Health sector reform and public sector health worker motivation: a conceptual framework

Motivation in the work context can be defined as an individual's degree of willingness to exert and maintain an effort towards organizational goals. Health sector performance is critically dependent on worker motivation, with service quality, efficiency, and equity, all directly mediated by workers' willingness to apply themselves to their tasks. Resource availability and worker competence are essential but not sufficient to ensure desired worker performance. While financial incentives may be important determinants of worker motivation, they alone cannot and have not resolved all worker motivation problems. Worker motivation is a complex process and crosses many disciplinary boundaries, including economics, psychology, organizational development, human resource management, and sociology. This paper discusses the many layers of influences upon health worker motivation: the internal individual-level determinants, determinants that operate at organizational (work context) level, and determinants stemming from interactions with the broader societal culture. Worker motivation will be affected by health sector reforms which potentially affect organizational culture, reporting structures, human resource management, channels of accountability, types of interactions with clients and communities, etc. The conceptual model described in this paper clarifies ways in which worker motivation is influenced and how health sector reform can positively affect worker motivation. Among others, health sector policy makers can better facilitate goal congruence (between workers and the organizations they work for) and improved worker motivation by considering the following in their design and implementation of health sector reforms: addressing multiple channels for worker motivation, recognizing the importance of communication and leadership for reforms, identifying organizational and cultural values that might facilitate or impede implementation of reforms, and understanding that reforms may have differential impacts on various cadres of health workers.     

Mapping the public health workforce I: a tool for classifying the public health workforce

We aimed to develop a tool to identify members of the public health workforce and classify them using categories developed for the Chief Medical Officer's project to strengthen the public health function. The tool was developed to gain a picture of London's public health workforce, and needed to be reliable and easy to use in many settings inside and outside the health service. We needed to be able to classify posts from brief information without interrogation of postholders, so that the entire workforces of large organisations could be classified from information provided by only a few key informants. Key questions and decision rules were defined by presenting interviewees in public health with brief information on nine jobs and discussing with them the process by which they determined whether each post was in the public health workforce, and if so, in which category. The questions and decision rules were refined into a classification tool which was presented as a flow diagram and a questionnaire. Application of the tool revealed that it was understood by key informants and resulted in classifications which were accepted by the researchers. The tool has now been applied extensively in London and yielded useful results. Many other applications in public health workforce planning and development are anticipated.     

Training of public health workforce at the National School of Public Health: meeting Africa's needs

PROBLEM: The inadequate number of trained public health personnel in Africa remains a challenge. In sub-Saharan Africa, the estimated workforce of public health practitioners is 1.3% of the world's health workforce addressing 25% of the world's burden of disease. APPROACH: To address this gap, the National School of Public Health at the then Medical University of Southern Africa created an innovative approach using distance learning components to deliver its public health programmes. Compulsory classroom teaching is limited to four two-week blocks. RELEVABT CHANGES: Combining mainly online components with traditional classroom curricula reduced limitations caused by geographical distances. At the same time, the curriculum was structured to contextualize continental health issues in both course work and research specific to students' needs. LESSONS LEARNED: The approach used by the National School of Public Health allows for a steady increase in the number of public health personnel in Africa. Because of the flexible e-learning components and African-specific research projects, graduates from 16 African countries could avail of this programme. An evaluation showed that such programmes need to constantly motivate participants to reduce student dropout rates and computer literacy needs to be a pre-requisite for entry into the programme. Short certificate courses in relevant public health areas would be beneficial in the African context. This programme could be replicated in other regions of the continent.     

Health sector reforms in Kenya: an examination of district level planning

The paper examines health sector reforms in Kenya at the district level based on the Government of Kenya's Health Policy Framework of 1994. The authors present the context of and historical perspective to health sector reforms in Kenya and discuss the major reform policies including decentralization to the district level. The authors then review intended policy outcomes, investigating assumptions on which the implementation and effectiveness of the reform agenda at the local level are based. The authors argue that emphasis on outcomes rather than process has not supported sustainable reforms or achieved the government's goal of improving health and ensuring equity for the citizens of the country.     

Migration as a form of workforce attrition: a nine-country study of pharmacists

Background  

There is a lack of evidence to inform policy development on the reasons why health professionals migrate. Few studies have sought to empirically determine factors influencing the intention to migrate and none have explored the relationship between factors. This paper reports on the first international attempt to investigate the migration intentions of pharmacy students and identify migration factors and their relationships.     

Undergraduate public health education: a workforce perspective

OBJECTIVE: To describe the career paths of students who majored in public health at the undergraduate level and to assess the skills and knowledge these graduates believed were most useful to them in the public health workforce. METHOD: A telephone survey was conducted of all graduates from Adelaide University's Bachelor of Health Sciences degree from 1992-99 who had majored in public health (124 graduates). RESULTS: The response rate to the graduate survey was 71%. Using the definition of public health functions from the National Delphi Study on Public Health Functions to delineate the public health workforce, 59% of respondents were employed in public health. Graduates working in public health valued generic skills such as communication and collaboration more highly than more specific public health skills and knowledge areas. However, they also believed their undergraduate course would have been improved by a more practical orientation. CONCLUSIONS: A high proportion of graduates from this generalist degree who major in public health find employment in the public health workforce. They greatly value the generic skills associated with their undergraduate public health education and believe their entry into the workforce would have been further facilitated by stronger links between their academic program and the working environment of public health professionals. Implications: Studies of workforce training programs in public health must differentiate between the educational needs of undergraduate and postgraduate students. In particular, strategies need to be developed to provide stronger links between undergraduate students and the public health workforce.     

Education for the public health profession: a new look at the Roemer proposal

Demands for a high level of professionalism in public health practice, and concomitant strengthening of public health education to match 21st-century community challenges provide an opportunity to reconsider the current paradigm for professional degrees in public health. In this article, we consider whether the currently typical public health education meets the requirements of a professional education, examine the current state of public health education, and provide a rationale for renewed emphasis on the doctor of public health (DrPH) degree. We also present one potential three-year DrPH curriculum to stimulate further discussion, while acknowledging the multiple challenges that face any school of public health moving to implement such an education.     

Improving performance at the local level: implementing a public health learning workforce intervention.

In an effort to continually improve performance of the essential public health services with community partners, the diverse public health workforce in a major metropolitan area engaged in an organizational learning process. Core public health organizational competencies, identified in a multi-year collaborative applied research initiative, provided the curricula content for the public health learning experience. All members (about 600) of the Columbus and Franklin County (Ohio) Health Departments participated in four one-half day small group, highly interactive modules conducted during a 2-year period. The purpose of this article is to describe the design and implementation of this workforce intervention, the lessons learned, and implications for developing organizational capacity and improved performance.     

Health and housing conditions in public sector housing estates

This article reports some of the findings of a study of health and housing conditions ina sample of households from eight different types of council housing areas in Gateshead.Controlling for age, there were found to be marked and consistent differences in self-reported health between individuals from different areas. For all age groups up to 65 years old, those living in “bad” housing areas reported poorer health, more long-standing illness, more recent illness and more symptoms of respiratory disease and depression. The clearest associations between poor health and bad housing emerged for the generally fittest age-groups (the under 25 years). For the people over 65 years the position was reversed, with those in “good” housing areas reporting poorer health, with the exception of recent illness. This is argued to be the result of local authority lettings policy, which gives priority to re-housing the less-fit elderly.Those in “bad” housing areas were also more likely to report housing defects which affected their health and to feel that their health could be improved by a change in their housing.The study found that “bad” council housing areas did not necessarily conform to thestereotype of non-traditional construction, or high-rise flats. Some consisted of traditionally built houses, while there was a sizeable representation among the “good” housing of system-built high-rise flats. The “bad” housing areas were marked off more by their location, their poor environment and the low quality of their construction.     

Developing a speciality: regearing the specialist public health workforce

OBJECTIVES: To identify issues surrounding the future training needs of the specialist public health workforce following the most recent restructuring of the National Health Service (NHS) in England. METHODS: All directors of public health (DsPH) based in strategic health authorities and nine senior staff working in public health at the regional level were invited to participate in a semi-structured telephone interview. RESULTS: Twenty-six people were interviewed. Many interviewees expressed concern that because consultants and specialists in public health will be working in much smaller teams than hitherto, they will have to generalize their skills to cover a much wider range of functions (including board-level duties). This may result in a loss of specialist expertise. Successful public health practice in the new structures will require new ways of interorganizational working that will add an administrative burden to specialists in public health. Also, the creation of a board-level post in each primary care trust (PCT) has resulted in more time spent on corporate responsibilities and less on public health for DsPH, who are often the only fully trained specialist in public health in their PCT. Furthermore, interviewees expressed their anxiety about the lack of diversity in the posts available to specialists in public health and particularly to those newly completing their specialist training. Generally, interviewees felt that traditional public health roles and responsibilities were being eclipsed by corporate and managerial ones. Professional development activities were being carried out, but in a rather ad-hoc fashion. Interviewees were hopeful that public health networks would lead professional development initiatives once they were more established. CONCLUSIONS: It is important that excellence in public health is maintained through a set of accreditable standards, whilst corporate skills, essential to successful public health practice in the new UK NHS, are developed among specialists in public health.     

Focusing on public health: a different look at translating research to practice

ABSTRACT The Centers for Disease Control and Prevention (CDC) is committed to achieving true improvements in people's health. In chronic disease prevention and health promotion, we have a good deal of evidence about which intervention strategies work in clinics and in communities to improve health, but we need to accelerate translating that evidence into practice. This paper provides an overview of initial efforts of the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) within the CDC to identify and organize the fundamental elements of translation, with the goal of understanding what our constituents need for success and to identify key issues to consider in translation.     

Coming soon to a health sector near you: An advance look at the new Ontario Personal Health Information Protection Act (PHIPA)

This is Part I of a two-part article that provides a broad overview of the new health sector privacy legislation in Ontario, and compares this legislation to personal health legislation in other provinces. In Part I, we discuss the objectives, structure and scope of, as well as the substantive rights and obligations created by, the Ontario Act. In Part II, which will appear in the Fall 2004 issue, we will discuss the administrative obligations under the Ontario Act, as well as the provisions relating to enforcement and remedies. We will also discuss the approach to the protection of personal health information taken by other provinces, including Alberta, Saskatchewan and Manitoba, which have already enacted legislation that is similar in many respects to the Ontario Act.