Cardiovascular disease contributes substantially to the non-communicable disease (NCD) burden in low-income and middle-income countries, which also often have substantial health personnel shortages. In this observational study the authors investigated whether community health workers could do community-based screenings to predict cardiovascular disease risk as effectively as could physicians or nurses, with a simple, non-invasive risk prediction indicator in low-income and middle-income countries. This observation study was done in Bangladesh, Guatemala, Mexico, and South Africa. Each site recruited at least ten to 15 community health workers based on usual site-specific norms for required levels of education and language competency. Community health workers had to reside in the community where the screenings were done and had to be fluent in that community's predominant language. These workers were trained to calculate an absolute cardiovascular disease risk score with a previously validated simple, non-invasive screening indicator. Community health workers who successfully finished the training screened community residents aged 35–74 years without a previous diagnosis of hypertension, diabetes, or heart disease. Health professionals independently generated a second risk score with the same instrument and the two sets of scores were compared for agreement. The study found that community health workers can be adequately trained to effectively screen for, and identify, people at high risk of cardiovascular disease.
Human Resources
This paper describes long-term treatment outcomes of a paediatric HIV cohort in Mozambique, in the Chamanculo Health District of Maputo. The subjects involved a total of 1,335 antiretroviral treatment (ART) naïve children <15 years of age enrolled in HIV care between 2002 and 2010. The interventions included HIV care, ART (since 2003), task shifting to lower cadre nurses, counseling by lay counselors, active patient tracing, nutritional support, support by a psychologist, targeted viral load testing, and switch to second-line treatment. The main outcome measures included Kaplan–Meier estimates for retention in care (RIC), CD4 cell percentage, body mass index for age z-score, and adjusted incidence rate ratios for attrition (death or loss to follow-up) as calculated by Poisson regression. The RIC at 6 years in the pre-ART cohort was 44% and the one at 8 years in the ART cohort was 70%. Risk factors for attrition included young age, low CD4 percentage, underweight, active tuberculosis, and enrollment/treatment initiation after 2006. The mean CD4 percentage increased strongly at 1 year on treatment and remained high thereafter. The body mass index for age sharply increased at 1 year after treatment initiation before stabilizing at pre-ART levels thereafter. The study concludes that good clinical and immunological treatment outcomes up to 8 years of follow-up on ART can be achieved in a context of shortage of health workers and a high level of task-shifting approach.
This article analyses the work of community disability workers (CDWs) in three southern African countries to demonstrate the competencies that these workers acquired to make a contribution to social justice for persons with disabilities and their families. It points to some gaps and then argues that these competencies should be consolidated and strengthened in curricula, training and policy. Purposive sampling was used to select and interviews held with 16 CDWs who had at least 5 years experience of disability-related work in a rural area. Three main themes emerged, related to the integrated management of health conditions and impairments within a family focus; disability-inclusive community development and coordinated intersectoral management systems. The CDWs were found to facilitate change and manage the multiple transitions experienced by the families at different stages of the disabled person’s development. Disability-inclusive development is argued to require a workforce equipped with skills to work intersectorally and in a cross-disciplinary manner to operationalise the community-based rehabilitation guidelines that are designed to promote delivery of services in remote and rural areas. The author argues for their recognition as a CDWs as a cross-disciplinary profession.
In Kenya, more than half of the women deliver without the assistance of a skilled attendant and this has contributed to high maternal mortality rates. The free maternal healthcare services policy in all public facilities was initiated as a strategy to improve access to skilled care and reduce poor maternal health outcomes. This study aimed to explore the perspectives of the service providers and facility administrators of the free maternal health care service policy that was introduced in Kenya in 2013. A qualitative inquiry using semi-structured one-on-one interviews was conducted in Malindi District, Kenya. The participants included maternal health service providers and facility administrators recruited from five different healthcare facilities. Free maternal healthcare service provision was perceived to boost skilled care utilisation during pregnancy and delivery. However, challenges including; delays in the reimbursement of funds by the government to the facilities, stock outs of essential commodities in the facilities to facilitate service provision, increased workload amidst staff shortage and lack of consultation and sensitisation of key stakeholders were perceived as barriers to effective implementation of this policy. The authors note that implementation of the policy would be more effective if; the healthcare facilities were upgraded, equipped with adequate supplies, funds and staff; the community are continually sensitised on the importance of seeking skilled care during pregnancy and delivery; and inclusivity and collaboration with other key stakeholders be fostered in addressing poor maternal health outcomes in the country.
The Institute of Development Studies (IDS) partnered with ActionAid International (AAI) in Uganda to develop and implement an advocacy strategy to make unpaid care work more visible in public policy, as well as to integrate unpaid care issues into each country’s programming. It used an action learning methodology to look at what works and does not work in making the care economy more visible. It aimed to track and capture changes in policy and practice in order to improve understanding around the uptake of evidence. This report covers the progress of the programme in Uganda over the first two and a half years of the four-year programme. The work identified that making unpaid care work more visible calls for a collective voice amongst those involved and engaging and working effectively with the media with clear messaging.
Community health workers (CHWs) are often spoken about or for, but there is little evidence of CHWs’ own characterisation of their practice. This paper addresses this issue. A case study approach was undertaken in a series of four steps. Firstly, groups of CHWs from two communities met and reported what their daily work consisted of. Secondly, individual CHWs were interviewed so that they could provide fuller, more detailed accounts of their work and experiences; in addition, community health extension workers and community health committee members were interviewed, to provide alternative perspectives. Thirdly, notes and observations were taken in community meetings and monthly meetings. The data were then analysed thematically, creating an account of how CHWs describe their own work, and the tensions and challenges that they face. CHWs’ accounts of both successes and challenges involved material elements: leaky tins and dishracks evidenced successful health interventions, whilst bicycles, empty first aid kits and recruiting stretcher bearers evidenced the difficulties of resourcing and geography they are required to overcome. CHWs described their work was as healthcare generalists, working to serve their community and to integrate it with the official health system. Their work involves referrals, monitoring, reporting and educational interactions. Whilst they face problems with resources and training, their accounts show that they respond to this in creative ways, working within established systems of community power and formal authority to achieve their goals, rather than falling into a ‘deficit’ position that requires remedial external intervention. Their work is widely appreciated, although some households do resist their interventions, and figures of authority sometimes question their manner and expertise. The material challenges that they face have both practical and community aspects, since coping with scarcity brings community members together. The authors suggest that programmes co-designed with CHWs will be easier to implement because of their relevance to their practices and experiences, whereas those that seek to use CHWs as an instrument to implement external priorities are likely to disrupt their work.
Mobile health (mHealth) applications, such as innovative electronic forms on smartphones, could potentially improve the performance of health care workers and health systems in developing countries. A pretested semistructured questionnaire was used to assess health workers’ experiences, barriers, preferences, and motivating factors in using mobile health forms on smartphones in the context of maternal health care in Ethiopia. Twenty-five health extension workers (HEWs) and midwives, working in 13 primary health care facilities in Tigray region, Ethiopia, participated in this study. Sixteen (69.6%) workers believed the forms were good reminders on what to do and what questions needed to be asked. Twelve (52.2%) workers said electronic forms were comprehensive and 9 (39.1%) workers saw electronic forms as learning tools. All workers preferred unrestricted use of the smartphones and believed it helped them adapt to the smartphones and electronic forms for work purposes. Identified barriers for not using electronic forms consistently included challenges related to electronic forms and smartphones and health system issues such as frequent movement of health workers. Both HEWs and midwives found the electronic forms on smartphones useful for their day-to-day maternal health care services delivery. However, tyhe authors found that sustainable use and implementation of such work tools at scale would be daunting without providing technical support to health workers, securing mobile network airtime and improving key functions of the larger health system.
New medical schools in Africa have developed curricula that include community and rural health components, long-term family attachments, and admission processes that are more equitable for disadvantaged students. These worthwhile innovations have been incorporated in previous reforms of medical education, but the authors ask in this paper if they are sufficient to meet the challenges of achieving universal health care.
Tanzania suffers a severe shortage of pharmaceutical staff negatively affecting the provision of pharmaceutical services and access to medicines, particularly in rural areas. Task shifting has been proposed as a way to mitigate this. This study aimed to understand the context and extent of task shifting in pharmaceutical management in Dodoma Region, Tanzania. The authors explored 1) the number of trained pharmaceutical staff as compared to clinical cadres managing medicines, 2) the national establishment for staffing levels, 3) job descriptions, 4) supply management training conducted and 5) availability of medicines and adherence to Good Storage Practice in 270 public health facilities in 2011. In 95.5% of studied health facilities medicines management was done by non-pharmaceutically trained cadres, predominantly medical attendants. Task shifting was found to be a reality in the pharmaceutical sector in Tanzania occurring mainly as a coping mechanism rather than a formal response to the workforce crisis. Pharmacy-related tasks and supply management were informally shifted to clinical staff without policy guidance, explicit job descriptions, and without the necessary support through training. It was argued that implicit task shifting be recognised and formalised and job orientation, training and operational procedures be used to support non-pharmaceutical health workers to effectively manage medicine supply.
Nurses have long been identified as key contributors to strategies to reduce health inequalities. This qualitative research project explored public health nurse educators’ understanding of public health as a strategy to reduce health inequalities. 26 semi-structured interviews were conducted with higher education institution-based public health nurse educators. Public health nurse educators described health inequalities as the foundation on which a public health framework should be built. Two distinct views emerged of how health inequalities should be tackled: some proposed a population approach focusing on upstream preventive strategies, whilst others proposed behavioural approaches focusing on empowering vulnerable individuals to improve their own health. Despite upstream interventions to reduce inequalities in health being proved to have more leverage than individual behavioural interventions in tackling the fundamental causes of health inequalities, some nurses have a better understanding of individual interventions than population approaches.