Human Resources for Health

Background: Follow-up studies of former students are an efficient way to organize the entire process of professional training and curriculum evaluation. The aim of this study was to identify professional profile subgroups based on job-related variables in a sample of former students of a Brazilian public dental school. Methods: A web-based password-protected questionnaire was sent to 633 registered dentists who graduated from the Federal University of Goias between 1988 and 2007. Job-related information was retrieved from 14 closed questions, on subjects such as gender, occupational routine, training, profits, income status, and self-perception of professional career, generating an automatic database for analysis. The two-step cluster method was used for dividing dentists into groups on the basis of minimal within-group and maximal between-group variation, using job-related variables to represent attributes upon which the clustering was based. Results: There were 322 respondents (50.9%), predominantly female (64.9%) and the mean age was 34 years (SD = 6.0). The automatic selection of an optimal number of clusters included 289 cases (89.8%) in 3 natural clusters. Clusters 1, 2 and 3 included 52.2%, 30.8% and 17.0% of the sample respectively. Interpretation of within-group rank of variable importance for cluster segmentation resulted in the following characterization of clusters: Cluster 1 - specialist dentists with higher profits and positive views of the profession; Cluster 2 - general dental practitioners in small cities; Cluster 3 - underpaid and less motivated dentists with negative views of the profession. Male dentists were predominant in cluster 1 and females in cluster 3. One-way Anova showed that age and time since graduation were significantly lower in Cluster 2 (P < 0.001). Alternative solutions with 4 and 5 clusters revealed specific discrimination of Cluster 1 by gender and dental education professionals. Conclusions: Cluster analysis was a valuable method for identifying natural grouping with relatively homogeneous cases, providing potentially meaningful information for professional orientation in dentistry in a variety of professional situations and environments.

Background: Shortages of health workers are obstacles to utilising global health initiative (GHI) funds effectively in Africa. This paper reports and analyses two countries' health workforce responses during a period of large increases in GHI funds. Methods: Health facility record reviews were conducted in 52 facilities in Malawi and 39 facilities in Zambia in 2006/07 and 2008; quarterly totals from the last quarter of 2005 to the first quarter of 2008 inclusive in Malawi; and annual totals for 2004 to 2007 inclusive in Zambia. Topic-guided interviews were conducted with facility and district managers in both countries, and with health workers in Malawi. Results: Facility data confirm significant scale-up in HIV/AIDS service delivery in both countries. In Malawi, this was supported by a large increase in lower trained cadres and only a modest increase in clinical staff numbers. Routine outpatient workload fell in urban facilities, in rural health centres and in facilities not providing antiretroviral treatment (ART), while it increased at district hospitals and in facilities providing ART. In Zambia, total staff and clinical staff numbers stagnated between 2004 and 2007. In rural areas, outpatient workload, which was higher than at urban facilities, increased further. Key informants described the effects of increased workloads in both countries and attributed staff migration from public health facilities to non-government facilities in Zambia to PEPFAR. Conclusions: Malawi, which received large levels of GHI funding from only the Global Fund, managed to increase facility staff across all levels of the health system: urban, district and rural health facilities, supported by task-shifting to lower trained staff. The more complex GHI arena in Zambia, where both Global Fund and PEPFAR provided large levels of support, may have undermined a coordinated national workforce response to addressing health worker shortages, leading to a less effective response in rural areas.

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. Methods: Alumni data from African FETPs were reviewed in order to establish graduate retention. Retention was defined as a graduate staying and working in their home country for at least 3 years after graduation. African FETPs are located in Burkina Faso, Ethiopia, Ghana, Kenya, Nigeria, Rwanda, South Africa, the United Republic of Tanzania, Uganda and Zimbabwe. However, this paper only includes the Uganda and Zimbabwe FETPs, as all the others are recent programmes. Results: This review shows that enrolment increased over the years, and that there is high graduate retention, with 85.1% (223/261) of graduates working within country of training; most working with Ministries of Health (46.2%; 105/261) and non-governmental organizations (17.5%; 40/261). Retention of graduates with a medical undergraduate degree was higher (Zimbabwe 80% [36/83]; Uganda 90.6% [125/178]) than for those with other undergraduate qualifications (Zimbabwe 71.1% [27/83]; Uganda 87.5% [35/178]). Conclusions: African FETPs have unique features which may explain their high retention of graduates. These include: programme ownership by ministries of health and local universities; well defined career paths; competence-based training coupled with a focus on field practice during training; awarding degrees upon completion; extensive training and research opportunities made available to graduates; and the social capital acquired during training.

IntroductionCapacity-building programs are vital for healthcare workforce development in low- and middle-income countries. In addition to increasing human capital, participation in such programs may lead to new professional networks and access to social capital. Although network development and social capital generation were not explicit program goals, we took advantage of a natural experiment and studied the social networks that developed in the first year of an executive-education Master of Hospital and Healthcare Administration (MHA) program in Jimma, Ethiopia.Case descriptionWe conducted a sociometric network analysis, which included all program participants and supporters (formally affiliated educators and mentors). We studied two networks: the Trainee Network (all 25 trainees) and the Trainee-Supporter Network (25 trainees and 38 supporters). The independent variable of interest was out-degree, the number of program-related connections reported by each respondent. We assessed social capital exchange in terms of resource exchange, both informational and functional. Contingency table analysis for relational data was used to evaluate the relationship between out-degree and informational and functional exchange.Discussion and evaluationBoth networks demonstrated growth and inclusion of most or all network members. In the Trainee Network, those with the highest level of out-degree had the highest reports of informational exchange, χ2 (1, N = 23) = 123.61, p < 0.01. We did not find a statistically significant relationship between out-degree and functional exchange in this network, χ2(1, N = 23) = 26.11, p > 0.05. In the Trainee-Supporter Network, trainees with the highest level of out-degree had the highest reports of informational exchange, χ2 (1, N = 23) = 74.93, p < 0.05. The same pattern held for functional exchange, χ2 (1, N = 23) = 81.31, p < 0.01. Conclusions: We found substantial and productive development of social networks in the first year of a healthcare management capacity-building program. Environmental constraints, such as limited access to information and communication technologies, or challenges with transportation and logistics, may limit the ability of some participants to engage in the networks fully. This work suggests that intentional social network development may be an important opportunity for capacity-building programs as healthcare systems improve their ability to manage resources and tackle emerging problems.

Background: The aim of this study is to determine the prevalence of burnout in Greek medical residents, investigate its relationship with training satisfaction during residency and survey Greek medical residents' opinion towards the European Work Time Directive (EWTD). Methods: A Multi-centre, cross-sectional survey of Greek residents was performed. The Maslach Burnout Inventory (MBI) was used to measure burnout, which was defined as high emotional exhaustion, combined with high depersonalization or low personal accomplishment. In addition, seven questions were designed for this study to evaluate self-reported resident training satisfaction and three questions queried residents' opinion on the EWTD and its effects on their personal and social life as well as their medical training. Univariate, bivariate and multivariate statistical models were used for the evaluation of data. Results: Out of 311 respondents (77.8% response rate), 154 (49.5%) met burnout criteria and 99 (31.8%) indicated burnout on all three subscale scores. The number of residents that were dissatisfied with the overall quality of their residency training were 113 individuals (36.3%). Only 32 residents (10.3%) believed that the EWTD implementation will not have any beneficial effects for them. Conclusions: Both burnout and training dissatisfaction were common among Greek residents. Systemic interventions are thus required within the Greek health system, aimed at reducing resident impairment due to burnout and at improving their educational and professional perspectives. Although residents' opinion on the EWTD was not associated with burnout levels, the EWTD was found to be predominantly supported and anticipated by Greek residents and should be implemented to alleviate their workload and stress.

Background: The Ministry of Health (MOH) in Zambia is currently operating with fewer than half of the health workers required to deliver basic health services. The MOH has developed a human resources for health (HRH) strategic plan to address the crisis through improved training, hiring, and retention. However, the projected success of each strategy or combination of strategies is unclear. Methods: We developed a model to forecast the size of the public sector health workforce in Zambia over the next ten years to identify a combination of interventions that would expand the workforce to meet staffing targets. The key forecasting variables are training enrolment, graduation rates, public sector entry rates for graduates, and attrition of workforce staff. We model, using Excel (Office, Microsoft; 2007), the effects of changes in these variables on the projected number of doctors, clinical officers, nurses and midwives in the public sector workforce in 2018. Results: With no changes to current training, hiring, and attrition conditions, the total number of doctors, clinical officers, nurses, and midwives will increase from 44% to 59% of the minimum necessary staff by 2018. No combination of changes in staff retention, graduation rates, and public sector entry rates of graduates by 2010, without including training expansion, is sufficient to meet staffing targets by 2018 for any cadre except midwives. Training enrolment needs to increase by a factor of between three and thirteen for doctors, three and four for clinical officers, two and three for nurses, and one and two for midwives by 2010 to reach staffing targets by 2018. Necessary enrolment increases can be held to a minimum if the rates of retention, graduation, and public sector entry increase to 100% by 2010, but will need to increase if these rates remain at 2008 levels. Conclusions: Meeting the minimum need for health workers in Zambia this decade will require an increase in health training school enrolment. Supplemental interventions targeting attrition, graduation and public sector entry rates can help close the gap. HRH modelling can help MOH policy makers determine the relative priority and level of investment needed to expand Zambia's workforce to target staffing levels.

IntroductionIn the context of the current human resources for health (HRH) crisis, the need for comprehensive Human Resources Development Plans (HRDP) is acute, especially in resource-scarce sub-Saharan African countries. However, the financial implications of such plans rarely receive due consideration, despite the availability of much advice and examples in the literature on how to conduct HRDP costing. Global initiatives have also been launched recently to standardise costing methodologies and respective tools. Methods: This paper reports on two separate experiences of HRDP costing in Mozambique and Guinea Bissau, with the objective to provide an insight into the practice of costing exercises in information-poor settings, as well as to contribute to the existing debate on HRH costing methodologies. The study adopts a case-study approach to analyse the methodologies developed in the two countries, their contexts, policy processes and actors involved. Results: From the analysis of the two cases, it emerged that the costing exercises represented an important driver of the HRDP elaboration, which lent credibility to the process, and provided a financial framework within which HRH policies could be discussed. In both cases, bottom-up and country-specific methods were designed to overcome the countries' lack of cost and financing data, as well as to interpret their financial systems. Such an approach also allowed the costing exercises to feed directly into the national planning and budgeting process. Conclusions: The authors conclude that bottom-up and country-specific costing methodologies have the potential to serve adequately the multi-faceted purpose of the exercise. It is recognised that standardised tools and methodologies may help reduce local governments' dependency on foreign expertise to conduct the HRDP costing and facilitate regional and international comparisons. However, adopting pre-defined and insufficiently flexible tools may undermine the credibility of the costing exercise, and reduce the space for policy negotiation opportunities within the HRDP elaboration process.