A novel approach to estimate the impact of health workforce investments on health outcomes through increased coverage of HIV, TB and malaria services

BACKGROUND

Globally, HIV, TB and malaria account for an estimated three million deaths annually. The Global Fund partnered with the World Health Organization to assist countries with health workforce planning in these areas through the development of an integrated health workforce investment impact tool. Our study illustrates the development of a user-friendly tool (with two MS Excel calculator subcomponents) that computes associations between human resources for health (HRH) investment inputs and reduced morbidity and mortality from HIV, TB, and malaria via increased coverage of effective treatment services.

METHODS

We retrieved from the peer-reviewed literature quantitative estimates of the relation among HRH inputs and HRH employment and productivity. We converted these values to additional full-time-equivalent doctors, nurses and midwives (DNMs). We used log-linear regression to estimate the relation between DNMs and treatment service coverage outcomes for HIV, TB, and malaria. We then retrieved treatment effectiveness parameters from the literature to calculate lives saved due to expanded treatment coverage for HIV, TB, and malaria. After integrating these estimates into the tool, we piloted it in four countries.

RESULTS

In most countries with a considerable burden of HIV, TB, and malaria, the health workforce investments include a mix of pre-service education, full remuneration of new hires, various forms of incentives and in-service training. These investments were associated with elevated HIV, TB and malaria treatment service coverage and additional lives saved. The country case studies we developed in addition, indicate the feasibility and utility of the tool for a variety of international and local actors interested in HRH planning.

CONCLUSIONS

The modelled estimates developed for illustrative purposes and tested through country case studies suggest that HRH investments result in lives saved across HIV, TB, and malaria. Furthermore, findings show that attainment of high targets of specific treatment coverage indicators would require a substantially greater health workforce than what is currently available in most LMICs. The open access tool can assist with future HRH planning efforts, particularly in LMICs.

The roles and involvement of global health partners in the health workforce: an exploratory analysis

Development partners and global health initiatives are important actors in financing health systems in many countries. Despite the importance of the health workforce to the attainment of global health targets, the contribution of global health initiatives to health workforce strengthening is unclear. A 2020 milestone in the Global Strategy on Human Resources for Health is that "all bilateral and multilateral agencies have participated in efforts to strengthen health workforce assessments and information exchange in countries." This milestone exists to encourage strategic investments in the health workforce that are evidence-based and incorporate a health labour market approach as an indication of policy comprehensiveness. To assess progress against this milestone, we reviewed the activities of 23 organizations (11 multilaterals and 12 bilaterals) which provide financial and technical assistance to countries for human resources for health, by mapping grey and peer-reviewed literature published between 2016 and 2021. The Global Strategy states that health workforce assessment involves a "deliberate strategy and accountability mechanisms on how specific programming contributes to health workforce capacity-building efforts" and avoids health labour market distortions. Health workforce investments are widely recognized as essential for the achievement of global health goals, and some partners identify health workforce as a key strategic focus in their policy and strategy documents. However, most do not identify it as a key focus, and few have a published specific policy or strategy to guide health workforce investments. Several partners include optional health workforce indicators in their monitoring and evaluation processes and/or require an impact assessment for issues such as the environment and gender equality. Very few, however, have embedded efforts in their governance mechanisms to strengthen health workforce assessments. On the other hand, most have participated in health workforce information exchange activities, including strengthening information systems and health labour market analyses. Although there is evidence of participation in efforts to strengthen health workforce assessments and (especially) information exchange, the achievement of this milestone of the Global Strategy requires more structured policies for the monitoring and evaluation of health workforce investments to optimize the value of these investments and contribute towards global and national health goals.

Planetary health benefits from strengthening health workforce education on the social determinants of health

Social inequalities are perpetuating unhealthy living and working conditions and behaviours. These causes are commonly called 'the social determinants of health'. Social inequalities are also impacting climate change and vice-versa, which, is causing profound negative impacts on planetary health. Achieving greater sustainability for human and planetary health demands that the health sector assumes a greater leadership role in addressing social inequalities. This requires equipping health and social care workers to better understand how the social determinants of health impact patients and communities. Integration of the social determinants of health into education and training will prepare the workforce to adjust clinical practice, define appropriate public health programmes and leverage cross-sector policies and mechanisms being put in place to address climate change. Educators should guide health and social workforce learners using competency-based approaches to explore critical pathways of social determinants of health, and what measurements and interventions may apply according to the structural and intermediary determinants of health and health equity. Key institutional and instructional reforms by decision-makers are also needed to ensure that the progressive integration and strengthening of education and training on the social determinants of health is delivered equitably, including by ensuring the leadership and participation of marginalized and minority groups. Training on the social determinants of health should apply broadly to three categories of health and social workforce learners, namely, those acting on global or national policies; those working in districts and communities; and those providing clinical services to individual families and patients.

Digital Education for Health Professionals: An Evidence Map, Conceptual Framework, and Research Agenda

BACKGROUND

Health professions education has undergone major changes with the advent and adoption of digital technologies worldwide.

OBJECTIVE

This study aims to map the existing evidence and identify gaps and research priorities to enable robust and relevant research in digital health professions education.

METHODS

We searched for systematic reviews on the digital education of practicing and student health care professionals. We searched MEDLINE, Embase, Cochrane Library, Educational Research Information Center, CINAHL, and gray literature sources from January 2014 to July 2020. A total of 2 authors independently screened the studies, extracted the data, and synthesized the findings. We outlined the key characteristics of the included reviews, the quality of the evidence they synthesized, and recommendations for future research. We mapped the empirical findings and research recommendations against the newly developed conceptual framework.

RESULTS

We identified 77 eligible systematic reviews. All of them included experimental studies and evaluated the effectiveness of digital education interventions in different health care disciplines or different digital education modalities. Most reviews included studies on various digital education modalities (22/77, 29%), virtual reality (19/77, 25%), and online education (10/77, 13%). Most reviews focused on health professions education in general (36/77, 47%), surgery (13/77, 17%), and nursing (11/77, 14%). The reviews mainly assessed participants' skills (51/77, 66%) and knowledge (49/77, 64%) and included data from high-income countries (53/77, 69%). Our novel conceptual framework of digital health professions education comprises 6 key domains (context, infrastructure, education, learners, research, and quality improvement) and 16 subdomains. Finally, we identified 61 unique questions for future research in these reviews; these mapped to framework domains of education (29/61, 47% recommendations), context (17/61, 28% recommendations), infrastructure (9/61, 15% recommendations), learners (3/61, 5% recommendations), and research (3/61, 5% recommendations).

CONCLUSIONS

We identified a large number of research questions regarding digital education, which collectively reflect a diverse and comprehensive research agenda. Our conceptual framework will help educators and researchers plan, develop, and study digital education. More evidence from low- and middle-income countries is needed.

Increasing access to health workers in rural and remote areas: what do stakeholders' value and find feasible and acceptable?

BACKGROUND

The primary aim of this study is to assess stakeholders' views of the acceptability and feasibility of policy options and outcome indicators presented in the 2010 World Health Organization (WHO) global policy recommendations on increasing access to health workers in remote and rural areas through improved retention.

METHODS

A survey on the acceptability, feasibility of recruitment and retention policy options, and the importance of their outcome indicators was developed. It followed a cross-sectional approach targeting health workers in rural and remote settings as well as policy- and decision-makers involved in the development of recruitment and retention policies for such areas. Respondents were asked their perception of the importance of the policy outcomes of interest, as well as the acceptability and feasibility of the 2010 WHO guidelines' policy options using a 9-point Likert scale.

RESULTS

In total, 336 participants completed the survey. Almost a third worked in government; most participants worked in community settings and were involved in the administration and management of rural health workers. Almost all 19 outcomes of interests assessed were valued as important or critical. For the 16 guideline policy options, most were perceived to be "definitely acceptable" and "definitely feasible", although the policy options were generally considered to be more acceptable than feasible.

CONCLUSION

The findings of this study provide insight into the revision and update of the 2010 WHO guideline on increasing access to health workers in remote and rural areas. Stakeholders' views of the acceptability, feasibility of policy options and the importance of outcomes of interest are important for the development of relevant and effective policies to improve access to health workers in rural and remote areas.

Correction to: Are the Global Strategic Directions for Strengthening Nursing and Midwifery 2016-2020 being implemented in countries? Findings from a cross-sectional analysis

An amendment to this paper has been published and can be accessed via the original article.

Health Professions Digital Education on Antibiotic Management: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration

BACKGROUND

Inappropriate antibiotic prescription is one of the key contributors to antibiotic resistance, which is managed with a range of interventions including education.

OBJECTIVE

We aimed to summarize evidence on the effectiveness of digital education of antibiotic management compared to traditional education for improving health care professionals' knowledge, skills, attitudes, and clinical practice.

METHODS

Seven electronic databases and two trial registries were searched for randomized controlled trials (RCTs) and cluster RCTs published between January 1, 1990, and September 20, 2018. There were no language restrictions. We also searched the International Clinical Trials Registry Platform Search Portal and metaRegister of Controlled Trials to identify unpublished trials and checked the reference lists of included studies and relevant systematic reviews for study eligibility. We followed Cochrane methods to select studies, extract data, and appraise and synthesize eligible studies. We used random-effect models for the pooled analysis and assessed statistical heterogeneity by visual inspection of a forest plot and calculation of the I² statistic.

RESULTS

Six cluster RCTs and two RCTs with 655 primary care practices, 1392 primary care physicians, and 485,632 patients were included. The interventions included personal digital assistants; short text messages; online digital education including emails and websites; and online blended education, which used a combination of online digital education and traditional education materials. The control groups received traditional education. Six studies assessed postintervention change in clinical practice. The majority of the studies (4/6) reported greater reduction in antibiotic prescription or dispensing rate with digital education than with traditional education. Two studies showed significant differences in postintervention knowledge scores in favor of mobile education over traditional education (standardized mean difference=1.09, 95% CI 0.90-1.28; I²=0%; large effect size; 491 participants [2 studies]). The findings for health care professionals' attitudes and patient-related outcomes were mixed or inconclusive. Three studies found digital education to be more cost-effective than traditional education. None of the included studies reported on skills, satisfaction, or potential adverse effects.

CONCLUSIONS

Findings from studies deploying mobile or online modalities of digital education on antibiotic management were complementary and found to be more cost-effective than traditional education in improving clinical practice and postintervention knowledge, particularly in postregistration settings. There is a lack of evidence on the effectiveness of other digital education modalities such as virtual reality or serious games. Future studies should also include health care professionals working in settings other than primary care and low- and middle-income countries.

CLINICAL TRIAL

PROSPERO CRD42018109742; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=109742.

Are the Global Strategic Directions for Strengthening Nursing and Midwifery 2016-2020 being implemented in countries? Findings from a cross-sectional analysis

BACKGROUND

Nurses and midwives are the largest component of the health workforce in many countries. The World Health Organization (WHO) together with its partners facilitates the joint development of strategic policy guidance for countries to support the optimization of their nursing and midwifery workforce. The Global Strategic Directions for Strengthening Nursing and Midwifery 2016-2020 (SDNM) is a global policy guidance tool that provides a framework for Member States, the WHO and its partners to adapt, develop, implement and evaluate nursing and midwifery policy interventions in Member States. As part of the broader monitoring and accountability functions of the WHO, assessing the progress of the SDNM implementation at a country level is key to ensuring that countries stay on track towards achieving universal health coverage (UHC) and the sustainable development goals (SDGs).

METHODS

This is a cross-sectional mixed methods study involving the analysis of quantitative and qualitative data on the implementation of country-level interventions in the SDNM. Data was provided by government chief nursing and midwifery officers or their representatives using an online self-reported questionnaire. The quantitative data was assessed using a three-level scale and descriptive statistics while qualitative comments were analysed and presented narratively.

RESULTS

Thirty-five countries completed the survey. Summing up the implementation frequency of interventions across all thematic areas, 19% of responses were in the category of "completed"; 55% were reportedly "in progress" and 26% indicated a status of "not started". Findings reveal a stronger level of implementation for areas of nursing and midwifery development related to enhancing regulation and education, creating stronger roles for professional associations and policy strengthening. Leadership and interprofessional collaboration are intervention areas that were less implemented.

CONCLUSION

Monitoring and accountability of countries' commitments towards implementing nursing and midwifery interventions, as outlined in the SDNM, contributes to strengthening the evidence base for policy reforms in countries. This stock-taking can inform policy- and decision-makers' deliberations on strengthening the contributions of nurses and midwives to achieving UHC and the SDGs.

Stakeholders' perceptions of policy options to support the integration of community health workers in health systems

BACKGROUND

Community health workers (CHWs) are an important component of the health workforce in many countries. The World Health Organization (WHO) has developed a guideline to support the integration of CHWs into health systems. This study assesses stakeholders' valuation of outcomes of interest, acceptability and feasibility of policy options considered for the CHW guideline development.

METHODS

A cross-sectional mixed methods (quantitative and qualitative) study targeting stakeholders involved directly or indirectly in country implementation of CHW programmes was conducted in 2017. Data was collected from 96 stakeholders from five WHO regions using an online questionnaire. A Likert scale (1 to 9) was used to grade participants' assessments of the outcomes of interest, and the acceptability and feasibility of policy options were considered.

RESULTS

All outcomes of interest were considered by at least 90% of participants as 'important' or 'critical'. Most critical outcomes were 'improved quality of CHW health services' and 'increased health service coverage' (91.5% and 86.2% participants judging them as 'critical' respectively). Out of 40 policy options, 35 were considered as 'definitely acceptable' and 36 'definitely feasible' by most participants. The least acceptable option (37% of participants rating 'definitely not acceptable') was the selection of candidates based on age. The least feasible option (29% of participants rating 'definitely not feasible') was the selection of CHWs with a minimum of secondary education.

CONCLUSION

Outcomes of interest and policy options proposed were rated highly by most stakeholders. This finding helps to reinforce their usefulness in meeting the expectations of the CHW guideline end-users to properly integrate CHWs into health systems.

Health policy and system support to optimise community health worker programmes: an abridged WHO guideline

Optimising community health worker (CHW) programmes requires evidence-based policies on their education, deployment, and management. This guideline aims to inform efforts by planners, policy makers, and managers to improve CHW programmes as part of an integrated approach to strengthen primary health care and health systems. The development of this guideline followed the standard WHO approach to developing global guidelines. We conducted one overview of reviews, 15 systematic reviews (each one on a specific policy question), and a survey of stakeholders' views on the acceptability and feasibility of the interventions under consideration. We assessed the quality of systematic reviews using the AMSTAR tool, and the certainty of the evidence using the GRADE methodology. The overview of reviews identified 122 eligible articles and the systematic reviews identified 137 eligible primary studies. The stakeholder perception survey obtained inputs from 96 respondents. Recommendations were developed in the areas of CHW selection, preservice education, certification, supervision, remuneration and career advancement, planning, community embeddedness, and health system support. These are the first evidence-based global guidelines for health policy and system support to optimise community health worker programmes. Key considerations for implementation include the need to define the role of CHWs in relation to other health workers and plan for the health workforce as a whole rather than by specific occupational groups; appropriately integrate CHW programmes into the general health system and existing community systems; and ensure internal coherence and consistency across different policies and programmes affecting CHWs.