Health workforce skill mix and task shifting in low income countries: a review of recent evidence
TL;DR: Task shifting is a promising policy option to increase the productive efficiency of the delivery of health care services, increasing the number of services provided at a given quality and cost.
Abstract: Health workforce needs-based shortages and skill mix imbalances are significant health workforce challenges. Task shifting, defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training, is a potential strategy to address these challenges. This study uses an economics perspective to review the skill mix literature to determine its strength of the evidence, identify gaps in the evidence, and to propose a research agenda. Studies primarily from low-income countries published between 2006 and September 2010 were found using Google Scholar and PubMed. Keywords included terms such as skill mix, task shifting, assistant medical officer, assistant clinical officer, assistant nurse, assistant pharmacist, and community health worker. Thirty-one studies were selected to analyze, based on the strength of evidence. First, the studies provide substantial evidence that task shifting is an important policy option to help alleviate workforce shortages and skill mix imbalances. For example, in Mozambique, surgically trained assistant medical officers, who were the key providers in district hospitals, produced similar patient outcomes at a significantly lower cost as compared to physician obstetricians and gynaecologists. Second, although task shifting is promising, it can present its own challenges. For example, a study analyzing task shifting in HIV/AIDS in sub-Saharan Africa noted quality and safety concerns, professional and institutional resistance, and the need to sustain motivation and performance. Third, most task shifting studies compare the results of the new cadre with the traditional cadre. Studies also need to compare the new cadre's results to the results from the care that would have been provided--if any care at all--had task shifting not occurred. Task shifting is a promising policy option to increase the productive efficiency of the delivery of health care services, increasing the number of services provided at a given quality and cost. Future studies should examine the development of new professional cadres that evolve with technology and country-specific labour markets. To strengthen the evidence, skill mix changes need to be evaluated with a rigorous research design to estimate the effect on patient health outcomes, quality of care, and costs.
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TL;DR: Perceptions of students from health professions about career choice, job expectations, motivations and potential incentives to work in a rural area are explored to improve targeting and selection of undergraduate students and to stimulate the inclination of students to choose a rural job upon graduation.
Abstract: Deployment of health workforce in rural areas is critical to reach universal health coverage. Students’ perceptions towards practice in rural areas likely influence their later choice of a rural post. We aimed at exploring perceptions of students from health professions about career choice, job expectations, motivations and potential incentives to work in a rural area. In-depth interviews and focus groups were conducted among medical, nursing and midwifery students from universities of two Peruvian cities (Ica and Ayacucho). Themes for assessment and analysis included career choice, job expectations, motivations and incentives, according to a background theory a priori built for the study purpose. Preference for urban jobs was already established at this undergraduate level. Solidarity, better income expectations, professional and personal recognition, early life experience and family models influenced career choice. Students also expressed altruism, willingness to choose a rural job after graduation and potential responsiveness to incentives for practising in rural areas, which emerged more frequent from the discourse of nursing and midwifery students and from all students of rural origin. Medical students expressed expectations to work in large urban hospitals offering higher salaries. They showed higher personal, professional and family welfare expectations. Participants consistently favoured both financial and non-financial incentives. Nursing and midwifery students showed a higher disposition to work in rural areas than medical doctors, which was more evident in students of rural origin. Our results may be useful to improve targeting and selection of undergraduate students, to stimulate the inclination of students to choose a rural job upon graduation and to reorient school programmes towards the production of socially committed health professionals. Policymakers may also consider using our results when planning and implementing interventions to improve rural deployment of health professionals.
14 citations
Cites background from "Health workforce skill mix and task..."
...However, there is evidence that mid-level health providers perform at least as well as medical doctors in several tasks [21,22] and that the context-specific skill mix of several health cadres other than doctors may guarantee quality health care provision [23-25]....
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TL;DR: The need for and use of simulation as a tool for physician reentry is discussed and high-stakes, highfidelity simulation-based assessment is described to both evaluate and specifically tailor the curriculum for the physician seeking reentry.
Abstract: Physician shortages, whether real or perceived, remain a constant reality of modern health care. Shortages may be attributed to increasing demand and decreasing supply of physicians due to economic and political pressures. However, there are a multitude of individual reasons why many physicians may leave the workforce. Retraining physicians who have left medicine to return to practice is one method proposed to overcome these shortages. There are multiple programs, both in the United States and abroad, describing methods by which attending physicians can accomplish this task. The American Medical Association (AMA) has emphasized the need for reentry programs, and has set forth guidelines that should be met when creating such curricula. Although guidelines provide a framework for curriculum design, the AMA intentionally left the teaching methods open-ended to allow for educational flexibility, and to permit programs to be tailored to local and specialized needs. Using high-stakes, highfidelity simulation-based assessment to both evaluate and specifically tailor the curriculum for the physician seeking reentry is 1 unique method described. Although simulation-based assessment is controversial and poses significant challenges, its utility has been illustrated in the reentry of physicians in multiple fields and represents a realistic method for returning to practice. In this article we will discuss the need for and use of simulation as a tool for physician reentry.
14 citations
16 Feb 2018
TL;DR: The MSS had the potential to bring about system-wide changes; however, weak implementation severely hampered its achievement of the intended outcomes and dampened the expectations of significant improvements in the health systems.
Abstract: The flagship Midwives Service Scheme (MSS) was introduced in 2009 as the first large-scale intervention to address rural retention of midwives in Nigeria. This was a multi-component intervention including financial incentives to midwives, provision of accommodation and systems level support, aiming to improve human resource capacity to provide quality services. This study explores how effectively the scheme’s design and implementation drew on the health system’s context, resources, needs and population preferences, and how it contributed to strengthening health systems at all levels. To meet the objectives, 87 in-depth interviews and eight focus group discussions with policymakers, implementers, midwives and community members were conducted in two Nigerian states and at the federal level. Drawing on a systems-thinking approach, the study developed a new framework examining the fit of the intervention with the local health system’s context considering: i) leadership and commitment ii) policy and financing context iii) human resource management capacity, and iv) stakeholder participation. The framework informed the framing of the study and guided data collection; however, themes were identified and synthesised inductively. The broad principles and features of the scheme were widely supported by program managers and policy-makers across the three health systems levels (local, state, federal). However, its design was based on federal level program managers’ knowledge of maternal health and health worker issues, and limited recognition of the decentralised nature of the health system. Implementation was hampered by inadequate management and logistical capacity to deal with the complex design, poor absorptive capacity of states for the posted midwives, failure to provide continued supervision, and welfare issues that affected the midwives. The MSS was successful in attracting midwives including those employed in the private sector due to the promised pay package and capacity building opportunities offered under it. Several factors affected motivation of midwives and impacted on midwife retention. These include low and unpaid salaries and incentives, housing difficulties and distance of housing from the facility, and travel costs and hardships incurred from commuting to the facility. Unmet career development priorities were an additional source of demotivation. The findings point to poor retention of midwives in both states. Retention was better among retired midwives compared to other categories. Younger midwives were more mobile and exited the scheme mainly to the private sector. The MSS had the potential to bring about system-wide changes; however, weak implementation severely hampered its achievement of the intended outcomes and dampened the expectations of significant improvements in the health systems. The findings underscore the importance of reflecting overall health systems structures and processes and local contextual factors, including local health workers’ preferences in designing effective human resource retention schemes. The scheme is potentially replicable as a bundled package of interventions to improve access to skilled workers in rural communities in LMICs. Since decentralisation critically modifies the decision-making space, an inclusive process where sub-national actors participate in choosing policy options should be a prerequisite.
14 citations
TL;DR: To investigate the influence of antenatal provider type on maternity care in rural Ghana, a large number of patients believe that their provider of choice should be determined by the sex of the mother.
Abstract: Objectives
To investigate the influence of antenatal provider type on maternity care in rural Ghana.
Methods
An analysis of maternal care by antenatal provider type using the 2008 Ghana Demographic and Health Survey. Study population included rural Ghanaian women aged 15–49 years with report of a live birth between 2003 and 2008. Bivariate chi-square analysis was performed to examine differences in maternal report of WHO Maternal Health Interventions. Multivariate linear and logistic regression were performed to assess differences in antenatal care (ANC) scales and maternal care packages.
Results
Thousand and three hundred and sixty-seven rural women reported a live birth. Provider distribution was: doctor, 15.6%; midwife, 70%; community health officer (CHO), 9.1%; no provider, 5.3%. Women from lower socio-demographic categories were more likely to report midwife or CHO. Report of CHO vs. no provider was positively associated with maternal services (P < 0.01). Report of doctor or midwife vs. CHO was significantly associated with maternal services (P < 0.01).
Conclusion
There is a positive association between antenatal provider length of training and maternal specialization and report of maternal services. Community-based providers are associated with markedly increased report of maternal services compared with no provider. Structural factors appear to underlie some differences in service provision.
Objectifs
Etudier l'influence du type de prestataire de soins prenataux sur les soins maternels dans les regions rurales du Ghana.
Methodes
Analyse des soins maternels selon le type de prestataire de soins prenataux en utilisant l'Enquete Demographique et de Sante du Ghana de 2008. La population d’etude comprenait des femmes de zones rurales ghaneennes âgees de 15 a 49 ans, ayant un report d'une naissance vivante entre 2003–2008. Une analyse bivariee de chi-carre a ete realisee pour examiner les differences dans les reports maternels des interventions de sante maternelle de l’OMS. La regression lineaire et logistique multivariee a ete effectuee pour evaluer les differences dans les echelles de soins prenataux et dans les ensembles de soins maternels.
Resultats
1367 femmes rurales ont declare une naissance vivante. La distribution des prestataires etait comme suit: medecins, 15,6%; sages-femmes, 70%; agent de sante communautaire (ASC), 9,1%; non prestataires, 5,3%. Les femmes issues des categories sociodemographiques plus faibles etaient plus susceptibles de declarer des prestataires de niveau moyen. Le report d’ASC versus celui des non prestataires etait positivement associe a des services de maternite (P < 0,01). Le report de medecin ou de sage-femme versus celui d’ASC etait significativement associe a des services de maternite (P < 0,01).
Conclusion
Il existe une association positive entre la duree de formation du prestataire de soins prenataux et la specialisation maternelle avec le report de services maternels. Les prestataires communautaires sont associes avec un report nettement accru de services de sante maternelle compares au non prestataires. Des facteurs structurels semblent etre a l'origine des differences dans la prestation de services.
Objetivos
Investigar la influencia del tipo de proveedor prenatal sobre los cuidados de maternidad en zonas rurales de Ghana.
Metodos
Analisis de los cuidados maternos segun el proveedor prenatal, utilizando datos del 2008 del Censo Demografico y Sanitario de Ghana. La poblacion de estudio incluyo a mujeres de zonas rurales de Ghana con edades entre los 15–49 anos que reportaron haber tenido un parto de feto vivo entre el 2003–2008. Se realizo un analisis bivariado de chi-cuadrado para examinar las diferencias en el informe de la OMS sobre intervenciones en salud materna. Se realizaron regresiones multivariadas y logisticas para evaluar las diferencias en las escalas de cuidados prenatales (CPN) y los paquetes de cuidados maternos.
Resultados
1,367 mujeres rurales reportaron un parto de feto vivo. La distribucion de los proveedores fue la siguiente: Medico, 15.6%; Partera, 70%; Oficial Sanitario Asistencial (OSA), 9.1%; Sin proveedor, 5.3%. Las mujeres de categorias sociodemograficas inferiores tenian una mayor probabilidad de reportar un proveedor de nivel medio. El reportar un CPN recibido de un OSA versus no el tener un proveedor estaba asociado de forma positiva con los servicios maternos (P < 0.01). El reportar un CPN recibido de un medico o partera versus de un OSA estaba significativamente asociado con los servicios maternos (P < 0.01).
Conclusion
Existe una asociacion positiva entre el tiempo de formacion del proveedor prenatal y la especializacion en maternidad y el reportar servicios maternos. Los proveedores basados en la comunidad estan asociados con un aumento marcado en el reporte de servicios maternos comparado con una falta de proveedor. Los factores estructurales parecen estar asociados con algunas diferencias en la provision del servicio. Los proveedores de nivel medio y basados en la comunidad juegan un papel critico a la hora de proveer servicios maternos a mujeres de zonas rurales.
14 citations
Cites background from "Health workforce skill mix and task..."
...It has been suggested that cost-effective care in low-income countries requires a strengthened mid-level workforce (Fulton et al. 2011)....
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...Prioritizing and strengthening health workforce capacity-building efforts hinges on knowing the location, activities and abilities of different health workers (Dovlo 2004; Mullan & Frehywot 2007; Fulton et al. 2011; Gupta et al. 2011)....
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...Prioritizing and strengthening health workforce capacity-building efforts hinges on knowing the location, activities and abilities of different health workers (Dovlo 2004; Mullan & Frehywot 2007; Fulton et al. 2011; Gupta et al. 2011)....
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...In many countries facing critical health worker shortages, the ‘no provider’ category remains the norm rather than the exception (Kruk et al. 2007; Fulton et al. 2011)....
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01 Jan 2017
TL;DR: In this paper, the authors discuss the benefits of school mental health programs both broadly and in the context of rural communities, including those in rural settings, and discuss the need to increase access to quality mental health care for the most vulnerable communities.
Abstract: School mental health (SMH) refers to systematic and streamlined partnerships between schools and communities to support a full continuum of mental health supports in schools. SMH programs have increased substantially over the past few decades, showing promise for enhancing the wellness and reducing the mental illness of children across the United States. In particular, SMH programs help to increase access to quality mental health care for the most vulnerable communities, including those in rural settings. In addition to facilitating access to care, SMH offers numerous benefits including greater follow-through with initiated care, ability to see students in their natural environment (school) and generalize skills to that setting, ability to engage key socialization agents (teachers, parents), opportunities for screening and early identification of mental health concerns, and opportunities to offer mental health activities across a full continuum of care (i.e., multitiered systems and supports). This chapter discusses these benefits of SMH programs both broadly and in the context of rural communities.
14 citations
References
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Book•
01 Oct 1984
TL;DR: In this article, buku ini mencakup lebih dari 50 studi kasus, memberikan perhatian untuk analisis kuantitatif, membahas lebah lengkap penggunaan desain metode campuran penelitian, and termasuk wawasan metodologi baru.
Abstract: Buku ini menyediakan sebuah portal lengkap untuk dunia penelitian studi kasus, buku ini menawarkan cakupan yang luas dari desain dan penggunaan metode studi kasus sebagai alat penelitian yang valid. Dalam buku ini mencakup lebih dari 50 studi kasus, memberikan perhatian untuk analisis kuantitatif, membahas lebih lengkap penggunaan desain metode campuran penelitian, dan termasuk wawasan metodologi baru.
78,012 citations
TL;DR: A systematic review and meta-analysis of placebo-controlled studies examined the efficacy and tolerability of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products in adults with somatoform disorders in adults to improve optimal treatment decisions.
Abstract: BACKGROUND: Somatoform disorders are characterised by chronic, medically unexplained physical symptoms (MUPS). Although different medications are part of treatment routines for people with somatoform disorders in clinics and private practices, there exists no systematic review or meta-analysis on the efficacy and tolerability of these medications. We aimed to synthesise to improve optimal treatment decisions.OBJECTIVES: To assess the effects of pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, and pain disorder) in adults.SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 17 January 2014). This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). To identify ongoing trials, we searched ClinicalTrials.gov, Current Controlled Trials metaRegister, the World Health Organization International Clinical Trials Registry Platform, and the Chinese Clinical Trials Registry. For grey literature, we searched ProQuest Dissertation {\&} Theses Database, OpenGrey, and BIOSIS Previews. We handsearched conference proceedings and reference lists of potentially relevant papers and systematic reviews and contacted experts in the field.SELECTION CRITERIA: We selected RCTs or cluster RCTs of pharmacological interventions versus placebo, treatment as usual, another medication, or a combination of different medications for somatoform disorders in adults. We included people fulfilling standardised diagnostic criteria for somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, or somatoform pain disorder.DATA COLLECTION AND ANALYSIS: One review author and one research assistant independently extracted data and assessed risk of bias. Primary outcomes included the severity of MUPS on a continuous measure, and acceptability of treatment.MAIN RESULTS: We included 26 RCTs (33 reports), with 2159 participants, in the review. They examined the efficacy of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products (NPs). The duration of the studies ranged between two and 12 weeks.One meta-analysis of placebo-controlled studies showed no clear evidence of a significant difference between tricyclic antidepressants (TCAs) and placebo for the outcome severity of MUPS (SMD -0.13; 95{\%} CI -0.39 to 0.13; 2 studies, 239 participants; I(2) = 2{\%}; low-quality evidence). For new-generation antidepressants (NGAs), there was very low-quality evidence showing they were effective in reducing the severity of MUPS (SMD -0.91; 95{\%} CI -1.36 to -0.46; 3 studies, 243 participants; I(2) = 63{\%}). For NPs there was low-quality evidence that they were effective in reducing the severity of MUPS (SMD -0.74; 95{\%} CI -0.97 to -0.51; 2 studies, 322 participants; I(2) = 0{\%}).One meta-analysis showed no clear evidence of a difference between TCAs and NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.55 to 0.23; 3 studies, 177 participants; I(2) = 42{\%}; low-quality evidence). There was also no difference between NGAs and other NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.45 to 0.14; 4 studies, 182 participants; I(2) = 0{\%}).Finally, one meta-analysis comparing selective serotonin reuptake inhibitors (SSRIs) with a combination of SSRIs and antipsychotics showed low-quality evidence in favour of combined treatment for severity of MUPS (SMD 0.77; 95{\%} CI 0.32 to 1.22; 2 studies, 107 participants; I(2) = 23{\%}).Differences regarding the acceptability of the treatment (rate of all-cause drop-outs) were neither found between NGAs and placebo (RR 1.01, 95{\%} CI 0.64 to 1.61; 2 studies, 163 participants; I(2) = 0{\%}; low-quality evidence) or NPs and placebo (RR 0.85, 95{\%} CI 0.40 to 1.78; 3 studies, 506 participants; I(2) = 0{\%}; low-quality evidence); nor between TCAs and other medication (RR 1.48, 95{\%} CI 0.59 to 3.72; 8 studies, 556 participants; I(2) =14{\%}; low-quality evidence); nor between antidepressants and the combination of an antidepressant and an antipsychotic (RR 0.80, 95{\%} CI 0.25 to 2.52; 2 studies, 118 participants; I(2) = 0{\%}; low-quality evidence). Percental attrition rates due to adverse effects were high in all antidepressant treatments (0{\%} to 32{\%}), but low for NPs (0{\%} to 1.7{\%}).The risk of bias was high in many domains across studies. Seventeen trials (65.4{\%}) gave no information about random sequence generation and only two (7.7{\%}) provided information about allocation concealment. Eighteen studies (69.2{\%}) revealed a high or unclear risk in blinding participants and study personnel; 23 studies had high risk of bias relating to blinding assessors. For the comparison NGA versus placebo, there was relatively high imprecision and heterogeneity due to one outlier study. Although we identified 26 studies, each comparison only contained a few studies and small numbers of participants so the results were imprecise.AUTHORS' CONCLUSIONS: The current review found very low-quality evidence for NGAs and low-quality evidence for NPs being effective in treating somatoform symptoms in adults when compared with placebo. There was some evidence that different classes of antidepressants did not differ in efficacy; however, this was limited and of low to very low quality. These results had serious shortcomings such as the high risk of bias, strong heterogeneity in the data, and small sample sizes. Furthermore, the significant effects of antidepressant treatment have to be balanced against the relatively high rates of adverse effects. Adverse effects produced by medication can have amplifying effects on symptom perceptions, particularly in people focusing on somatic symptoms without medical causes. We can only draw conclusions about short-term efficacy of the pharmacological interventions because no trial included follow-up assessments. For each of the comparisons where there were available data on acceptability rates (NGAs versus placebo, NPs versus placebo, TCAs versus other medication, and antidepressants versus a combination of an antidepressant and an antipsychotic), no clear differences between the intervention and comparator were found.Future high-quality research should be carried out to determine the effectiveness of medications other than antidepressants, to compare antidepressants more thoroughly, and to follow-up participants over longer periods (the longest follow up was just 12 weeks). Another idea for future research would be to include other outcomes such as functional impairment or dysfunctional behaviours and cognitions as well as the classical outcomes such as symptom severity, depression, or anxiety.
11,458 citations
TL;DR: Two studies show SU leading to earlier insulin dependence and a meta-analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin.
Abstract: Background
Latent autoimmune diabetes in adults (LADA) is a slowly developing type 1 diabetes.
Objectives
To compare interventions used for LADA.
Search methods
Studies were obtained from searches of electronic databases, supplemented by handsearches, conference proceedings and consultation with experts. Date of last search was December 2010.
Selection criteria
Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating interventions for LADA or type 2 diabetes with antibodies were included.
Data collection and analysis
Two authors independently extracted data and assessed risk of bias. Studies were summarised using meta-analysis or descriptive methods.
Main results
Searches identified 13,306 citations. Fifteen publications (ten studies) were included, involving 1019 participants who were followed between three months to 10 years (1060 randomised). All studies had a high risk of bias. Sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone at three months (one study, n = 15) and at 12 months (one study, n = 14) of treatment and follow-up. SU (with or without metformin) gave poorer metabolic control compared to insulin alone (mean difference in glycosylated haemoglobin A1c (HbA1c) from baseline to end of study, for insulin compared to oral therapy: -1.3% (95% confidence interval (CI) -2.4 to -0.1; P = 0.03, 160 participants, four studies, follow-up/duration of therapy: 12, 30, 36 and 60 months; however, heterogeneity was considerable). In addition, there was evidence that SU caused earlier insulin dependence (proportion requiring insulin at two years was 30% in the SU group compared to 5% in conventional care group (P < 0.001); patients classified as insulin dependent was 64% (SU group) and 12.5% (insulin group, P = 0.007). No intervention influenced fasting C-peptide, but insulin maintained stimulated C-peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5)). In a five year follow-up of GAD65 (glutamic acid decarboxylase formulated with aluminium hydroxide), improvements in fasting and stimulated C-peptide levels (20 μg group) were maintained after five years. Short term (three months) follow-up in one study (n = 74) using Chinese remedies did not demonstrate a significant difference in improving fasting C-peptide levels compared to insulin alone (0.07 µg/L (95% CI -0.05 to 0.19). One study using vitamin D with insulin showed steady fasting C-peptide levels in the vitamin D group but declining fasting C-peptide levels (368 to 179 pmol/L, P = 0.006) in the insulin alone group at 12 months follow-up. Comparing studies was difficult as there was a great deal of heterogeneity in the studies and in their selection criteria. There was no information regarding health-related quality of life, complications of diabetes, cost or health service utilisation, mortality and limited evidence on adverse events (studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic episodes).
Authors' conclusions
Two studies show SU leading to earlier insulin dependence and a meta-analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin. One study showed that vitamin D with insulin may protect pancreatic beta cells in LADA. Novel treatments such as GAD65 in certain doses (20 μg) have been suggested to maintain fasting and stimulated C-peptide levels. However, there is no significant evidence for or against other lines of treatment of LADA.
6,882 citations
TL;DR: Despite uncertainties about mortality and burden of disease estimates, the findings suggest that substantial gains in health have been achieved in most populations, countered by the HIV/AIDS epidemic in Sub-Saharan Africa and setbacks in adult mortality in countries of the former Soviet Union.
5,168 citations
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