From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management

Throughout the world, countries are experiencing shortages of health care workers. Policy-makers and system managers have developed a range of methods and initiatives to optimise the available workforce and achieve the right number and mix of personnel needed to provide high-quality care. Our literature review found that such initiatives often focus more on staff types than on staff members' skills and the effective use of those skills. Our review describes evidence about the benefits and pitfalls of current approaches to human resources optimisation in health care. We conclude that in order to use human resources most effectively, health care organisations must consider a more systemic approach - one that accounts for factors beyond narrowly defined human resources management practices and includes organisational and institutional conditions.     

Impact of human resource management practices on nursing home performance.

Management scholars and practitioners alike have become increasingly interested in learning more about the ability of certain 'progressive' or 'high-performance' human resource management (HRM) practices to enhance organizational effectiveness. There is growing evidence to suggest that the contribution of various HRM practices to impact firm performance may be synergistic in effect yet contingent on a number of contextual factors, including workplace climate. A contingency theory perspective suggests that in order to be effective, HMR policies and practices must be consistent with other aspects of the organization, including its environment. This paper reports on empirical findings from research that examines the relationship between HRM practices, workplace climate and perceptions of organizational performance, in a large sample of Canadian nursing homes. Data from 283 nursing homes were collected by means of a mail survey that included questions on HRM practices, programmes, and policies, on human resource aspects of workplace climate, as well as a variety of indicators that include employee, customer/resident and facility measures of organizational performance. Results derived from ordered probit analysis suggest that nursing homes in our sample which had implemented more 'progressive' HRM practices and which reported a workplace climate that strongly values employee participation, empowerment and accountability tended to be perceived to generally perform better on a number of valued organizational outcomes. Nursing homes in our sample that performed best overall were found to be more likely to not only have implemented more of these HRM practices, but also to report having a workplace climate that reflects the seminal value that it places on its human resources. This finding is consistent with the conclusion that simply introducing HRM practices or programmes, in the absence of an appropriately supportive workplace climate, will be insufficient to attain optimal organizational performance.     

Are schools a good setting for adolescent sexual health promotion in rural Africa? A qualitative assessment from Tanzania

African adolescents are at high risk of poor sexual health. School-based interventions could reach many adolescents in a sustainable and replicable way, if enrolment, funding and infrastructure are adequate. This study examined pupils', recent school leavers', parents' and teachers' views and experiences of rural Tanzanian primary schools, focusing on the implications for potential sexual health programmes. From 1999 to 2002, participant observation was conducted in nine villages for 158 person-weeks. Half of Year 7 pupils were 15-17 years old, and few went on to secondary school, suggesting that primary schools may be a good venue for such programmes. However, serious challenges include low enrolment and attendance rates, limited teacher training, little access to teaching resources and official and unofficial practices that may alienate pupils and their parents, e.g. corporal punishment, pupils being made to do unpaid work, forced pregnancy examinations, and some teachers' alcohol or sexual abuse. At a national level, improved teacher training and supervision are critical, as well as policies that better prevent, identify and correct undesired practices. At a programme level, intervention developers need to simplify the subject matter, introduce alternative teaching methods, help improve teacher-pupil and teacher-community relationships, and closely supervise and appropriately respond to undesired practices.     

河南省疾病预防控制机构人力资源现状分析

目的通过对河南省疾病控制机构卫生人力资源的分析,及时掌据我省疾控卫生人力资源现况,以便为制定适应我省公共卫生事业发展策略及措施提供依据。方法本文应用描述流行病学方法对资料进行分析。结果全省每千人口拥有疾控机构人员0.21人,疾控机构人员中有专业技术人员16583人,占疾控机构工作人员的82.16%;年龄分布以25岁~44岁为主,占总数的68.24%;学历以大专居多,占35.6l%;执业医师占23.57%;执业助理医师6.69%。结论提高疾控人员的综合素质,改善知识结构,健全内部管理机制,加强人员的继续教育和岗位培训,制订在职人员绩效评估标准,建立一系列引人、用人、育人、留人的管理机制,将对疾控机构人力资源建设与发展起到巨人的促进作用。     

Field Epidemiology Training Programmes in Africa - Where are the Graduates?

Background  

The current shortage of human resources for health threatens the attainment of the Millennium Development Goals. There is currently limited published evidence of health-related training programmes in Africa that have produced graduates, who remain and work in their countries after graduation. However, anecdotal evidence suggests that the majority of graduates of field epidemiology training programmes (FETPs) in Africa stay on to work in their home countries--many as valuable resources to overstretched health systems.     

Promising practices in employer health and productivity management efforts: findings from a benchmarking study

OBJECTIVE: To identify key success factors related to employer-based health and productivity management (HPM) programs. METHODS: Data regarding promising practices in HPM were gathered via literature review, discussions with subject matter experts, online inventory, and site visits. RESULTS: Promising practices in HPM include 1) integrating HPM programs into the organization's operations; 2) simultaneously addressing individual, environmental, policy, and cultural factors affecting health and productivity; 3) targeting several health issues; 4) tailoring programs to address specific needs; 5) attaining high participation; 6) rigorously evaluating programs; and 7) communicating successful outcomes to key stakeholders. CONCLUSION: Increased efforts should be directed at disseminating the experiences of promising practices. However, more research is needed in this area, so that additional public and private funding is made available for applied research in "real-life" business settings. Finally, employers should be provided effective tools and resources to support their HPM efforts.     

Advances in participatory occupational health aimed at good practices in small enterprises and the informal sector

Participatory programmes for occupational risk reduction are gaining importance particularly in small workplaces in both industrially developing and developed countries. To discuss the types of effective support, participatory steps commonly seen in our "work improvement-Asia" network are reviewed. The review covered training programmes for small enterprises, farmers, home workers and trade union members. Participatory steps commonly focusing on low-cost good practices locally achieved have led to concrete improvements in multiple technical areas including materials handling, workstation ergonomics, physical environment and work organization. These steps take advantage of positive features of small workplaces in two distinct ways. First, local key persons are ready to accept local good practices conveyed through personal, informal approaches. Second, workers and farmers are capable of understanding technical problems affecting routine work and taking flexible actions leading to solving them. This process is facilitated by the use of locally adjusted training tools such as local good examples, action checklists and group work methods. It is suggested that participatory occupational health programmes can work in small workplaces when they utilize low-cost good practices in a flexible manner. Networking of these positive experiences is essential.     

Resources for development of training in public health and health managment in Eastern Europe: the Kaunas experience

The aim of this paper is to review the resources and steps required for development and evaluation of training in public health and management of public health as experienced in Kaunas University of Medicine, Lithuania. The transition from Departments of Social Medicine and Hygiene to a Faculty of Public Health of international standards requires a process of adaptation and development of human resources more than physical facilities. After restoration of independence in 1990, rapid development of training in public health was started in Lithuania. Great support was provided by the international projects Baltic Rim Partnership for Public Health (BRIMHEALTH) and European Union Trans-European Mobility Scheme for University Students (TEMPUS). Undergraduate and postgraduate training programs were successfully implemented in the Faculty of Public Health, Kaunas University of Medicine. Lithuanian experience could serve as an example of success and pitfalls in training a critical mass of professionals who should act as powerful advocates for health, promoting analysis, continuity and success of public health interventions, and health care reforms in countries in transition.     

History of veterinary public health in the Eastern Mediterranean and Africa

Brucellosis, rabies, salmonellosis, anthrax and hydatidosis are among the main zoonotic diseases which constitute a threat to human health and welfare. Surveillance, prevention and control of such zoonoses and related food-borne diseases are problems of considerable magnitude. Despite their obvious importance, relatively few systematic control efforts have been made by national authorities. Major constraints include the scarcity of public health veterinarians and related sub-professional staff to plan and implement adequate surveillance and control of zoonoses, and the lack of appropriate legislation and adequate laboratory services. Veterinarians have been contributing to public health for many years, but despite considerable efforts by the World Health Organisation (WHO), the Food and Agriculture Organisation of the United Nations (FAO) and other organisations in establishing veterinary public health (VPH) programmes over several decades, the veterinarian as a career specialist in public health is a relatively new phenomenon. In the last decade, emphasis has been placed on: --supporting the training and development of human resources to promote VPH services and cover all its components --promoting and upgrading national epidemiological surveillance and control programmes for the major zoonotic and food-borne diseases --cooperating and assisting in local production of safe and effective vaccines, primarily for the control of rabies and brucellosis. The most encouraging aspects of the present situation is the growing awareness among governments of the need to develop programmes for the control of zoonoses and related food-borne diseases.     

Improving antibiotic use in low-income countries: an overview of evidence on determinants

The inappropriate use of antibiotics has often been identified as a problem in effective health care delivery. High levels of antibiotics use, often clinically unnecessary, have led to a steady increase in drug resistance. Low-income countries, home to the majority of the world's population, are believed to have an important role in this phenomena. Effective intervention in these practices is often constrained by the paucity of information on determinants of antibiotic use.This review provides information from studies on the factors that influence the use of antibiotics by health providers, dispensers and community members in low-income countries. A proper understanding of these factors should be seen as a precondition for the development of more effective policies and programmes to address inappropriate antibiotic use.The review encompasses physicians' practices, the role of drug dispensers, and the influences on patterns of drug use across community members. Although a set of papers with useful research data was identified, probably the most important finding of the review was the scarcity of research. If interventions into antibiotic use are to be effective, future research must explore in more depth the socio-cultural rationality of antibiotic usage. The most productive approach would be to combine quantitative studies of the patterns of antibiotic use with the rich variety of qualitative methods like case simulations, focus group discussions, in-depth interviews, informal interviews, or illness diaries to explore determinants.Research programmes alone are unlikely to improve antibiotic use. Priority programme activities would include a carefully designed mix of activities by governments, health delivery systems, health training institutions, professional societies, pharmaceutical companies, consumer organisations, and international organisations. Strategies that lean too heavily on professional education are unlikely to result in large-scale or long-lasting improvement.     

Perspectives from micronutrient malnutrition elimination/eradication programmes

Micronutrient malnutrition cannot be eradicated, but the elimination and control of iron, vitamin A and iodine deficiencies and their health-related consequences as public health problems are currently the targets of global programmes. Remarkable progress is occurring in the control of goitre and xerophthalmia, but iron-deficiency anaemia (IDA) has been less responsive to prevention and control efforts. Subclinical consequences of micronutrient deficiencies, i.e. "hidden hunger", include compromised immune functions that increase the risk of morbidity and mortality, impaired cognitive development and growth, and reduced reproductive and work capacity and performance. The implications are obvious for human health and national and global economic and social development. Mixes of affordable interventions are available which, when appropriately adapted to resource availability and context, are proven to be effective. These include both food-based interventions, particularly fortification programmes, such as salt iodization, and use of concentrated micronutrient supplements. A mix of accompanying programmes for infection control, community participation, including education, communication and information exchange, and private sector involvement are lessons learned for overcoming deterrents and sustaining progress towards elimination.     

Alternatives to current HIV/AIDS policies and practices in South African prisons

Prisoners in South Africa face problems of overcrowding, violence and poor nutrition. Added to this burden in recent times is the increased threat from HIV. The HIV epidemic has been relatively late in coming to South Africa but infection rates are now 20% in the adult population. However, there is no data available on the level of HIV infection in the prison population. Overseas studies suggest that the characteristics of prisoners place them at much greater risk of HIV infection. Factors which contribute to increased levels of HIV infection include poor health care facilities, lack of condoms and lack of disinfectants. Current policies and practices on HIV in prison attempt to balance the constraints of limited resources with the need to preserve prisoner human rights. The outcomes include: mass testing not freely available, HIV education is limited, and early release of prisoners with advanced AIDS is not allowed. Constraints on the implementation of effective HIV prevention strategies include: bureaucratic inefficiency, lack of resources, and a reluctance by prison authorities to address the issue of HIV in prison. These problems can possibly be overcome by addressing the issue from both management and prisoner perspectives. On the management side, increased resources, increased training of prison officials, and increased political commitment to address the issue are required. Outside partnerships are probably required for an effective response. Prisoners require better nutrition, better living conditions, better health care, freely available condoms and disinfectants.     

Addressing health system barriers to access to and use of skilled delivery services: perspectives from Ghana

Poor access to and use of skilled delivery services have been identified as a major contributory factor to poor maternal and newborn health in sub‐Saharan African countries, including Ghana. However, many previous studies that examine norms of childbirth and care‐seeking behaviours have focused on identifying the norms of non‐use of services, rather than factors, that can promote service use. Based on primary qualitative research with a total of 185 expectant and lactating mothers, and 20 healthcare providers in six communities in Ghana, this paper reports on strategies that can be used to overcome health system barriers to the use of skilled delivery services. The strategies identified include expansion and redistribution of existing maternal health resources and infrastructure, training of more skilled maternity caregivers, instituting special programmes to target women most in need, improving the quality of maternity care services provided, improving doctor–patient relationships in maternity wards, promotion of choice, protecting privacy and patient dignity in maternity wards and building partnerships with traditional birth attendants and other non‐state actors. The findings suggest the need for structural changes to maternity clinics and routine nursing practices, including an emphasis on those doctor–patient relational practices that positively influence women's healthcare‐seeking behaviours. Copyright © 2015 John Wiley & Sons, Ltd.     

Pregnancy and birth in an indigenous Huichol community: from structural violence to structural policy responses

Mexico's indigenous regions are characterised by socio-economic marginalisation and poor health outcomes and the Maternal Mortality Rate in indigenous communities continues to be around six times higher than the national rate. Using as a case study the Huichol community of North-Western Mexico we will discuss how institutional health and welfare programmes which aim to address accepted risk factors for maternal health are undermined by a series of structural barriers which put indigenous women especially in harm's way. Semi-structured interviews and observational data were gathered between 2009 and 2011 in highland communities and on coastal tobacco plantations to where a large number of this ethnic group migrate. Many Huichol women birth alone, and to facilitate this process they maintain a low nutritional intake to reduce their infant's growth and seek spiritual guidance during pregnancy from a shaman. These practices are reinforced by feelings of shame and humiliation encountered when using institutional health provision. These are some of the structural barriers to care that need to be addressed. Effective interventions could include addressing the training of health professionals, focusing on educational inequalities and the structural determinants of poverty whilst designing locally specific programmes that encourage acceptance of available health care.     

Building human resources capability in health care: a global analysis of best practice--Part I.

This paper is one of a series of three, covering very comprehensively human resource practices in a global and generic context. The series of papers presents practices which are directly of relevance to the health-care context, and which are based on proven, effective and pioneering approaches. The first paper covers practices based on British and European experiences, gathered from world-class organisations that have either been finalists or went on to win prestigious quality awards such as the British and European Quality Awards. The benchmarking analysis presented in this paper is based on the sub-criteria prescribed by the European Quality Awards Model, which include: how people resources are planned and improved; how the skills and capabilities of people are preserved and developed through recruitment, training and career progression; how people and teams agree targets and continuously review performance; how the involvement of everyone in continuous improvement is prompted and people empowered to take appropriate action; how effective top-down and bottom-up communication is achieved.     

Critical interactions between Global Fund-supported programmes and health systems: a case study in Papua New Guinea

In Papua New Guinea, investment by the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) has played an important role in scaling up the response to HIV and tuberculosis (TB). As part of a series of case studies on how Global Fund-supported programmes interact with national health systems, we assessed the nature and extent of integration of the Global Fund portfolios within the national HIV and TB programmes, the integration of the HIV and TB programmes within the general health system, and system-wide effects of Global Fund support in Papua New Guinea. The study relied on a literature review and 30 interviews with key stakeholders using the Systemic Rapid Assessment Toolkit and thematic analysis. Global Fund-supported activities were found to be largely integrated, or at least coordinated, with the national HIV and TB programmes. However, this has reinforced the vertical nature of these programmes with respect to the general health system, with parallel systems established to meet the demands of programme scale-up and the performance-based nature of Global Fund investment in the weak health system context of Papua New Guinea. The more parallel functions include monitoring and evaluation, and procurement and supply chain systems, while human resources and infrastructure for service delivery are increasingly integrated at more local levels. Positive synergies of Global Fund support include engagement of civil-society partners, and a reliable supply of high-quality drugs which may have increased patient confidence in the health system. However, the severely limited and overburdened pool of human resources has been skewed towards the three diseases, both at management and service delivery levels. There is also concern surrounding the sustainability of the disease programmes, given their dependence on donors. Increasing Global Fund attention towards health system strengthening was viewed positively, but should acknowledge that system changes are slow, difficult to measure and require long-term support.     

"Care" and public nutrition

In 1990, the Unicef conceptual framework for nutrition recognised the role of care, along with household food security and health services and environment, as one of the three underlying factors of child survival, growth, and development. This model has been adopted at a policy level at the International Conference on Nutrition (Rome, 1992) and over the past ten years the concept of care has been refined through literature reviews, consultative meetings and empirical works. "Care is the provision in the household and the community of time, attention, and support to meet the physical, mental, and social needs of the growing child and other household members". Basically, care refers to the actions of caregivers (mainly, but not only mothers) that translate food and health resources into positive outcomes for the child's nutrition. Even under circumstances of poverty, enhanced caregiving can optimise the use of resources to promote good nutrition. Care practices have been grouped into six categories: care for women, breastfeeding and child feeding practices, psychosocial care, food preparation, hygiene practices, household health practices. They cover a wide range of behaviours, are often culturally specific and are daily, repetitive, and time-consuming activities. It must be underlined that the way care practices are performed (i.e., quality of care) is as important as the practices themselves. It has also been emphasised that children play a significant role in determining the quality of care that they receive, through an interactive process: an active child elicits more care from the caregiver, who is in turn more responsive. Care resources at household level have been described according to three categories: human (knowledge, beliefs, education, physical and mental health of the caregiver), economic (control on income, workload and time), and organisational (alternate caregivers, community support). But the availability of care also depends on support at the national or international level. As the mother is the primary caregiver, most of the obstacles to care are the constraints to the mothers, the most common characteristic of which being the low status of women in many societies. More studies are required to better understand the causal relationship between care and nutrition. Methods to measure the qualitative aspects of care and indicators that capture the complexity of care must be developed and cross-culturally tested. These will also be useful to design and monitor more effective interventions incorporating care. These programmes should first identify and support the good traditional care practices rather than simply ask for change; the activities proposed should not break the balance between the time women spend on care and the time they spend on work. Therefore one must be sure that enough resources are available. Finally, to achieve sustainable changes a participatory and comprehensive approach is definitely needed.     

Leading a change process to improve health service delivery

In the fields of health and development, donors channel multiple resources into the design of new practices and technologies, as well as small-scale programmes to test them. But successful practices are rarely scaled up to the level where they beneficially impact large, impoverished populations. An effective process for change is to use the experiences of new practices gained at the programme level for full-scale implementation. To make an impact, new practices need to be applied, and supported by management systems, at many organizational levels. At every level, potential implementers and likely beneficiaries must first recognize some characteristics that would benefit them in the new practices. An effective change process, led by a dedicated internal change agent, comprises several well-defined phases that successively broaden and institutionalize the use of new practices.     

Preparing racially and ethnically diverse communities for public health emergencies

The tragedy of Hurricane Katrina in New Orleans confirmed that effective implementation of public health preparedness programs and policies will require compliance from all racial and ethnic populations. This study reviews current resources and limitations and suggests future directions for integrating diverse communities into related strategies. It documents research and interventions, including promising models and practices that address preparedness for minorities. However, findings reveal a general lack of focus on diversity and suggest that future preparedness efforts need to fully integrate factors related to race, culture, and language into risk communication, public health training, measurement, coordination, and policy at all levels.     

Neonatal screening and clinical care programmes for sickle cell disorders in sub-Saharan Africa: lessons from pilot studies

OBJECTIVES: Despite the widespread use of neonatal screening programmes for sickle cell disease in Western regions, few studies have focused on the special healthcare needs in sub-Saharan African countries. The purpose of this review is to evaluate the need for a neonatal screening programme for sickle cell disease, and if justified, to propose a realistic healthcare programme for sickle cell newborns in those countries based on personal experiences in Kinshasa (Democratic Republic of the Congo) and Ouagadougou (Burkina Faso) as well as from a review of the literature. REVIEW: There are well-established criteria for the development of neonatal screening programmes for sickle cell disease in sub-Saharan African countries. In particular, in regions where incidence of the disease is 0.5 per 1000 or higher, a sickle cell screening programme can be proposed that includes the systematic screening of all newborns, or the targeted screening of those newborns who have a mother with a sickle cell or haemoglobin C trait. Screening should be preferentially organized using cord blood, with a simple, effective and affordable screening method such as isoelectric focusing. If necessary, confirmation of results should be performed using another cost-effective technique such as citrate agar electrophoresis at an acidic pH. There is also a need for a sickle cell disease clinical care programme which should include: infection prophylaxis with penicillin and malarial prophylaxis; family training to identify early severe or persistent symptoms and the gravity of malarial crises; the evaluation of nutritional status and adequate fluid intake; and the importance of regular medical visits. Improved knowledge of the diagnosis was found to reduce the need for unnecessary and unsafe blood transfusions. CONCLUSIONS: This paper provides an overview of practices employed in neonatal screening and clinical care programmes for sickle cell disease in sub-Saharan African countries. The development of these programmes is pivotal to improving the health care of those affected by haemoglobin disorders. However, such programmes require major economic and organizational resources, which must taken into account and balanced against other local health priorities.