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A solution to reducing maternal mortality? The role of community midwives

Author(s) Monika Christofori-Khadka1
Affiliation(s) 1International Cooperation, Swiss Red Cross, Bern, Switzerland.
Country - ies of focus Pakistan
Relevant to the conference tracks Health Workforce
Summary Over the last 12 years, many countries have tried to reduce the high rates of maternal mortality by 75 % as outlined in the MDGs. However, not all countries have been successful so far. One of the major bottlenecks to reach the goal is the lack of skilled birth attendants. The Swiss Red Cross has been supporting different countries in their endeavour to increase their workforce. The approaches range from scaling up the quantity and quality of the skilled birth attendants in rural areas to providing on-the job training and facilitating community integration. These measures have resulted in increased antenatal care and institutional deliveries and helped to reduce access barriers.
What challenges does your project address and why is it of importance? UNFPA's report (2011) states that 350,000 skilled midwives are needed to fully meet the needs of women around the world. In the light of meeting the MDGs, some countries have been investing in the training of skilled birth attendants (SBA) by scaling up their number and by scaling up the quality of their service. However, the SBAs often lack practical experience when it comes to deliveries and complicated cases. They rarely have the chance to be teamed up with an experienced midwife and are left alone to take important decisions and conduct deliveries under difficult circumstances. Other countries do not even foresee midwifery in their health system and doctors exclusively carry out deliveries. SBA's prefer to work in urban and semi-urban health facilities therefore there is a lack of SBA's in rural areas. At the community level, cultural restrictions may hamper the access of a pregnant woman to a health centre. Lack of resources, transport possibilities, decision-making power and a functional referral system are causes which contribute to life-threatening delays during pregnancy and childbirth.The SRC projects attempt to address these challenges in different countries of the world by using tailor-made approaches to strengthen community midwifery, their role and uptake.
How have you addressed these challenges? Do you see a solution? The SRC project in Laos aims to better prepare already trained community midwives for their assignments in rural health centres. The project focuses on the hands-on training and exposure to sufficient practical skills with on-the job trainings. A functioning mentoring system and continuous on the job supervision are important features to successfully introduce the SBA to their role and to the community. Qualified and confident staff will earn the trust of the community and thus increase the number of safe deliveries in the country. Alongside the human resources, the local health authorities are trained to collect health data regularly and accurately as well as use the analysis to feed back achievements of the community midwife model. In rural Pakistan, the SRC project scaled up the number of skilled birth attendants in rural health centers. Their role is to do regular home visits and be available 24 hours on-call for deliveries. They accompany a pregnant woman to the nearest hospital in case of complications and emergency. The on-call transport system with an ambulance and driver enables quick and safe transport. A midwife is based at the referral hospital and specially designated to receive referred cases from the rural areas in order to facilitate quick administration, treatment and procedures.In Honduras only doctors are allowed to conduct deliveries and the profession of midwife does not exist in the formal Honduran health system. While most health centers in the rural areas are not staffed with a doctor, SRC tries to enhance service delivery by providing special trainings to traditional birth attendants and selected women from community committees. The courses are endorsed by the Government and complete with an official examination. The focus of the course is on antenatal and postnatal care and on preparedness of the pregnant woman and her family for an institutional delivery. The birth attendants act as a bridge between the pregnant women in remote areas and the health system, but are also prepared for safe delivery if transport not possible.
How do you know whether you have made a difference? Before project commences, all SRC projects conduct a needs assessment and integrate a baseline survey in the initiation phase. Inbuilt into the project design is regular monitoring through health system management information systems (HMIS), reviewing of secondary health data as well as carrying out regular ‘Knowledge, Attitude and Practise’ surveys with the beneficiary community. Analysis of the data depicts the changes the projects have contributed. Individual interviews and case stories show the impact the project makes in a person's life. While the project in Laos is only at its initiation stage (we hope to have more data by April 2014), the Community Midwife project in Pakistan has already illustrated an increased uptake of antenatal care services by 50 % in basic health units and 33 % in the district hospital within only 6 months of project start. In two out of five basic health units the Institutional deliveries have increased three fold and in the district hospital by 61 %. Similar data has been received from Honduras, where 92% of pregnant women attend four antenatal care visits and institutional deliveries have increased about 30% in the intervention area.
Have you or the project mobilized others and if so, who, why and how? Since SRC projects usually work together with local Community Based Organisations or the local Red Cross Partner, volunteers play an important role. The volunteers assist to promote the health services and deliveries with skilled birth attendants. They also disseminate the rights of the patients and ensure that particularly the poor are aware of incentive programmes for institutionalised deliveries, e.g. the Health Equity Fund in Laos or the safe delivery package in Pakistan. In order to bridge the gap between health provider and community, SRC projects establish community committees, who regularly meet with the health providers and monitor their presence, discuss problems and develop solutions. The main aim is to build good rapport and accountability, which will enhance trust, increase provider performance and result in a higher utilisation rate of the health centre and its staff. In the communities, the community committee disseminates information about the services and encourages families to use skilled birth attendants. Special focus is given to mobilise male decision-makers and heads of households to increase their understanding and consent as to why deliveries with a skilled birth attendant are important. The families are encouraged to start with precautions in the early stages of pregnancy, i.e. start saving for delivery costs, arrange transport etc. Well accepted and interested female community members receive basic training to become an important link to the health services in the rural areas. In Honduras more than 80 female and two male members have participated in the trainings.Traditional birth attendants are another important group targeted by all SRC projects. They are included in the service delivery and serves as important links with the community. They accompany pregnant women to the health centres, call the midwives for home services and are important assistants during deliveries. In Honduras, due to the absence of midwifes, they play an important service role in family preparedness, antenatal care, detecting danger signs and facilitating the referral to the next SBA.
When your donor funding runs out how will your idea continue to live? All SRC projects are designed to obtain sustainability by the end of the project period. Sustainability is tackled from both ends: the community and the service provider. Anchoring the projects in the community aims at decreasing access barriers and creating sustainable structures which tackle the four delays in delivery. Similarly, a positive experience of a pregnant woman and her family in the health centre will have a long term impact upon her health seeking behaviour and that of her immediate neighbours and family. Promoting the right to health and facilitating social accountability structures empowers local communities to demand public service provision. At the service provider level, all projects work with the existing health system providing interventions which enhance quality and quantity of service provision. Advocacy from the community level to policy level are geared towards positive change. However, levels of sustainability vary. In countries where community approach is supported by respective Government policies for the health system and where providers are motivated and encouraged by the public service system sustainability is reached in a shorter time frame and with less effort than in countries where the Government and public staff are not motivated for change.The projects are embedded within the pre-existing health system structures of the governments. Except in Pakistan, all skilled birth attendants are employed by the government and thus will continue working in the future. However, in some countries the management of the community midwives is not yet clear as to the importance of their role. The community midwifes are transferred to replace nurses or other health staff and may end up in health centers without equipment or appreciation of their skills. The SRC projects are sensitizing the Ministries of Health and governmental line managers in the careful management of their community midwives.In Pakistan, the project is a pilot intervention which will be used to lobby the local government to redistribute their existing workforce to rural areas, introduce regular outreach and ensure a functional transport system through ambulances etc. Rigorous research, which accompanies the pilot, shall demonstrate the effectiveness of the project and lead to policy change as well as increased strict performance and attendance supervision.

Connecting Policy and Practice using Needs-Based HRH and Health Care Service Planning: Partnership between Zambia and Canada.

Author(s) Fastone Goma1, Gail Tomblin Murphy2, Adrian MacKenzie3, Gogi Greeley 4, Selestine Nzala 5, Miriam Libetwa6, Fred Montpetit7, Kenneth Rockwood8
Affiliation(s) 1School of Medicine, University of Zambia, Lusaka, Zambia, 2WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 3WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 4Department of Health and Social Services, Government of Nunavut, Iqaluit, Canada, 5School of Medicine, University of Zambia, Lusaka, Zambia, 6HRH Directorate, Zambia Ministry of Health, Lusaka, Zambia, 7Department of Health and Social Services, Government of Nunavut, Iqaluit, Canada, 8School of Medicine, Dalhousie University, Halifax, Canada
Country - ies of focus Canada,Zambia
Relevant to the conference tracks Advocacy and Communication
Summary In the midst of a global human resources for health (HRH) crisis, researchers and decision-makers are seeking new and innovative evidence-based strategies for HRH planning. For several years, Canadian and Zambian researchers and policy and decision-makers have been working to adapt a needs-based approach to develop service-based strategies and tools for HRH planning. This approach is based explicitly upon the needs of people, considers the multiple contextual and process factors in the different country contexts, and aims to improve patient, provider and system outcomes.
Background Historically, HRH planning in Canada and Zambia, as in most countries, has been based on supply, use and/or health care expenditures. None of these approaches account for changes in population health needs, provider productivity, or models of care delivery. Since most of Zambia and parts of Canada face critical HRH shortages, it is essential to make the most efficient possible use of these scarce resources in the short term, and to adopt more responsive HRH planning methods in the long term. Service-based HRH planning compares the number and type of services required by populations, given their needs, with the capacity of existing HRH to perform those services. This allows policy makers to collaborate with researchers, educators and providers to identify and compare strategies to address health care system gaps at the level of specific services rather than for particular professions. The unit of analysis used in this framework is the particular health care service that is to be performed by a health care provider to address a certain health care need within the target population. This contrasts with most HRH planning approaches where the health care provider is the unit of analysis.
Objectives The purpose of this paper is to describe the adaptation and application of an analytical framework for service-based HRH planning to different contexts in rural areas of Canada and Zambia. Specific objectives are to: (a) Provide an overview of the analytical framework for service or competency-based HRH planning; (b) Describe the processes used to engage partners in adapting the framework to inform planning in the northern Canadian territory of Nunavut as well as the rural Zambian districts of Chibombo and Gwembe; and (c) Share the lessons learned through collaboration between the researchers and policy and decision-makers across sectors in each application, at the district, provincial/territorial and national levels.
Methodology The framework calls for two quantities to be estimated and compared: how often a particular service is required by the target population (requirements), and how often that service can be performed by the available health workforce (supply). Estimating the first requires the identification of the leading health conditions which drive the need for health care (according to whatever criteria are deemed appropriate by planners in their particular context, such as rates of mortality and/or morbidity), knowledge of the size of the population and the incidence or prevalence of each leading condition within it, the range of health care services required to address each condition, and the frequency with which each service is required by persons with those conditions. Estimating the latter requires data on the size of the available health care workforce as well as their level of participation in it, their levels of activity (e.g. hours worked) and productivity (e.g. cases treated per day), and the prevalence of the competency to perform each service across the existing workforce.The study in Nunavut was funded by Health Canada. The Zambia Study was funded as part of the African Health Systems Initiative. In Zambia, the study was conducted in two rural districts - Gwembe and Chibombo – and considered the needs of their entire populations. In Canada, the study was conducted in the northern territory of Nunavut and was specific to the needs of older adults. In both Zambia and Canada, the research and stakeholder engagement processes were guided by steering committees of local clinicians, educators and policy-makers. Leading health conditions were identified using a combination of administrative data consultations with local stakeholders. Data on population size and the incidence or prevalence of each condition were obtained from administrative sources. The number and type of health care services required to address these conditions were compiled based on published guidelines and then validated by local clinicians. The size and characteristics of the existing health workforces were estimated using a combination of administrative records and a questionnaire administered to health workers in each jurisdiction.
Results The primary health conditions identified in the two Zambian districts were HIV/AIDS and malaria. Although the competencies of the districts’ existing health workforces mostly aligned with these conditions, some substantial gaps were found. The largest gaps identified in both districts were performing laboratory testing and interpreting results, performing diagnostic imaging and interpreting results, taking and interpreting a medical history, performing a physical exam, identifying and diagnosing the illness in question, and assessing eligibility for antiretroviral treatment. In both districts, these services are required very often yet few HWs report feeling competent to perform them – a combination of high need and low supply.Leading conditions among older adults in Nunavut were arthritis, cancer, chronic obstructive pulmonary disease (COPD), diabetes, and hypertension. As in Zambia, while the competencies of Nunavut’s existing health workforce were largely aligned with the health care service needs of its older adults, there were some significant gaps. The largest of these related to ongoing client assessments (mental health, safety, and fall risk), pharmacy services (dispensing, monitoring effectiveness, and addressing polypharmacy issues), and client and family education (related to health promotion and goal setting). Similar to Zambia, these gaps were present because, although required frequently by older adults in Nunavut, relatively few members of the territory’s health workforce have the knowledge, skills and judgement to provide these services.These findings were discussed in deliberative forums in Zambia and Canada with participants representing clinicians, government, educational institutions, regulatory bodies, and health care organizations to ensure their validity and to discuss potential strategies to address the identified gaps. Some suggested solutions for Zambia included targeted professional development in the short term, and, in the long term, increased collaboration between health and education to better align the latter with population health needs, and increased collaboration across sectors to improve living and working conditions for the workforces in these districts. Some strategies suggested for Nunavut included increased dialogue to improve coordination between the home and acute care sectors and between health and education, and expanded use of electronic health records to reduce polypharmacy issues.
Conclusion Although each of the jurisdictions studied possess active, productive and competent health workforces, each also has significant gaps in the services it can provide to meet the health care needs of their populations. The rural and remote locations of the communities in these jurisdictions makes recruitment and retention of highly trained professionals, not limited to HRH, an ongoing challenge. In the short-term, on-site training of existing health workers may be the best approach to address specific competency shortages. In the long term, along with investments in improved infrastructure, continued use of the service-based approach will enhance policy-makers’ ability to align the training, management and deployment of health workforces to meet the needs of its people. This approach provides the flexibility needed to change the composition of health care workforces to align with the changing health needs of the people they serve. The application of the service-based framework in this setting and the relevance of findings to dialogue with policy makers and clinical stakeholders demonstrate its potential utility for other jurisdictions and health care settings in Zambia, Canada, and internationally.The studies in both countries were limited by low numbers of participating health workers, and by the use of self-reported data to measure important concepts such as competence. However, the study’s findings were validated by local steering committees as being consistent with their experiences.In addition to the applications of the service-based approach to HRH, there were a number of mutual learnings from the collaborations between and among researchers and researcher users in these studies. These lessons learned included: 1) the importance of understanding the unique health governance, cultural, economic, historical and political contexts in each country and/or regional setting; 2) the importance of engagement and time to build effective, respectful and trusting partnerships with all stakeholders, across multiple sectors, including researchers and research users; and 3) the importance of capacity building to creating viable processes and strategies for human resources for health and health system sustainability. Most importantly, these connections are key examples of how multi-sectoral partnerships support shared accountability for integrated solutions for HRH planning to advance local and global health.

SolidarMed support to Zambia’s Medical Licentiate Training Programme.

Author(s) Anel Bowa1, Uwe Graf2.
Affiliation(s) 1Chainama College of Health Sciences, Chainama College of Health Sciences, Lusaka, Zambia, 2Medical Licentiates Department Chainama College of Health Sciences, SolidarMed, Lusaka, Zambia.
Country - ies of focus Zambia
Relevant to the conference tracks Health Workforce
Summary The Medical Licentiate Training Programme (MLTP), adapted to Zambia’s requirements and circumstances, is one response to the severe shortage of doctors. The MLTP provides training in internal medicine, paediatrics and child health, obstetrics and gynaecology and surgery. It enables Clinical Officers (COs) to upgrade their skills so that they can perform the role of doctors (task shifting) including lifesaving operations. Since 2009 SolidarMed supports the MLTP with the assistance of the LED. SolidarMed’s association with the MLTP and cooperation with Chainama College of Health Sciences (CCHS) has already proved fruitful as intakes and practical sites have successfully been doubled.
What challenges does your project address and why is it of importance? The project supports the training of MLs at CCHS for the Ministry of Health (MoH) in Zambia. The project aims at increasing, in fact doubling, the number of trained Medical Licentiates. The Zambian health sector faces a constant shortage of human resources. Rural areas have been more disadvantaged and, while the population has been increasing, the number of Medical Officers (MOs) has remained constant. As a consequence, CCHS commenced the MLTP in January 2002. The Programme was introduced with a purpose of helping fill the void where there were no MOs, especially in rural Zambia. The purpose was to augment the functions of MOs due to their long standing shortage in rural hospitals. At that time the attrition rate for MOs was said to be at 80 per cent. The MLs are trained to work at Level I Hospitals. The aim of the MLTP is to train a first line mid-level health worker that handles medical emergencies and has skills in all the four major disciplines of medicine which are: Internal Medicine, Obstetrics and Gynaecology, Surgery as well as Pediatrics and Child Health. Therefore ML practitioners are the ideal cadre to address Millennium Development Goal 4 and 5. Candidates to the programme are COs with at least 2 years clinical experience.
How have you addressed these challenges? Do you see a solution? The Medical Licentiates Training Programme, adapted to Zambia’s requirements and circumstances, is one response to the severe shortage of doctors especially in rural Zambia. Clinical officers play an important role in the Zambian health service and are usually employed in rural health hospitals. The MLTP provides further training in internal medicine, paediatrics, gynaecology and surgery, and enables Clinical Officers to upgrade their skills, so that they can perform the role of doctors, and be able to diagnose and perform operations as well as manage and run District (Level 1) hospitals. It opens a career path for clinical officers. An additional focus of the MLTP is on emergency care, which constitutes a big need in the periphery. MLs are able to help those in need of immediate assistance such as those patients who might die if they have to wait for referral and transfer to the next level of care. This training on critical care makes MLs more suitable for rural hospitals. Stabilised patients are then referred to the next level of care if the need arises. Since the inauguration of the training programme, not a single ML has left the country. Available data suggests that brain drain for this cadre is very limited. Neither internal brain drain into the private or Non-Governmental Organisation (NGO) sector, nor external brain drain to neighbouring countries or the region can be observed, unlike with medical doctors. MLs are retained in the rural areas and in areas that are underserved and medical doctors are not to be found. SolidarMed’s involvement in the MLTP started in 2009, with the assistance of the LED. The project aims at increasing, in fact doubling, the number of trained MLs. SolidarMed’s association with the MLTP and cooperation with CCHS has already proved fruitful as intakes and practical sites have successfully been doubled. Acknowledging the professional capacities of the MLs, the MoH in 2012 increased the national ML target from 216 (3 per district) to 600.
How do you know whether you have made a difference? The first step in achieving this was to institute an annual intake of 24 students (instead of one intake every two years as before). To achieve this, the number of practical training hospitals had to be doubled. Out of the 4 new training sites, SolidarMed supported 3: St. Luke’s Mission Hospital in Mpanshya (Obstetrics and Gynaecology); Kafue District Hospital (Internal Medicine) and Livingstone General Hospital (Paediatrics). Support to these training hospitals included infrastructure development like student hostels and staff houses, targeted investments including essential medical equipment, provision of an enrolling fund and the deployment of three consultants (in Obstetrics/Gynaecology, Internal medicine, and previously in Paediatrics for which a Zambian doctor subsequently took over the position). The consultants participate in theoretical training at CCHS and are in charge of the practical training of MLs during their 4 month practical training units. The SolidarMed consultants have a dual teaching/training role. As well as holding lectures for ML students during the theoretical part of their training at CCHS in Lusaka, they are in charge of their practical, hands-on training in Obstetrics/ Gynaecology and internal medicine during their practical training attachment at St. Luke’s Mission Hospital, Mpanshya and Kafue District Hospital respectively. This dual role is unusual in the training programme, where the lecturers have little involvement in practical training and vice versa. However, knowing the demands of both the theoretical and the practical training and being able to meet both has been a unique advantage of the SolidarMed consultants. In 2011 the project underwent a comprehensive Midterm Review which acknowledged the success of the project. As a result there was a creation of a full-time position for a Technical Advisor at the CCHS and the construction of the urgently required new office building for the ML Department. The construction of the additional lecture room is underway.
Having created a database for all the MLs that have graduated from CCHS by the Project, it was discovered that all the MLs were working within the country and over 90 per cent of them were in rural based district hospitals where they are carrying out emergency surgical operations in addition to their routine job requirements.
Have you or the project mobilized others and if so, who, why and how? The Project is working closely and collaborating with various partners. The closest partners include: CCHS, MoH, Ministry of Education (MoE) through the University of Zambia School of Medicine (UNZA/SOM), and the Ministry of Community Development, Mother and Child Health (MoCDMCH). Other partners are: Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPEIGO), Clinton Health Access Initiative (CHAI), European Union (EU) through the Clinical Officer Surgical Training in Africa (COST Africa), the Volunteer Service Organisation (VSO), the Health Professions Council of Zambia (HPCZ), the Zambia Medical Licentiate Practitioner Association (ZMLPA) and the (Pan) African Network of Associate Clinicians (ANAC).
The various cooperating partners have been mobilized to play specific roles in the sustainability of the MLTP, quality assurance of the programme, deployment of the graduates, sponsorship of the students, curriculum review and improvement of the quality of theoretical and practical training. With the help of all stakeholders the curriculum for MLs was upgraded from advanced diploma level to Bachelor of Sciences (BSc) level. Enrolment into the programme is gradually increasing which shows the success of the programme.
The Project uses various strategies to reach and work with various partners. These include: networking, lobbying and advocacy work, collaboration, multilateral meetings and exchange visits.
When your donor funding runs out how will your idea continue to live? The programme is embedded into the Zambian education system. The MLTP is supported and recognised by all relevant Government Ministries (MoH, MoE, MCDMCH and Ministry of Finance (MoF)), policy stakeholders and networking partners. Active political support and recognition of the MLTP by crucial ministries like MoH, MoE, MCDMCH and MoF as well as other policy stakeholders and networking partners are key for the sustainability of the MLTP. Therefore:
 The SolidarMed Project Manager (PM)/Technical Advisor (TA) has been participating in Technical Working Groups at the MoH, in addition to meeting regularly with those responsible in order to advocate for the concerns of the MLTP.
 The SolidarMed PM/TA has pro-actively been promoting networking and exchange with the Zambia Medical Licentiate Practitioners Association (ZMLPA), as well as the Africa Network for Associate Clinicians (ANAC).
 Operational Research on the impact of MLs in Zambia will be carried out in collaboration with the SolidarMed PM/TA and the results of this shared.
The project supports an already existing programme. At the end of the project, it is expected that the programme would be strengthened further, including improvement of quality of training, strengthening of the management of the ML Department and the introduction of a Bachelor of Science degree programme. The infrastructure that has been constructed will leave a permanent mark of the support from the project and will continue to be used to produce the required category quality and number of health workers. It is envisaged that the MoH and other relevant Ministries and partners will sustain the programme.
In addition, after 2015 there will be need for a period of consolidation at all levels of the MLTP - locally within CCHS, nationally with all relevant ministries and all other relevant key stakeholders from the government sector, as well as regionally through the ANAC. The network most likely would need to be focused on with more intensified support and steering. Another key factor in the attractiveness and sustainability of the MLTP will be its ability to confer a degree.

Self-Efficacy of Nurses in the Performance of Counselling-Related Tasks: Eldoret, Kenya.

Author(s) Carolyne Chakua1.
Affiliation(s) 1Educational Psychology, Moi University, Eldoret, Kenya.
Country - ies of focus Kenya
Relevant to the conference tracks Health Workforce
Summary This study investigated the self-efficacy of nurses at Moi Teaching and Referral Hospital in the performance of counselling-related tasks. A self-efficacy questionnaire was used to assess the nurses’ self-efficacy in the performance of counselling tasks. The findings revealed that whereas age, experience and additional training in nursing had a significant influence on nurses’ self-efficacy in performing counselling tasks, gender and level of training had a non-significant influence. These findings pose significant implications for managers and trainers of healthcare professionals in ensuring an enabling environment for the practicing and training of professionals in counselling tasks.
Background Counselling as a fundamental element of nursing has been acknowledged repeatedly. Nursing is recognized as being the art and science of caring. The artistic part of nursing demands ability in the creative use of nursing actions. The scientific part involves an analytical, systematic process to solve clinical nursing problems. Irrespective of which approach nurses take, the need for counselling-related skills is inherent in nursing tasks. Despite numerous opportunities for nurses to utilize counselling skills, their ability to effectively provide these services using the knowledge and skills gained during their training is an issue of concern. For a long time now, concern has grown that nurses may often be ineffective counsellors, and that deficiencies exist in training for counselling-related skills in nursing. It is against this background that the study investigated the perceptions of nurses regarding their performance in counselling-related tasks. This was achieved through the measurement of nurses’ self-efficacy. Self-efficacy measures were identified through statements identifying counselling tasks, where the participants were required to indicate their level of confidence in performing these activities.
Objectives 1. To investigate the relationship between age and self-efficacy of nurses at Moi Teaching and Referral Hospital (MTRH) in performing counselling tasks.
2. To investigate the relationship between gender and self-efficacy of nurses at MTRH in performing counselling tasks.
3. To investigate the influence of level of training in nursing on the self-efficacy of nurses at MTRH in performing counselling tasks.
4. To investigate the effect of experience in nursing on the self-efficacy of nurses at MTRH in performing counselling tasks.
5. To investigate the influence of additional training in counselling skills on the self-efficacy of nurses at MTRH in performing counselling tasks.
Methodology The study employed a causal comparative research design, a type of descriptive research that describes conditions that already exist, with an attempt to determine reasons, or causes, for preexisting differences in groups of individuals. This study adopted simple random and stratified sampling as probability techniques to select participants involved in the collection of the data. At the very outset of this research process, stratified sampling was used to select practicing nurses based on the departments they worked in. From each stratum, simple random sampling technique was then employed to select participants from each department. This was achieved through computer generation of random numbers from the list of nurses in each department to come up with a total of 212 nurses. The Self-Efficacy Questionnaire was used as a close-ended questionnaire with 30 statements describing counselling-related tasks. The respondents were required to answer on a 5 point likert scale, where 1 = Not true; 2 = Hardly true; 3 = Not Sure; 4= Moderately true and 5 = Very true. T-test for independent samples was used to compare the difference in mean self-efficacy scores for the categorical variables in this study that had only 2 groups: gender (male and female) and additional training (yes and no). One-way ANOVA was used to compare mean difference in self-efficacy along the variables of age-group, level of training and length of experience in nursing, and variables that had more than two groups. All tests were considered significant at 95% confidence level.
Results 1. Relationship between age and self-efficacy in performing counselling-related tasks: The results indicated that there was a statistically significant difference in mean efficacy score by age of nurses, F(192 ) = 1.52, p = .03. From these results, it was then concluded that age does influence self-efficacy of nurses in the performance of counselling. The older the nurses, the more efficacious they are in performing counselling tasks.
2. Relationship between gender and self-efficacy in performing counselling-related tasks: The result of the analysis indicated that there was a non-significant difference, t(193) = -.50, p = .619. It was then concluded that gender had no significant influence on the self-effcacy of nurses at MTRH in performing counselling tasks.
3. Relationship between level of training in nursing and self-efficacy in performing counselling-related tasks: The results indicated that there was a statistically non-significant difference, F(190) = 2.0, p = .117. The interpretation thereof was that the level of training in nursing, whether certificate, diploma or undergraduate degree, did not exert any significant influence on nurses’ self-efficacy in performing counselling tasks.
4. Relationship between length of nursing experience and self-efficacy in performing counselling-related tasks: The results obtained indicated that there was a significant difference among the mean scores, F(191) = 3.12, p = .046. Therefore, nurses with longer experience had a higher self-efficacy in performing counselling tasks than those who had less work experience.
5. Do nurses who have received additional training in counselling skills and those who have not differ in self-efficacy in performing counselling-related tasks? Nurses with additional training in counselling skills were defined as those nurses who have undertaken additional training in counselling, outside of their regular nursing training programme. The result of the analysis indicated that there was a statistically significant difference between the mean scores, t(192) = 2.51, p = .013. Consequently, it was concluded that nurses with additional training in counselling were more self-efficacious in performing counselling tasks than those without additional training.
Conclusion Self-efficacy of nurses in performance of counselling tasks was investigated along various variables namely age, gender, level of training, experience in nursing and additional training in counselling skills. Of these variables, the study found out that gender and level of training do not significantly influence the self-efficacy of nurses in performing counselling tasks. On the other hand, this study revealed that additional training, age and experience in nursing positively influence self-efficacy of nurses in performing counselling tasks. Bandura (1977) asserts that self-efficacy is enhanced by interventions. In the case of nurses at MTRH, their self-efficacy in performing counselling was enhanced by additional training in counselling, advance in age and increase in experience. All these three factors are external interventions that positively impacted performance of nurses. In essence, the self-efficacy of nurses in performing counselling tasks had everything to do with external interventions as opposed to personal attributes. Furthermore, these interventions enabled exposure to specific activities in a deliberate manner. This could explain why the level of training in nursing, though an intervention, had a non-significant effect on self-efficacy as the nursing training in itself does not deliberately address preparation in task specific counselling activities. These findings provide insights for all stakeholders in the field of medical education on the relevant areas of emphasis in training healthcare workers. This in turn will translate to competent professionals and high levels of patient satisfaction.

Staff houses in rural areas – a social investment approach for hospitals.

Author(s) Klaus Thieme1, Martina Weber2.
Affiliation(s) 1SolidarMed Zambia, SolidarMed Zambia, Chongwe, Zambia, 2Zambia, Solidarmed Zambia, Chongwe, Zambia.
Country - ies of focus Zambia
Relevant to the conference tracks Health Workforce
Summary The SolidarMed pilot project Staff houses and income generation for rural hospitals in Zambia started in 2013. The project targets improved attraction, recruitment and retention of rural health workers and focuses on the staff’s accommodation problem at rural hospitals. The innovative feature is that the staff houses are not handed over to the hospitals. They are rented out in the context of the Zambian housing allowance, so the rental income can be used for maintenance of the houses and further hospital improvements. While the state maintains the obligation to pay for housing, rural staff are familiarized with paying rent.
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 terms of providing sufficient human resources for health. Especially rural hospitals show a drastic gap between the planned establishment of medical staff and the actual staffing situation. One of the problems of the hospitals is that they cannot offer adequate staff accommodation to the required staff. Even the already placed staff lack adequate accommodation, meaning that hospital staff and their families often need to share small and sometimes run down houses meant for only one family. Funding of hospitals and salary payment is centralized by the Ministry of Health – but the governmental monthly grants for hospitals are so low that they hardly cover the running costs. There are no funds left to renovate the existing houses or build new ones. Accommodation for rent is not available in the rural areas.
Following the WHO Global Policy Recommendations (2010) where “increasing access to health workers in remote and rural areas through improved retention” the project perceives accommodation as a fundamental aspect of living conditions, so implemented a public benefit housing cooperative for medical staff.
How have you addressed these challenges? Do you see a solution? Staff without hospital-offered accommodation receive a housing allowance as a part of their salary. Ironically there is no possibility for renting accommodation in most rural areas. Existing staff houses are too few and oftentimes rundown. Additionally the Ministry of Health only sends new staff if enough accommodation is secured. In this way a bad accommodation situation will contribute to a bad staffing situation at the hospitals, and in turn reduces the availability of medical services in the rural areas.
A preliminary case-study of the impact of investment in constructing and renting out staff houses in the rural areas was done in 2012. The target was to study the feasibility of an impact investment in constructing and renting out staff houses in rural Zambia. The case study included a market analysis and undertook research on land acquisition, building processes, costs of construction in rural Zambia and issues of management and administration, maintenance and investment terms. Profitable construction and renting out of staff houses is not possible in the rural areas because of high construction costs and low return-assumption. The difficulty of regaining the invested money within a decent time period is a clear obstacle for involving private initiatives in constructing staff houses and renting them out for profit. In this context, donor funding offers an alternative for channeling large-scale private capital for social benefit.
The SolidarMed pilot project “Staff houses and income generation for rural hospitals in Zambia” is addressing this problem with an innovative approach. New staff houses are built and rented out in a cost-effective way at different rural hospital sites by a private public benefit cooperative.
The rentals will be collected by deduction codes at the Ministry level to secure reliable and regular payments. Hitherto deduction codes were used for back-payments of loans only, but for this project were innovatively utilized for rent collection. The rental income will be used for the maintenance of the project houses and the expected surplus will be used for further hospital development. In this way, the hospitals will be supplied with needed staff houses, will attract additional staff, better retain existing staff, and raise their monthly income. Communication and advocacy with all district and ministerial health administration levels are ensured throughout all processes.
How do you know whether you have made a difference? The pilot started 2013 with a proof of concept with three semi-detached duplex houses at one rural construction site. Depending on the further success of fundraising, the aspired target would be the construction and renting out of 26 duplex houses within a timeframe of three and a half years.
Constructing and renting out staff houses addresses one of the most urgent problems of the rural health system as it possibly solves the lack of medical staff. With the availability of adequate accommodation, existing staff can be retained and new staff could be attracted to the rural areas. With satisfying and sufficient room for retreat and recreation, job satisfaction and performance are likely to rise for employees.
Satisfied staff are less absent due to illnesses and perform better services. Additionally, if new staff are attracted by staff houses, and existing staff are more motivated to remain at the hospital, the health services at the hospital will improve.
Rent at the amount of the housing allowance will be collected by deduction code at Ministry level to secure reliable and regular payments. The income will primarily be used for maintenance and renovation of the houses and the residue will be used for further hospital development. Given how small the governmental grants for hospitals are, the additional income for the hospitals are needed for equipment acquisition as well as for renovation works. This will reduce the dependency on the governmental funding and raise the scope for the hospital management as well.
The local communities can be involved in a large scale by using local workmanship and local suppliers for construction materials. Construction works will trickle down income to the communities, particularly if not underdone by companies from the urbanized centers of Zambia or even by the often used Chinese contractors. By engaging local craftsmen work and construction skills will be enhanced and self-esteem of the local workers can be raised.
The project offers further learning oportunities for the project partners in Zambia. For the hospitals the pilot will offer insights in construction and management of staff houses as a private corporation. The project with its new approach of supporting hospitals through the attraction of additional staff houses as well as rental income is in line with the Zambian Ministry of Health’s new policy of the proliferation of private-public-partnerships.
Have you or the project mobilized others and if so, who, why and how? Direct partners of the pilot project are the Hospital Management Teams of Chongwe District Hospital, Sacred Heart Mission Hospital Katondwe and St. Luke`s Mission Hospital Mpanshya, all in Lusaka province in Zambia.
As a pilot, this project attracts high interest at all levels: from traditional authorities, health facilities, district health administration and ministerial level likewise. The Ministry of Health, the Ministry of Community Development and Mother & Child Health and the Ministry of Finance are involved and show support in all processes because of the well-known problem of lacking accommodation in rural areas for all state workers.
Other institutional players (NGOs) have started to copy the pilot already. In future, especially the now proven and executable possibility of obtaining deduction codes at ministry level, will most probably attract private-for-profit investors.
When your donor funding runs out how will your idea continue to live? The housing cooperative is self-financed at the moment when the first accommodation units are ready for occupancy and to commence rent collection, therefore it is sustainable. Because of the executable deduction code only low administration effort is needed in terms of rent collection. Through the involvement of the housing committees of the respective hospitals and the collected rent income, maintenance is ensured. The extension of the housing cooperative with respect to new participating hospitals and / or more houses at this stage is not predictable but possible. But a Zambian-wide cooperative is not the focus rather the main output idea is the “proof of concept” and the its widespread emulation.

Labour Force Participation of Disabled People in Italy: An Empirical Analysis.

Author(s) Tindara Addabbo1, Jaya Krishnakumar2, Elena Sarti3.
Affiliation(s) Department of Economics, University of Modena and Reggio Emilia, Modena, Italy, Department of Economics, University of Geneva, Geneva, Switzerland, Department of Economics, University of Geneva, Geneva, Switzerland.
Country - ies of focus Italy
Relevant to the conference tracks Health Workforce
Summary This paper is an empirical study on the work opportunities of people with disability using Italian data collected through a survey carried out by ISTAT in 2004. Our analysis is guided by the conceptual framework of the capability approach and investigates the role of conversion factors in the ability to be employed and the type of employment obtained.
This study contributes to the scarce literature about working conditions of disabled people, especially in the Italian context, and contributes to the knowledge of labour market dynamics for this population across countries.
Background The living conditions of people with disabilities have become a topical issue in recent years, for policy-makers and scholars alike. In the past, people with disability were con fined to hospitals and excluded from the society. In modern societies, the value of every person is increasingly recognized and protected, independently of his or her health condition. This study applies the conceptual framework of the capability approach to the analysis of the disability status. More speci fically, we study the working opportunities and patterns of labour market participation of disabled people in Italy.
The literature on disability and employment clearly shows di fferent likelihoods of employment by types of disability and there is a strong heterogeneity according to the types of disability that should be accounted for in an applied research. This made us locate a survey that could detect di fferent health conditions in order to assess their impact on the probability of being included in the labour force. Moreover, the sample allows the data be be disaggregated according to geographical location, which is particularly relevant in a country like Italy which is characterized by deep di fferences in the labour market across areas.
Objectives In this paper we would like to identify which characteristics increase the probability of being in the labour force for disabled persons in Italy. We make use of a unique dataset constructed from a national survey that was undertaken speci fically to collect data on disabled people and their labour market outcomes. This research  contributes to the scarce literature on their working conditions, especially in Italy. The Italian case is of particular interest, since the country has among the highest employment quota and non-compliance sanctions on firms, which makes Italian legislation a flagship case in the European setting.
Given the speci fic focus of the paper, the capability approach framework makes it possibile to split the research  between those who work (and, indeed, have the capability to work) and those who don't but may possess the capability of working. A crucial empirical challenge is to verify whether disabled persons have the practical opportunity to work taking into account their personal characteristics, the environment where they live and the resources available. After having analysed these groups within the disabled population, a further diff erentiation is done with respect to gender and how it a ffects the attitudes and perspectives towards employment.
Methodology The data used in this paper are from the Italian Survey on People with Disability, carried out in 2004 by ISTAT (Italian National Institute of Statistics). The survey counts 1,632 individuals.
To draw model-based inference from the data, a probit model is used to identify the personal characteristics and environmental factors that influence the probability of labour force inclusion, with a focus on the di fferences between men and women. Our endogenous variable is an indicator of whether the person feels (s)he is able to work or not, denoted by whether the person actually has a job or is actively seeking a job, and this is seen in accordance with the capability approach framework where the effect of disability is analysed.
To dig further into the mechanisms behind our fi ndings, we use a sequential logit model that allows us to focus on the 'transitions' between diff erent working conditions. This model can be interpreted as corresponding to a tree decision structure. More speci fically, the model fi rst identi fies which factors influence entry into the labour force. Once an individual is in the labour force, then (s)he can be unemployed or employed. If (s)he is employed, then (s)he could be a part-time or a full-time worker. Each of these 'transitions' can be influenced by di fferent personal and external factors, such as age, marital status, gender, education level, place of residence and health.
Finally, the sequential logit model is compared with a multinomial logit, which has the limitation of assuming the property of IIA, however we do not make this assumption a priori in our model.
Results We apply several probit and logit models to analyse the impact of classical human capital as well as disability factors on labour force participation and the type of work. Regarding labour force participation, we fi nd the usual evidence of a positive eff ect of education upon labour force participation. Disability, instead, does not seem to be signi ficant when men and women are pooled together, whereas chronic illness is. Separating men and women leads to specifi c eff ects of disability and chronic illness on women's labour force participation, but not for men.
Focussing on disabled people, we fi nd intellectual and hearing disabilities to be the most a ffecting types, and, for women, emotional disability to a lower extent. In all variants, living in the South/Islands of Italy has a negative influence.
Simple probit estimation results also confi rm the negative eff ect of a precarious health condition (because of disability, chronic diseases or both) in accessing the labour market, as well as the disadvantage faced by women, especially if married. Finally, high education levels seem to be necessary to access the labour market and to obtain a good job position for both men and women.
Going further into the type of labour status using a sequential logit model, we find that having a disability and/or a chronic disease fails to pass the labour force and employment transitions, with chronic diseases having a greater impact than disability. Being married negatively affects labour force participation and employment for women. These results are across diff erent sequential and multinomial speci fications. A direct multinomial logit model seems to be the least satisfactory speci fication as it fails to off er adequate explanations for the working status of participants.
One of the disadvantage of our data is that the survey we use is not a primary source of data with a capability oriented questionnaire and this also makes it difficult to ascertain the defi nition of disability in the capability approach. Also many studies on disability use secondary sources of data not designed in the capability approach so the use of appropriate econometrics techniques tackle this problem.
A useful future research would be to analyse the impact of disability on other capabilities in life, in particular the capability to be educated and to be socially active. Finally, using different data sources, our analysis could be applied to other countries and de finitions of disability.
Conclusion From a policy perspective, our results suggest that satisfactory outcomes in terms of the placement of disabled people can be attained through coherent and tailored programmes that involve educational institutions and health authorities. Our estimations, in fact, show that any education level higher than the primary school certi ficate has a positive and signi ficant impact on the probability of entering the labour force for men. However for women it was found that the significant impact on labour force participation was correlative with a university degree or a high school diploma. In addition, it is important that interventions distinguished between specifi c types of disability and provided the necessary support to disabled people to be able to acquire an appropriate education level and skills
suited to their characteristics.

Effective elderly home care in Belarus.

Author(s) Christine Rutschmann 1, Irina Moroz 2, Tatyana Kalinina 3, Tatyana Svetlovic 4, Viktor Kalbanov 5, Svetlana Anatsko 6, Monika Christofori-Khadka 7,
Affiliation(s) Department of International Cooperation, Swiss Red Cross, Bern, Switzerland, Public health and Health care Faculty, Belarusian Medical Academy of postgraduate education, Minsk, Belarus, Public health and Health care Faculty, Belarusian Medical Academy of postgraduate education, Minsk, Belarus, Medical and Social Department, Belarus Red Cross Society, Minsk, Belarus, Belarus Red Cross Society, Belarus Red Cross Society, Minsk, Belarus, Medical Social Department, Belarus Red Cross, Minsk, Belarus, Department of International Cooperation, Swiss Red Cross, Bern, Switzerland,
Country - ies of focus Belarus
Relevant to the conference tracks Health Workforce
Summary In order to effectively lobby for home care services of the elderly and disabled, a study was conducted among different medical and social service providers in the public and non-profit sector to elicit the medical, social and cost-effectiveness of the different services. Integrated home care services through providers which do medical and social tasks has proved to be highly effective and more cost-effective than services provided by different professional groups. A high level of beneficiary satisfaction and less ambulance calls, less hospitalisation as well as better mental well-being call for a scale up of integrated home care services with one service provider.
Background Worldwide there is an increase of the proportion of older people in need of constant medical and social care. According to experts, about 20% of elderly people have different functional disorders and require medical and social care in their daily life. At present, about 20% of the population of the Republic of Belarus are people aged 60 and over. Many of them have different functional impairments and are in need of long-term medical and social care.
Medical and social care is mainly provided by public health institutions and social protection structures either in institutions or through home care. The Belarusian Red Cross (BRC) is the only non-governmental organization providing integrated medical and social home care comprising of medical assistance, individual care, social and household services united in one service provider, the Visiting Nurses (VNS). The VNS professional nurses and volunteers primarily visit lonely elderly people and the disabled who live alone. Depending on their health status, they are classified in disability levels I-III, with level I being the most severe. The services delivered by the VNS are appreciated by beneficiaries and receive a positive assessment from the state.
Objectives Despite various previous commitments, the Government has not yet been able to scale up the number of VNS. In order to lobby for a scale up, the effectiveness and cost-effectiveness of the VNS services was assessed. The objective of the study was to compare medical, social and economic effectiveness (cost-effectiveness) of integrated home care delivered by the VNS with different state-owned medical care and social care providers in providing care for the elderly (all persons above 60 year of age). The study was carried out in 2 districts of Grodno region (Lida and Oshmyany) and 2 districts of Vitebsk region (Lepel and Polotsk). The study aimed to show that medical and social services united in one service provider are of higher quality, serve the needs of the elderly better and are more effective. Additionally, the research assumed that VNS services are more cost-effective as a duplication of services can be avoided when the medical and social services are integrated. Likewise, the study wanted to test the present trend of elderly care in the Belarusian context and assess whether caring for the elderly at home results in a higher self-perception of quality of life than when being cared for in a public setting.
This was first research to canvas the effectiveness and cost-effectiveness of different health and social care providers in the country and compare the performance of the public sector versus the NGO sector.
Methodology This study was conducted in two stages between 2011 and 2012.
To assess the effectiveness of medical and social home care, a desk review was done of the various medical records and financial statements of the different health institutions and social protection structures of the Government, as well as those of the BRC VNS services in 2011. More than 30 official documents were analyzed. They included: reports of health institutions, social protection structures and the BRC VNS on the amount of care provision and financial expenses for 2010, the official statistical compilations of the Ministry of Health of the Republic of Belarus for 2002 – 2010, 12 specially designed statistical maps to assess the effectiveness of the provision of medical and social home care by health institutions and social protection structures and the VNS and 123 individual patient cards assessing the effectiveness of medical and social home care provision to the VNS beneficiaries. All data were analyzed in terms of medical effectiveness (analyzing length of stay in health institutions, frequency of VNS visits, workload per VNC, frequency of calls for emergency services and hospitalization) and social effectiveness (restoration of lost functions of the patient, patient satisfaction).
To assess the quality of life of lonely and living alone elderly people (60 years and older) under various conditions of medical and social care provision, individual interviews with 780 randomly selected lonely and living alone elderly were conducted in February 2012. A team of researchers applied the SF 36 (Health Status Survey Short Form, the Russian version). 150 respondents were randomly selected from inpatient departments of the various medical and social providers, 561 outpatients and 89 clients of VNS were randomly selected and included in the study. Data processing was carried out using «Statistics 6."
Results The study showed that VNS care for patients who are not well covered by the state structures. More than 41 % of their patients are classified ‘disability level 1’ (highest level of disability and mostly severe chronic diseases and bed ridden patients), as well as HIV positive or suffering form tuberculosis. Even though the frequency of home visits of the VNS is the same as the ones of social workers, the VNS care for 30 % more patients than the social workers. Patients taken care of by VNS are hospitalised far less often than patients taken care of by state structures. Among the 780 respondents, 52 persons were hospitalized in 2011, out of them 8% of patients from VNS. Despite being generally sicker than the patients of social workers, the VNS patients also call an ambulance less often. More than 98 % of patients were satisfied with the VNS services and more than 62% of patients registered improvement in their self-care and mobility over the past year.
The analysis of quality of life of the elderly in different medical and social care provision settings showed that the VNS services are more cost-effective in achieving the psychological dimensions of health of the elderly - 40.9 points (95% CI, 38,5 – 43,2), and the disabled of group I - 40.3 points (95% CI 31,4-49,3) compared to the same categories of the population served by the public health institutions and social protection structures. The indicators of the physical health component of the elderly receiving the VNS medical and social care were not cost-effective in comparison to other service providers, but they remain more constant and show almost no decrease with increasing age of the elderly and the disabled respondents. Since the VNS medical nurses provide medical and social care to the most severe ill patients (people with disabilities of group I and II) this, in general, explains the lower values of the physical health features.
The work of the VNS BRC medical nurses is supported by volunteers whose activity contributes not only to the provision of medical and social care, but also reduced the cost of its provision. Moreover, it is considered that the provision of medical and social home care increases the economic productivity of those who are caring for elderly relatives.
Conclusion The study showed that the BRC VNS is an important resource to meet the needs of the population in medical and social home care and is characterized by medical, social and economic effectiveness. The study also showed that to meet the needs of the elderly in the medical and social care it is necessary to develop different medical and social care provision forms to canvass the difference between medical and social care at home and in hospital settings.
An integrated approach to the provision of medical and social home care to elderly patients, especially when combined with the involvement of volunteers, can be an effective model of service delivery, which expands capacity by removing the burden of medical and social care provision of the state.
An in-depth study on the living conditions and quality of services for older people should be carried out to better understand the dependence of the quality of life of older people on the quality and type of medical and social care service-providing organizations. In addition, the study should be repeated in 1-2 years, which will not only allow a comparison of the effectiveness of medical and social care providers, but also enable a comparison of changes in the subjective health status of patients and to evaluate the effectiveness of the provision of medical and social care of the same service provider over time.

What motivates and retains health workers in Pakistan?

Author(s) Ali Mohammad Mir1, Gul Rashida2.
Affiliation(s) 1Program and Research, Population Council, Islamabad, Pakistan, 2Training Department, Population Council, Islamabad, Pakistan.
Country - ies of focus Pakistan
Relevant to the conference tracks Health Workforce
Summary Pakistan is a long way from achieving its Millennium Development Goals (MDGs) four and five. The national study on “Assessing Retention and Motivation of Public Healthcare Providers (Particularly Female Providers) in Rural Pakistan” was carried out by the Population Council to assess the core issue of availability of health providers, especially female providers and to ascertain the link between retention in the public sector and to identify factors that motivate providers to offer high quality services. This research tackled the confluence of job-related, institutional, demographic, social, and economic issues that health workers face in rural Pakistan.
Background One of the critical issues influencing reproductive health indicators in Pakistan has been access to services that impinge closely on the availability and quality of appropriate health care providers. This constraint applies in particular to women and their special needs, given limited autonomy and mobility especially in rural and distant areas. However, female providers in these remote areas are also confined by the same societal values as the women they serve. This is especially the case for women working in areas to which they themselves do not belong. The problem is self-reinforcing: areas that are backward in terms of female education and reflect the poor status of women are unlikely to have trained female providers. These areas lack indigenous healthcare providers and therefore have to depend on workers to come in from other districts. These workers require both residences and strong incentives to serve the villages and remote settlements they are relocating to. Therefore, it is important to address the core issue of availability of health providers, especially female providers and other issues such as work status and motivation, which affect the quality of care in Pakistan.
Objectives The main objectives of this project were to identify the core issue of availability of health providers, especially female providers that are required for provision of maternal and neonatal healthcare in Pakistan and determine the range of factors that either constrain or motivate providers to serve in key positions in public facilities in rural areas.
The following is a list of objectives that were identified for this study:
• To review and critically analyse past and existing intervention programmes on improving health worker retention in Pakistan and globally, and learn how the results were translated into specific policies;
• To analyse factors influencing the decisions and choices of health providers in rural and hard-to-reach areas by cadre (general, including MOs, WMOs, LHVs, nurses, dispensers and health technicians and specialists) and gender, on what motivates their retention or contributes to their leaving;
• To recommend strategies that can be employed in the provincial context to increase the retention of health providers in rural and remote areas in a sustainable manner, especially to improve maternal and newborn health outcomes.
Methodology A national study on ‘Assessing Retention and Motivation of Public Healthcare Providers (particularly female providers) in Rural Pakistan’ was conducted in 2012 in a representative sample of 28 randomly selected districts within eight regions in Pakistan. It consisted of a survey of health professionals interviewing 1365 providers and managers. A qualitative component comprised Focus Group Discussions with female providers and in-depth interviews with selected health providers and managers. Additionally, 533 primary, referral and tertiary care health facilities were assessed in the sampled districts to gauge the capacity of these facilities to provide MNCH services, as well as to explore the relationship between availability of equipment, medicines and supplies and health worker’s motivation and retention.We divided the country into seven strata. They comprised North and South Punjab, Sindh, KP, Balochistan, AJK (Azad Jammu Kashmir), Gilgit Baltistan (GB), and FATA. The reason for assigning two strata to Punjab was the vast differences between Northern and Southern Punjab. In the case of GB and FATA, we collapsed them into one stratum due to the paucity of health providers in these areas. However, due to the socio-demographic, cultural, political and geographical differences between GB and FATA, they were analysed as two separate strata.We randomly selected four districts on the basis of socio-economic index rankings and skilled birth attendance in each strata. One district per strata in the upper and middle socio-economic bands and two districts from the lower rung of district ranking were selected to over-represent the less or underserved areas of each strata. This was because we recognized that the problem of staff motivation and retention was greater in these areas. The oversampling of the lower-ranked districts was to ensure provider representation in precisely the areas where staff retention and motivation were problems.All facilities providing basic and comprehensive care, including teaching hospitals within the sampled districts were assessed as part of a situation analysis. Different levels of facilities that qualified as potential MNCH service outlets were randomly selected in each district, which included Districts Headquarter Hospitals, Tehsil Headquarter Hospitals, Rural Health Centres, Basic Health Units and Maternal and Child healthcare Centres.
Results The study findings reveal that a third of the providers are dissatisfied with their jobs to the extent that they would consider leaving for the private sector. The compelling factors include dissatisfaction with salary, political interference, lack of infrastructure and medicines. While the providers’ general level of satisfaction with their current jobs was high, more than half of them reported dissatisfaction with promotion opportunities, and more than a quarter of them were dissatisfied with the current method of annual appraisal. They reported that it lacked objectivity as it fails to capture staff performance and accomplishments. An important finding from this study is that 32% of all providers had never been promoted despite being in service for more than 16 years. These findings are a reason for concern as staff attrition can further compound the issue of staff non-availability in rural areas. Political interference was cited as a major issue impacting work by provinces in FATA and AJK.
The top three factors that motivated staff in their work included an opportunity to serve the community, professional growth and the respect accorded to them by the people because of the nature of their profession. Of the providers interviewed, nearly a fifth had not received any training at all since they joined the service signifying the need for having a Human Resource Development Policy. The research evidence raises serious concerns about safety and security issues confronting providers. Almost a quarter of providers reported not having a boundary wall around their facilities, which significantly impacts their perceived and actual safety levels. A fairly low proportion of providers are residing within the facilities due to non-availability of staff residences. This means long commutes from their residences to places of work. Compassion and altruism were identified as important reasons for joining as well as choosing to remain in government service.
This study also highlights some of the specific problems confronting female providers, such as issues of mobility, safety and security and community interference. These factors have been discussed in detail in the qualitative component of the report.
Conclusion This study identifies a number of problems faced by healthcare providers working in the public healthcare system in Pakistan. In order to increase the quality of and accessibility to healthcare, especially for women and children, policy makers must take steps to rectify the problems identified by the study. What is required:-
• Ensuring Implementation of a Human Resource for Health Management System: All provinces must ensure implementation of a “Human Resources for Health Management System” that includes the following components:-
• Training and development
A staff training and career development strategy must be established to include routine new and refresher trainings as part of a continuing education system.
• Filling of vacant posts
There should be a functioning MIS that can be used to dynamically identify areas of staff vacancies and these can then be filled either though redistribution of existing staff from urban to rural areas, or by hiring new staff.
• Strict adherence to organizational policies on recruitment, transfer, and promotion. All provincial health departments must adhere to the existing staff recruitment, promotion, and transfer policies.
• Improving the Physical Work Environment and Ensuring the Availability of Equipment, Medicine, and Supplies: All provinces must undertake a comprehensive facility infrastructure assessment; draw up a list of infrastructure repair, refurbishment and upgradation requirements and also carry out new construction such as of boundary walls and staff residences.
• Putting in Place a National Private Practice Regulation Policy: A national private practice regulation policy can contribute to improving providers’ performance as it will help in ensuring that they are able to rationally devote time to their official duties, both within and after office hours and to their private practice.
• Incentives for Attracting and Retaining Staff: A comprehensive rural services package needs to be developed that clearly incentivizes and makes working in the rural areas more attractive, especially for female providers. This should include monetary and non-monetary rewards, including a salary package that is competitive to the market.

Perceptions of Medical Brain Drain among Young Doctors in Kenya: A Cross-Sectional Study

Author(s) Paul Yonga1, Henry Muchiri2, Were Onyino3
Affiliation(s) 1Clinical Services, Ministry of Health, Nairobi, Kenya, 2Clinical services, Ministry of Health, Nairobi, Kenya, 3Clinical Services, International Committee of Red Cross, Nairobi, Kenya.
Country - ies of focus Kenya
Relevant to the conference tracks Health Workforce
Summary The objective of this study was to determine the perceptions of medical brain drain among young doctors in Kenya. A descriptive cross-sectional study was carried out between March and May 2012 among young doctors aged 50 years and below in all the seven provinces of Kenya using multi-stage sampling, and the research instruments were semi-structured self-administered questionnaires. 288 doctors were interviewed and data entry and analysis was done using Epi-data and SPSS version 17 respectively. 91.5% were not satisfied with their remuneration and 85.9% have thought, or are thinking of seeking for employment outside Kenya. This is a worrying trend which should be swiftly addressed.
Background The movement of trained health personnel out of developing countries is one of the most numerous health crises facing the African continent, inclusive of Kenya. This phenomenon of “medical brain drain” has been described as rich countries “looting” doctors and other health professionals from developing countries. Emigration results from a combination of push factors (in source countries) and pull factors (in recipient countries), and several authors have addressed the push-pull theory of migration.This phenomenon has exacerbated the already weak national, provincial, and district health systems in Kenya, thus proving a serious challenge for the realization of the United Nations Millennium Development Goals (MDGs).
Objectives The major objective of this study was to examine the perceptions on medical brain drain among young doctors in Kenya. The specific objectives were to determine the level of satisfaction as far as remuneration and support in the work environment is concerned, to discover the common reasons for wanting to work outside Kenya and to determine factors that can help in stemming the tide of medical brain drain in Kenya.
Methodology This was a descriptive cross-sectional study carried out between March and May 2012 in Kenya among young doctors, which is defined as doctors aged 50 years and below. Until recently, the government health facilities in Kenya where doctors could be accessed were national, provincial, and district hospitals. After the promulgation of the new Kenyan Constitution in 2010, the health structure has been divided into county health systems where there are now 47 counties and each county will have at least one major county hospital staffed with doctors. However, due to the incomplete implementation of the new system, the study was carried out as per the former structure, where the seven provinces in Kenya were used as study sites.
A sample size of 1,571 doctors who met the age cut-off criteria was arrived at using the Kish and Leslie formula. A multi-stage sampling method was employed in sample selection whereby in stage I all the seven provinces in Kenya, that is, Rift-Valley, Western, Central, Nyanza, Coast, North-Eastern, and Nairobi provinces, were used as strata for the study. In stage II, the government provincial and district hospitals within each province, as well as private hospitals including health-provider non-governmental organizations (NGOs) within each province, were included. In stage III, in each facility, the doctors aged 50 years and below were selected and systematic random sampling used to arrive at the sample size of 1,571.
Data collection instruments were semi-structured, self-administered pre-tested questionnaires that were divided into three sections. Study variables included satisfaction with remuneration, if the doctor ever thought of, or is currently thinking of practicing outside Kenya and if yes the reasons why, and finally possible solutions that can help stem the medical brain stem tide in Kenya.
Of the 1,571 questionnaires distributed 288 were duly filled and returned to the primary author and co-authors. After data cleaning and validation, entry was done using Epidata software and analysis was done using PASW (SPSS) version 17.
Results 91.5% (n=260) of the doctors interviewed were not satisfied with their current remuneration. 85.9% (n=244) have ever thought of, or are currently thinking of seeking for employment outside Kenya, of which 43.7% (n=124) cited poor economic returns as the major reason for wanting to relocate. 73.3% (n=208) were generally dissatisfied with the work support they receive in their working environment, of which 45.1% (n=128) on a scale of 1 to 4 were very dissatisfied. 77.5% (n=220) of the young doctors advocated for better remuneration, 71.8% (n=204) advocated for more funding for health services, and 38.0% (n=108) advocated for more involvement in policy making changes as some of the top solutions that would help in stemming the tide of medical brain drain among young doctors in Kenya.
Conclusion Human resources is a key element that makes organizational or national goals attainable. The state of a nation’s health sector is strategic to growth and development. Thus, with the majority of young doctors practicing in government health facilities, their views and opinions are vital in addressing medical brain drain and should be involved in key health policy-making decisions that will strengthen the health system through adequate funding to avert this challenge. Otherwise, at the moment, without any concrete solutions and lack of political will, Kenyans should surely be worried as they will be disadvantaged further in a society already in dire need of health care reform and quality health care.

Global Patients, Global Doctors: Lessons from the Health System of the Maritime Industry

Author(s): D. Lucero-Prisno1
Affiliation(s): 1IMHA, Tacloban City, Philippines
Keywords: Maritime health, health system, seafarers, global health

The maritime sector is a highly globalized industry with an international workforce of 1.5 million seafarers working on literally all waters of the world. As a risky profession (second only to commercial fishermen), seafarers are exposed to a multitude of occupational and health hazards. This equates to USD 135 million of compensation for personal injury from the P&I Clubs (insurance) every year, which is more than the claims for maritime pollution. As ships ply their routes, medical services all over the world are always at bay waiting for patient calls once needed. These highly organized services are specifically designed for the industry with medical services provided regardless of the nationality of neither the seafare nor the medical staff, the flag of the ship, nor the port of call.


To understand how health services are delivered and provided to the global seafarers. To understand the framework governing the scheme of health service provision beyond nationalities and borders. To deduce learning from this industry for other ‘global’ health systems. To assess the weaknesses, strengths and gaps of the maritime health system.


The workforce of maritime industry is composed of seafarers from different countries with a big percentage from East Asia and Eastern Europe. Filipinos comprise almost a third. These seafarers work on ships flagged under different countries with Liberia and Panama on top of the list. Globalization paved the way to this scheme despite real ownership in other countries. For every tour of duty of the seafarers, a medical examination is required in the home country of the seafarer. This screening identifies those who are fit to work. The countries where the ships are flagged accredit these clinics. Insurance companies support this screening to avoid health claims from those who have existing health problems. These companies have a separate accreditation scheme of all the clinics where seafarers can go in case they are afflicted with a malady while on board or on contract. They can easily approach health services at different ports without too much financial worry. These clinics and hospitals make claims from the representatives of the shipping or insurance companies within the area. Despite the lack of international standards, the maritime industry is able to carry out its task of taking care of the health and welfare of its workers; though maybe not to a perfect degree. The International Maritime Health Association (IMHA) is the only international organization of health professionals who have direct contacts with seafarers. They lead the initiative of developing an international medical standard for the seafaring sector so that services and diagnosis will be similar throughout the world. WHO accredits four Collaborating Centres on health of seafarers based in Germany, Denmark, Ukraine and Poland. They are clustered under occupational health. WHO, ILO and the IMO have some collaboration in the area of health of seafarers. The industry observes ‘self-regulation’ and maintains certain standards without too much intervention from nation-states.

Lessons learned:

The health system of the maritime industry is an interesting model of a responsive and effective global health system beyond the consideration of the nationalities of neither the patients nor the health providers and without considering national borders. Though this study does not claim for it to be a perfect global health system, it has many characteristics that are worth emulating. Its well-organized structure allows easy access for its clients to quality health services. The major strength of the system is its strong health-financing scheme that is backed by a rich maritime industry. Quality and access are assured because of the good compensation given to the health providers. Keeping maritime workers healthy is imperative because they literally run 90% of the global trade.