This study interviewed healthcare workers involved in tuberculosis (TB) control on what they consider to be the drivers of the TB epidemic in Angola. Twenty four in-depth qualitative interviews were conducted with medical staff working in this field in the provinces of Luanda and Benguela. The healthcare professionals see the migrant working poor as a particular problem for the control of TB. Migrants are constructed as ‘Rural People’ and are seen as non-compliant and late-presenting. This is a stigmatized and marginal group contending with the additional stigma associated with TB infection. The healthcare professionals interviewed also see the interruption of treatment and self-medication generally as a better explanation for the TB epidemic than urbanization or lack of medication. The local narrative is in contrast to explanations used elsewhere. To be effective policy must recognize the local issues of the migrant workforce, interruption of treatment and the stigma associated with TB in Angola.
Human Resources
This paper presents findings from a study which sought to understand why health workers working under the results-based financing (RBF) arrangements in Zimbabwe reported being satisfied with the improvements in working conditions and compensation, but paradoxically reported lower motivation levels compared to those not working under RBF arrangements. A qualitative study was conducted amongst health workers and managers working in health facilities that were implementing the RBF arrangements and those that were not. Through purposeful sampling, 4 facilities in RBF implementing districts that reported poor motivation and satisfaction, were included as study sites. Four facilities located in non-RBF districts which reported high motivation and satisfaction were also included. Data was collected through in-depth interviews and analyzed using the framework approach. Findings reveal that insufficient preparedness of people and processes for this change, constrained managers and workers performance. Results based financing arrangements introduce explicit and tacit changes, including but not limited to, incentive logics, in the system. Findings show that unless systematic efforts are made to enable the absorption of these changes in the system: eg, through reconfiguring the decision space available at various levels, through clarification of accountability relationships, through building personnel and process capacities, before instituting changes, the full potential of the RBF arrangements cannot be realised. This study demonstrates the importance of analysing existing institutional, management and governance arrangements and capabilities and taking these into account when designing and implementing RBF interventions. Introducing RBF arrangements cannot alone overcome chronic systemic weaknesses. For a system wide change, as RBF arguably is, to be effected, explicit organisational change management processes need to be put in place, across the system. The authors argue that carefully designed processes, which take into account the interest and willingness of various actors to change, and which are cognizant of and constructively engage with potential bottlenecks and points of resistance, should accompany any health system change initiative.
This paper reviews Malawi’s strategy, with particular focus on the interface between health surveillance assistants (HSAs), volunteers in community-based programmes and the community health team. The authors analysis identified key challenges that may impede the strategy’s implementation inadequate training, imbalance of skill sets within community health team (CHT) and unclear job descriptions for community health volunteers (CHVs); proposed community-level interventions require expansion of pre-existing roles for most CHT members; and district authorities may face challenges meeting financial obligations and filling community-level positions. For effective implementation, attention and further deliberation is argued to be needed on the appropriate CHV support, CHT composition with possibilities of co-opting trained CHVs from existing volunteer programmes into CHTs, review of CHT competencies and workload and strengthening coordination and communication across all community actors.
In this paper, the authors investigated the comprehensibility and the internal reliability of Context Assessment for Community Health and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique. The cross-sectional survey using Context Assessment for Community Health, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique. Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the work culture, leadership, and Informal payment dimensions.
This paper explores the differential roles of male and female Community health workers (CHWs)in rural Wakiso district, Uganda, using photovoice, a community-based participatory research approach. The authors trained ten CHWs on key concepts about gender and photovoice. The CHWs took photographs for 5 months on their gender-related roles which were discussed in monthly meetings. The discussions from the meetings were recorded, transcribed, and translated to English, and emerging data were analysed using content analysis. Although responsibilities were the same for both male and female CHWs, they reported that in practice, CHWs were predominantly involved in different types of work depending on their gender. Social norms led to men being more comfortable seeking care from male CHWs and females turning to female CHWs. Due to their privileged ownership and access to motorcycles, male CHWs were noted to be able to assist patients faster with referrals to facilities during health emergencies, cover larger geographic distances during community mobilization activities, and take up supervisory responsibilities. Due to the gendered division of labour in communities, male CHWs were also observed to be more involved in manual work such as cleaning wells. The gendered division of labour also reinforced female caregiving roles related to child care, and also made female CHWs more available to address local problems. CHWs reflected both strategic and conformist gendered implications of their community work. The authors argue that the differing roles and perspectives about the nature of male and female CHWs while performing their roles should be considered while designing and implementing CHW programmes, without further retrenching gender inequalities or norms.
This pilot study compares traditional training with using locally made videos loaded onto low-cost Android tablets to train community health workers (CHWs)on the pneumonia component of Integrated Community Case Management (iCCM). The authors conducted a pilot randomised controlled trial with CHWs in the Mukono District of Uganda. The unit of randomisation was the sub-county level, and the unit of analysis was at the level of the individual CHW. Eligible CHWs had completed basic iCCM training but had not received any refresher training on the pneumonia component of iCCM in the preceding 2 years. CHWs in the control group received training in the recognition, treatment, and prevention of pneumonia as it is currently delivered, through a 1-day, in-person workshop. CHWs allocated to the intervention group received training via locally made educational videos hosted on low-cost Android tablets. The primary outcome was change in knowledge acquisition, assessed through a multiple-choice questionnaire before and after training, and a post-training clinical assessment. The secondary outcome was a qualitative evaluation of CHW experiences of using the tablet platform. In the study, 129 CHWs were enrolled, 66 and 63 in the control and intervention groups respectively. CHWs in both groups demonstrated an improvement in multiple choice question test scores before and after training; however, there was no statistically significant difference in the improvement between groups. There was a statistically significant positive correlation linking years of education to improvement in test scores in the control group, which was not present in the intervention group. The majority of CHWs expressed satisfaction with the use of tablets as a training tool; however, some reported technical issues. The authors note that tablet-based training is comparable to traditional training in terms of knowledge acquisition. It also proved to be feasible and a satisfactory means of delivering training to CHWs. They argue that further research is required to understand the impacts of scaling such an intervention.
This study examines the behaviour change-related activities of community health volunteers (CHVs) community health workers affiliated with the Kenyan Ministry of Health in a peri-urban settlement in Kenya, in order to assess their capabilities, opportunities to work effectively, and sources of motivation. This mixed-methods study included a census of 16 CHVs who work in the study area. All CHVs participated in structured observations of their daily duties, structured questionnaires, in-depth interviews, and two focus group discussions. In addition to their responsibilities with the Ministry of Health, CHVs partnered with a range of non-governmental organizations engaged in health and development programming, often receiving small stipends from these organizations. CHVs reported employing a limited number of behaviour change techniques when interacting with community members at the household level. While supervision and support from the MOH was robust, CHV training was inconsistent and inadequate with regard to behaviour change and CHVs often lacked material resources necessary for their work. CHVs spent very little time with the households in their allocated catchment area. The number of households contacted per day was insufficient to reach all assigned households within a given month as required and the brief time spent with households limited the quality of engagement. Lack of compensation was noted as a demotivating factor for CHVs. This was compounded by the challenging social environment and CHVs’ low motivation to encourage behaviour change in local communities. In a complex urban environment, CHVs faced challenges that limited their capacity to be involved in behaviour change interventions. The authors argue that more resources, better coordination, and additional training in modern behaviour change approaches are needed to ensure their optimal performance in implementing health programmes.
This paper examines and seeks to contribute to understanding of external multiple job holding practices in public health training institutions based in prominent public universities in three sub-Saharan Africa countries. A qualitative multiple case study approach was used. Data were collected through document reviews and in-depth interviews with 18 key informants. Data were then triangulated and analyzed thematically. External multiple job holding practices among faculty of the three public health training institutions were widely prevalent. Different factors at individual, institutional, and national levels were reported to underlie and mediate the practice. While the authors report that it contributes to increasing income of academics, which many described as enabling their continuing employment in the public sector, many pointed to negative effects. Similarities were found regarding the nature and drivers of the practice across the institutions, but differences exist with respect to mechanisms for and extent of regulation. Regulatory mechanisms were often not clear or enforced, and academics are often left to self-regulate their engagement. Lack of regulation is cited as allowing excessive engagement in multiple job holding practice among academics at the expense of their core institutional responsibility. This could further weaken institutional capacity and performance, and quality of training and support to students. The research describes the complexity of external multiple job holding practices, which is characterized by a cluster of drivers, multiple processes and actors, and lack of consensus about its implication for individual and institutional capacity. They argue that in the absence of a strong accountability mechanism, the practice could perpetuate and aggravate the fledgling capacity of public health training institutions.
In this paper the authors present a systematic review of empirical studies investigating the relationship between human resource management and performance in Sub-Saharan Africa hospitals, based on a total of 111 included studies that represent 19 out of 48 Sub-Saharan Africa countries. From a human resource management perspective, most studies researched human practices from motivation-enhancing, skills-enhancing, and empowerment-enhancing domains. Motivation-enhancing practices were most frequently researched, followed by skills-enhancing practices and empowerment-enhancing practices. Few studies focused on single human resource management practices. Training and education were the most researched single practices, followed by task shifting. Most studies report human resource management interventions to have positively impacted performance in one way or another. The authors found that specific outcome improvements can be accomplished by different human resource management interventions and conversely that similar human resource management interventions are reported to affect different outcome measures. The review also identified little evidence on the relationship between human resource management and patient outcomes and the evidence often fails to provide contextual characteristics which can affect the impact of human resource management interventions. The authors call for more coordinated research efforts.
The paper synthesizes the current understanding of how community-based health worker programs can best be designed and operated in health systems. The authors searched 11 databases for review articles published between January 2005 and June 2017. The authors identified 122 reviews, 83 from low- and middle-income countries, 29 from high income countries and 10 global. Community-based health worker programs included in these reviews are diverse in interventions provided, selection and training of community-based health workers, supervision, remuneration, and integration into the health system. Features that enable positive community-based health worker program outcomes include community embeddedness, supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of community-based health worker programs into health systems can bolster program sustainability and credibility, clarify community-based health worker roles, and foster collaboration between community-based health workers and higher-level health system actors. The authors found gaps in the review evidence, including on the rights and needs of community-based health workers, on effective approaches to training and supervision, on community-based health workers as community change agents, and on the influence of health system decentralization, social accountability, and governance.