic talent development in socioeconomic context by considering a set of alternative ethical frameworks. It juxtaposes the ideals of civic virtue, which involve a concern for the common good, with the reality that socioeconomic deprivation and sociocultural practices severely constrain talent development opportunities and choice.

Design/methodology/approach

The paper draws on several frameworks complementary to the ideals of civic virtue – the basic goods approach, human capital theory, the capabilities approach and the ethic of care – to elucidate the barriers to talent development embodied in sociocultural context, as well as policy and institutional practices to overcoming these barriers.

Findings

While multiple ethical frameworks are necessary to fully capture the issues related to authentic talent development in socioeconomic context, a focus on the ethic of care and basic goods provision is an important starting point. There are also a few fundamental starting points for human resource development in responding to ethical concerns regarding authentic talent development.

Originality/value

While the prevailing approach to talent development is implicitly based on a logic of social identity ascription, this paper promotes an alternative approach based on the ethics of civic virtue. While the former is oriented to the support of social hierarchies based on identity, the latter is oriented to fostering both social and human well-being via choice and authentic talent development.

Should developing countries ban dual practice by physicians? Analysis under mixed hospital competition

Dual practice, where physicians work both in public and private hospitals, is a widely observed phenomenon, particularly in developing countries. This paper studies a multi-stage game where hospitals compete for physicians as well as patients and, the service provided by physicians endogenously depends on the competitive setting in which hospitals operate. Specifically, we examine the impact of allowing dual practice on hospital payoffs, physician's service and societal welfare. We find that dual practice is socially desirable, since it softens the competition for physician's exclusive service while also increasing the amount of their service. However, if the degree of competition between the hospitals is significant, dual practice may not yield the highest payoffs for both public and private hospitals.

Work time allocation at primary health care level in two regions of Albania

Introduction

Although well-performing workforce is essential to equitable and efficient health service delivery, few countries have systematically addressed performance improvements. How health workers use their work time and what tasks they accomplish is here an important starting point. Therefore, a time motion study was conducted to assess the work time allocation patterns of primary health care doctors and nurses in two regions of Albania.

Methods

We used observation tool to record the time allocation along eight predefined main categories of activities. Conditional to presence at work, 48 health workers were continuously observed in early 2020 before start of the Covid-19 pandemic over five consecutive working days.

Results

The observed health workers spent 40.7% of their overall working time unproductively (36.8% on waiting for patients and 3.9% on breaks), 25.3% on service provision to users, 18.7% on administrative activities, 12.7% on outreach activities, 1.6% on continuous medical education and 1% on meetings. The study found variations in work time allocation patterns across cadres, with nurses spending more time unproductively, on administrative activities and on outreach and less on all other activities than doctors. Further, the work time allocation patterns were similar between urban and rural settings, except for nurses in rural settings spending less time than those in urban settings on administrative work.

Conclusion

This study found that primary health care workers in Albania devote a substantial amount of work time to unproductive, service provision to users and administrative activities. Consequently, there is possibility for productivity, respectively efficiency gains in how health workers use their time.

Evaluating the feasibility of the Community Score Card and subsequent contraceptive behavior in Kisumu, Kenya

BACKGROUND

Women seeking family planning services from public-sector facilities in low- and middle-income countries sometimes face provider-imposed barriers to care. Social accountability is an approach that could address provider-imposed barriers by empowering communities to hold their service providers to account for service quality. Yet little is known about the feasibility and potential impact of such efforts in the context of contraceptive care. We piloted a social accountability intervention-the Community Score Card (CSC)-in three public healthcare facilities in western Kenya and use a mix of quantitative and qualitative methodologies to describe the feasibility and impact on family planning service provision.

METHODS

We implemented and evaluated the CSC in a convenience sample of three public-sector facility-community dyads in Kisumu County, Kenya. Within each dyad, communities met to identify and prioritize needs, develop corresponding indicators, and used a score card to rate the quality of family planning service provision and monitor improvement. To ensure young, unmarried people had a voice in identifying the unique challenges they face, youth working groups (YWG) led all CSC activities. The feasibility and impact of CSC activities were evaluated using mystery client visits, unannounced visits, focus group discussions with YWG members and providers, repeated assessment of score card indicators, and service delivery statistics.

RESULTS

The involvement of community health volunteers and supportive community members - as well as the willingness of some providers to consider changes to their own behaviors-were key score card facilitators. Conversely, community bias against family planning was a barrier to wider participation in score card activities and the intractability of some provider behaviors led to only small shifts in quality improvement. Service statistics did not reveal an increase in the percent of women receiving family planning services.

CONCLUSION

Successful and impactful implementation of the CSC in the Kenyan context requires intensive community and provider sensitization, and pandemic conditions may have muted the impact on contraceptive uptake in this small pilot effort. Further investigation is needed to understand whether the CSC - or other social accountability efforts - can result in improved contraceptive access.

Leveraging mHealth usage logs to inform health worker performance in a Resource-Limited setting: Case example of mUzima use for a chronic disease program in Western Kenya

BACKGROUND

Health systems in low- and middle-income countries (LMICs) can be strengthened when quality information on health worker performance is readily available. With increasing adoption of mobile health (mHealth) technologies in LMICs, there is an opportunity to improve work-performance and supportive supervision of workers. The objective of this study was to evaluate usefulness of mHealth usage logs (paradata) to inform health worker performance.

METHODOLOGY

This study was conducted at a chronic disease program in Kenya. It involved 23 health providers serving 89 facilities and 24 community-based groups. Study participants, who already used an mHealth application (mUzima) during clinical care, were consented and equipped with an enhanced version of the application that captured usage logs. Three months of log data were used to determine work performance metrics, including: (a) number of patients seen; (b) days worked; (c) work hours; and (d) length of patient encounters.

PRINCIPAL FINDINGS

Pearson correlation coefficient for days worked per participant as derived from logs as well as from records in the Electronic Medical Record system showed a strong positive correlation between the two data sources (r(11) = .92, p < .0005), indicating mUzima logs could be relied upon for analyses. Over the study period, only 13 (56.3%) participants used mUzima in 2,497 clinical encounters. 563 (22.5%) of encounters were entered outside of regular work hours, with five health providers working on weekends. On average, 14.5 (range 1-53) patients were seen per day by providers.

CONCLUSIONS / SIGNIFICANCE

mHealth-derived usage logs can reliably inform work patterns and augment supervision mechanisms made particularly challenging during the COVID-19 pandemic. Derived metrics highlight variabilities in work performance between providers. Log data also highlight areas of suboptimal use, of the application, such as for retrospective data entry for an application meant for use during the patient encounter to best leverage built-in clinical decision support functionality.

Corruption in the health sector: A problem in need of a systems-thinking approach

Health systems are comprised of complex interactions between multiple different actors with differential knowledge and understanding of the subject and system. It is exactly this complexity that makes it particularly vulnerable to corruption, which has a deleterious impact on the functioning of health systems and the health of populations. Consequently, reducing corruption in the health sector is imperative to strengthening health systems and advancing health equity, particularly in low- and middle-income countries (LMICs). Although health sector corruption is a global problem, there are key differences in the forms of and motivations underlying corruption in health systems in LMICs and high-income countries (HICs). Recognizing these differences and understanding the underlying system structures that enable corruption are essential to developing anti-corruption interventions. Consequently, health sector corruption is a problem in need of a systems-thinking approach. Anti-corruption strategies that are devised without this understanding of the system may have unintended consequences that waste limited resources, exacerbate corruption, and/or further weaken health systems. A systems-thinking approach is important to developing and successfully implementing corruption mitigation strategies that result in sustainable improvements in health systems and consequently, the health of populations.

Contraceptive self-injection through routine service delivery: Experiences of Ugandan women in the public health system

Contraceptive self-injection (SI) is a new self-care practice with potential to transform women's family planning access by putting a popular method, injectable contraception, directly into the hands of users. Research shows that SI is feasible and acceptable; evidence regarding how to design and implement SI programs under real-world conditions is still needed. This evaluation examined women's experiences when self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was introduced in Uganda alongside other contraceptive options in the context of informed choice. We conducted structured survey interviews with 958 randomly selected SI clients trained in three districts in 2019. SI clients demonstrated their injection technique on a model to permit an assessment of injection proficiency. A randomly selected subset of 200 were re-interviewed 10-17 months post-training to understand resupply experiences, waste disposal practices and continuation. Finally, we conducted survey interviews with a random sample of 200 clients who participated in training but declined to self-inject. Data were analyzed using Stata IC/14.2. Differences between groups were measured using chi square and t-tests. Multivariate analyses predicting injection proficiency and SI adoption employed mixed effects logistic regression. Nearly three quarters of SI clients (73%) were able to demonstrate injection proficiency without additional instruction from a provider. Years of education, having received a complete training, practicing, and taking home a job aid were associated with higher odds of proficiency. Self-reported satisfaction and continuation were high, with 93% reinjecting independently 3 months post-training. However, a substantial share of those trained opted not to self-inject. Being single, having a partner supportive of family planning use, training with a job aid, practicing, witnessing a demonstration and exposure to a full training were associated with higher odds of becoming an SI client; conversely, those trained in a group had reduced odds of becoming an SI client. The self-care program was successful for the majority of women who became self-injectors, enabling most women to demonstrate SI proficiency. Nearly all those who opted to self-inject reinjected independently, and the majority continued self-injecting for at least 1 year. Additional research should identify strategies to facilitate adoption by women who wish to self-inject but face challenges.

Navigating the healthcare system in Nairobi City County: perspectives and experiences in the utilization of oral healthcare by caregivers of children with HIV/AIDS

Background

The healthcare system in any republic can cause inequalities in health outcomes if they do not take into account the needs of deprived populations. Children with HIV/AIDS are known to have a high vulnerability to oral diseases; yet, they continue to face limitations in the utilization of oral healthcare. While other determinants of healthcare utilization may co-exist, possible gaps in the oral healthcare system can collectively affect a vulnerable group disproportionately in the utilization of oral healthcare.

Objective

To explore qualitatively, the perspectives, experiences and attributions of a cohort of caregivers of children with HIV/AIDS and their Health Care Providers (HCPs), on the utilization of oral healthcare within the structure of the oral healthcare system in Nairobi City County (NCC).

Design

A cross-sectional explorative mixed methods study design of two hundred and twenty one (221) female caregivers of children with HIV/AIDS and their HCPs using a survey, Focus Group Discussions (FGDs) and In-depth Interviews (IDIs). The study setting was the HIV-Care Facilities (HIV-CCFs) at three large hospitals in NCC.

Results

Caregivers mainly utilized independent ‘nearby’ private dental clinics for oral healthcare services, attributing their selection to cheaper user-fees, proximal service location, and recommendations from social networks. Wait time, opening and closing hours, health workers’ attitudes and inferred opportunity costs were perceived as important quality issues in the utilization of oral healthcare.

Conclusion

The oral healthcare system in NCC does not support the utilization of oral healthcare within the context of providing comprehensive healthcare for children with HIV/AIDS. Absence of ‘in-house’ oral health services at the HIV- CCFs is viewed as a defining structural barrier.

Absenteeism among family planning providers: a mixed-methods study in western Kenya

Public-sector healthcare providers are on the frontline of family planning service delivery in low- and middle-income countries like Kenya, yet research suggests public-sector providers are frequently absent. The current prevalence of absenteeism in Western Kenya, as well as the impact on family planning clients, is unknown. The objective of this paper is to quantify the prevalence of public-sector healthcare provider absenteeism in this region of Kenya, to describe the potential impact on family planning uptake and to source locally grounded solutions to provider absenteeism. We used multiple data collection methods including unannounced visits to a random sample of 60 public-sector healthcare facilities in Western Kenya, focus group discussions with current and former family planning users, key informant interviews (KIIs) with senior staff from healthcare facilities and both governmental and non-governmental organizations and journey mapping activities with current family planning providers and clients. We found healthcare providers were absent in nearly 60% of unannounced visits and, among those present, 19% were not working at the time of the visit. In 20% of unannounced visits, the facility had no providers present. Provider absenteeism took many forms including providers arriving late to work, taking an extended lunch break, not returning from lunch or being absent for the entire day. While 56% of provider absences resulted from sanctioned activities such as planned vacation, sick leave or off-site work responsibilities, nearly half of the absences were unsanctioned, meaning providers were reportedly running personal errands, intending to arrive later or no one at the facility could explain the absence. Key informants and focus group participants reported high provider absence is a substantial barrier to contraceptive use, but solutions for resolving this problem remain elusive. Identification and rigorous evaluation of interventions designed to redress provider absenteeism are needed.

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

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

Teacher absenteeism, improving learning, and financial incentives for teachers

We know that learning is in crisis. We know that teachers are key to addressing the crisis. Yet, the significant investments in supporting teachers to improve learning have not enabled improved learning outcomes. This article examines a key reason for this: teacher absenteeism. Poor teacher motivation is highlighted as an explanation for teacher absenteeism, with poor remuneration emerging as teachers' main reason for not attending school and/or class. This article explores the use of financial incentives, which have been sidelined within the education aid architecture, to improve teacher motivation, address teacher absenteeism, and improve learning. It distils the successes and lessons learned from the research literature, which can be used to devise a framework to guide financial-incentive-focused strategies. The framework is currently informing a research-based intervention in schools in Uganda that is using a cost-effective mobile-phone-based and teacher-motivation-focused strategy and tools to improve learning.

Unmet need for treatment-seeking from public health facilities in India: An analysis of sociodemographic, regional and disease-wise variations

Treatment-seeking behaviour is closely associated with the health status of individuals and countries. About 800 million people have no access to health services in the developing world. Though the situation has been improving, the inequalities across geographical regions, socioeconomic status, and disease types continued to persist. The available literature suggests research gaps in examining the unmet need for treatment-seeking from public health facilities across sociodemographic characteristics, regions, and specific diseases. Data for this study comes from the three rounds of National Sample Survey (NSS) (2004, 2014, 2018). We applied descriptive, bivariate, and multivariable analysis to investigate the unmet need for treatment-seeking for public health facilities across sociodemographic characteristics, regions, and specific diseases between 2004 and 2018. The unmet need for treatment-seeking from public health facilities remained high at 60% in 2004 to 62% in 2018. However, the proportion of respondents who did not seek treatment has reduced 12% to 3% from 2004 to 2018. In states like Andhra Pradesh, Madhya Pradesh, Maharashtra, Punjab, Telangana, Uttar Pradesh, and West Bengal, the unmet need for treatment-seeking from public health facilities was more than 60% in 2018. For 2018, the quality of services at public health facilities was the main reason for showing a higher unmet need for treatment-seeking in the richer MPCE quintiles. On the other hand, the ailment not considered serious as the main reason for the unmet need for treatment-seeking from any sources has got nearly doubled from 36% in 2004 to 71% in 2018. This study concludes that improving the availability of various kinds of services at public health facilities should be a priority under India's universal health coverage program. Education plays a vital role in treatment-seeking. Thus, there is an urgent need for increasing awareness among people for treatment-seeking. Ensuring a minimum quality of health care services and reducing long waiting timing would reduce the apathy to receive services from the public health facilities.

The Effects of Chronic Disease Management in Primary Health Care: Evidence from Rural China

Health systems globally face increasing morbidity and mortality from chronic diseases, yet many - especially in low- and middle-income countries - lack strong chronic disease management in primary health care (PHC). We provide evidence on China's efforts to promote PHC management using unique five-year panel data in a rural county, including health care utilization from medical claims and health outcomes from biomarkers. Utilizing plausibly exogenous variation in management intensity generated by administrative and geographic boundaries, we compare hypertension/diabetes patients in villages within two kilometers distance but managed by different townships. Results show that, compared to patients in townships with median management intensity, patients in high-intensity townships have 4.8% more PHC visits, 5.2% fewer specialist visits, 11.7% lower likelihood of having an inpatient admission, and 3.6% lower medical spending. They also tend to have better medication adherence and better control of blood pressure. The resource savings from avoided inpatient admissions substantially outweigh the costs of the program.

Paths towards Universal Health Coverage: beyond political commitments

The rapid economic growth in low and middle-income countries provides the opportunity of translating political commitment into action for achieving Universal Health Coverage. However, this is not straightforward. High donor dependence in low income countries; the lack of fiscal space; the inadequacy of attention to primary health care and under-developed pre-payment systems all pose challenges. Windows of political opportunity open up and ensuring that Universal Health Coverage makes it into the agenda of parties and subsequent holding them accountable by citizens can address political inertia. Not only is more money for health needed, but governments also need to gain more health for money through effective strategic purchasing and addressing the main drivers of inefficiency. Moving Universal Health Coverage from political aspiration to reality requires approaching it as a citizen's rights and entitlement to health, through full subsidies for the poor and vulnerable.

Corruption: An Impediment to Delivering Pathology and Laboratory Services in Resource-Limited Settings

OBJECTIVES

Corruption is a widely acknowledged problem in the health sector of low- and middle-income countries (LMICs). Yet, little is known about the types of corruption that affect the delivery of pathology and laboratory medicine (PALM) services. This review is a first step at examining corruption risks in PALM.

METHODS

We performed a critical review of medical literature focused on health sector corruption in LMICs. To provide context, we categorized cases of laboratory-related fraud and abuse in the United States.

RESULTS

Forms of corruption in LMICs that may affect the provision of PALM services include informal payments, absenteeism, theft and diversion, kickbacks, self-referral, and fraudulent billing.

CONCLUSIONS

Corruption represents a functional reality in many LMICs and hinders the delivery of services and distribution of resources to which individuals and entities are legally entitled. Further study is needed to estimate the extent of corruption in PALM and develop appropriate anticorruption strategies.

Collaboration With People With Lived Experience of Mental Illness to Reduce Stigma and Improve Primary Care Services: A Pilot Cluster Randomized Clinical Trial

IMPORTANCE

Collaboration with people with lived experience of mental illness (PWLE), also referred to as service users, is a growing priority to reduce stigma and improve mental health care.

OBJECTIVE

To examine feasibility and acceptability of conducting an antistigma intervention in collaboration with PWLE during mental health training of primary care practitioners (PCPs).

DESIGN, SETTING, AND PARTICIPANTS

This pilot cluster randomized clinical trial was conducted from February 7, 2016, to August 10, 2018, with assessors, PCPs, and patients blinded to group assignment. The participants were PCPs and primary care patients diagnosed with depression, psychosis, or alcohol use disorder at primary care facilities (the cluster unit of randomization) in Nepal. Statistical analysis was performed from February 2020 to February 2021.

INTERVENTIONS

In the control group, PCPs were trained on the World Health Organization Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG). In the Reducing Stigma Among Healthcare Providers (RESHAPE) group, the mhGAP-IG trainings for PCPs were cofacilitated by PWLE who presented recovery testimonials through photographic narratives.

MAIN OUTCOMES AND MEASURES

Prespecified feasibility and acceptability measures were adequacy of randomization, retention rates, intervention fidelity, data missingness, and safety. Outcome measures for PCPs included the Social Distance Scale (SDS), accuracy of diagnoses of mental illness in standardized role-plays using the Enhancing Assessment of Common Therapeutic factors tool (ENACT), and accuracy of diagnosis with actual patients. The primary end point was 16 months posttraining.

RESULTS

Among the overall sample of 88 PCPs, 75 (85.2%) were men and 67 (76.1%) were upper caste Hindus; the mean (SD) age was 36.2 (8.8) years. Nine of the PCPs (10.2%) were physicians, whereas the remaining 79 PCPs (89.8%) were health assistants or auxiliary health workers. Thirty-four facilities were randomized to RESHAPE or the control group. All eligible PCPs participated: 43 in RESHAPE and 45 in the control group, with 76.7% (n = 33) and 73.3% (n = 33) retention at end line, respectively. Due to PCP dropout, 29 facilities (85.3%) were included in end line analysis. Of 15 PWLE trained as cofacilitators, 11 (73.3%) participated throughout the 3 months of PCP trainings. Among PCPs, mean SDS changes from pretraining to 16 months were -10.6 points (95% CI, -14.5 to -6.74 points) in RESHAPE and -2.79 points (-8.29 to 2.70 points) in the control group. Role-play-based diagnoses with ENACT were 78.1% (25 of 32) accurate in RESHAPE and 66.7% (22 of 33) in the control group. Patient diagnoses were 72.5% (29 of 40) accurate by PCPs in RESHAPE compared with 34.5% (10 of 29) by PCPs in the control group. There were no serious adverse events.

CONCLUSIONS AND RELEVANCE

This pilot cluster randomized clinical trial found that procedures were feasible and acceptable for PCPs to be trained by PWLE. These pilot results will help inform a full trial to evaluate benefits of collaboration with PWLE during training of PCPs to reduce stigma and improve diagnostic accuracy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02793271.

Health Worker Absenteeism in Selected Health Facilities in Enugu State: Do Internal and External Supervision Matter?

Background: Absenteeism is widespread in Nigerian health facilities and is a major barrier to achievement of effective Universal Health Coverage. We have examined the role of internal (by managerial staff within facilities) and external (by managers at a higher level) supervision arrangements on health worker absenteeism. Specifically, we sought to determine whether these forms of supervision have any role to play in reducing health worker absenteeism in health facilities in Enugu State Nigeria. Methods: We conducted interviews with 412 health workers in urban and rural areas of Enugu State, in South-Eastern Nigeria. We used binary logistic regression to estimate the role of different types of supervision on health worker absenteeism in selected health facilities in Enugu State. Results: Internal supervision arrangements significantly reduce health worker absenteeism (odds ratio = 0.516, p = 0.03). In contrast, existing external supervision arrangements were associated with a small but significant increase in absenteeism (OR = 1.02, 0.043). Those reporting a better financial situation were more likely to report being absent (OR = 1.36, p < 0.01) but there was no association with age and marital status of respondents. Our findings also pointed to the potential for alternative forms of supervision, provided in a supportive rather than punitive way, for example by community groups monitoring the activities of health workers but trying to understand what support these workers may need, within or beyond the work environment. Conclusion: The existing system of external supervision of absenteeism in health facilities in Nigeria is not working but alternatives that take a more holistic approach to the lived experiences of health workers might offer an alternative.

Challenges to improved animal rabies surveillance: Experiences from pilot implementation of decentralized diagnostic units in Chad

Better surveillance is desperately needed to guide rabies prevention and control to achieve the goal of zero dog-mediated human rabies by 2030, defined by the World Health Organization (WHO) and partners in 2015. With the help of funding from the Vaccine Alliance (GAVI) learning agenda, we implemented animal rabies surveillance based on One Health communication, improved accessibility of diagnostic testing and facilitated sample transport to increase case detection in three regions of Chad. Through the project, rabies surveillance, previously only available in N'Djaména, was extended to selected provincial rural and urban areas. Nine decentralized diagnostic units (DDU) were established, hosted by veterinary district agencies (VDA) in four different administrative regions. Four additional VDAs in the study area were reinforced with facilitation of sample collection and transport. Staff from all these 13 veterinary facilities were trained in sample collection and diagnostics. DDUs performed Rapid Immunodiagnostic Tests (RIDT) providing a preliminary result before samples were sent to the central laboratory in N'Djamena for confirmation with the standard Florescent Antibody Test (FAT). Within the project period from June 2016 to March 2018, 115 samples were reported by veterinary facilities in the study areas compared to 63 samples received from outside the study area, the vast majority of them originating from the capital city N'Djaména (N=61). Eighty nine percent of all 178 samples reported to IRED during the project period tested positive. Most of the samples originated from dogs (92%). Other confirmed rabies positive animals observed were cats, a donkey and a pig. Although surveillance of animal rabies was the focus, four human saliva samples were also submitted for diagnosis. We observed high differences in reporting rates between the four study regions. This could be attributable to differences in rabies epidemiology but are also influenced by the distance to the central laboratory in N'Djaména, the cultural background and the level of public awareness. The possibility for local testing through RIDT was very welcomed by local veterinary staff and preliminary insights suggest a positive influence on One Health communication and PEP initiation. However, these aspects as well as the relative impact of local testing on sample collection in comparison to reinforcement of sample collection and transport alone, need to be further investigated. Challenges encountered related to poor infrastructure (buildings, appliances, materials) and low logistic capacity (lacking means and material for transport and communication) of veterinary services in Chad. In addition, veterinary personnel lack experience in data management. Together with staff turnover, this leads to a need for repeated training. Major shortcoming of the approach was the high cost per sample and limited sustainability beyond the project timeframe.

The impact of health worker absenteeism on patient health care seeking behavior, testing and treatment: A longitudinal analysis in Uganda

INTRODUCTION

Absenteeism of frontline health workers in public sector facilities is widespread in low-income countries. There is little quantitative evidence on how health worker absenteeism influences patient treatment seeking behavior, though low public sector utilization and heavy reliance on the informal sector are well documented in low-income settings.

METHODS

Using a unique panel dataset covering health facilities and households over a 10-month period in Uganda, we investigate the extent to which health worker absenteeism (defined as zero health workers present at a health facility) impacts patient care seeking behavior, testing, and treatment.

RESULTS

We find high rates of health worker absenteeism at public sector health facilities, with most of the absenteeism occurring at lower level public health clinics. On average, no health worker was present in 42% of all days monitored in lowest level public health clinics, whereas this number was less than 5% in high level public hospitals and private facilities. In our preferred empirical model with household fixed effects, we find that health worker absenteeism reduces the odds that a patient seeks care in the public sector (OR = 0.65, 95% CI = 0.44-0.95) and receives malaria testing (OR = 0.73, 95% CI = 0.53-0.99) and increases the odds of paying out-of-pocket for treatment (OR = 1.41, 95% CI = 1.10-1.80). The estimated differences in care-seeking are larger for children under-five than for the overall study population.

CONCLUSIONS

The impact of health worker absenteeism on the quality of care received as well as the financial burden faced by households in sub-Saharan Africa is substantial.

NEONATAL DEATH IN INDIA: BIRTH ORDER IN A CONTEXT OF MATERNAL UNDERNUTRITION

We document a novel fact about neonatal death, or death in the first month of life. Globally, neonatal mortality is disproportionately concentrated in India. We identify a large effect of birth order on neonatal mortality that is unique to India: later-born siblings have a steep survival advantage relative to the birth-order gradient in other developing countries. We show that India's high prevalence of maternal undernutrition and its correlation with age and childbearing can explain this pattern. We find that Indian mothers exit the underweight body mass range at an internationally comparatively high rate as they progress through childbearing careers.

Prioritising Quantity over Quality: Lopsided Approach to Girl Child Education in the Bihar Government’s Schemes

Based on a field survey conducted in five districts of Bihar and involving 1,119 respondents, this article examines the role of schemes initiated by the Bihar Government to achieve a dramatic transformation in female literacy. It argues that the schemes, though successful in taking care of economic factors that act as hurdles in the enrolment and retention of girls in schools, suffer limitations in their implementation and also overlook the importance of other factors that impact the girl child’s education, especially at the school level. At the same time, though there is an overemphasis on increasing the number of learners, the issue of quality in education has been grossly neglected. The article concludes that, in the long run, neglecting school-related factors and the quality of education defeats the real purpose of the schemes. Based on the study, some recommendations are also offered to manage the quantity–quality equilibrium in relation to girl child education.

Ensuring the ordinary: Politics and public service in municipal primary care in India

This paper examines the political embeddedness of public-sector primary care in urban India. The low quality of urban healthcare in many low- and middle-income countries is well documented. But there is relatively little analysis showing how the politics of urban healthcare delivery contribute to quality shortfalls. This study integrates urban and political theory and draws on ethnographic fieldwork in municipal government-run primary care clinics in Pune, India. I conceptualize Pune's municipal doctors as street-level bureaucrats: frontline state agents charged with delivering public services, who regularly confront conflicts between their mandate and its realization in practice. I observe how the municipal doctors experience and respond to these conflicts; delineate the historical design of the municipal institutions in which they operate; and interview doctors, nurses, nonclinical staff, administrators, and elected officials, who collectively shape primary care delivery in municipal clinics. My findings show how the doctors' work is characterized by routine departures from public service ideals. The departures stem from local electoral politics (politicians' patronage and clientelistic relations with municipal employees and patients) and weak administrative capacity (misuse and incompetent planning of public resources). The doctors are compelled to follow extra-policy directives, meaning instructions that have little to do with healthcare goals and that emphasize the political utility rather than medical purpose of their work. In response, the doctors circumscribe their clinical practice. They aim, as one doctor put it, only to "ensure the ordinary," or to sustain a deficient status quo. In these conditions, improving quality of care requires not just behavioral interventions targeted at doctors. It requires normative, social, and organizational shifts in public service planning and delivery so that doctors are positioned - materially and affectively - to meet urban healthcare challenges in low-resource contexts.

Analysis of implementation outcomes of quality improvement initiatives in Haiti: the fingerprint initiative

Objective

To assess the process and outcomes of the implementation of an electronic fingerprint initiative as part of quality improvement in three health facilities in the Northern Department of Haiti, in terms of its acceptability, adoption, feasibility, fidelity, and sustainability. In Haiti, poor attendance of the healthcare workforce is a nationwide problem, closely related to the quality of care. Three health institutions have tried to implement an electronic fingerprint system to monitor and improve attendance.

Methods

An exploratory and qualitative descriptive study of the implementation outcomes of the fingerprint initiative. It was based on semi-structured interviews and one group discussion using purposeful sampling techniques to recruit participants, and an open coding system and deductive approach to analyze the data using ATLAS.ti 8.

Results

The fingerprint initiative was successfully implemented in a non-governmental organization supported health facility but, despite some planning, it was never implemented in the public health facilities. The acceptability of the implementation was high in the not-for-profit organization and low in the public settings, mostly in relation to the presence of champions and the leadership at each health facility.

Conclusions

We recommend more involvement of the leadership of health facilities in the different phases of the implementation process in order to guarantee acceptability, adoption, fidelity and sustainabiliy. More research is needed to articulate this technology-driven initiative in the Haitian health system.

Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries

OBJECTIVE

Assess the quality of healthcare across African countries based on health providers' clinical knowledge, their clinic attendance and drug availability, with a focus on seven conditions accounting for a large share of child and maternal mortality in sub-Saharan Africa: malaria, tuberculosis, diarrhoea, pneumonia, diabetes, neonatal asphyxia and postpartum haemorrhage.

METHODS

With nationally representative, cross-sectional data from ten countries in sub-Saharan Africa, collected using clinical vignettes (to assess provider knowledge), unannounced visits (to assess provider absenteeism) and visual inspections of facilities (to assess availability of drugs and equipment), we assess whether health providers are available and have sufficient knowledge and means to diagnose and treat patients suffering from common conditions amenable to primary healthcare. We draw on data from 8061 primary and secondary care facilities in Kenya, Madagascar, Mozambique, Nigeria, Niger, Senegal, Sierra Leone, Tanzania, Togo and Uganda, and 22 746 health workers including doctors, clinical officers, nurses and community health workers. Facilities were selected using a multistage cluster-sampling design to ensure data were representative of rural and urban areas, private and public facilities, and of different facility types. These data were gathered under the Service Delivery Indicators programme.

RESULTS

Across all conditions and countries, healthcare providers were able to correctly diagnose 64% (95% CI 62% to 65%) of the clinical vignette cases, and in 45% (95% CI 43% to 46%) of the cases, the treatment plan was aligned with the correct diagnosis. For diarrhoea and pneumonia, two common causes of under-5 deaths, 27% (95% CI 25% to 29%) of the providers correctly diagnosed and prescribed the appropriate treatment for both conditions. On average, 70% of health workers were present in the facilities to provide care during facility hours when those workers are scheduled to be on duty. Taken together, we estimate that the likelihood that a facility has at least one staff present with competency and key inputs required to provide child, neonatal and maternity care that meets minimum quality standards is 14%. On average, poor clinical knowledge is a greater constraint in care readiness than drug availability or health workers' absenteeism in the 10 countries. However, we document substantial heterogeneity across countries in the extent to which drug availability and absenteeism matter quantitatively.

CONCLUSION

Our findings highlight the need to boost the knowledge of healthcare workers to achieve greater care readiness. Training programmes have shown mixed results, so systems may need to adopt a combination of competency-based preservice and in-service training for healthcare providers (with evaluation to ensure the effectiveness of the training), and hiring practices that ensure the most prepared workers enter the systems. We conclude that in settings where clinical knowledge is poor, improving drug availability or reducing health workers' absenteeism would only modestly increase the average care readiness that meets minimum quality standards.

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.

Health care provider time in public primary care facilities in Lima, Peru: a cross-sectional time motion study

BACKGROUND

In Peru, a majority of individuals bypass primary care facilities even for routine services. Efforts to strengthen primary care must be informed by understanding of current practice. We conducted a time motion assessment in primary care facilities in Lima with the goals of assessing the feasibility of this method in an urban health care setting in Latin America and of providing policy makers with empirical evidence on the use of health care provider time in primary care.

METHODS

This cross-sectional continuous observation time motion study took place from July - September 2019. We used two-stage sampling to draw a sample of shifts for doctors, nurses, and midwives in primary health facilities and applied the Work Observation Method by Activity Timing tool to capture type and duration of provider activities over a 6-h shift. We summarized time spent on patient care, paper and electronic record-keeping, and non-work (personal and inactive) activities across provider cadres. Observations are weighted by inverse probability of selection.

RESULTS

Two hundred seventy-five providers were sampled from 60 facilities; 20% could not be observed due to provider absence (2% schedule error, 8% schedule change, 10% failure to appear). One hundred seventy-four of the 220 identified providers consented (79.1%) and were observed for a total of 898 h of provider time comprising 30,312 unique tasks. Outpatient shifts included substantial time on patient interaction (110, 82, and 130 min for doctors, nurses, and midwives respectively) and on paper records (132, 97, and 141 min) on average. Across all shifts, 1 in 6 h was spent inactive or on personal activities. Two thirds of midwives used computers compared to half of nurses and one third of doctors.

CONCLUSIONS

The time motion study is a feasible method to capture primary care operations in Latin American countries and inform health system strengthening. In the case of Lima, absenteeism undermines health worker availability in primary care facilities, and inactive time further erodes health workforce availability. Productive time is divided between patient-facing activities and a substantial burden of paper-based record keeping for clinical and administrative purposes. Electronic health records remain incompletely integrated within routine care, particularly beyond midwifery.

Preventing rather than punishing: An early warning model of malfeasance in public procurement

Is it possible to predict malfeasance in public procurement? With the proliferation of e-procurement systems in the public sector, anti-corruption agencies and watchdog organizations have access to valuable sources of information with which to identify transactions that are likely to become troublesome and why. In this article, we discuss the promises and challenges of using machine learning models to predict inefficiency and corruption in public procurement. We illustrate this approach with a dataset with more than two million public procurement contracts in Colombia. We trained machine learning models to predict which of them will result in corruption investigations, a breach of contract, or implementation inefficiencies. We then discuss how our models can help practitioners better understand the drivers of corruption and inefficiency in public procurement. Our approach will be useful to governments interested in exploiting large administrative datasets to improve the provision of public goods, and it highlights some of the tradeoffs and challenges that they might face throughout this process.

Developing medical leadership in India: A mission impossible?

Purpose

Globally, there have been calls to enhance medical leadership in healthcare, although we know little about how this objective has been pursued in low-income middle-income contexts such as India. This paper highlights the opportunities to strengthen leadership in this context, while also considering the obstacles to this change and how they might be overcome.

Methods

The paper draws on a review of available secondary sources including published journal articles in the academic and grey literature, reports published by the Indian government and transnational organisations. The search focused specifically on medical leadership, clinical leadership, management and governance in the Indian healthcare system.

Findings

India is currently in the throes of the world’s biggest experiment in universal healthcare popularly known as ‘Modicare’. However, these reforms have been criticised with regard to the lack of solid healthcare management framework in the country. The current National Health Policy highlights the need for specialised ‘public health management cadre, human resource governance and leadership development’. Nevertheless, the available research highlights a gap in the research on this topic, specifically about the development of medical leadership competencies. Our findings highlight not only the opportunities to develop medical leadership but also the obstacles to this process. Inadequate training and education, spiralling workloads, low salaries in the public sector and a growing culture of kickbacks have all stifled attempts to engage more doctors in leadership roles.

Conclusions

While the Indian government is now focusing more on the need to strengthen medical leadership, there are significant barriers to change. In future, building leadership capabilities will require deeper reforms in training, regulation and remuneration of doctors to generate sufficient incentives especially in the public sector.

Healthcare worker attendance during the early stages of the COVID-19 pandemic: A longitudinal analysis of fingerprint-verified data from all public-sector secondary and tertiary care facilities in Bangladesh

Background

The COVID-19 pandemic has overwhelmed hospitals in several areas in high-income countries. An effective response to this pandemic requires health care workers (HCWs) to be present at work, particularly in low- and middle-income countries (LMICs) where they are already in critically low supply. To inform whether and to what degree policymakers in Bangladesh, and LMICs more broadly, should expect a drop in HCW attendance as COVID-19 continues to spread, this study aims to determine how HCW attendance has changed during the early stages of the COVID-19 pandemic in Bangladesh.

Methods

This study analyzed daily fingerprint-verified attendance data from all 527 public-sector secondary and tertiary care facilities in Bangladesh to describe HCW attendance from January 26, 2019 to March 22, 2020, by cadre, hospital type, and geographic division. We then regressed HCW attendance onto fixed effects for day-of-week, month, and hospital, as well as indicators for each of three pandemic periods: a China-focused period (January 11, 2020 (first confirmed COVID-19 death in China) until January 29, 2020), international-spread period (January 30, 2020 (World Health Organization’s declaration of a global emergency) until March 6, 2020), and local-spread period (March 7, 2020 (first confirmed COVID-19 case in Bangladesh) until the end of the study period).

Findings

On average between January 26, 2019 and March 22, 2020, 34.1% of doctors, 64.6% of nurses, and 70.6% of other health care staff were present for their scheduled shift. HCWs’ attendance rate increased with time in 2019 among all cadres. Nurses’ attendance level dropped by 2.5% points (95% confidence interval (CI) = -3.2% to -1.8%) and 3.5% points (95% CI = -4.5% to -2.5%) during the international-spread and the local-spread periods of the COVID-19 pandemic, relative to the China-focused period. Similarly, the attendance level of other health care staff declined by 0.3% points (95% CI = -0.8% to 0.2%) and 2.3% points (95% CI = -3.0% to -1.6%) during the international-spread and local-spread periods, respectively. Among doctors, however, the international-spread and local-spread periods were associated with a statistically significant increase in attendance by 3.7% points (95% CI = 2.5% to 4.8%) and 4.9% points (95% CI = 3.5% to 6.4%), respectively. The reduction in attendance levels across all HCWs during the local-spread period was much greater at large hospitals, where the majority of COVID-19 testing and treatment took place, than that at small hospitals.

Conclusions

After a year of significant improvements, HCWs’ attendance levels among nurses and other health care staff (who form the majority of Bangladesh’s health care workforce) have declined during the early stages of the COVID-19 pandemic. This finding may portend an even greater decrease in attendance if COVID-19 continues to spread in Bangladesh. Policymakers in Bangladesh and similar LMICs should undertake major efforts to achieve high attendance levels among HCWs, particularly nurses, such as by providing sufficient personal protective equipment as well as monetary and non-monetary incentives.