Sub-Saharan Africa is facing a crisis in human health resources due to a critical shortage of health workers. The shortage is compounded by a high burden of infectious diseases; emigration of trained professionals; difficult working conditions and low motivation. In particular, the burden of HIV/AIDS has led to the concept of task shifting being increasingly promoted as a way of rapidly expanding human resource capacity. This refers to the delegation of medical and health service responsibilities from higher to lower cadres of health staff, in some cases non-professionals. This paper, drawing on Medecins Sans Frontieres' experience of scaling-up antiretroviral treatment in three sub-Saharan African countries (Malawi, South Africa and Lesotho) and supplemented by a review of the literature, highlights the main opportunities and challenges posed by task shifting and proposes specific actions to tackle the challenges. The opportunities include: increasing access to life-saving treatment; improving the workforce skills mix and health-system efficiency; enhancing the role of the community; cost advantages and reducing attrition and international 'brain drain'. The challenges include: maintaining quality and safety; addressing professional and institutional resistance; sustaining motivation and performance and preventing deaths of health workers from HIV/AIDS. Task shifting should not undermine the primary objective of improving patient benefits and public health outcomes.

Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa

There is increasing evidence that lack of facilities, equipment, and expertise in district hospitals across many low- and middle-income countries constitutes a major barrier to accessing surgical care. However, what is less clear, is the extent to which people perceive barriers when trying to access surgical care. PubMed and EMBASE were searched using key words (“access” and “surgery,” “barrier” and “surgery,” “barrier” and “access”), MeSH headings (“health services availability,” “developing countries,” “rural population”), and the subject heading “health care access.” Articles were included if they were qualitative and applied to illnesses where the treatment is primarily surgical. Key barriers included difficulty accessing surgical services due to distance, poor roads, and lack of suitable transport; lack of local resources and expertise; direct and indirect costs related to surgical care; and fear of undergoing surgery and anesthesia. The significance of cultural, financial, and structural barriers pertinent to surgery and their role in wider health care issues are discussed. Immediate action to improve financial and geographic accessibility along with investment in district hospitals is likely to make a significant impact on overcoming access and barrier issues. Further research is needed to identify issues that need to be addressed to close the gap between the care needed and that provided.

Systematic review of barriers to surgical care in low-income and middle-income countries.

Objective
To look at nurse migration flows in the light of national nursing workforce imbalances, examine factors that encourage or inhibit nurse mobility, and explore the potential benefits of circular migration.

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Nurses on the move: a global overview.

Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1016/j.ijgo.2009.07.012

Linking families and facilities for care at birth: What works to avert intrapartum-related deaths?

Background
For a health district to function referral from health centres to district hospitals is critical. In many developing countries referral systems perform well below expectations. Niger is not an exception in this matter. Beyond obvious problems of cost and access this study shows to what extent the behaviour of the health worker in its interaction with the patient can be a barrier of its own.

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The weakest link: competence and prestige as constraints to referral by isolated nurses in rural Niger.

The main objective of this study is to establish a benchmark for referral rates in rural Niger so as to allow interpretation of routine referral data to assess the performance of the referral system in Niger. Strict and controlled application of existing clinical decision trees in a sample of rural health centres allowed the estimation of the corresponding need for and characteristics of curative referrals in rural Niger. Compliance of referral was monitored as well. Need was matched against actual referral in 11 rural districts. The referral patterns were registered so as to get an idea on the types of pathology referred. The referral rate benchmark was set at 2.5 % of patients consulting at the health centre for curative reasons. Niger's rural districts have a referral rate of less than half this benchmark. Acceptability of referrals is low for the population and is adding to the deficient referral system in Niger. Mortality because of under-referral is highest among young children. Referral patterns show that the present programme approach to deliver health care leaves a large amount of unmet need for which only comprehensive first and second line health services can provide a proper answer. On the other hand, the benchmark suggests that well functioning health centres can take care of the vast majority of problems patients present with.

/pdf/monitoring-the-referral-system-through-benchmarking-in-rural-3f1glpv8mr.pdf

Monitoring the referral system through benchmarking in rural Niger: an evaluation of the functional relation between health centres and the district hospital

Summary


Objectives An important investment was made in two health districts in Niger to organize an emergency referral system. This study estimates its impact and cost-effectiveness in relation with external determinants.



Methods  After installing a solar radio network in the health centres, emergency calls and related data were monitored over 7 years and investment and recurrent costs for the system were estimated.



Results  The number of emergency calls increased significantly in both districts. In 2003, the total yearly cost for the district amounted to US$ 14 147, the cost per useful and successful call was US$ 49 and the cost per inhabitant and per year was about US$ 0.06.



Conclusion  The impressive and immediate impact on the health system, the relatively low recurrent cost and the minimal management requirements for the health service make the investment very worthwhile. Organizing emergency evacuation systems should be a priority for any health district in the world.

Paul Bossyns

Papers

The weakest link: competence and prestige as constraints to referral by isolated nurses in rural Niger.

Monitoring the referral system through benchmarking in rural Niger: an evaluation of the functional relation between health centres and the district hospital

Unaffordable or cost-effective?: introducing an emergency referral system in rural Niger.