Human Resources

Migrant health workers are faced with a set of options that are a combination of economic, social and psychological factors and family choices. They trade decisions related to their career opportunities - and to financial security for their families - against the psychological and social costs of leaving their country, family and friends. The comments of health workers themselves reflect the "push and pull" nature of the choices underpinning these "journeys of hope". Demotivating working conditions, coupled with low salaries, are set against the likelihood of prosperity for themselves and their families (by remittances), work in well-equipped hospitals, and the opportunity for professional development. An article in the WHO Bulletin points out that young, well-educated individuals are most likely to migrate, especially in pursuit of higher education.

Despite the expanding literature on how reforms may affect health workers and which reactions they may provoke, little research has been conducted on the mechanisms of effect through which health sector reforms either promote or discourage health worker performance. This paper seeks to trace these mechanisms and examines the contextual framework of reform objectives in Uganda and Bangladesh, and health workers' responses to the changes in their working environments by taking a 'realistic evaluation' approach.

This paper uses focus group methodology to explore health worker perspectives on the challenges posed to integration of mental health into primary care by generic health system weakness. Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 20 health workers drawn from a randomised controlled trial to evaluate the impact of a mental health training programme for primary care, 10 from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training). These focus group discussions suggested that there are a number of generic health system weaknesses in Kenya which impact on the ability of health workers to care for clients with mental health problems and to implement new skills acquired during a mental health continuing professional development training programmes. These weaknesses include the medicine supply, health management information system, district level supervision to primary care clinics, the lack of attention to mental health in the national health sector targets, and especially its absence in district level targets, which results in the exclusion of mental health from such district level supervision as exists, and the lack of awareness in the district management team about mental health. The lack of mental health coverage included in HIV training courses experienced by the health workers was also striking, as was the intensive focus during district supervision on HIV to the detriment of other health issues.

The emerging crisis of health manpower in Africa could defeat the efforts of governments, private health care providers, NGOs, and donors in controlling the HIV/AIDS epidemic. This was one of the principal findings of a consultative meeting on improving collaboration amongst health professionals, government and other stakeholders on health workers issues, recently held by WHO and the World Bank in Addis Ababa, Ethiopia.