Geneva Health Forum Archive

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Training Management Information System as a Tool for Addressing Public Health Workforce needs and rational deployment in India.

Author(s) Nidhi Chaudhary1, Srilekha Chakrabarty2, Gaurav Sharma3, Linh Cu Le4, Dineke Venekamp5.
Affiliation(s) 1ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, Chandigarh, India, 2ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, New Delhi, India, 3Centre for Health Informatics, National Institute of Health and Family Welfare, New Delhi, India, 4ITS Project, KIT, Netherlands, New Delhi,India, 5ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Health Workforce
Summary Skills based training of health personnel and task shifting have been two strategies under NRHM to address the shortfall of human resources in health in India. Training Management Information system, a web based “single window” software application was developed to create a nationwide database for health personnel that can be updated in real time at the training centres. The TMIS software pilot, launched in five states, helps collate individual level training information about each health personnel as well as health facility level information about the availability of trained health personnel. The TMIS facilitates monitoring and decision making for the policy makers and program managers.
What challenges does your project address and why is it of importance? India finds itself ranked 52 of the 57 countries facing a Human Resources for Health (HRH) crisis. India’s major limitation has been in the production and distribution of human resources across multiple levels of care. As of March 2010, the overall HRH shortfalls range from 63% for specialists to 10% for allopathic doctors, and 9% for Auxiliary Nurse Midwives (ANMs), respectively.
Health curricula in the country have not kept pace with the changing dynamics of public health, health policies and demographics. The ANM and General Nursing & Midwifery (GNM) curricula have only twice been revised in the past 40 years. Current medical and nursing graduates in the country, trained in urban environments, are ill-prepared and unmotivated to practice in rural settings.
The health reforms under National Rural Health Mission (NRHM), include a focus on skills based training of existing health staff and task shifting to meet the shortfall for the health workforce. However, there are challenges in terms of identifying appropriate candidates for trainings, incomplete database on training status of health personnel, equity in professional development opportunities, rational posting of trained personnel and post training performance follow up of trained personnel.
How have you addressed these challenges? Do you see a solution? The National Institute of Health and Family Welfare is the nodal agency for conducting, coordinating and monitoring performance of various trainings conducted under NRHM. The EU supported Institutional and Technical Support Project (ITS) is providing technical assistance for institutional capacity strengthening of the National and eight State Institutes of Health and Family Welfare (NIHFW, SIHFWs). The Ministry of Health and Family Welfare (MoHFW) identified quality assurance of trainings as one of the expected outputs under the ITS project which would strengthen the NIHFW and SIHFWs.
The Training Management Information System (TMIS) is a web based software application, developed by the ITS project, for nationwide database of skilled human resource to strengthen the public sector health delivery system. The TMIS will help to plan and manage RCH trainings under NRHM, rationalise deployment of trained personnel in different health facilities and strengthen monitoring of quality of training.
The web based TMIS software help collate individual personnel level training information as well as health facility level information about availability of trained health personnel. The TMIS software has two parts - dynamic and static. The dynamic section automates the data related to human resource, trainers, participants, training centres, health facilities and type of training. The real time trainings’ data is captured, updated and generates district, state and national level training reports. It integrates sms alerts to trainers and participants. The static section includes all the documents related to trainings like training guidelines, training manuals, course content, training calendars, circulars and other relevant online material.
TMIS addresses the problem of the re-entry of existing HR and training data collected over the years in excel format by bulk uploading the same into TMIS software. The TMIS facilitates monitoring and decision making for the policy makers and program managers at all levels. It will help to recommend corrective actions based on the analysis of the human resource skills gap.
In the long run, TMIS will facilitate tracking of the resource pool of trainers and of the trained personnel through GIS mapping facilitating monitoring, better planning and resource optimization. The report generated through the software will help in monitoring and evaluating the achievement in reaching MDGs.
How do you know whether you have made a difference? The user training and pilot launch of TMIS has been done in five states – Odisha, Haryana, Uttar Pradesh, Karnataka and Andhra Pradesh from April to June 2013. The SIHFWs are the nodal agencies for TMIS management at the state level. In total, 443 district and state level data entry operators were trained on the use of the TMIS software, data preparation, data cleaning and online-entry. The database software built on SQL server platform (using .NET framework) using key variables such as: trainees, trainers, training courses at different levels of health system in India which is available on the NIHFW website. To date, basic human resources data of at least 77 districts from 5 pilot states has been collected by the district data entry operators and centrally uploaded on the software by the team at NIHFW. This uploading of the human resource data is a one time activity which will be followed by online real time updates on personnel trainings. Draft user manuals and technical training documents for TMIS software have been developed. A help desk has been set up centrally at NIHFW for answering queries of the state. The help desk has received on average at least 40 queries per month from 5 states in the last 3 months. The TMIS software has been demonstrated to all national program managers at MoHFW and has been modified to meet the needs of both national and state level authorities.
In the select districts which have started using TMIS, the health department is able to nominate appropriate candidates, facilitate post training placements and name based tracking of health professionals. The sms alerts to the trainers and participants before the trainings and the instant online certificate generation through TMIS has already streamlined the training process and has overcome the limitations of manual compilation of training data in the country. The detailed pilot data report on utilisation and application of TMIS will be available by December 2013 and will be presented in the conference. However, to date all the health authorities at pilot states have shown great enthusiasm and provided positive feedback about the practicability and effectiveness of this application.
Have you or the project mobilized others and if so, who, why and how? Through the ITS project we have mobilised the resources at the NIHFW and SIHFWs for implementing the TMIS application. The existing staff at NIHFW and SIHFW have been trained as master trainers for training further district data entry operators. Two staff at NIHFW have been identified to act as a help desk for states and support the TMIS tasks of bulk uploading of human resource data. Similarly SIHFW’s nodal officers for TMIS have been identified and state data entry operators have been trained to address minor issues that the district level operators may encounter. The NIHFW and SIHFW infrastructure was leveraged for conducting trainings. With the TMIS deployed at state and district levels, the health authority would be equipped with a useful tool to manage training activities on-site. Further use of TMIS and integration with existing human resources for health database can speed up better manpower management and utilisation.
When your donor funding runs out how will your idea continue to live? The sustainability plan for TMIS has been developed for 10 years and presented to NIHFW and MOHFW for formal approval. The TMIS sustainability plan specifically aims to: build up a TMIS team in the NIHFW to maintain a national/country wide database of skilled and trained human resources; assist decision makers and stakeholders to perform gap analysis of trained human resource in public health sector delivery system; maintain a Government to Government (G2G) web based application for monitoring and planning of skilled and trained health care providers and create a foundation (if required) to make TMIS cell at NIHFW to become a “centre of excellence” in Health Information Systems. The involvement of policy makers at the national level through regular interaction to exchange inputs into TMIS design, meeting with different program divisions, and the implementation of health facility hierarchy of established ministry level software Health Management Information System (HMIS) into TMIS indicate that TMIS is viewed as useful tool by MoHFW. The MoHFW has expressed their commitment in scaling the application to a national level after the pilots. The Steering Committee meeting, chaired by the Joint Secretaries of MoHFW responsible for training, and NRHM will be allocating financial resources from the next financial year.
Based on the request from MoHFW, ITS team visited a non ITS intervention state of Tamil Nadu to explore the integration of TMIS with existing Human Resource Management Information System. It is planned that further customisation of TMIS at national and state level may even enable the users to get routine statistics on training activities going on at each level, to generate automatic reports as well as get better overview of training needs and relevant demands at each geographic regions. The TMIS would certainly help human resource development and management in India in the long run.

Strengthening the competencies and skills of nurses in mental health: Experiences from Bosnia and Herzegovina

Author(s) Selma Kukic1, Zvjezdana Stjepanovic2.
Affiliation(s) Mental health, Mental health Project in BH, Sarajevo, Bosnia and Herzegovina, Mental Health, Mental Health Project in BH, Banja Luka, Bosnia and Herzegovina.
Country - ies of focus Bosnia and Herzegovina
Relevant to the conference tracks Health Workforce
Summary The mental health reform in BiH was launched in 1996 focusing on community-based care and so far has made significant progress in the development of a large network of community mental health centers. In the centers multidisciplinary teams operate, however nurses are the largest and least skilled professional category of professionals and have the highest fluctuation rate within health system. The reform project in BiH (Mental Health Project in Bosnia and Herzegovina) is focused on the informal education of nursing staff with the objective of professional development, empowering and providing networking as a first steps toward a systematic re-profiling of nurses in mental health.
What challenges does your project address and why is it of importance? In 2008/09 the survey "Situation analysis and assessment of community-based mental health services in Bosnia-Herzegovina“ (Mental Health in SEE Project 2009) was undertaken. The findings of the 2008/09 survey were used as the baseline for the Mental Health Project in BiH to monitor changes and improvements made with the project's support. A self-assessment of the middle-level nursing staff in this survey revealed that the staff believed they were under-trained. 46% of nurses believed they had not received enough training to work in a mental health centre, and the MHC team members believed that the work of the nursing staff was not recognised by other health professionals and that there were prejudices caused by vaguely defined job descriptions for the nursing staff working in a MHC team. A new concept of nursing, as well as the empowerment of nurses within the system of community mental health, requires well trained nurses, whose knowledge is closely linked to psychological, sociological, philosophical, educational, medical and expert training. This would improve the ability of nurses to assume new tasks. This can be achieved through formal education, non-formal education, continuing professional education, as well as initiative and creativity in the field of nursing.
How have you addressed these challenges? Do you see a solution? The adequate re-profiling of nurses in mental health is optimally achieved through formal education. This project presented informal education as the first step to a systematic aproach. Education has garnered excellent results in terms of narrowing the gap of professional training, but the benefits of education are more reflected in the development of contacts, exchange of experiences and formal networking of these professional groups that did not previously exist in the form of professional associations. The results indicate that associated advocacy for the development of nursing legislation on education and employment in mental health is required.
How do you know whether you have made a difference? The results of the performance evaluation of the Conducted Educations suggested key improvements in the work of this professional group. 96 % of respondents felt that the education contributed to providing quality services to patients and their families through individual or team work. Particular emphasis was upon the acquisition and use of new knowledge, skills and techniques in work (88%), the rights and obligations of medical professionals and patients (66%) and combating the stigma of mentally ill patients in society (32%). 90 % of respondents observed changes in the area of respect for the professional attitudes of mental health nurses by other team members. Particular emphasis was on the experience exchanges among colleagues (65%), the level of self- confidence in the process of presenting opinions to their superiors (64%) and an additional level of competence to work within a multidisciplinary team (53%). With continous collaboration with mental health staff in MHCs there is greater viability for the initiatives taken by nurses to process their difficulties in work.
Have you or the project mobilized others and if so, who, why and how? The key project holders and implementers were the Ministries of Health, and their key responsibility was to make the entire process a success by ensuring the participation of nursing stuff and relevant experts and key stakeholders in the implementation of activities, as well as to provide further support to the continuing education of nursing staff.
When your donor funding runs out how will your idea continue to live? Sustainability is ensured through cooperation with other projects whose main goal is to work on legislation that would provide a legal framework for the employment of nurses in mental health, including formal education, by providing needed information and support.

Scaling up family medicine and primary health care in Africa.

Author(s) Jan De Maeseneer1, Maaike Flinkenflögel2
Affiliation(s) 1Department Family Medicine and Primary Health Care, Ghent University, Gent, Belgium, 2Department of Family Medicine and Primary Health Care, Ghent University, Gent, Belgium.
Country - ies of focus Global
Relevant to the conference tracks Health Workforce
Summary Increasingly, there is an emphasis upon the need for scaling up the capacity of primary health care. The Primafamed-network (, at its workshop in November 2012 formulated a statement on human resources for primary health care. They formulated a plan that will lead to 30.000 new family physicians in sub-saharan Africa by 2020. There is an increasing need for skilled primary health care providers, and also family physicians at the primary health care level in Africa. Until now, in different African countries only a small number of family physicians have been trained. There is a huge problem of recruitment of family physicians in the medical faculties.
Background Accessible and comprehensive primary health care is a key factor to solve the health problems of the developing countries, also in Africa. There is a need to scale up both quality and capacity of family medicine in the context of primary health care teams in Africa. The actual programs have only been able to train a very limited number of family physicians. Increasingly, countries and ministries of health recognised the importance of this discipline to strengthen health systems.
Objectives To formulate a policy statement to scale up family medicine and primary health care in Africa and to develop a strategy accordingly.
Methodology At the recent Primafamed-workshop in Vic Falls (Zimbabwe), a gathering of African representatives from 20 African countries discussed the different strategic options in order to scale up the capacity of family medicine and primary health care. The result was a statement published in the African Journal of Primary Health Care and Family Medicine (
Results Starting from reports from various countries, with a diverse scale of strategic approaches to capacity building in family medicine, a debate formulated a statement on scaling up. Important choices are related to the duration of the training, increasing the recruitment from undergraduate curriculum, and utilising appropriate educational strategies to train family physicians in the communities. Increasing exposure in undergraduate training to family and community service is essential to improve recruitment. Although some countries are in favour of a 4-years training, probably a 2-years program will be able to contribute to the achievement of the needed scaling up to capacity.
Conclusion The participants agreed that, if the strategy could lead to the fact that 50% of the graduates would be trained in family medicine from 2013 onwards, this will lead to 30.000 new family physicians in sub-saharan Africa by 2020 in a 2-year program.

Performance of Community Health Workers in Community Case Management: Uganda

Author(s) Agnes Nanyonjo1, Edmound Kertho2, Seyi Soremekun3, Frida Kastenge 4, Guus TenAsbroek 5, James Tibenderana6, Karin Kallander7
Affiliation(s) 1Technical, Uganda Country Office, Malaria Consortium, Kampala, Uganda, 2Technical, Uganda Country Oficce, Malaria Consortium, Kampala, Uganda, 3Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom, 4Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom, 5Population Health, London School of Hygiene and Tropical Medicine, Amsterdam, Netherlands, 6Technical, Africa Region Ofiice, Malaria Consortium, Kampala, Uganda, 7Technical, Africa Region Office, Malaria Consortium, Kampala, Uganda.
Country - ies of focus Uganda
Relevant to the conference tracks Health Workforce
Summary Integrated community case management is key child survival strategy in resource poor settings. There is paucity of data on performance of community health workers in this strategy and how this performance can be measured. We report on a study that evaluated the performance of community health workers using case vignettes. Overall community health workers perform well with respect to treatment. However omissions in terms of probing for danger signs and other illness symptoms and provision of general health education required by the treatment guidelines deter community health worker performance.
Background Integrated community case management for malaria, pneumonia and diarrhoea (iCCM) is one of the key interventions tailored towards curbing child mortality in low income countries. In iCCM lay community health workers (CHWs) use a given algorithm provided in a job aid to ask about illness symptoms, assess signs, classify and treat disease or refer severely ill children. They treat malaria with artemether lumefantrine combination, pneumonia with amoxycillin and diarrhoea with oral rehydration salts (ORS) and zinc. They are also required to offer health education regarding disease prevention. Although measurement of performance in itself poses key challenges in terms of choice of method used, assessment and understanding of the performance of CHWs is crucial to ensure high quality care of the sick children.
Objectives The objective of the study was to assess the performance of CHWs while managing children with solitary disease such as malaria alone or mixed infections such as malaria and pneumonia by using case vignettes.
Methodology The study was conducted among a sample of 360 CHWs who had been practicing iCCM for at least three to eight months in eight districts in Midwestern Uganda. CHWs were given four case vignettes; one after the other. Using probing questions the CHWs were asked to describe the actions they would take from the time they encountered the sick child and his/her caregiver to the time they finished the consultation. The CHWs were allowed to use their job aid during the evaluation. One case vignette emulated a 6 months old child with an uncomplicated malaria classification presenting with fever, poor appetite and no danger signs; requiring a malaria rapid diagnostic test, malaria treatment and health education. Another vignette depicted a 3 year old child with diarrhoea and no blood in stool; requiring zinc, ORS and health education. The third vignette was about a child with both cough fast breathing and fever and a history of stiff feet early that morning depicting a child with pneumonia and complicated malaria requiring referral and pre-referral treatment due to the danger sign. The last case was about a child with fever and cough, essentially with uncomplicated malaria but no pneumonia. Each appropriate action, i.e. questions the CHW should have asked, test CHW should have performed and treatment and health education CHW should have given basing on the guidelines, was assigned a weight of one. The average performance score for each CHW was generated on a scale of 0-100. Scores were also sub-analyzed per case managed as well as association with socio-demographic factors, such as sex, literacy and district of the CHWs.
Results Out of all actions that should have been taken for each case, the overall mean performance score of the CHWs was 41.5 (SD 8.6). The mean performance score based on case scenarios was 46.6 (SD 16.3) for the uncomplicated malaria case, 59.3 (SD 15.6) for the case of uncomplicated malaria with cough, 36.5 (SD 13.6) for the diarrhoea case, and 23.5 (SD 14.4) for the case with pneumonia and complicated malaria and. Overall, CHWs ability to state the correct treatment and dose for the simulated case was high, with 93.3% sating the correct treatment for a child case with malaria alone; 94.4% stating the appropriate treatment for a child case with diarrhoea, and 84.4% being able to suggest referral for a child case with a history of a danger sign. However, the problematic areas in the management algorithm that appeared to decrease the overall mean performance score included: a) failure to ask about dangers signs and symptoms that are not mentioned by the caregiver. Overall only 1% of the CHWs remembered to probe for the presence of any danger signs and other symptoms not automatically volunteered by the care taker in at least one of the case scenarios; b) Failure to assess for key illness symptoms. In the pneumonia and complicated malaria case only 22.7% of CHWs mentioned that they would assess the respiratory rate of the child; c) Failure to give pre-referral treatment. Only 28.1% and 9.7% CHWs mentioned that they would give pre-referral treatment for malaria and pneumonia, respectively; d) Failure to give instructions on how to administer the drug, especially in the diarrhoea case scenario where only 40% mentioned at least one instruction they would give to the caretaker regarding how to mix and give ORS; e) Failure to provide general health education and information on when to take the child to the health facility for further treatment. Twenty percent of CHWs did not give caretakers any of the recommended advice. Performance levels were positively associated with the district of the CHWs (p<0.001) and to the increasing number of patients the CHW had seen in the last week (p=0.015).
Conclusion If the case scenarios where a reflection of a real life situation our data suggest that majority of children seen by CHWs would get the appropriate curative treatment or action required. However they would not be able to benefit optimally from their visit to the CHWs due to omitted actions, such as provision of pre-referral treatment, health education and counseling, and demonstration to caregivers on how to give the first dose. Supportive supervision and refresher training of CHWs should which emphasizes strict adherence to treatment algorithms, and which offers strengthening of interpersonal communication skills should be implemented.

Distance to basic services and Retention of Health Workers in Tanzania: A multivariate logistic and GIS Model Approach.

Author(s) Benjamin Mayala1, Jonathan Mcharo2, Vitus Nyigo3.
Affiliation(s) 1Disease Surveillance and GIS, NIMR, Dar es Salaam, Tanzania, 2HRH, NIMR, Dar es Salaam, Tanzania, 3Traditional Medicine, NIMR, Dar es Salaam, Tanzania.
Country - ies of focus Tanzania
Relevant to the conference tracks Health Workforce
Summary Lack of basic services in some areas of the country is one of the major reasons for health workers to migrate to areas with better services but this causes other areas to remain with few health staffs, and resultant poor health care. A simple analysis to determine the availability of these services and at what distance a health worker can access them can be a great solution to policy makers.
Background Tanzania has been implementing the Primary Health Service Development Program policy to increase the accessibility of health care services to its people at a distance of 5km. Although this policy has been introduced in the various districts in the country, its implementation has been a challenge due to the fact that retaining health workers at these facilities remains problematic. Lack of basic services in some areas of the country is one of the major reasons for health workers to migrate to areas with better services which results in other areas retaining fewer health workers with poorer health care provision in the country. Lack of health care provision in terms of health workers can present barriers to patient’s access to health facilities, who might be forced to travel long distances to access health care. Understanding the problems of health workers, including the availability of basic services in their localities, is important. Distance to basic services has an impact on health worker retention. Travel times, lack of access to transportation, and seasonally inaccessible roadways can present barriers to health workers access to important services such as banks, security or schools for their children.
Objectives We hypothesized that the lack of basic services was a key factor for health worker migration to other districts that possessed better services. The main goal of this study was to determine the availability and distribution of basic key services that are important to health workers and how close they can be accessed. Specifically, we used spatial analysis to establish a network that considers geographic position and the existence of basic services that could influence the retention of health workers.
In order to achieve this goal we focused on the following questions:
• Is there a reliable water supply source and what is the nearest distance to this source?
• How accessible are the health facility (your place of work)?
• Are there roads which can easily access different routes to services?
• Are there schools that can be accessible by health workers?
• Is there reliable transport (public) that can be used by health workers to move from one point to another?
In particular Euclidian distances from health workers houses to the basic services were computed. Using data on health workers moving in/out of a particular district, we applied multivariate spatial logistic regression to determine the variables that were statistically significant.
Methodology The study was undertaken in 16 selected district in Tanzania in 2007. Districts were chosen to represent the spatial zonal distribution of the country. Four of the districts (Kigoma Urban, Mtwara Urban, Nymagana and Temeke) were considered urban and the other 12 (Biharamulo, Kilwa, Kondoa, Lushoto, Mafinga, Manyoni, Mbinga, Mpanda, Same, Ulanga, Urambo and Rungwe) were rural districts. Four villages were selected in each district, and three to four health workers houses were selected for inclusion in the mapping exercise. For each district we first assessed all the basic services available, then a hand held Global Positioning System (GPS) was used to map the geographic locations of those services, this includes banks, water source, post office, police post, shops/open market location, schools and bus stops. Other features that located were the health facilities and health worker households. We used ArcGIS 10.1 analysis tools to map the locations of basic services and distances to the nearest services from each health worker household was calculated using simple Euclidean distance. Multivariate logistic regression were used to model the distances to bank, post office, police, schools, referral hospital, water sources and bus stops. Then we compared the significance variables to the data on overall district move in/out of health workers.
Other covariate variables of interest that we included in the spatial logistic model that could be important in our analysis included elevation, rainfall and temperature data.
Results Main sources of Water: Our results indicated that most of the health worker households and the health facilities they work were not connected to piped water, because there was no such services in the districts. Therefore, health workers are forced to walk long distances (up to 15km) to access water services.
Distance to bank, police and post office services: Most of the health workers in public health facilities collect their salaries through a bank. Our analysis indicated some health workers travel a distance of 160 km to obtain bank, post or police services. This was seen to be a burden especially in those areas where public transport is a major problem (i.e. one bus a day), and that health workers had to take two or three days off, spend nights in a guest house near the bank, and also incur costs for fare and food, which are deducted from their salary.
Accessibility of Health facilities: in most the districts visited during the research, quite large number of health facilities are located near to the roads (0.2 to 3 km). This means that they (in principle) can be accessed by public transport. However, this is not the situation in most of the rural areas where we conducted this research. As mentioned before, public transport is not reliable and the situation is worse during rainy season.
Distance to School: The distance analysis to access schools indicated that schools can be accessed up to 12 km which is also a burden for most children in the rural areas without transport.
Our initial logistic regression models confirmed a statistical significance of distance to basic services and moved in/out of health workers.
Conclusion In this study we have used GIS and spatial logistic analysis to determine the spatial distribution of existing basic services for health workers. Apart from others, issues like better salary, promotion and various ways of motivating a health worker and understanding the distance to access basic service is important. This is due to the fact that lack of services in some area may cause health workers to migrate to those areas with better services. The application of GIS technology has shown how a health worker can access basic services in terms of travel distance. A multivariate analysis indicated the significance of some variables to the migration of health workers.

Engaging village doctors in mHealth program? An experience from rural Bangladesh.

Author(s) Shahidul Hoque1, Mohammad Iqbal2, Sabrina Rasheed3, SMA Hanifi 4, Tanvir Ahmed 5, Abbas Bhuiya6.
Affiliation(s) 1Centre for Equity and Health Systems, icddr,b, Chakaria, Cox's Bazar, Bangladesh, 2Centre for Equity and Health Systems, icddr,b, Dhaka, Bangladesh, 3Centre for Equity and Health Systems, icddr,b, Dhaka, Bangladesh, 4Centre for Equity and Health Systems, icddr,b, Dhaka, Bangladesh, 5Centre for Equity and Health Systems, icddr,b, Dhaka, Bangladesh, 6Centre for Equity and Health Systems, icddr,b, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Health Workforce
Summary Bangladesh is one of the 57 countries with a serious shortage of trained doctors, paramedics, nurses and midwives. Village doctors, a group of informally trained practitioners in modern drugs, are the dominant health care providers in the rural area. Village doctors, trained by the Centre for Equity and Health Systems (icddd,b) who had achieved an acceptable level of performance in dispensing drugs and in other desired areas related to the practice, were branded as ShasthyaSena (health soldier). The ShasthyaSenas took part in an intervention that combined their competence with that of qualified physicians through an mHealth call centre with the objective of bringing better health services to the rural community they served in.
Background Bangladesh is one of the developing countries where 80% of the population lives in rural areas. The village doctors were most prominent contact person for consultation for any illness by the rural poor in Bangladesh. 53% of the rural population resorted to village doctors for their health services. But the village doctors are not recognized by the public sector as authentic health service providers. icddr,b has tried to train the village doctors in order to reduce harmful treatment practices since 2006 in Chakaria. There is a dearth of study regarding the engagement of village doctors or informal healthcare providers in tele-consultation (mHealth) of patients with formal provider. icddr,b operates a project to engage village doctors with the consultations of graduate doctors through mobile phones and with technical guidance from Telemedicine Reference Centre Limited (TRCL) a private entrepreneur in Bangladesh.
Objectives The objectives of the project were to design a) an appropriate disease management scheme available to the village doctors for on the spot consultation with qualified medical personnel through a mobile phone. The range of management includes prescription by the formal physicians through SMS, prescription drugs supplied by the village doctors and referral to appropriate facilities if needed.
b) A business model aka financial incentive that can compensate village doctors and limit excess profit gained from unnecessary prescriptions.
Methodology The study was carried out in Chakaria, a rural south east sub-district of Bangladesh. Village doctors were trained on do and don’ts for providing treatment to patients and a membership-based-network involving trained and eligible Village Doctors branded as “ShasthyaSena” (Health Frontiers) was established which give the Village Doctors logos and badges. In 2011 ShaysthaSena’s were trained on the use of mobile phone (mHealth) for consulting with graduate doctors for their patients within a revenue sharing process. A Call Centre was established, eClinic24, to link the informal providers with the formal by (TRCL). TRCL provided technical and expert support for the project. We kept all the details of implementation i.e. inception, modification, challenges, perceptions etc. and periodic process documentation.
Results During 2011-12 program implementation periods, 110 ShasthyaSenas participated in the training and 55 registered with the eClinic24 system. Of those who registered, the utilization of the services was somewhat low. A total of 415 calls were enacted and only 26 ShasthyaSenas made those calls. 50 calls ended up in receiving prescriptions. Although there was a lot of enthusiasm among the ShasthyaSenas and the community about the mHealth, as the numbers of utilization indicates, the uptake was far below than what was expected. The major reasons for the low uptake of mHealth services mentioned by the ShasthyaSenas revolved around the problem of accessing the call centre, such as doctors not picking up the calls, long waiting period, and problems with the phones the ShasthyaSenas owned.
Conclusion Despite low uptake at initial program implementation, mHealth can be an effective means of health services in future and ShastyaSenas can be a viable options to engage as the community have confident on them. More research in this field needed by resolving the technical problems encountered during initial phase.

The perception of Family Medicine by Medical Student and Clinical Teaching Staff: Tajikistan

Author(s) Dilrabo Kadirova1, Jura Inomzoda2, Sabine Kiefer3, Erik van Twillert 4, Kaspar Wyss 5
Affiliation(s) 1Chair of Family Medicine Nb. 1, Tajik State Medical University, Dushanbe, Tajikistan, 2Chair of Family Medicine Nb. 2, Tajik State Medical University, Dushanbe, Tajikistan, 33Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 4Medical Education Project, Swiss Tropical and Public Health Institute, Dushanbe, Tajikistan, 53Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland.
Country - ies of focus Tajikistan
Relevant to the conference tracks Health Workforce
Summary The Tajik government is committed to promoting a family medicine model for Tajikistan. However, recent trends show that family medicine remains an unpopular choice among medical students. The study explores, in a cross-sectional survey, the perception of students as well as teaching staff on family medicine. Results show that several steps can be taken by the university to improve the perception of family medicine among students and staff (e.g. orientation events, early exposure to family medicine training). However, extrinsic incentives are perceived as the most promising drivers for changing students’ perception of family medicine.
Background The Tajik government is, in its National Strategy 2010–2020, committed to a family medicine model by which affordable primary health care should be introduced throughout the country. To successfully implement the strategy, reforming medical education to increase the number of family doctors is therefore a priority. The Swiss Agency for Development and Cooperation is assisting these efforts through the Medical Education Project (MEP) being implemented by the Swiss Tropical and Public Health Institute.Though the changes are on-going, it is being observed that many students and health workers find family medicine still unattractive. The number of interns registering for family medicine has, similar to other Central Asian Countries, decreased strongly over the last years.It is assumed that several factors during undergraduate studies influence the choice of specialisation. Among these factors are the mediated perception of family medicine through medical teaching staff as well as the students own perception. To increase the number of family doctors, it is essential to understand the perception of family medicine at different stages of a students’ lifecycle at university and the possible positive or negative influences of these through teaching staffs’ own perception of family medicine.
Objectives The objective of the study was to generate insight into the prevailing perceptions of family medicine among medical undergraduate students and teaching staff. Possible determinants including the influence of socio-demographic aspects and clinical teaching. The changes to students' perception over the course of study were also investigated.
Methodology In 2013 a cross sectional survey among 1st, 4th and 6th year students as well as all clinical teaching staff at the Tajik State Medical University (TSMU) was carried out by the chairs of family medicine. Perception of respondents towards family medicine was assessed through a set of items relating to family medicine. Respondents were asked to rate them on a 5-point Likert scale.
In total more than 2’500 students and more than 350 staff of TSMU were included in the study. The ratings were analysed through factor analysis to identify underlying dimensions in the perception items. Each factor was combined in a composite score to compare opinions of different groups using statistical tests for independent samples and outcome variables to investigate the influence of socio-demographics.
Results Students were mostly interested in working in specialities other than family medicine, most prominently surgery and obstetrics and gynaecology. In their speciality choice, students rated the possibility to work in Dushanbe and/or abroad, as well as prestige and salary very highly. Teaching staff reinforced these aspects as main drivers for students’ choices but also added that career opportunities/professional possibilities would play an important role. Overall students and staff of all three cohorts agreed that working as a family doctor is currently not very attractive in Tajikistan.
There was also large agreement that most students, as well as teaching staff, do not actually know what family medicine is really about. Moreover, students were convinced that society and other medical professionals have a low opinion and perception of family medicine.
Nevertheless, students showed themselves to be open to family medicine. Students and teaching staff both agreed that everyone should receive training in family medicine, no matter what specialty they choose later. Students supported the idea that family medicine should have the same prestige as any other speciality. This was seen differently by some teaching staff. However, students and teaching staff did not agree that family doctors should receive higher salaries than narrow specialists or that the access to specialists should be controlled by family doctors.
The majority of students did not recall any comments by teaching staff about family medicine. Of those who had heard about family medicine, many reported that the statements were neutral or positive.
More in-depth results are currently being analysed and will be presented at the Geneva Health Forum 2014.
Conclusion The study provides insight into Tajik medical undergraduate students’ perception of family medicine and indicates that targeted interventions are necessary to increase the interest and commitment of students to become family doctors.
Several steps can be taken in conjunction with the university, the chairs of family medicine and through the medical education curriculum to improve students and staff perception of family medicine.
Given the low level of knowledge of family medicine, it is concerning that students and staff have a rather bad perception of family medicine. The majority of teaching staff and students were unfamiliar with family medicine. Once students enter university orientation and information events are essential. Contents of family medicine lectures, as well as career pathways, should be presented to the students. Similarly, information and promotion activities for the teaching staff would lead to a better perception of family medicine. Adapting the curriculum to provide an earlier and intensified exposure to family medicine training is required. Attractiveness and participation in practical trainings in family medicine should also be incentivised.A higher appreciation of family doctors, through extrinsic incentives, would positively change student perceptions. The most important aspects for students choosing a speciality were those which currently cannot be offered by family medicine positions in Tajikistan, specifically the placement in the Dushanbe or the higher prestige of a speciality. These aspects need reforms and continuous efforts from the Tajik Ministry of Health to better the conditions for family doctors and provide incentives for students to take up family medicine. Incentives for students need to be well-designed and structured to ensure that they truly raise students’ interest in family medicine. Beside higher salaries for the family doctors compared to other narrow specialities, this could include mandatory internships in family medicine.Based on the Tajik national health sector strategy, a strong political commitment from the government outlining the possible career pathways and opportunities for family doctors would clearly enhance the perception, value and popularity of family medicine.

Maternal Health Workforce Management in Vietnamese Health Communes

Author(s) Thi Hoai Thu Nguyen1, Andrew Wilson2, Fiona McDonald3
Affiliation(s) 1Faculty of Health, The Queensland University of Technology, Hanoi, Vietnam, 2Menzies Centre for Health Policy, The University of Sydney, Brisbane, Australia, 3Faculty of Law, The Queensland University of Technology, Brisbane, Australia.
Country - ies of focus Vietnam
Relevant to the conference tracks Health Workforce
Summary As part of a study into the governance of health workforce in Vietnam, this study examined the impact of staff qualifications, training opportunities and other factors on reported ability to perform Essential Obstetric Care services (EOCs) in two provinces. While qualifications and training were the most important factors, national and district policies, such as which health professionals can prescribe essential medications, were also important factors in limiting provision of EOCs.
Background Vietnam’s national policies recognise the importance for an effective health system to ensure sufficient human resources (Politburo Resolution No. 46/NQ-TW dated 23 February). However, current analysis indicates a number of issues, including an imbalance and maldistribution of the essential health workforce, shortages of appropriately skilled health workers and constraints in management and utilization of health workers. Parallel studies on the impact of health policies on the health workforce, the implementation of health policies and provision of health care services in Vietnam have identified a number of governance-related issues, including a lack of staff accountability, quality control measures in relation to workforce training and skills maintenance, inadequate participation of community and civil society organizations, and an unreliable health information system. Underdevelopment of governance mechanisms may be a significant barrier to the effective implementation of policies. However, so far there has been no systematic analysis to identify the points of weakness and gaps in the governance and internal management of human resources in the health care system at the provincial and district levels in Vietnam.
Objectives Ensuring access to good maternal health services is critical for Vietnam to achieve the relevant Millennium Development Goals and this requires a well-qualified maternal health workforce able to provide the EOCs. This study aims to examine the impact of national and district policies relevant to human resource management and organisational factors on the maternal health services. Specific objectives were:a) To identify the availability and qualifications of maternal healthcare providers at commune level in two provinces.
b) To identify the ability of maternal healthcare providers to provide the EOCs and the barriers to providing these services.
c) To understand how the existing organizational and policy factors influence maternal healthcare provider’s ability to provide EOCs.
Methodology The research has been conducted in five districts in two provinces in the Northern mountainous area of Vietnam. A mixed methods approach was used consisting of a self-administered questionnaire given to commune level staff and in-depth interviews with commune maternal healthcare providers and managers engaged in maternal health at district and provincial levels. The questionnaire consisted of four sections namely: demographic information relevant to maternal healthcare providers, the training opportunities they attended, self-rated ability to perform EOCs and a scale to measure elements of work motivation.The sample for the quantitative survey is 192 maternal healthcare staff who volunteered to complete the questionnaire. In-depth interviews were conducted with 60 participants of whom 18 chosen to represent the different workforce groupings and have been fully analysed.Initial analysis to explore the differences in maternal health workforce between the two provinces consisted of two way tabulations with statistical significance testing using the Chi-square test. All variables found to be significant in this analysis and the potentially confounding variables were incorporated into multivariate regression analysis to identify the independent associations with the ability to perform EOCs.

For the qualitative analysis the subset of 18 interviews was transcribed. Inductive analysis was used to identify, code and organize themes arising from the raw data, with quotations servings as units of analysis. Data was analysed for consistently occurring themes or categories using a qualitative research package, N-Vivo software.

Results Analysis of the survey indicates there are distinct differences between the provinces as to the mix of maternal health professionals, their qualifications, their access to further training, and their self-reported ability to perform EOCs at the commune levels.The multiple logistic regression analysis showed that staff were more likely to report having training on all EOCs if they worked at district level, had higher qualifications (university and equivalent or higher) and obstetric expertise.In both provinces, only 21.6% of staff reported being able to perform all EOCs. The most common reasons reported by staff for not being able to perform EOC services is “Because I am not allowed to do this”, followed by “Lack of training” and “Lack of drugs and equipment”.

The most important determinants of ability to perform the EOCs were qualification and training. Although having attended training course in the last 12 months was not significantly associated with ability to perform EOCs in univariate analysis, in the multivariate analysis it was significant.

Data from the in-depth interviews confirms a common theme that respondents felt constrained in their potential roles by policies. It is also identified other organizational, policy and resource constraints faced by staff and managers at the commune and district levels.

Conclusion 1. The study provides a better understanding of the factors influencing the health workforce’s capacity and capability in the maternal health context in Vietnam.
2. The restrictions on who can perform EOCs should be reviewed to improve access to full EOCs.
3. To use health workforce most efficiently and effectively, all appropriately trained staff need to be given the authority to carry out all EOCs including prescription of essential medicine regardless of qualifications.Given that access to maternal health services provided by appropriately trained health care workers has been shown to be important to better maternal and child health, this reform would assist Vietnam to achieve the MDGs.

Evaluating Systems-Thinking for District Managers: Ghana

Author(s) Aku Kwamie1, Han van Dijk2, Irene Agyepong3.
Affiliation(s) Health Policy, Planning and Management, University of Ghana, School of Public Health, Accra, Ghana, Anthropology and Sociology of Development, Wageningen University, Utrecht, Netherlands, Health Policy, Planning and Management, University of Ghana, School of Public Health, Accra, Ghana.
Country - ies of focus Ghana
Relevant to the conference tracks Health Workforce
Summary This presentation examines a management and leadership capacity strengthening intervention for district health managers in the Greater Accra Region of Ghana. It is based on the continuous quality improvement philosophy. In particular, the study's interest was in whether the intervention supports the development of systems-thinking in district managers in order to enhance their decision-making in implementing policies and organizing service delivery at district level. We undertook a realist evaluation in order to understand the mechanisms of the how the intervention worked given the context in which the intervention was introduced.
Background Across district health systems in low and middle income countries, district managers have the integrative role of interfacing between national-level policy formulation, and ensuring policy implementation at facility level. In aiming to strengthen health systems to better deliver services, weaknesses in district-level management and leadership capacities are often cited as bottlenecks to achieving health outcomes. Leadership and management are critical, complex functions of any health system. While there is widespread agreement on the need to strengthen these capacities for more effective health systems and better decision-making, there is limited understanding as to how such capacity strengthening interventions work. This is particularly true at the district level. To date, studies on management and leadership capacity strengthening in low and middle income country health systems have focused on skills acquisition and few have focused on the mechanisms of how such interventions work. There is a need to better understand the dynamics of district health system leadership and management in order to better strengthen them.
Objectives District managerial decision-making takes place in complex contexts, and thus capacity strengthening approaches must recognize systems theory and complexity. Continuous quality improvement is a management philosophy which supports both management processes and structures. Continuous quality improvement philosophy is based on the assumption that problems within the organization are not clinically, nor administratively rooted, but rather are systemic, and arise out of a structural inability to perform as intended. The systems-thinking perspectives of continuous quality improvement require an ability to analytically integrate the relationships, linkages and interactions at play among actors within the system which influence the capacity to perform. However, continuous quality improvement has two paradoxical goals inherent within it: while it focuses on controls, uniformity and standards, it is also focused on creativity, learning and organizational cultural change. The goal which dominates any continuous quality improvement process will depend on the degree of contextual uncertainty in the system into which it is introduced.
Continuous quality improvement has as its prime objective the establishment of quality as a key priority in management practice, to shift management’s role to one of creating a system able to produce quality outcomes, and to empower staff to make decisions. Previous work in Ghana has indicated the potential for implementing continuous quality improvement within the health system. Thus the objectives of this paper are to understand: (a) how and why a leadership and management intervention based on continuous quality improvement influences district manager decision-making; (b) whether the intervention leads to increased systems-thinking in district managers; and (c) by which mechanism the observed outcomes of the intervention are brought about.
Methodology We undertook a realist evaluation to investigate the mechanisms of the intervention, and the contexts in which the mechanisms are triggered. Realist evaluation moves towards a more generative perspective on “how did the intervention work, for whom, and in which contexts”, thereby integrating theories of causality with the actors and structures involved in a given system. Beginning with two working hypotheses to be tested, we built an explanatory case study of one rural district in the Greater Accra Region of Ghana where the intervention was introduced. The first theory hypothesized systems-thinking as the means for organizational change (through a mechanism of control). The second theory hypothesized systems-thinking as the ends of organizational change (through a mechanism of learning). Data collection included participant observation, document review and semi-structured interviews with district managers prior to, during, and after the intervention. District managers were defined as (i) members of the district health management team, including the district director of health services, (ii) members of the district hospital management team, and (iii) members of the three sub-district health teams. These managers were selected because, within the district, they represent the top-management for decision-making for organization and delivery of services. Interviews were also conducted with members of the regional facilitation team. The intervention consisted of a six-month cycle, where district teams made up of managers and staff came together in the capital city Accra three times on a bi-monthly schedule for face-to-face two-day workshops with the facilitation team. Face-to-face workshops were interspersed by monthly coaching visits; facilitators attended teams in their facilities with their broader staff to ensure that practices that had been taught to the core teams had been dispersed organization-wide. Working backwards from the observed immediate outcomes of the intervention, and examining the intermediate outcomes since the end of the intervention, we systematically built a causal map linking the outcomes and contexts to potential mechanisms of the intervention.
Results District managers had little prior training in management, and most learnt their management roles on the job. District managers faced serious time constraints due to ‘crash programmes’, the concurrent scheduling of training workshops and meetings programmed by various vertical programme units from the regional level. There was little evidence of integration of the intervention practices amongst the teams. The lack of institutionalization was influenced by the time constraints of routine work, and was further compromised by a change of leadership at regional, district and sub-district levels. We found four mechanisms at play which accounted for these observations: first, the novelty of the intervention itself provided an increased sense of urgency among teams. District managers were open to engaging with the process, and the imposition of deadlines heightened the perception of needing to achieve results, as compared to when the same work is required to achieve routine targets. Secondly, the intervention helped district managers to develop their initiative and reduce excuse-making. It was acknowledged that some problems faced by teams were ‘beyond’ district managers, and as such, initiative-taking was encouraged on a ‘small-scale’ basis mainly. Linked to this, the third mechanism was learning how to better prioritize. Through better prioritization, district managers felt better able to manage crash programmes, and as such viewed themselves as becoming more efficient in their work. Fourthly, supporting teamwork through teaching district managers on how to acknowledge and inspire their staff was important in contributing to the sense of improved work climate. Despite these positive developments, the intervention did not bring about systems-thinking in district managers. This correlated with the context of high resource uncertainty, partly determined by the highly centralized decision-making around both human and financial resources. Coupled to the top-down manner in which the intervention was introduced to district teams, this context further triggered the intervention’s underlying focus on organizational control, as opposed to organizational learning. Critically, organizational culture in this case remained unchanged.
Conclusion Our findings indicate that the top-down nature in which the intervention was introduced emphasized the primary goal of organizational control. This explains the lack of evidence of organizational learning and creativity. These findings uphold earlier work which describes the rigidity and lack of responsiveness in command-and-control structures observed in several African health systems as contributing partly to the challenge of quality of care in service delivery. Factors which reduce effectiveness of continuous quality improvements, namely vertical introduction, lacking systemic perspectives, and tool-driven processes were apparent in this case. In considering how the intervention might have been implemented differently, we see five ways which could have potentially altered the causal path: 1) had the facilitation team been peers instead of superiors (i.e., had facilitators been other district managers previously exposed to the intervention rather than regional managers) this may have weakened the hierarchical authority, thereby reducing the top-down nature of the intervention’s introduction; 2) had districts volunteered to receive the intervention instead of being randomly selected; and 3) had ongoing mentorship and coaching been built into the process through systematic follow-up, this may have supported institutionalization of the intervention practices; 4) had the time-frame of the intervention been lengthened beyond six months, this may have had deeper-lasting effects in becoming routine in daily management practices; and 5) had organizational learning been an explicit goal of the intervention (also supported by longer time-frames), with reflection processes built in as a major part of the intervention, this may have provided greater opportunity for more systems-thinking to develop in district managers.
As the health sector considers scaling-up the intervention to other districts, these findings will provide inputs into this process. This is particularly critical given the context of the health sector, which can be the more important dimension of complexity, as opposed to the intervention itself. Continuous quality improvement interventions interact with the contexts in which they are introduced, thus determining the types of outcomes possible. Such considerations must be kept in mind. Already, two members of the research team are affiliated with the Ghana Health Service and have ongoing policy dialogues with key actors in the Service.

Decentralized nurse training in rural Zambia – triplicating the output of trained nurses.

Author(s) Martina Weber1, Toddy Sinkamba2, Klaus Thieme3.
Affiliation(s) Zambia, SolidarMed, Chongwe, Zambia, 2 St. Luke's School of Nursing, Mpanshya, Zambia, 3 SolidarMed, Chongwe, Zambia.
Country - ies of focus Zambia
Relevant to the conference tracks Health Workforce
Summary The SolidarMed pilot project decentralized practical nurse training in rural Zambia started in 2012 with St. Luke’s School of Nursing in Mpanshya. The project aims at providing nurses for rural districts of Zambia by triplicating the annual student intake, and by delivering quality theoretical and decentralised practical training to meet quality standards. It is a pilot project presented as a valuable model for nurse training in Zambia to the Ministry of Health and other interested stakeholders. The project is based on the recommendations of WHO Global Policy Recommendations (2010) on Improving access to health workers in remote and rural areas through improved retention.
What challenges does your project address and why is it of importance? Zambia, like many other low income countries in the region, faces considerable challenges in providing sufficient human resources for health. In Zambia only about half of the health facility workforce are trained. Nurses and midwives are crucial in an already struggling health system, and not having enough key staff like nurses weakens the health system. Zambia has a shortfall of 9’000 nurses which is approximately 60% of its requirement. Rural hospitals particularly illustrate a drastic gap between the planned medical staff and the actual staffing situation. Historically, Zambia has not invested enough in its health training institutions. The under-funding of health institutions, poor training and accommodation facilities, inadequate equipment and study materials, as well as inadequate teaching staff have resulted in high attrition rates from pre-service training (like nursing), fewer graduates and an overall deterioration in the quality of outputs.
How have you addressed these challenges? Do you see a solution? The SolidarMed pilot project tries to target all these recommendations in the partnership with St. Luke’s School of Nursing at St. Luke’s Mission Hospital in rural Mpanshya / Zambia. The school had 30 students in 2009. The project target is to double the output of students by decentralisation of practical training. The first external practical training site is Sacred Heart Mission Hospital in Katondwe – a small hospital in a very rural and remote part of the Province. Experiencing clinical practice is essential for the student nurses to understand their professional future. Nurses are likely to find themselves as one of the few health professionals within a rural health institution. If they have never experienced the reality of rural practice and learnt to deal and adapt to its challenges, the outlook for their retention in the rural areas is not good. Given the limitations of a rural posting, where there is likely to be staff and equipment shortages as well as crumbling infrastructure, nurses need to be trained for this. And this kind of training is only possible if you actually train within a rural, peripheral context. The second external practical training site will be Chongwe District Hospital. This Level 1 District hospital is quite close to Lusaka, in the District capital of Chongwe and here nursing students supplement their experience of clinical practice in a remote rural area with practical training in a more urban hospital. Patient numbers are high, which is also valuable preparation for their professional future. In addition, being based in Chongwe allows nursing students easier access to Chainama Hills Hospital where they complete a practical rotation in mental health. Two clinical instructors are placed at all three practical training sites. The combination of learning and experience available at these three quite different hospitals provides a balanced mix of exposures to various professional settings. This allows nursing students to experience as many aspects of their practical work as possible, and thus gives them the best possible training for their future career.
How do you know whether you have made a difference? The project is on-going. The overall goal is to improve the provision of nurses for rural health care in rural districts of Zambia. In order to achieve this goal, SolidarMed invested in infrastructure and equipment at the decentralised training sites by building a student hostel and staff houses for the clinical instructors at Sacred Heart Mission Hospital in Katondwe and at Chongwe District Hospital, as well as staff houses for the clinical instructors at St. Luke’s School of Nursing in Mpanshya. Additionally, teaching and learning equipment is constantly upgraded. Furthermore, SolidarMed is supporting the training of one nurse tutor and six clinical instructors, incentivising the latter and supporting St. Luke’s Nursing School by placing them on the payroll of the individual practical training sites. To ensure cooperation between the Nursing School and the decentralised sites works smoothly, a comprehensive Framework Agreement is drawn up to define roles and responsibilities. The relevant Ministry of Health and Ministry of Community Development, Mother, Child Health are very interested in both the negative and positive outcomes of this pilot project. It is seen as a way of increasing the output of trained nurses in a relatively cost effective way with the additional benefits for the participating decentralised practical hospitals. Since the start of the project the intake of nurse students has been increased to 103 in 2013. This triples the number of students since the Nursing School started.
Have you or the project mobilized others and if so, who, why and how? This project is a pilot project for the Zambian training system for medical personnel. As well as the training institution, St. Luke’s School of Nursing and its Hospital involved other parties at the decentralized training sites at Katondwe Sacred Heart Mission Hospital and Chongwe District Hospital. All lessons learnt are shared with all stakeholders – e.g. the General Nursing Council of Zambia, the Ministry of Health and the Ministry of Community Development and Mother & Child Health and all other training institutes interested in scaling up their output. The involvement of the General Nursing Council is crucial for the success of this pilot project. This professional body registers nurses and midwives and regulates their professional conduct and education while also registering nursing and midwifery schools. It also has an advisory role in the Ministry of Health on matters relating to nurses and midwives. With regard to nursing and midwifery schools, the General Nursing Council sets the monitoring and evaluation standards, decides whether facilities are suitable for training, conducts supportive supervision visits and evaluates the training programmes offered at individual institutions. Furthermore, the General Nursing Council also develops and reviews curricula, teaching and learning materials, evaluates the implementation of these curricula and conducts knowledge and skills updates for teaching and clinical staff. The lessons learnt could be applicable for other job training institutions in Zambia that focus on topics other than health.
When your donor funding runs out how will your idea continue to live? The design of the SolidarMed project is that the decentralized nurse training can continue after funding runs out. The nursing school benefits from investment in its infrastructure and faculty and will be strengthened in the area of quality assurance. SolidarMed experienced that the practical training sites hosting the students benefited from their participation in nursing training. Nurses in training are a form of additional manpower in the context of a human resource crisis. SolidarMed has not created separate cadres of health professionals or designed its own brand of training, but rather supports Zambian training programmes, tailored to Zambian requirements. The project supports local ownership of human resource for health strategies. So it is fully consistent with Zambia’s national health priorities and strategies as defined in the Government of the Republic of Zambia’s Fifth National Development Plan 2006 -2010 as well as the Ministry of Health’s National Health Strategic Plan 2006 -2010, and the Human Resources for Health Strategic Plan 2011-2015. Preliminary drafts of the Sixth National Development Plan 2011-2015 suggest that this project is in line with Zambia’s future national health priorities and strategies. Local ownership is key to sustainability. SolidarMed supports Zambian solutions to Zambian problems, and this project is fully in line with this strategy. In doing so, SolidarMed recognises that a home-grown solution is more likely to be effective in addressing context-specific challenges, and more efficient and affordable. SolidarMed seeks out local knowledge and expertise to achieve its aims and contributes its own experience to build capacities and strengthen its partners.