This study systematically reviewed and consolidated existing evidence of the impact of financial and non-financial incentives on the motivation and retention of health workers. Four literature databases were searched, as well as grey literature studies and informational papers. Twenty qualitative and quantitative studies were selected. There was some evidence to suggest that the use of initiatives to improve motivation had been effective in helping retention. While motivational factors are undoubtedly country specific, financial incentives, career development and management issues are core factors. Nevertheless, financial incentives alone are not enough to motivate health workers. Workplace recognition and adequate resources and infrastructure can also improve morale significantly.
Human Resources
This article describes the experience of the Family Life Education Programme (FLEP), a reproductive health program that provides community-based health services through 40 clinics in five districts of Uganda, in improving retention and performance by using the Management Sciences for Health (MSH) Human Resource Management Rapid Assessment Tool. A few years ago, the FLEP of Busoga Diocese began to see an increase in staff turnover and a decrease in overall organisational performance. An action plan to improve their human resource management (HRM) system was developed and implemented. By implementing the various recommended changes, FLEP established an improved, responsive HRM system. Increased employee satisfaction led to less staff turnover, better performance, and increased utilisation of health services. These benefits were achieved by cost-effective measures focused on professionalising the organisation's approach to HRM.
In this article, the authors describe how governance issues have influenced HRH policy development and identify governance strategies that have been used, successfully or not, to improve HRH policy implementation in low- and middle-income countries (LMIC). They performed a descriptive literature review of HRH case studies which describe or evaluate a governance-related intervention at country or district level in LMIC, including a total of 16 case studies. This review shows that the term 'governance' is neither prominent nor frequent in recent HRH literature. It provides initial lessons regarding the influence of governance on HRH policy development and implementation. The review also shows that the evidence base needs to be improved in this field in order to better understand how governance influences HRH policy development and implementation. Tentative lessons are discussed, based on the case studies.
This qualitative formative research study aimed to inform the design of interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, the authors aimed to determine what leads to improved performance of CHWs. The CHW cadres studied were the rural health motivators, mothers-to-mothers mentors, HIV expert clients, and a community outreach team for HIV. Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: increased monetary compensation of CHWs, a more reliable supply of equipment and consumables, additional training, and an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as key factors.
This paper draws on ethnographic research conducted in HIV clinics and in a public hospital to examine how health workers experience and reflect upon the juxtaposition of 'global' medicine with 'local' medicine. We show that health workers face an uneven playing field. High-prestige jobs are available in HIV research and treatment, funded by donors, while other diseases and health issues receive less attention. Outside HIV clinics, patient's access to medicines and laboratory tests is expensive, and diagnostic equipment is unreliable. Clinicians must tailor their decisions about treatment to the available medical technologies, medicines and resources. How do health workers reflect on working in these environments and how do their experiences influence professional ambitions and commitments? The need to improvise in the face of inadequate diagnostic tools and unreliable facilities was stressful for all health workers. Added to this stress was the degree to which health workers had to attend to patient poverty. While staff within HIV/AIDS clinics also faced these issues, hospital staff often found them overwhelming as they were confronted daily and relentlessly with the moral dilemma of how to deal with patients who could not afford treatment. In this situation, the strain of being forced to practice medicine that was only ‘good enough’ was a source of stress and frustration. Among interns, the moral complexity of their situation added to their uneasy positioning as young professionals struggling to gain a sense of professional identity and competence.
The World Health Organization’s (WHO) recommendations focus on education, regulatory mechanisms, financial incentives, and personal and professional support. In terms of education, WHO recommends that countries use targeted admission policies to enrol students with a rural background in education programmes to increase the likelihood of graduates choosing to practise in rural areas. Undergraduate students should be exposed to rural community experiences and clinical rotations and study curricula should be revised to include rural health topics. Regulatory recommendations include introducing and regulating enhanced scopes of practice in rural and remote areas to increase the potential for job satisfaction. Compulsory service requirements in rural and remote areas should be accompanied with appropriate support and incentives to increase recruitment and subsequent retention of health professionals in these areas. Governments should use a combination of fiscally sustainable financial incentives, such as hardship allowances, grants for housing, free transportation and paid vacations, to improve rural retention. Personal and professional support should also be offered by improving living conditions for health workers and their families and investing in infrastructure and services. A good and safe working environment should be provided, with sufficient equipment and supplies.
Many countries have developed strategies to attract and retain qualified health workers in underserved areas, but there is only scarce and weak evidence on their successes or failures. It is difficult to compare lessons and measure results from the few evaluations that are available. Evaluation faces several challenges, including the heterogeneity of the terminology, the complexity of the interventions, the difficulty of assessing the influence of contextual factors, the lack of baseline information, and the need for multi-method and multi-disciplinary approaches for monitoring and evaluation. Moreover, the social, political and economic context in which interventions are designed and implemented is rarely considered in monitoring and evaluating interventions for human resources for health. This paper proposes a conceptual framework that offers a model for monitoring and evaluation of retention interventions taking into account such challenges. The conceptual framework is based on a systems approach and aims to guide the thinking in evaluating an intervention to increase access to health workers in underserved areas, from its design phase through to its results. It also aims to guide the monitoring of interventions through the routine collection of a set of indicators, applicable to the specific context. It suggests that a comprehensive approach needs to be used for the design, implementation, monitoring, evaluation and review of the interventions. The framework is not intended to be prescriptive and can be applied flexibly to each country context. It promotes the use of a common understanding on how attraction and retention interventions work, using a systems perspective.
This paper presents policy-makers and programme managers with key considerations for a model to improve the work environment as an important approach to increase community health worker (CHW) productivity and, ultimately, the effectiveness of community-based strategies. Researchers conducted a desk review of selective published and unpublished articles and reports on CHW programmes in developing countries to identify the elements that influence CHW productivity. They found that CHW productivity is determined in large part by the conditions under which they work. Attention to the provision of an enabling work environment for CHWs is essential for achieving high levels of productivity. They present a model in which the work environment encompasses four essential elements: workload, supportive supervision, supplies and equipment, and respect from the community and the health system. Establishing a balance among the four elements that constitute a CHW’s work environment will help make great strides in improving the effectiveness and quality of the services provided by CHWs.
This review and assessment of Tanzania’s current distance learning programmes for health care workers, as well as those in countries with similar human resource challenges, was undertaken to determine the feasibility of using distance learning to meet the need of an increased and more skilled health workforce. Data was collected from 25 distance learning programmes at health training institutions, universities and non-governmental organizations throughout Tanzania from May to August 2008. The authors identified a number of challenges, including: a lack of guidelines for administrators, instructors and preceptors of distance learning programmes regarding roles and responsibilities; absence of competencies for clinical components of curricula; and technological constraints such as lack of access to computers and to the internet. Insufficient funding resulted in personnel shortages, lack of appropriate training for personnel and lack of materials for students. Nonetheless, current and prospective students expressed overwhelming enthusiasm for scale-up of distance learning. The authors argue that a blended print-based distance learning model is most feasible at the national level due to current resource and infrastructure constraints.
According to this paper, about 59 million people make up the health workforce of paid full-time health workers world-wide. However, enormous gaps remain between the potential of health systems and their actual performance, and there are far too many inequities in the distribution of health workers between countries and within countries. Sub-Saharan Africa, with about 11% of the world’s population, bears over 24% of the global disease burden, is home to only 3% of the global health workforce, and spends less than 1% of the world’s financial resources on health. In most developing countries, the health workforce is concentrated in the major towns and cities, while rural areas can only boast of about 23% and 38% of the country’s doctors and nurses respectively. The imbalances exist not only in the total numbers and geographical distribution of health workers, but also in the skills mix of available health workers. Countries in sub-Saharan Africa would need to increase their health workforce by about 140% to achieve enough coverage for essential health interventions to make a positive difference in the health and life expectancy of their populations. The paper argues that the global health workforce crisis can be tackled if there is global responsibility, political will, financial commitment and public-private partnership for country-led and country-specific interventions that seek solutions beyond the health sector. Only when enough health workers can be trained, sustained and retained in sub-Saharan African countries will there be meaningful socio-economic development and the faintest hope of attaining the Millennium Development Goals in the sub-continent.