http://www.human-resources-health.com The latest research articles published by Human Resources for Health 2012-02-01T00:00:00Z Background: Modern healthcare managers are faced with pressure to deliver effective, efficient services within the context of fixed budget constraints. Managers are required to make decisions regarding the skill mix of the workforce particularly when staffing new services. One measure used to identify numbers and mix of staff in healthcare settings is workforce ratio. The aim of this study was to identify workforce ratios in nine allied health professions and to identify whether these measures are useful for planning allied health workforce requirements. Methods: A systematic literature search using relevant MeSH headings of business, medical and allied health databases and relevant grey literature for the period 2000-2008 was undertaken. Results: Twelve articles were identified which described the use of workforce ratios in allied health services. Only one of these was a staffing ratio linked to clinical outcomes. The most comprehensive measures were identified in rehabilitation medicine. Conclusion: The evidence for use of staffing ratios for allied health practitioners is scarce and lags behind the fields of nursing and medicine. http://www.human-resources-health.com/content/10/1/2 Linda Cartmill Tracy Comans Michele Clark Susan Ash Lorraine Sheppard Human Resources for Health 2012, null:2 2012-02-01T00:00:00Z doi:10.1186/1478-4491-10-2 /content/figures/1478-4491-10-2-toc.gif Human Resources for Health 1478-4491 ${item.volume} 2 2012-02-01T00:00:00Z PDF Background: One group often identified as having low socioeconomic status, those living in remote or rural areas, are often recognised as bearing an unequal burden of illness in society. This paper aims to examine equity of utilisation of general practitioner services in Australia. Methods: Using the 2005 National Health Survey undertaken by the Australian Bureau of Statistics a microsimulation model was developed to determine the distribution of GP services that would occur if all Australians had equal utilisation of health services relative to need. Results: It was estimated that those who are unemployed would experience a 19% increase in GP services. Persons residing in regional areas would receive about 5.7 million additional GP visits per year if they had the same access to care as Australians residing in major cities. This would be a 18% increase. There would be a 20% increase for inner regional residents and a 14% increase for residents of more remote regional areas. Overall there would be a 5% increase in GP visits nationally if those in regional areas had the same access to care as those in major cities. Conclusion: Parity is an insufficient goal and disadvantaged persons and underserved areas require greater access to health services than the well served metropolitan areas due to their greater poverty and poorer health status. Currently under-served Australians suffer a double disadvantage: poorer health and poorer access to health services. http://www.human-resources-health.com/content/10/1/1 Deborah Schofield Rupendra Shrestha Emily Callander Human Resources for Health 2012, null:1 2012-01-22T00:00:00Z doi:10.1186/1478-4491-10-1 /content/figures/1478-4491-10-1-toc.gif Human Resources for Health 1478-4491 ${item.volume} 1 2012-01-22T00:00:00Z PDF IntroductionCurrent health policy directions in Zambia are formulated in the National Health Strategic Plan. The Plan focuses on national health priorities, which include the human resources (HR) crisis. In this paper we describe the way the HRH establishment is distributed in the different provinces of Zambia, with a view to assess the dimension of shortages and of imbalances in the distribution of health workers by province and by level of care.Population and methodsWe used secondary data from the "March 2008 payroll data base", which lists all the public servants on the payroll of the Ministry of Health and of the National Health Service facilities. We computed rates and ratios and compared them. Results: The highest relative concentration of all categories of workers was observed in Northern, Eastern, Lusaka, Western and Luapula provinces (in decreasing order of number of health workers).The ratio of clinical officers (mid-level clinical practitioners) to general medical officer (doctors with university training) varied from 3.77 in the Lusaka to 19.33 in the Northwestern provinces. For registered nurses (3 to 4 years of mid-level training), the ratio went from 3.54 in the Western to 15.00 in Eastern provinces and for enrolled nurses (two years of basic training) from 4.91 in the Luapula to 36.18 in the Southern provinces.This unequal distribution was reflected in the ratio of population per cadre. The provincial distribution of personnel showed a skewed staff distribution in favour of urbanized provinces, e.g. in Lusaka's doctor: population ratio was 1: 6,247 compared to Northern province's ratio of 1: 65,763.In the whole country, the data set showed only 109 staff in health posts: 1 clinical officer, 3 environmental health technologists, 2 registered nurses, 12 enrolled midwives, 32 enrolled nurses, and 59 other.The vacancy rates for level 3 facilities(central hospitals, national level) varied from 5% in Lusaka to 38% in Copperbelt Province; for level 2 facilities (provincial level hospitals), from 30% for Western to 70% for Copperbelt Province; for level 1 facilities (district level hospitals), from 54% for the Southern to 80% for the Western provinces; for rural health centres, vacancies varied from 15% to 63% (for Lusaka and Luapula provinces respectively); for urban health centres the observed vacancy rates varied from 13% for the Lusaka to 96% for the Western provinces. We observed significant shortages in most staff categories, except for support staff, which had a significant surplus.Discussion and ConclusionsThis case study documents how a peaceful, politically stable African country with a longstanding tradition of strategic management of the health sector and with a track record of innovative approaches dealt with its HRH problems, but still remains with a major absolute and relative shortage of health workers. The case of Zambia reinforces the idea that training more staff is necessary to address the human resources crisis, but it is not sufficient and has to be completed with measures to mitigate attrition and to increase productivity. http://www.human-resources-health.com/content/9/1/30 Paulo Ferrinho Seter Siziya Fastone Goma Gilles Dussault Human Resources for Health 2011, null:30 2011-12-19T00:00:00Z doi:10.1186/1478-4491-9-30 /content/figures/1478-4491-9-30-toc.gif Human Resources for Health 1478-4491 ${item.volume} 30 2011-12-19T00:00:00Z PDF Despite an increase in efforts to address shortage and performance of Human Resources for Health (HRH), HRH problems continue to hamper quality service delivery. We believe that the influence of governance is undervalued in addressing the HRH crisis, both globally and at country level. This thematic series has aimed to expand the evidence base on the role of governance in addressing the HRH crisis. The six articles comprising the series present a range of experiences. The articles report on governance in relation to developing a joint vision, building adherence and strengthening accountability, and on governance with respect to planning, implementation, and monitoring. Other governance issues warrant attention as well, such as corruption and transparency in decision-making in HRH policies and strategies. Acknowledging and dealing with governance should be part and parcel of HRH planning and implementation. To date, few experiences have been shared on improving governance for HRH policy making and implementation, and many questions remain unanswered. There is an urgent need to document experiences and for mutual learning. http://www.human-resources-health.com/content/9/1/29 Marjolein Dieleman Thea Hilhorst Human Resources for Health 2011, null:29 2011-11-24T00:00:00Z doi:10.1186/1478-4491-9-29 /content/figures/1478-4491-9-29-toc.gif Human Resources for Health 1478-4491 ${item.volume} 29 2011-11-24T00:00:00Z PDF Background: With 15-30% met need for comprehensive emergency obstetrical care (CEmOC) and a 3% caesarean section rate, Tanzania needs to expand the number of facilities providing these services in more remote areas. Considering severe shortage of human resources for health in the country, currently operating at 32% of the required skilled workforce, an intensive three-month course was developed to train non-physician clinicians for remote health centres. Methods: Competency-based curricula for assistant medical officers' (AMOs) training in CEmOC, and for nurses, midwives and clinical officers in anaesthesia and operation theatre etiquette were developed and implemented in Ifakara, Tanzania. The required key competencies were identified, taught and objectively assessed. The training involved hands-on sessions, lectures and discussions. Participants were purposely selected in teams from remote health centres where CEmOC services were planned. Monthly supportive supervision after graduation was carried out in the upgraded health centres Results: A total of 43 care providers from 12 health centres located in 11 rural districts in Tanzania and 2 from Somalia were trained from June 2009 to April 2010. Of these 14 were AMOs trained in CEmOC and 31 nurse-midwives and clinical officers trained in anaesthesia. During training, participants performed 278 major obstetric surgeries, 141 manual removal of placenta and evacuation of incomplete and septic abortions, and 1161 anaesthetic procedures under supervision. The first 8 months after introduction of CEmOC services in 3 health centres resulted in 179 caesarean sections, a remarkable increase of institutional deliveries by up to 300%, decreased fresh stillbirth rate (OR: 0.4; 95% CI: 0.1-1.7) and reduced obstetric referrals (OR: 0.2; 95% CI: 0.1-0.4)). There were two maternal deaths, both arriving in a moribund condition. Conclusions: Tanzanian AMOs, clinical officers, and nurse-midwives can be trained as a team, in a three-month course, to provide effective CEmOC and anaesthesia in remote health centres. http://www.human-resources-health.com/content/9/1/28 Angelo Nyamtema Senga Pemba Godfrey Mbaruku Fulgence Rutasha Jos Roosmalen Human Resources for Health 2011, null:28 2011-11-09T00:00:00Z doi:10.1186/1478-4491-9-28 /content/figures/1478-4491-9-28-toc.gif Human Resources for Health 1478-4491 ${item.volume} 28 2011-11-09T00:00:00Z XML Background: Over thirty years have passed since the Alma-Ata Declaration on primary health care in 1978. Many governments in the first decade following the declaration responded by developing national programmes of community health workers (CHWs), but evaluations of these often demonstrated poor outcomes. As many CHW programmes have responded to the HIV/AIDS pandemic, international interest in them has returned and their role in the response to other diseases should be examined carefully so that lessons can be applied to their new roles. Over half of the deaths in African children under five years of age are due to malaria, diarrhoea and pneumonia - a situation which could be addressed through the use of cheap and effective interventions delivered by CHWs. However, to date there is very little evidence from randomised controlled trials of the impacts of CHW programmes on child mortality in Africa. Evidence from non-randomised controlled studies has not previously been reviewed systematically. Methods: We searched databases of published and unpublished studies for RCTs and non-randomised studies evaluating CHW programmes delivering curative treatments, with or without preventive components, for malaria, diarrhoea or pneumonia, in children in sub-Saharan Africa from 1987 to 2007. The impact of these programmes on morbidity or mortality in children under six years of age was reviewed. A descriptive analysis of interventional and contextual factors associated with these impacts was attempted. Results: The review identified seven studies evaluating CHWs, delivering a range of interventions. Limited descriptive data on programmes, contexts or process outcomes for these CHW programmes were available. CHWs in national programmes achieved large mortality reductions of 63% and 36% respectively, when insecticide-treated nets and anti-malarial chemoprophylaxis were delivered, in addition to curative interventions. Conclusions: CHW programmes could potentially achieve large gains in child survival in sub-Saharan Africa if these programmes were implemented at scale. Large-scale rigorous studies, including RCTs, are urgently needed to provide policymakers with more evidence on the effects of CHWs delivering these interventions. http://www.human-resources-health.com/content/9/1/27 Jason Christopher Alex Le May Simon Lewin David Ross Human Resources for Health 2011, null:27 2011-10-24T00:00:00Z doi:10.1186/1478-4491-9-27 Reducing child mortality Using large-scale community health worker programmes to implement curative and preventative interventions can achieve large gains in child survival in sub-Saharan Africa, although a larger body of evidence is still needed to persuade policy makers. /content/figures/1478-4491-9-27-toc.gif Human Resources for Health 1478-4491 ${item.volume} 27 2011-10-24T00:00:00Z XML IntroductionLow and middle-income countries suffer an ongoing deficit of trained public health workers, yet optimizing postgraduate education to best address these training needs remains a challenge. Much international public health education literature has focused on global capacity building and/or the description of innovative programmes, but less on quality and appropriateness.Case descriptionThe MSc in Global Health Science at the University of Oxford is a relatively new, full-time one year master's degree in international public health. The programme is intended for individuals with significant evidence of commitment to health in low and middle income countries. The intake is small, with only about 25 students each year, but they are from diverse professional and geographical backgrounds. Given the diversity of their backgrounds, we wanted to determine the extent to which student background influenced their perceptions of the quality of their learning experience and their learning outcomes. We conducted virtual or face-to-face semi-structured individual interviews with students who had graduated from the course at least one year previously. Of the 2005 to 2007 intake years, 52 of 63 graduates (83%) were interviewed. We used thematic analysis to analyze the data, then linked results to student characteristics.DiscussionThe findings from the evaluation suggested that all MSc GHS graduates who spoke with us, irrespective of background, appreciated the curriculum structure drawing on the strengths of a small, diverse student group, and the contribution the programme had made to their breadth of understanding and their careers. This evaluation also demonstrated the feasibility of an educational evaluation conducted several years after programme completion and when graduates were 'in the field'. This is important in ensuring international public health programmes are relevant to the day-to-day work of public health practitioners and researchers in low and middle-income countries. Conclusions: Feedback from students, when they had either resumed their positions 'in the field' or pursued further training, was useful in identifying valuable and positive aspects of the programme and also in identifying areas for further action and development by the programme's management and by individual teaching staff. http://www.human-resources-health.com/content/9/1/26 Emma Plugge Donald Cole Human Resources for Health 2011, null:26 2011-10-21T00:00:00Z doi:10.1186/1478-4491-9-26 /content/figures/1478-4491-9-26-toc.gif Human Resources for Health 1478-4491 ${item.volume} 26 2011-10-21T00:00:00Z XML Background: Gender issues remain a neglected area in most approaches to health workforce policy, planning and research. There is an accumulating body of evidence on gender differences in health workers' employment patterns and pay, but inequalities in access to non-pecuniary benefits between men and women have received little attention. This study investigates empirically whether gender differences can be observed in health workers' access to non-pecuniary benefits across six low- and middle-income countries. Methods: The analysis draws on cross-nationally comparable data from health facility surveys conducted in Chad, Côte d'Ivoire, Jamaica, Mozambique, Sri Lanka and Zimbabwe. Probit regression models are used to investigate whether female and male physicians, nurses and midwives enjoy the same access to housing allowance, paid vacations, in-service training and other benefits, controlling for other individual and facility-level characteristics. Results: While the analysis did not uncover any consistent pattern of gender imbalance in access to non-monetary benefits, some important differences were revealed. Notably, female nursing and midwifery personnel (the majority of the sample) are found significantly less likely than their male counterparts to have accessed in-service training, identified not only as an incentive to attract and retain workers but also essential for strengthening workforce quality. Conclusion: This study sought to mainstream gender considerations by exploring and documenting sex differences in selected employment indicators across health labour markets. Strengthening the global evidence base about the extent to which gender is independently associated with health workforce performance requires improved generation and dissemination of sex-disaggregated data and research with particular attention to gender dimensions. http://www.human-resources-health.com/content/9/1/25 Neeru Gupta Marco Alfano Human Resources for Health 2011, null:25 2011-10-19T00:00:00Z doi:10.1186/1478-4491-9-25 /content/figures/1478-4491-9-25-toc.gif Human Resources for Health 1478-4491 ${item.volume} 25 2011-10-19T00:00:00Z XML IntroductionOne of the components of the Health Observatory for Latin American and the Caribbean (HO-LAC) is the design and implementation of metrics for human resources for health. Under the HO-LAC initiative, researchers from nine countries in the region formed the Collaborative Community on Human Resources for Health in Latin America and the Caribbean to identify common metrics applicable to the field of human resources for health (HRH).Case descriptionThe case description comprises three stages: a) the origins of an initiative in which a non-governmental organization brings together researchers involved in HRH policy in LAC, b) a literature search to identify initiatives to develop methods and metrics to assess the HRH field in the region, and c) subsequent discussions held by the group of researchers regarding the possibilities of identifying an appropriate set of metrics and indicators to assess HRH throughout the region.Discussion and evaluationA total of 101 documents produced between 1985 and 2008 in the LAC region were identified. Thirty-three of the papers included a variety of measurements comprising counts, percentages, proportions, indicators, averages and metrics, but only 13 were able to fully describe the methods used to identify these metrics and indicators. Of the 33 articles with measurements, 47% addressed labor market issues, 25% were about working conditions, 23% were on HRH training and 5% addressed regulations. Based on these results, through iterative discussions, metrics were defined into three broad categories (training, labor market and working conditions) and available sources of information for their estimation were proposed. While only three of the countries have data on working conditions, all countries have sufficient data to measure at least one aspect of HRH training and the HRH labor market. Conclusions: Information gleaned from HRH metrics makes it possible to carry out comparisons on a determined experience in space and time, in a given country and/or region. The results should then constitute evidence for policy formulation and HRH planning and programs, with improved health system performance ultimately contributing to improved population health. The results of this study are expected to guide decision making by incentivizing the construction of metrics that provide information about HRH problems in LAC countries. http://www.human-resources-health.com/content/9/1/24 Gustavo Nigenda Maria Machado Fernando Ruiz Victor Carrasco Patricia Moline Sabado Girardi Human Resources for Health 2011, null:24 2011-10-14T00:00:00Z doi:10.1186/1478-4491-9-24 /content/figures/1478-4491-9-24-toc.gif Human Resources for Health 1478-4491 ${item.volume} 24 2011-10-14T00:00:00Z XML Background: There is a growing interest in using pay-for-performance mechanisms in low and middle-income countries in order to improve the performance of health care providers. However, at present there is a dearth of independent evaluations of such approaches which can guide understanding of their potential and risks in differing contexts. This article presents the results of an evaluation of a project managed by an international non-governmental organisation in one district of Pakistan. It aims to contribute to learning about the design and implementation of pay-for-performance systems and their impact on health worker motivation. Methods: Quantitative analysis was conducted of health management information system (HMIS) data, financial records, and project documents covering the period 2007-2010. Key informant interviews were carried out with stakeholders at all levels. At facility level, in-depth interviews were held, as were focus group discussions with staff and community members. Results: The wider project in Battagram had contributed to rebuilding district health services at a cost of less than US$4.5 per capita and achieved growth in outputs. Staff, managers and clients were appreciative of the gains in availability and quality of services. However, the role that the performance-based incentive (PBI) component played was less clear--PBI formed a relatively small component of pay, and did not increase in line with outputs. There was little evidence from interviews and data that the conditional element of the PBIs influenced behaviour. They were appreciated as a top-up to pay, but remained low in relative terms, and only slightly and indirectly related to individual performance. Moreover, they were implemented independently of the wider health system and presented a clear challenge for longer term integration and sustainability. Conclusions: Challenges for performance-based pay approaches include the balance of rewarding individual versus team efforts; reflecting process and outcome indicators; judging the right level of incentives; allowing for very different starting points and situations; designing a system which is simple enough for participants to comprehend; and the tension between independent monitoring and integration in a national system. Further documentation of process and cost-effectiveness, and careful examination of the wider impacts of paying for performance, are still needed. http://www.human-resources-health.com/content/9/1/23 Sophie Witter Tehzeeb Zulfiqar Sarah Javeed Amanullah Khan Abdul Bari Human Resources for Health 2011, null:23 2011-10-07T00:00:00Z doi:10.1186/1478-4491-9-23 /content/figures/1478-4491-9-23-toc.gif Human Resources for Health 1478-4491 ${item.volume} 23 2011-10-07T00:00:00Z XML