Health workforce planning in Europe: Creating learning country clusters

In this article, the different dimensions and determinants of health workforce planning (HWF) are investigated to improve context-sensitivity and mutual learning among groups of countries with similar HWF characteristics. A novel approach to scoring countries according to their HFW characteristics and type of planning is introduced using data collected in 2012 by a large European Union project involving 35 European countries (the ‘Matrix Study’ [8]). HWF planning is measured in terms of three major dimensions: (1) data infrastructure to monitor the capacities and dynamics of health workforces, (2) the institutions involved in defining and implementing labour market regulations, and (3) the availability of models to estimate supply–demand gaps and to forecast imbalances. The result shows that the three dimensions of HWF planning are weakly interrelated, indicating that countries invest in HWF in different ways. Determinant analysis shows that countries with larger health labour markets, National Healthcare Service (NHS), mobility, and strong primary health care score higher on HWF planning dimensions than others. Consequently, the results suggest that clustering countries with similar conditions in terms of HWF planning is a way forward towards mutual and contextual learning.     

Primary eye care skills scores for health workers in routine and enhanced supervision settings

Introduction

Primary health care in Tanzania is provided at two types of health units, the dispensary and the health centre. Theoretically, primary health workers (with knowledge of primary eye care [PEC]) are ideally placed to identify people in need of eye care services. In Tanzania, they are expected to be able to identify, treat, or correctly refer a number of eye conditions including cataract, trauma, presbyopia, and the ‘red eye’. They are also expected to be able to measure visual acuity correctly and to educate the community about prevention.

Objectives

The objective was to determine the effect of enhanced supervision of health workers on PEC knowledge and skills in Kilimanjaro Region, Tanzania.

Study design

This was a quasi-experimental, cluster randomized intervention study of an enhanced supervisory method compared to a routine supervisory method; 36 dispensaries were randomly allocated into the two groups.

Participants

Health workers based at government dispensaries in Mwanga District.

Data collection

Participants were interviewed pre and post intervention and the information was recorded using a standardized pretested questionnaire.

Results

Mean scores of knowledge in healthcare workers was higher in the intervention group (score = 6.43, 80.4% improvement) compared to the non-intervention group (score = 4.71, 58.9% improvement). The ability to describe and demonstrate vision testing was better (score = 1.8) in the enhanced supervision group compared to the routine supervision group (score = 0.88, P = 0.03). There was a high level of attrition (24%) within one year from the time of baseline survey, especially amongst clinical officers (44%).

Conclusion

During the pilot study, enhanced supervision improved PEC knowledge and skills of health workers compared to health workers with routine supervision.

Recommendations

Training in PEC needs revision to become more practicum-based. There is need to revise supervision guidelines (to be skills-based) and the supervision skills of district eye coordinators (DECs) need to be enhanced. There is a huge need to improve governance (accountability and rule of law) of health staff.     

From cottage industry to a dominant mode of primary care: stages in the diffusion of a health care innovation (retail clinics)

Primary health care is essential to population health and there is increasing need for it, especially with an aging population with multiple comorbidities. Primary health care in the U.S. is widely considered in an ever-deepening crisis. This paper presents a detailed case study of the recent rise of a "disruptive innovation" - retail clinics - which have the potential to transform the face of primary health care in the US. We describe six stages in the diffusion of retail clinics, from cottage industry to a dominant mode for the delivery of primary health care, and consider sociopolitical influences that facilitate and impede their emerging potential. Retail clinics may provide a strategic opportunity to re-engineer the primary health care system, although they may also produce worrisome unanticipated consequences. Discussion concerning the potential threats and opportunities posed by retail clinics occurs in the absence of sound evidence concerning their comparative effectiveness and quality-of-care. This case study identifies the sociopolitical influences and processes that determine whether health care innovations rise or fall, and highlights critically important points along the pathway to health system change.     

The Joint Action on Health Workforce Planning and Forecasting: Results of a European programme to improve health workforce policies

Health workforce (HWF) planning and forecasting is faced with a number of challenges, most notably a lack of consistent terminology, a lack of data, limited model-, demand-based- and future-based planning, and limited inter-country collaboration. The Joint Action on Health Workforce Planning and Forecasting (JAHWF, 2013–2016) aimed to move forward on the HWF planning process and support countries in tackling the key challenges facing the HWF and HWF planning. This paper synthesizes and discusses the results of the JAHWF. It is shown that the JAHWF has provided important steps towards improved HWF planning and forecasting across Europe, among others through the creation of a minimum data set for HWF planning and the ‘Handbook on Health Workforce Planning Methodologies across EU countries’. At the same time, the context-sensitivity of HWF planning was repeatedly noticeable in the application of the tools through pilot- and feasibility studies. Further investments should be made by all actors involved to support and stimulate countries in their HWF efforts, among others by implementing the tools developed by the JAHWF in diverse national and regional contexts. Simultaneously, investments should be made in evaluation to build a more robust evidence base for HWF planning methods.     

Language barriers in health and social care consultations in the community: A comparative study of responses in Ireland and England

ObjectiveThis paper focuses on the implications of migration for host health and social care systems in terms of linguistic diversity, language barriers and language supports. The objective is to compare Ireland, as a context responding to the new challenge of language barriers in healthcare, and England, as a context in which the management of language barriers is being re-assessed.MethodsEmpirical data from two action research studies in Ireland and England are compared. The combined data set is 146 data collection episodes with service users with limited English and their health and social care providers.ResultsKey findings are that the same range of formal and informal responses to language barriers occurs in practice in both contexts but proportions of knowledge and use of these responses differ. English service providers have more awareness about the use of formal responses than Irish service providers but uptake of formal responses remains low in both contexts. Data from service users confirms these findings.ConclusionsThere is a need for more attention to the implementation of policies for language barriers in both Ireland and England, further research about the normalization processes associated with these consultations and knowledge transfer networks to facilitate on-going dialogue between all key stakeholders with an emphasis on supporting service users’ involvement and participation.     

Challenges facing primary health care in federated government systems: Implementation of Primary Health Networks in Australian states and territories

In many federated countries, there is divided health system responsibility that can affect primary health care (PHC) policy and implementation, and complicate collaboration between PHC actors. We examined an Australian policy initiative, Primary Health Networks (PHNs), which are regional PHC organisations, to examine how they collaborated with state and territory PHC actors, and what factors enhanced or constrained collaboration. For PHNs we surveyed 66 staff, interviewed 82 staff, examined board membership, and analysed documents from all 31 PHNs. We also interviewed 11 state and 5 federal health bureaucrats. We mapped the PHC system in each state, and conducted team thematic analysis of the qualitative data collected. We found variation in how well PHNs collaborated with state and territory actors, ranging from poor relationships through to strong cooperation and co-commissioning. This was affected by factors to do with the state health department, geography, PHN funding and regulations, ambiguities in the federal/state divided responsibilities for PHC, and the extent of use of collaboration mechanisms and strategies. Resourcing and supporting such collaboration mechanisms, and increasing regional funding flexibility of funding would increase the potential for regional organisations to successfully navigate ambiguities in responsibility and foster a more integrated, cohesive PHC system.     

发展城乡基层卫生事业是实施基本卫生保健制度的基础

当前城乡基层卫生事业存在卫生资源不足且城乡差距明显、基本医疗得不到保障舍近求远使看病难导致看病贵、公共卫生服务缺失使危害居民健康因素的隐患增大等主要问题，提出发展城乡基层卫生事业是实施基本卫生保健制度基础的观点，提出把巩固完善城乡基层卫生体系和提高卫生服务能力作为基础工程、把增加卫生投入和实行公共卫生服务政府埋单作为保障工程、把改造不良生活卫生环境和倡导健康生活方式作为配套工程等三个发展城乡基层卫生事业和实施国家基本卫生保健制度的政策建议。     

基层卫生服务医防融合：概念框架及指标体系构建

目的本研究致力于构建医疗服务和预防服务融合的概念框架, 设计医防融合水平测量的指标体系,并用实证数据测试指标体系的信度和适用性。方法结合现有整合型卫生服务体系的概念框架和我国卫生体系的特征,构建基层卫生服务提供中医防融合的概念框架;利用德尔菲专家咨询法构建医防融合水平测量的指标体系;测试指标体系的调查数据来自广西两县中6个乡镇的医疗机构、医务人员、重点疾病患者以及常住居民。结果我国基层卫生服务提供机构在“基本公共卫生服务”和“基本医疗服务”上的融合表现在个人、机构和体系三个层次上,融合的实现需要在筹资激励、组织、信息系统和人才培养等方面的支持环境,供方融合行为可促进需方预防性服务利用和健康行为的改善。基于此框架开发了包括5个维度、共28个指标的测量指标体系。在广西两县测试指标体系,显示测量结果与两县整合导向改革阶段相符合,并识别出医防融合支持环境中需要加强“激励”和“组织”维度。结论本研究指标体系整体信度较好,能识别需要加强的支持政策,在整合型卫生体系改革背景下,有在全国不同卫生体系发展水平地区测试和应用的价值。     

An activating state and active citizen groups in the German health care system

Summary Enabling state and active civil society in the German health care cystemThis paper discusses the question, to what extent concepts of an enabling state are realised in the German health policy and wether they meet active citizens with corresponding competencies. The analysis is based on a review of the literature refering to the promotion and development of the self-help movement and citizen partizipation in the German health care system. The results show, that since 1999 the following enabling health policy measures were adopted: the promotion of independent patient advisory services and shared decision-making, the enactment of participation rules in the rehabilitation system and the compulsory subsidy for self-help groups, self-help organisations and clearing houses for self-help. The active engagement of the citizens both as co-producers of health on the individual level and as participants in processes of communication and decision-making on the system level is still restricted to a small part of the population. An enabling health policy and a broad citizen participation are still in the beginning, but they have the potential to strengthen each other and to realise synergetic effects. Even though some corresponding institutions were already established and attitudes of the health care professionals start to alter, the question wether the health policy will change from a welfare producing state to an enabling state cannot be answered completely yet.

     

The Indigenous primary health care and policy research network: Guiding innovation within primary health care with Indigenous peoples in Alberta

In 2015, the Truth and Reconciliation Commission of Canada released its Final Report with 94 Calls to Action, several of which called upon the health care sector to reform based on the principles of reconciliation. In the province of Alberta, Canada, numerous initiatives have arisen to address the health legacy Calls to Action, yet there is no formal mechanism to connect them all. As such, these initiatives have resulted in limited improvements overall. Recognizing the need for clear leadership, responsibility, and dedicated funding, stakeholders from across Alberta were convened in the Spring of 2019 for two full-day roundtable meetings to provide direction for a proposed Canadian Institutes of Health Research Network Environment for Indigenous Health Research that focused on primary health care and policy research. The findings from these roundtable meetings were synthesized and integrated into the foundational principles of the Indigenous Primary Health Care and Policy Research (IPHCPR) Network. The IPHCPR Network has envisioned a renewed and transformed primary health care system to achieve Indigenous health equity, aligned with principles and health legacy Calls to Action advocated by the Truth and Reconciliation Commission of Canada.     

Why we need multi-level health workforce governance: Case studies from nursing and medicine in Germany

Health workforce needs have moved up on the reform agendas, but policymaking often remains ‘piece-meal work’ and does not respond to the complexity of health workforce challenges. This article argues for innovation in healthcare governance as a key to greater sustainability of health human resources. The aim is to develop a multi-level approach that helps to identify gaps in governance and improve policy interventions. Pilot research into nursing and medicine in Germany, carried out between 2013 and 2015 using a qualitative methodology, serves to illustrate systems-based governance weaknesses. Three explorative cases address major responses to health workforce shortages, comprising migration/mobility of nurses, reform of nursing education, and gender-sensitive work management of hospital doctors. The findings illustrate a lack of connections between transnational/EU and organizational governance, between national and local levels, occupational and sector governance, and organizations/hospital management and professional development. Consequently, innovations in the health workforce need a multi-level governance approach to get transformative potential and help closing the existing gaps in governance.     

The role of the 2011 patients' rights in cross-border health care directive in shaping seven national health systems: Looking beyond patient mobility

Reports on the implementation of the Directive on the application of Patients' Rights in Cross-border Healthcare indicate that it had little impact on the numbers of patients seeking care abroad. We set out to explore the effects of this directive on health systems in seven EU Member States. Key informants in Belgium, Estonia, Finland, Germany, Malta, Poland and The Netherlands filled out a structured questionnaire. Findings indicate that the impact of the directive varied between countries and was smaller in countries where a large degree of adaptation had already taken place in response to the European Court of Justice Rulings. The main reforms reported include a heightened emphasis on patient rights and the adoption of explicit benefits packages and tariffs. Countries may be facing increased pressure to treat patients within a medically justifiable time limit. The implementation of professional liability insurance, in countries where this did not previously exist, may also bring benefits for patients. Lowering of reimbursement tariffs to dissuade patients from seeking treatment abroad has been reported in Poland. The issue of discrimination against non-contracted domestic private providers in Estonia, Finland, Malta and The Netherlands remains largely unresolved. We conclude that evidence showing that patients using domestic health systems have actually benefitted from the directive remains scarce and further monitoring over a longer period of time is recommended.     

Dying in Germany - consequences of societal changes for palliative care and the health care system

The changes in the way people die and the new challenges in dealing with dying and death have not been realized to their full extent or discussed in respect to their implications and consequences for end-of-life care in Germany. The purpose of this problem analysis paper is to provide an overview of the most important societal changes and to address the consequences for end-of-life care in the German Health Care System from a public health nursing point of view. It will be demonstrated that an exclusive focus on fostering the development of palliative care as a form of specialized health care and thereby allowing only a few people access to qualified care at the end of life is not a sufficient approach. It will be rather necessary to make broad changes in all areas of health care in order to achieve a level of end-of-life care that is of high quality and appropriate to match people’s needs. The most important challenges to be managed in the German health care system will be presented and discussed.

Task shifting in the provision of home and social care in Ontario,Canada: implications for quality of care

Growing healthcare costs have caused home‐care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home‐care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home‐care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010–2011. Using a purposive sampling strategy, semi‐structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home‐care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G‐tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust‐based relationships with clients; and because task shifting reduced the number of care providers entering the client's home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed.