Human resources and the quality of emergency obstetric care in developing countries: a systematic review of the literature

Background

The overall human resource shortages and the distributional inequalities in the health workforce in many developing countries are well acknowledged. However, little has been done to measure the degree of inequality systematically. Moreover, few attempts have been made to analyse the implications of using alternative measures of health care needs in the measurement of health workforce distributional inequalities. Most studies have implicitly relied on population levels as the only criterion for measuring health care needs. This paper attempts to achieve two objectives. First, it describes and measures health worker distributional inequalities in Tanzania on a per capita basis; second, it suggests and applies additional health care needs indicators in the measurement of distributional inequalities.

Methods

We plotted Lorenz and concentration curves to illustrate graphically the distribution of the total health workforce and the cadre-specific (skill mix) distributions. Alternative indicators of health care needs were illustrated by concentration curves. Inequalities were measured by calculating Gini and concentration indices.

Results

There are significant inequalities in the distribution of health workers per capita. Overall, the population quintile with the fewest health workers per capita accounts for only 8% of all health workers, while the quintile with the most health workers accounts for 46%. Inequality is perceptible across both urban and rural districts. Skill mix inequalities are also large. Districts with a small share of the health workforce (relative to their population levels have an even smaller share of highly trained medical personnel. A small share of highly trained personnel is compensated by a larger share of clinical officers (a middle-level cadre) but not by a larger share of untrained health workers. Clinical officers are relatively equally distributed. Distributional inequalities tend to be more pronounced when under-five deaths are used as an indicator of health care needs. Conversely, if health care needs are measured by HIV prevalence, the distributional inequalities appear to decline.

Conclusion

The measure of inequality in the distribution of the health workforce may depend strongly on the underlying measure of health care needs. In cases of a non-uniform distribution of health care needs across geographical areas, other measures of health care needs than population levels may have to be developed in order to ensure a more meaningful measurement of distributional inequalities of the health workforce.     

Sustainability of the workforce: government policies and the rural fit

OBJECTIVES: Critical workforce issues among health care workers have raised public concerns about the ability of health care systems to provide adequate service. Services, however, are influenced by geographical and social factors. One important source of variation is rurality. This study evaluated the perception of the applicability of health human resource policies for rural areas. METHODS: An exploratory design was used. Twenty-one nurse administrators and 44 staff nurses from a sampling of 19 rural health care settings were interviewed. Hospitals with less than 100 beds were targeted. RESULTS: The government policies most frequently mentioned by study participants were the goal of 70% full-time employment, the new graduate policy and the late career initiative. Each presented challenges to managers attempting implementation. Urban bias is apparent in health care policy including health human resource policies. Little data is available about rural health care workers because health care statistics tend to be reported regionally. CONCLUSION: Rural institutions have difficulty accessing government funding intended to build sustainable workforces. Policies meant to be broadly implemented across jurisdictions may not fit the needs of rural institutions and their clients. Health care databases should include a rural variable to enhance understanding about this population.     

'We are also dying like any other people, we are also people': perceptions of the impact of HIV/AIDS on health workers in two districts in Zambia

In countries with a high AIDS prevalence, the health workforce is affected by AIDS in several ways. In Zambia, which has a prevalence rate of 16.5%, a study was carried out in 2004 with the aim to: explore the impact of HIV/AIDS on health workers, describe their coping mechanisms and recommend supportive measures. The qualitative study was complemented by a survey using self-administered questionnaires in four selected health facilities in two rural districts in Zambia, Mpika and Mazabuka. It is one of the few studies to have explored the impact of HIV/AIDS from the perspective of health workers and managers in the region. Thirty-four in-depth interviews and five group discussions were conducted with health workers, managers and volunteers, and 82 self-administered questionnaires were filled out by health workers. In addition, burnout among 42 health workers was measured using the Maslach Burnout Inventory (MBI). The MBI measures three components that contribute to burnout: emotional exhaustion, depersonalization and personal accomplishment. The results show that in both districts, HIV/AIDS has had a negative impact on workload and has considerably changed or added tasks to already overburdened health workers. In Mpika, 76% of respondents (29/38), and in Mazabuka, 79% (34/44) of respondents, expressed fear of infection at the workplace. HIV-positive health workers remained 'in hiding', did not talk about their illness and suffered in silence. Despite the fact that health workers were still relatively motivated, emotional exhaustion occurred among 62% of the respondents (26/42). The interviews revealed that counsellors and nurses were especially at risk for emotional exhaustion. In each of the selected facilities, organizational support for health workers to deal with HIV/AIDS was either haphazardly in place or not in place at all. AIDS complicates the already difficult work environment. In addition to health workers, management also needs support in dealing with AIDS at the workplace.     

The influence of a "culture of referral" on access to care in rural settings after myocardial infarction

Access to care is an issue for rural people who require tertiary care following a myocardial infarction (MI). Access to specialized cardiac health services is contingent upon referral to tertiary care in urban centers. Using a critical ethnographic approach, rural women, their nurses and physicians were interviewed to explore how rurality affected women's referral and access to care following a MI. Findings reflect that a previously undocumented culture of referral that was shaped by human factors influenced access to care. The culture of referral reflected an urban-centric approach to the provision of cardiovascular services and a medical hierarchy within the referral system. The findings extend conceptual understandings of access to health care in relation to rural populations.     

黔南州乡村家庭医生签约服务现状及村民获得感分析

在城镇化进程中,黔南州乡村人口大量流向城镇,留在农村的大多是中老年人、妇女和儿童,村民在满足日益增长的物质需求时也在不断追求健康的生活方式,对医疗卫生需求日益增长。然而,黔南州的医疗资源主要集中在城镇,乡村不仅缺医少药,而且就医秩序不畅,首诊转诊缺失,现有的乡村医疗卫生服务设施已经无法满足村民的健康需求。如何平衡黔南州城镇与乡村之间的医疗卫生资源,尤其是优质医疗卫生资源如何向乡村倾斜,成为黔南州乡村振兴战略工作中的一个难点。在黔南州乡村实施家庭医生签约服务政策不仅是全科医学分级诊疗制度的基础,还是促进城乡医疗卫生资源优化配置以及“健康乡村”战略的重要举措。     

综合干预措施对农村育龄妇女艾滋病防制效果的评价

通过妇幼保健系统对农村育龄妇女进行艾滋病 (AIDS)预防与控制健康教育干预 ,提高农村育龄妇女预防AIDS能力。干预前基础调查 ,培训妇幼保健机构人员 ,采取多种形式的健康教育干预 ,干预后调查、分析对比干预措施对农村育龄妇女AIDS预防与控制知识、态度、行为的影响。发现农村育龄妇女对AIDS三大传播途径的正确认识率分别有显著的提高 ,尤其对预防观念的认识有了大幅度的提高 ,认为“AIDS可通过日常生活接触传播的人数由干预前的 2 7.8%下降到干预后的 1.0 % ;对AIDS的态度有了明显改善 ,认为“只有城市人才可能得AIDS”的人数由干预前的 4 2 .1%下降到干预后的 6 .5 % ,基本消除了“AIDS离我们很遥远”的错误认识 ;通过干预 ,农村育龄妇女AIDS防制的行为也得到了加强 ,会正确使用避孕套的人数由 8.3%提高到 76 .9% ,使用过避孕套的人数由 8.3%提高到 2 6 .8% ,患过性病的人数由 4 .4 %下降到 0 .5 %。认为在妇幼保健系统实施AIDS防制健康教育干预效果明显 ;健康教育形式应多样化 ;加强基层组织人员培训 ,在农村社区建立AIDS宣传点 ;推广使用避孕套任重道远 ;充分发挥和利用各系统尤其是妇幼保健系统优势     

Remodeling pharmaceutical care in Sub‐Saharan Africa (SSA) amidst human resources challenges and the HIV/AIDS pandemic

Pharmaceutical care, meant to complement a proper drug supply system, is a key component of a robust health care system and is the direct, responsible provision of medication‐related care designed to achieve definite outcomes that improve a patient's quality of life. Beyond simply dispensing medicine, pharmaceutical care promotes adherence to therapeutic regimens and addresses problems such as overdosage, sub‐therapeutic dosage, adverse drug reactions, medication errors, and untreated indications. The dearth of health care workers trained in pharmaceutical care coupled with inadequate access to medications creates multiple disease management challenges in Sub‐Saharan Africa (SSA), which has 25% of the world's disease burden but only 1.3% of the world's health workforce. To prevent and treat HIV/AIDS, TB, malaria, and other maladies, the need is urgent to train and integrate the contributions of current workers who handle medications for major and minor health problems, especially those in licensed pharmacies and drug shops. On the aggregate in SSA, pharmaceutical care is in a nascent stage in most countries but needs to grow as a discipline as well as be tailored to specific country needs. The SSA solution lies in establishing health care system components where cadres of workers engage in pharmaceutical care practices, as well as store and distribute medications. Curriculum changes in pre‐service education, more continuing education for the health workforce in place, and training pharmacists to supervise a lower cadre of assistants and others are among the elements in a pharmaceutical care paradigm shift which is the focus of this article. Copyright © 2009 John Wiley & Sons, Ltd.     

黔南州乡村家庭医生签约服务现状及村民获得感分析

在城镇化进程中,黔南州乡村人口大量流向城镇,留在农村的大多是中老年人、妇女和儿童,村民在满足日益增长的物质需求时也在不断追求健康的生活方式,对医疗卫生需求日益增长。然而,黔南州的医疗资源主要集中在城镇,乡村不仅缺医少药,而且就医秩序不畅,首诊转诊缺失,现有的乡村医疗卫生服务设施已经无法满足村民的健康需求。如何平衡黔南州城镇与乡村之间的医疗卫生资源,尤其是优质医疗卫生资源如何向乡村倾斜,成为黔南州乡村振兴战略工作中的一个难点。在黔南州乡村实施家庭医生签约服务政策不仅是全科医学分级诊疗制度的基础,还是促进城乡医疗卫生资源优化配置以及“健康乡村”战略的重要举措。     

Health literacy training for Australian home care workers: Enablers and barriers

The rapidly expanding Australian home care workforce represents an untapped resource for improving health literacy (HL) and health outcomes of their clients. Nine home care workers (HCWs) were interviewed for this study to gain data around their experiences of providing HL support to their clients, key HL needs and priorities, and training that would best these needs. Findings indicate that HCWs are providing HL support, and identify a number of enablers and barriers to providing this support. Core inclusions for a HL training checklist are suggested. Implications for future research are considered.     

Beyond 50. challenges at work for older nurses and allied health workers in rural Australia: a thematic analysis of focus group discussions

Background  

The health workforce in Australia is ageing, particularly in rural areas, where this change will have the most immediate implications for health care delivery and workforce needs. In rural areas, the sustainability of health services will be dependent upon nurses and allied health workers being willing to work beyond middle age, yet the particular challenges for older health workers in rural Australia are not well known. The purpose of this research was to identify aspects of work that have become more difficult for rural health workers as they have become older; and the age-related changes and exacerbating factors that contribute to these difficulties. Findings will support efforts to make workplaces more 'user-friendly' for older health workers.     

Barriers to Quality Care for Dying Patients in Rural Communities

CONTEXT: Barriers to providing optimal palliative care in rural communities are not well understood. PURPOSE: To identify health care personnel's perceptions of the care provided to dying patients in rural Kansas and Colorado and to identify barriers to providing optimal care. METHODS: An anonymous self-administered survey was sent to health care personnel throughout 2 rural practice-based research networks. Targeted personnel included clinicians, nurses, medical assistants, chaplains, social workers, administrators, and ancillary staff, who worked at hospice organizations, hospitals, ambulatory clinics, public health agencies, home health agencies, and nursing homes. FINDINGS: Results from 363 completed surveys indicated that most health care personnel were satisfied with the palliative care being provided in their health care facilities (84%) and that most were comfortable helping dying patients transition from a curative to a palliative focus of care (87%). Yet, many reported that the palliative care provided could be improved and many reported that family members' avoidance of issues around dying (60%) was a barrier to providing optimal care in rural health care facilities. CONCLUSIONS: Findings suggest that health care personnel perceive they are effective at providing palliative care in their rural health care facilities, yet face barriers to providing optimal end-of-life care. Results of this study suggest that differences in training and experience may influence health care personnel's perceptions of the existing barriers. It may be important in rural areas to customize interventions to both the professional role and the site of care.     

北京市郊区农村基层医疗卫生服务能力现状及问题分析

目的分析北京市郊区村巡诊和村卫生室建设现状,为完善农村基层医疗卫生服务体系建设提供参考。方法对北京市郊7个区中119个行政村进行实地观察,并对652名相关研究对象进行半结构化访谈,包括对巡诊和卫生室的满意度、基层医疗机构的服务质量等。结果村巡诊服务效率不高,不能满足居民实际医疗服务需求;村卫生室医疗人员短缺,基本药物配备不全,报销途径不畅通,村民就医行为更倾向于选择乡镇卫生院和县医院。结论为更好落实卫生领域重要民生项目,切实提升农村居民就医体验,应进一步落实和丰富村巡诊内容,加强基层全科医生培养力度,提升卫生费用投资的针对性和有效性,把村卫生健康服务情况纳入村干部工作考核指标,优化基本药物目录,扩大新农合定点报销覆盖范围等。     

Contextual determinants of maternal mortality in rural Pakistan

Maternal mortality is high in Pakistan, particularly in the rural areas which have poor access to health services. We investigated the risk factors associated with maternal mortality in sixteen rural districts of Balochistan and the North-West Frontier (NWFP) provinces of Pakistan. We designed a nested case–control study comprising 261 cases (maternal deaths reported during last five years) and 9135 controls (women who survived a pregnancy during last five years). Using contextual analysis, we estimated the interactions between the biological risk factors of maternal mortality and the district-level indicators of health services. Women under 19 or over 39 yr of age, those having their first birth, and those having a previous history of fetal loss were at greater risk of maternal death. Staffing patterns of peripheral health facilities in the district and accessibility of essential obstetric care (EOC) were significantly associated with maternal mortality. These indicators also modified the effects of the biological risk factors of maternal mortality. For example, nulliparous women living in the under-served districts were at greater risk than those living in the better-served districts. Our results are consistent with several studies which have pointed out the role of health services in the causation of maternal mortality. Many such studies have implicated distance to hospital (an indicator of access to EOC) and lack of prenatal care as major determinants of maternal mortality. We conclude that better staffing of peripheral health facilities and improved access to EOC could reduce the risk of maternal mortality among women in rural Balochistan and the NWFP.     

Transforming Direct Care Jobs,Reimagining Long-Term Services and Supports

The diverse array of individuals who receive long-term services and supports share one common experience, which is the need for assistance with personal care and/or other daily activities. The direct care workers (including nursing assistants, home health aides, and personal care aides) who provide this assistance play a critical role in keeping individuals safe, supporting their health and well-being, and helping prevent adverse outcomes. Yet despite decades of research, advocacy, and incremental policy and practice reform, direct care workers remain inadequately compensated, supported, and respected. Long-standing direct care job quality concerns are linked to high turnover and job vacancy rates in this workforce, which in turn compromise the availability and quality of essential care for older adults and people with disabilities—which has never been more evident than during the COVID-19 pandemic. This special article makes the case for transforming direct care jobs and stabilizing this workforce as a centerpiece of efforts to reimagine long-term services and supports system in the United States, as a public health priority, and as a social justice imperative. Drawing on research evidence and examples from the field, the article demonstrates that a strong, stable direct care workforce requires: a competitive wage and adequate employment benefits for direct care workers; updated training standards and delivery systems that prepare these workers to meet increasingly complex care needs across settings, while also enhancing career mobility and workforce flexibility; investment in well-trained frontline supervisors and peer mentors to help direct care workers navigate their challenging roles; and an elevated position for direct care workers in relation to the interdisciplinary care team. The article concludes by highlighting federal and state policy opportunities to achieve direct care job transformation, as well as discussing research and practice implications.     

Source of Antenatal Care Influences Facility Delivery in Rural Tanzania: A Population-Based Study

Objective While antenatal care does not directly contribute to reducing maternal mortality, it may play an indirect role by encouraging women to deliver with a skilled birth attendant or in a health facility. We investigated whether the frequency of visits and select characteristics of antenatal care were associated with facility delivery. Methods We selected a population-representative sample of households in a rural district of western Tanzania. Women who had given birth within five years were asked about their most recent delivery and antenatal care. Results Of 1,204 women interviewed, 1,195 (99.3%) made at least one antenatal care visit, while only 438 (36.4%) delivered in a health facility. In adjusted analysis, women were significantly more likely to deliver in a health facility if they attended antenatal care at a government health center (OR 3.17, 95% CI: 1.60–6.30) or a mission facility (OR 2.87, 95% CI: 1.36–6.07), rather than a government dispensary. Women were significantly less likely to deliver in a health facility if their nearest health facility was outside their village (OR 0.38, 95% CI: 0.22–0.66). Conclusion Though facility utilization for antenatal care is frequent, most women who accessed antenatal care did not deliver in a health facility. Women who obtained antenatal care at higher level government facilities or mission facilities, which offered better quality of care, were more likely to deliver in any facility. Improving the quality of antenatal care may improve the health of mothers through encouraging women to return to facilities for delivery.     

Coverage of private sector community midwife services in rural Punjab,Pakistan: development and demand

Background

In 2007, the Government of Pakistan introduced a new cadre of community midwives (CMWs) to address low skilled birth attendance rates in rural areas; this workforce is located in the private-sector. There are concerns about the effectiveness of the programme for increasing skilled birth attendance as previous experience from private-sector programmes has been sub-optimal. Indonesia first promoted private sector midwifery care, but the initiative failed to provide universal coverage and reduce maternal mortality rates.

Methods

A clustered, stratified survey was conducted in the districts of Jhelum and Layyah, Punjab. A total of 1,457 women who gave birth in the 2 years prior to the survey were interviewed. χ² analyses were performed to assess variation in coverage of maternal health services between the two districts. Logistic regression models were developed to explore whether differentials in coverage between the two districts could be explained by differential levels of development and demand for skilled birth attendance. Mean cost of childbirth care by type of provider was also calculated.

Results

Overall, 7.9% of women surveyed reported a CMW-attended birth. Women in Jhelum were six times more likely to report a CMW-attended birth than women in Layyah. The mean cost of a CMW-attended birth compared favourably with a dai-attended birth. The CMWs were, however, having difficulty garnering community trust. The majority of women, when asked why they had not sought care from their neighbourhood CMW, cited a lack of trust in CMWs’ competency and that they wanted a different provider.

Conclusions

The CMWs have yet to emerge as a significant maternity care provider in rural Punjab. Levels of overall community development determined uptake and hence coverage of CMW care. The CMWs were able to insert themselves into the maternal health marketplace in Jhelum because of an existing demand. A lower demand in Layyah meant there was less ‘space’ for the CMWs to enter the market. To ensure universal coverage, there is a need to revisit the strategy of introducing a new midwifery workforce in the private sector in contexts of low demand and marketing the benefits of skilled birth attendance.

     

A lost cause? Extending verbal autopsy to investigate biomedical and socio-cultural causes of maternal death in Burkina Faso and Indonesia

Maternal mortality in developing countries is characterised by disadvantage and exclusion. Women who die whilst pregnant are typically poor and live in low-income and rural settings where access to quality care is constrained and where deaths, within and outside hospitals, often go unrecorded and unexamined. Verbal autopsy (VA) is an established method of determining cause(s) of death for people who die outside health facilities or without proper registration. This study extended VA to investigate socio-cultural factors relevant to outcomes. Interviews were conducted with relatives of 104 women who died during pregnancy, childbirth or postpartum in two rural districts in Indonesia and for 70 women in a rural district in Burkina Faso. Information was collected on medical signs and symptoms of the women prior to death and an extended section collected accounts of care pathways and opinions on preventability and cause of death. Illustrative quantitative and qualitative analyses were performed and the implications for health surveillance and planning were considered. The cause of death profiles were similar in both settings with infectious diseases, haemorrhage and malaria accounting for half the deaths. In both settings, delays in seeking, reaching and receiving care were reported by more than two-thirds of respondents. Relatives also provided information on their experiences of the emergencies revealing culturally-derived systems of explanation, causation and behaviour. Comparison of the qualitative and quantitative results suggested that the quantified delays may have been underestimated. The analysis suggests that broader empirical frameworks can inform more complete health planning by situating medical conditions within the socio-economic and cultural landscapes in which healthcare is situated and sought. Utilising local knowledge, extended VA has potential to inform the relative prioritisation of interventions that improve technical aspects of life-saving services with those that address the conditions that underlie health, for those whom services typically fail to reach.     

云南省农村妇女生育健康基础服务需要量研究

采用问卷调查与收集现有资料相结合的方法,对云南农村已婚育龄妇女的生育健康基础服务需要量进行了调查研究。结果表明;农村妇女对生育健康服务的需要是综合性的,既包括预防性服务也包括治疗性服务;当前农村育龄妇女面临的主要生育健康问题是以妊高症为主的孕期并发症与合并症、产伤、产后出血、生殖道感染、避孕方法的副作用和并发症等;贫困妇女对服务的需要量更大。要有效地改善农村妇女的生育健康状况,有关部门应向其提供综合性的生育健康基础服务,并把主要生育健康问题列为工作重点。     

Comparison of Domiciliary and Institutional Delivery-care Practices in Rural Rajasthan, India

A retrospective cross-sectional survey was conducted to assess key practices and costs relating to home- and institutional delivery care in rural Rajasthan, India. One block from each of two sample districts was covered (estimated population–279,132). Field investigators listed women who had delivered in the past three months and contacted them for structured case interview. In total, 1,947 (96%) of 2,031 listed women were successfully interviewed. An average of 2.4 and 1.7 care providers attended each home- and institutional delivery respectively. While 34% of the women delivered in health facilities, modern care providers attended half of all the deliveries. Intramuscular injections, intravenous drips, and abdominal fundal pressure were widely used for hastening delivery in both homes and facilities while post-delivery injections for active management of the third stage were administered to a minority of women in both the venues. Most women were discharged prematurely after institutional delivery, especially by smaller health facilities. The cost of accessing home-delivery care was Rs 379 (US$ 8) while the mean costs in facilities for elective, difficult vaginal deliveries and for caesarean sections were Rs 1,336 (US$ 30), Rs 2,419 (US$ 54), and Rs 11,146 (US$ 248) respectively. Most families took loans at high interest rates to meet these costs. It is concluded that widespread irrational practices by a range of care providers in both homes and facilities can adversely affect women and newborns while inadequate observance of beneficial practices and high costs are likely to reduce the benefits of institutional delivery, especially for the poor. Government health agencies need to strengthen regulation of delivery care and, especially, monitor perinatal outcomes. Family preference for hastening delivery and early discharge also require educational efforts.Key words: Childbirth, Cross-sectional studies, Emergency care, Fundal pressure, Knowledge, attitudes, and practice, Labour, Obstetric care, Oxytocin, Retrospective studies, Traditional birth attendants, India