Human Resources for Health - Latest Articles

Migration of Sri Lankan medical specialists

A De Silva — 2013-05-21T00:00:00Z

Background: The migration of health-care workers contributes to the shortage of health-care workers in many developing countries. This paper aims to describe the migration of medical specialists from Sri Lanka and to discuss the successes and failures of strategies to retain them. Methods: This paper presents data on all trainees who have left Sri Lanka for postgraduate training through the Post Graduate Institute of Medicine, University of Colombo, from April 1980 to June 2009. In addition, confidential interviews were conducted with 30 specialists who returned following foreign training within the last 5 years and 5 specialists who opted to migrate to foreign countries. Results: From a total of 1,915 specialists who left Sri Lanka for training, 215 (11%) have not returned or have left the country without completing the specified bond period. The majority (53%) migrated to Australia. Of the specialists who left before completion of the bond period, 148 (68.8%) have settled or have started settling the bond. All participants identified foreign training as beneficial for their career. The top reasons for staying in Sri Lanka were: job security, income from private practice, proximity to family and a culturally appropriate environment. The top reasons for migration were: better quality of life, having to work in rural parts of Sri Lanka, career development and social security. Conclusions: This paper attempts to discuss the reasons for the low rates of emigration of specialists from Sri Lanka. Determining the reasons for retaining these specialists may be useful in designing health systems and postgraduate programs in developing countries with high rates of emigration of specialists.

Cost-effectiveness analyses of training: a manager's guide

Gabrielle O¿Malley — 2013-05-20T00:00:00Z

The evidence on the cost and cost-effectiveness of global training programs is sparse. This manager's guide to cost-effectiveness analysis (CEA) is for professionals who want to recognize and support high quality CEA. It focuses on CEA of training in the context of program implementation or rapid program expansion. Cost analysis provides cost per output and CEA provides cost per outcome. The distinction between these two analyses is essential for making good decisions about value. A hypothetical example of a cost analyses compares the cost per trainee of a computer-based anti-retroviral therapy (ART) training to a more intensive ART training. In a CEA of the same example, cost per trainee who met ART clinical performance standards is compared. The cost analysis is misleading when the effectiveness differs across trainings. Two additional hypothetical examples progress from simple to more complex costs and from a narrow to a broader scope: 1) CEA of the cost per ART patient with 95% adherence that compares the performance of doctors to counselors who attend additional training, and 2) CEA of the cost per infant HIV infection averted for a Prevention of Mother to Child Transmission program that compares the current program to one with additional training. To create an evidence base on CEA of training, more well-designed analyses and data on the cost of training are needed. Analysts should understand more about how capacity is built, how quality is improved within a health facility, and the costs associated with them. Considering the life of an investment in training, evaluations are needed on how many trainees apply the skills taught, how long trainees continue to apply them, and how long the content of the training conforms to national or international guidelines. Better data on effectiveness of training is also needed. It is feasible to measure effectiveness by clinical performance standards, or intermediate outcomes and coverage. Intermediate outcomes and coverage can also be combined with published estimates on health outcomes.

Ten principles of good interdisciplinary team work

Susan Nancarrow — 2013-05-10T00:00:00Z

Background: Interdisciplinary team work is increasingly prevalent, supported by policies and practices that bring care closer to the patient and challenge traditional professional boundaries. To date, there has been a great deal of emphasis on the processes of team work, and in some cases, outcomes.MethodThis study draws on two sources of knowledge to identify the attributes of a good interdisciplinary team; a published systematic review of the literature on interdisciplinary team work, and the perceptions of over 253 staff from 11 community rehabilitation and intermediate care teams in the UK. These data sources were merged using qualitative content analysis to arrive at a framework that identifies characteristics and proposes ten competencies that support effective interdisciplinary team work. Results: Ten characteristics underpinning effective interdisciplinary team work were identified: positive leadership and management attributes; communication strategies and structures; personal rewards, training and development; appropriate resources and procedures; appropriate skill mix; supportive team climate; individual characteristics that support interdisciplinary team work; clarity of vision; quality and outcomes of care; and respecting and understanding roles. Conclusions: We propose competency statements that an effective interdisciplinary team functioning at a high level should demonstrate.

Capacity of middle management in health-care organizations for working with people¿the case of Slovenian hospitals

Brigita Skela Savi¿ — 2013-05-10T00:00:00Z

Background: Effective human resources management plays a vital role in the success of health-care sector reform. Leaders are selected for their clinical expertise and not their management skills, which is often the case at the middle-management level. The purpose of this study was to examine the situation in some fields that involve working with people in health-care organizations at middle-management level. Methods: The study included eight state-owned hospitals in Slovenia. A cross-sectional study included 119 middle managers and 778 employees. Quota sampling was used for the subgroups. Structured survey questionnaires were administered to leaders and employees, each consisting of 24 statements in four content sets evaluated on a 5-point Likert-type scale. Respondents were also asked about the type and number of training or education programmes they had participated in over the last three years. Descriptive statistics, two-way analysis of variance, Pearson's correlation coefficient and multiple linear regression were used. The study was conducted from March to December 2008. Results: Statistically significant differences were established between leaders and employees in all content sets; no significant differences were found when comparing health-care providers and health-administration workers. Employment position was found to be a significant predictor for employee development (beta = 0.273, P < 0.001), the leader--employee relationship (beta = 0.291, P < 0.001) and organizational motivation (beta = 0.258, P < 0.001). Area of work (beta = 0.113, P = 0.010) and employment position (beta = 0.389, P < 0.001) were significant predictors for personal involvement. Level of education correlated negatively with total scores for organizational motivation: respondents with a higher level of education were rated with a lower score (beta = -0.117, P = 0.024). Health-care providers participate in management programmes less frequently than do health-administration workers. Conclusion: Employee participation in change-implementation processes was low, as was awareness of the importance of employee development. Education of employees in Slovenian hospitals for leadership roles is still not perceived as a necessary investment for improving work processes. Hospitals are state owned and a national strategy should be developed on how to improve leadership and management in Slovenian hospitals.

Longitudinal study of rural health workforce in five counties in China: research design and baseline description

Huiwen Xu — 2013-05-04T00:00:00Z

Background: The village doctors have served rural residents for many decades in China, and their role in rural health system has been highly praised in the world; unfortunately, less attention has been paid to the health workforce during the ambitious healthcare reform in recent years. Therefore, we conducted a longitudinal study to explore the current situation and track the future evolution of the rural healthcare workforce. Methods: The self-administered structured Village Clinic Questionnaire and Village Doctor Questionnaire, which were modified from the official questionnaires of the Ministry of Health, were constructed after three focus groups, in-depth interviews in Hebei Province, and a pilot survey in Sichuan Province. Using a stratified multistage cluster sampling process, we gathered baseline data for a longitudinal survey of village doctors, village clinics from Changshu County, Liyang County, Yongchuan District, Mianzhu County, and Jingning County in China in 2011. Well-trained interviewers and strict procedures were employed to ensure the quality of this survey. Descriptive and correlation analyses were performed with Stata 12.0. Results: After four months of surveying, 1,982 Village Doctor Questionnaires were collected, and the response rate was 88.1%. There were 1,507 (76.0%) male and 475 (24.0%) female doctors, with an average age of 51.3 years. The majority of village doctors (58.5%) practiced both western medicine and Traditional Chinese Medicine, and 91.2% of the doctors received their education below college level. Their practice methods were not correlated with education level (P = 0.43), but closely related to the way they obtained their highest degree (that is, prior to starting work or as on-the-job training) (P < 0.01). The mean income of the village doctors was 1,817 (95% CI 1,733 to 1,900) RMB per month in 2011; only 757 (41.3%) doctors had pensions, and the self-reported expected pension was 1,965 RMB per month. Conclusions: Village doctors in rural China are facing critical challenges, including aging, gender imbalance, low education, and a lack of social protection. This study may be beneficial for making better policies for the development of the health workforce and China’s healthcare reform.

Assessment of graduate public health education in Nepal and perceived needs of faculty and students

Agya Mahat — 2013-04-26T00:00:00Z

Background: Despite the large body of evidence suggesting that effective public health infrastructure is vital to improving the health status of populations, many universities in developing countries offer minimal opportunities for graduate training in public health. In Nepal, for example, only two institutions currently offer a graduate public health degree. Both institutions confer only a general Masters in Public Health (MPH), and together produce 30 graduates per year. The objective of this assessment was to identify challenges in graduate public health education in Nepal, and explore ways to address these challenges. Methods: The assessment included in-person school visits and data collection through semi-structured in-depth interviews with primary stakeholders of Nepal’s public health academic sector. The 72 participants included faculty, students, alumni, and leaders of institutions that offered MPH programs, and the leadership of one government-funded institution that is currently developing an MPH program. Data were analyzed through content analysis to identify major themes. Results: Six themes characterizing the challenges of expanding and improving graduate public health training were identified: 1) a shortage of trained public health faculty, with consequent reliance on the internet to compensate for inadequate teaching resources; 2) teaching/learning cultures and bureaucratic traditions that are not optimal for graduate education; 3) within-institution dominance of clinical medicine over public health; 4) a desire for practice–oriented, contextually relevant training opportunities; 5) a demand for degree options in public health specialties (for example, epidemiology); and 6) a strong interest in international academic collaboration. Conclusion: Despite an enormous need for trained public health professionals, Nepal’s educational institutions face barriers to developing effective graduate programs. Overcoming these barriers will require: 1) increasing the investment in public health education and 2) improving the academic environment of educational institutions. Long term, committed academic collaborations with international universities may be a realistic way to: 1) redress immediate inadequacies in resources, including teachers; 2) encourage learning environments that promote inquiry, creativity, problem-solving, and critical thinking; and 3) support development of the in-country capacity of local institutions to produce a cadre of competent, well-trained public health practitioners, researchers, teachers, and leaders.

Understanding the factors influencing health-worker employment decisions in South Africa

Gavin George — 2013-04-23T00:00:00Z

Background: The provision of health care in South Africa has been compromised by the loss of trained health workers (HWs) over the past 20 years. The public-sector workforce is overburdened. There is a large disparity in service levels and workloads between the private and public sectors. There is little knowledge about the nonfinancial factors that influence HWs choice of employer (public, private or nongovernmental organization) or their choice of work location (urban, rural or overseas). This area is under-researched and this paper aims to fill these gaps in the literature.MethodThe study utilized cross-sectional survey data gathered in 2009 in the province of KwaZulu-Natal. The HWs sample came from three public hospitals (n = 430), two private hospitals (n = 131) and one nongovernmental organization (NGO) hospital (n = 133) in urban areas, and consisted of professional nurses, staff nurses and nursing assistants. Results: HWs in the public sector reported the poorest working conditions, as indicated by participants’ self-reports on stress, workloads, levels of remuneration, standard of work premises, level of human resources and frequency of in-service training. Interesting, however, HWs in the NGO sector expressed a greater desire than those in the public and private sectors to leave their current employer. Conclusions: To minimize attrition from the overburdened public-sector workforce and the negative effects of the overall shortage of HWs, innovative efforts are required to address the causes of HWs dissatisfaction and to further identify the nonfinancial factors that influence work choices of HWs. The results highlight the importance of considering a broad range of nonfinancial incentives that encourage HWs to remain in the already overburdened public sector.

A literature review: the role of the private sector in the production of nurses in India, Kenya, South Africa and Thailand

Jaratdao Reynolds — 2013-04-12T00:00:00Z

Background: The demand for nurses is growing and has not yet been met in most developing countries, including India, Kenya, South Africa, and Thailand. Efforts to increase the capacity for production of professional nurses, equitable distribution and better retention have been given high strategic priority. This study examines the supply of, demand for, and policy environment of private nurse production in four selected countries. Methods: A scoping systematic review was undertaken to assess the evidence for the role of private sector involvement in the production of nurses in India, Kenya, South Africa, and Thailand. An electronic database search was performed, and grey literature was also captured from the websites of Human Resources for Health (HRH)-related organizations and networks. The articles were reviewed and selected according to relevancy. Results: The review found that despite very different ratios of nurses to population ratios and differing degrees of international migration, there was a nursing shortage in all four countries which were struggling to meet growing demand. All four countries saw the private sector play an increasing role in nurse production. Policy responses varied from modifying regulation and accreditation schemes in Thailand, to easing regulation to speed up nurse production and recruitment in India. There were concerns about the quality of nurses being produced in private institutions. Conclusion: Strategies must be devised to ensure that private nursing graduates serve public health needs of their populations. There must be policy coherence between producing nurses for export and ensuring sufficient supply to meet domestic needs, in particular in under-served areas. This study points to the need for further research in particular assessing the contributions made by the private sector to nurse production, and to examine the variance in quality of nurses produced.

Aspirations for quality health care in Uganda: How do we get there?

Clare Chandler — 2013-03-22T00:00:00Z

Background: Despite significant investments and reforms, health care remains poor for many in Africa. To design an intervention to improve access and quality of health care at health facilities in eastern Uganda, we aimed to understand local priorities for qualities in health care, and factors that enable or prevent these qualities from being enacted. Methods: In 2009 to 2010, we carried out 69 in-depth interviews and 6 focus group discussions with 65 health workers at 17 health facilities, and 10 focus group discussions with 113 community members in Tororo District, Uganda. Results: Health-care workers and seekers valued technical, interpersonal and resource qualities in their aspirations for health care. However, such qualities were frequently not enacted, and our analysis suggests that meeting aspirations required social and financial resources to negotiate various power structures. Conclusions: We argue that achieving aspirations for qualities valued in health care will require a genuine reorientation of focus by health workers and their managers toward patients, through renewed respect and support for these providers as professionals.

Does salary affect the choice of residency in non-university teaching hospitals? A panel analysis of Japan Residency Matching Programme data

Taiji Enari — 2013-03-08T00:00:00Z

Background: Previous studies have investigated factors that are influential on the choice of training hospitals among residency physicians, but the effect of salary was not conclusive. In this study, we aimed to examine whether a higher salary attracted more residents to non-university hospitals participating in the Japanese Residency Matching Programme. Methods: Data on 475 hospitals/programmes between 2006 and 2009 were available for analysis. We first conducted an ordinary least squares regression analysis on the ratio of the number of applicants to the residency programme quota as an index of resident’s choice, for comparison with previous studies. We further performed panel data analysis to better control for unobserved heterogeneity across hospitals, which could be confounded by the amount of salary. We also performed stratified analysis by the population size of the hospital location. Results: In ordinary least squares regression, salary showed a positive, but not significant association, with the ratio of the number of applicants to the programme quota, while the results of a fixed effect model exhibited a positive and significant effect of salary (ε= 0.4995, P = 0.015) on the ratio. Analysis stratified by city size showed that the elasticity of salary was comparable (ε= 1.9089, P = 0.016 in large cities versus ε= 1.9185, P = 0.008 in small cities), while that of the number of teaching physicians was larger in large cities (ε= 1.9857, P = 0.009) compared with that in small cities (ε= 1.6253, P = 0.033). The number of teaching physicians had a significant and negative effect modification on salary, implying an antagonistic effect between these two attributes (ε= −1.5223, P = 0.038). Conclusions: Our results indicate that the amount of salary influences the choice of training hospitals among medical graduates who choose non-university settings. Use of a monetary reward in a residency programme could be a feasible tactic for hospitals to attract residents.