'Nobody is after you; it is your initiative to start work': a qualitative study of health workforce absenteeism in rural Uganda

Targeting systems not individuals: Institutional and structural drivers of absenteeism among primary healthcare workers in Nigeria

Universal Health Coverage (UHC) can only be achieved if people receive good quality care from health workers, yet in Nigeria, as in many other low- and middle-income countries (LMICs), many health workers are absent from work. Absenteeism is a well-known phenomenon but is often considered as the self-serving behaviour of individuals, independent from the characteristics of health systems structures and processes and the broader contexts that enable it. We undertook a qualitative inquiry among 40 key informants, comprising health facility heads and workers, community leaders and state-level health policymakers in Nigeria. We employed a phenomenology approach to examine their lived experiences and grouped findings into thematic clusters. Absenteeism by health workers was found to be a response to structural problems at two levels -midstream (facility-level) and upstream (government level) - rather than being a result of moral failure of individuals. The problems at midstream level pointed to an inconsistent and unfair application of rules and regulations in facilities and ineffective management, while the upstream drivers relate mainly to political interference and suboptimal health system leadership. Reducing absenteeism requires two-pronged interventions that tackle defects in the upstream and midstream rather than just focusing on sanctioning deviant staff (downstream).

Deconcentrating regulation in low- and middle-income country health systems: a proposed ambidextrous solution to problems with professional regulation for doctors and nurses in Kenya and Uganda

BACKGROUND

Regulation can improve professional practice and patient care, but is often weakly implemented and enforced in health systems in low- and middle-income countries (LMICs). Taking a de-centred and frontline perspective, we examine national regulatory actors' and health professionals' views and experiences of health professional regulation in Kenya and Uganda and discuss how it might be improved in LMICs more generally.

METHODS

We conducted large-scale research on professional regulation for doctors and nurses (including midwives) in Uganda and Kenya during 2019-2021. We interviewed 29 national regulatory stakeholders and 47 subnational regulatory actors, doctors, and nurses. We then ran a national survey of Kenyan and Ugandan doctors and nurses, which received 3466 responses. We thematically analysed qualitative data, conducted an exploratory factor analysis of survey data, and validated findings in four focus group discussions.

RESULTS

Kenyan and Ugandan regulators were generally perceived as resource-constrained, remote, and out of touch with health professionals. This resulted in weak regulation that did little to prevent malpractice and inadequate professional education and training. However, interviewees were positive about online licencing and regulation where they had relationships with accessible regulators. Building on these positive findings, we propose an ambidextrous approach to improving regulation in LMIC health systems, which we term deconcentrating regulation. This involves developing online licencing and streamlining regulatory administration to make efficiency savings, freeing regulatory resources. These resources should then be used to develop connected subnational regulatory offices, enhance relations between regulators and health professionals, and address problems at local level.

CONCLUSION

Professional regulation for doctors and nurses in Kenya and Uganda is generally perceived as weak. Yet these professionals are more positive about online licencing and regulation where they have relationships with regulators. Building on these positive findings, we propose deconcentrating regulation as a solution to regulatory problems in LMICs. However, we note resource, cultural and political barriers to its effective implementation.

Factors associated with perceived work-life balance among health workers in Gulu District, Northern Uganda: a health facility-based cross-sectional study

INTRODUCTION

Work-life balance (WLB) plays a significant role in improving career satisfaction and reducing burnout. While health workers' productivity is considered a key factor in client care, there is limited effort put into examining how health workers perceive the balance of their jobs with family and other societal responsibilities (PWLB), especially in low-income countries where the number of health workers in active patient care is low. The purpose of this study was to assess factors associated with perceived work-life balance (PWLB) among health workers in the rural district of Gulu, Northern Uganda.

METHODS

A health facility-based cross-sectional analytical study was conducted. A simple random sampling technique was used to select 384 study participants from the three main hospitals in Gulu District. Data were collected from health workers using a self-administered semi-structured questionnaire and analyzed using STATA version 15. Factors associated with PWLB were determined at a multivariable level using a modified Poisson regression with robust variance with a 95% confidence level and 5% statistical significance. Adjusted prevalent ratios (APR) were used to report the Factors associated with PWLB.

RESULTS

Only 157/384 (40.9%) of the health workers reported a positive perceived work-life balance. Multivariable modified Poisson regression analysis showed positive statistical association with PWLB of a laboratory worker(APR = 1.74, 95% CI: 1.10-2.75); a midwife(APR = 1.82, 95% CI:1.13-2.93) or a nurse (APR = 2.19, 95% CI = 1.45-3.30); working in the inpatient department (APR = 1.97, 95% CI: 1.31-2.96) or laboratory (APR = 2.09, 95%CI: 1.34-3.28); and having a flexible work schedule (APR = 28.32, 95%CI:14.52-55.22); feeling satisfied at work (APR = 1.58; 95% CI:1.17-2.10), and belonging to an association in the community (APR = 32.71, 95% Cl:11.91-89.88). On the other hand, employment tenure of 1-4 years (APR = 0.63,95% CI:0.40-0.99) was negatively associated with perceived work-life balance.

CONCLUSION

Only four in every 10 health workers experienced a positive perceived work-life balance. The type of profession, duty station, flexibility in work schedule, satisfaction with work, and availability of social support systems, were independent determinants of perceived WLB. Therefore, nurturing a system of reviews of the scheduling of health workers, allowing internal staff rotation, and fostering support systems around the health workers could be beneficial for WLB.

The Promise of Grassroots Approaches to Solving Absenteeism in Primary Health-Care Facilities in Nigeria: Evidence from a Qualitative Study

Absenteeism among primary health-care (PHC) workers in Nigeria is widespread and is a major obstacle to achieving Universal Health Coverage (UHC). There is increasing research on the forms it takes and what drives them, but limited evidence on how to address it. The dominant approach has involved government-led topdown solutions (vertical approach). However, these have rarely been successful in countries such as Nigeria. This paper explores alternative approaches based on grassroots (horizontal) approaches. Data collected from interviews with 40 PHC stakeholders in Enugu, Nigeria, were organized in thematic clusters that explored the contribution of horizontal interventions to solving absenteeism in primary health-care facilities. We applied phenomenology to analyze the lived (practical) experiences of respondents. Absenteeism by PHC workers was prevalent and is encouraged by the complex configuration of the PHC system and its operating environment, which constrains topdown interventions. We identified several horizontal approaches that may create effective incentives and compulsions to reduce absenteeism, which include leveraging community resources to improve security of facilities, tapping the resources of philanthropic individuals and organizations to provide accommodation for health workers, and engaging trained health workers as volunteers or placeholders to address shortages of health-care staff. Nevertheless, a holistic response to absenteeism must complement horizontal approaches with vertical measures, with the government supporting and encouraging the health system to develop self-enforcing mechanisms to tackle absenteeism.

Antimicrobial stewardship in private pharmacies in Wakiso district, Uganda: a qualitative study

BACKGROUND

Private pharmacies are the first point of contact for the public regarding acquisition of medicines and other pharmaceuticals in many low- and middle-income countries including Uganda. Most antimicrobial stewardship (AMS) programmes in Uganda have targeted pharmacies in public health facilities, with little known about private pharmacies. This study explored knowledge and practices related to AMS in private pharmacies in Wakiso district, central Uganda.

METHODS

This was a qualitative study that involved 31 in-depth interviews to explore AMS among retail private pharmacy staff including pharmacists, pharmacy technicians/dispensers, and nurses. Participants were asked about antimicrobial resistance (AMR) and AMS practices at their pharmacy. The audio-recorded interviews were transcribed verbatim and imported to NVivo 2020 (QSR International) for thematic analysis.

RESULTS

Five major themes emerged from the study: commonly sold antimicrobials; knowledge on AMR and AMS; potential contributors to AMR; practices related to AMS; and challenges to AMS. The commonly sold antimicrobials in the pharmacies with or without prescriptions were oral azithromycin, Ampiclox® (ampicillin and cloxacillin), amoxicillin, ciprofloxacin, Septrin® (co-trimoxazole), metronidazole, Flucamox® (amoxicillin and flucloxacillin), Augmentin® (amoxicillin and clavulanic acid), cephalexin, doxycycline, and chloramphenicol. Participants had heard about AMR but not AMS, although only a few correctly defined AMR. Lack of knowledge among health workers and local communities; the overuse, misuse, and abuse of antimicrobials such as non-adherence to dosage; self-medication; and purchase of drugs without prescription were identified as potential accelerators to the emergence of AMR. Current practices related to AMS in private pharmacies were limited to meetings, antimicrobial dispensing, providing client advice, record keeping, and monitoring of drugs. Cost of healthcare, client satisfaction and retention, outdated guidelines, and the business orientation of pharmacies were the main challenges related to AMS.

CONCLUSION

There was poor knowledge of AMR and AMS, and limited AMS practices in private pharmacies. Private pharmacies have the potential to contribute to Uganda's fight against AMR if motivated and equipped with adequate knowledge to enhance their practices related to AMS.

"I can't kill myself": Local narratives and meanings that foster absenteeism in Nigerian primary health centres

Background

Absenteeism in the health sector is increasingly seen as a form of harmful rule-breaking, with health workers receiving a salary although they are not present to provide care. It is a barrier to achieving universal health coverage yet remains widespread in primary health centres (PHCs) in Nigeria and many other low-resource settings. Traditional approaches to combatting absenteeism have relied on anti-corruption measures such as promoting accountability and transparency. However, more needs to be understood about the social and cultural realities, including perceptions and norms enabling or constraining the application of such measures in Nigeria and in similar contexts.

Methods

We conducted 34 in-depth interviews (IDIs) with frontline health workers and their managers/supervisors and two focus group discussions (FDGs) with service users (n = 22) in Enugu State, South Eastern Nigeria. We discussed their experiences and views about absenteeism, allowing the respondents' framings to emerge. We adopted a mixed approach of narrative analysis and phenomenology to examine respondents' narratives - identifying the concepts and social constructs within the narratives that manifested through the language used.

Results

Stakeholders acknowledged the problem of absenteeism but had differing perspectives on its dynamics. Health workers distinguished two forms of absenteeism: one as a mundane, everyday response to the poorly funded health system; and the other, brazen and often politically enabled absenteeism, where health workers whom powerful politicians protect are absent without facing consequences. There is a general feeling of powerlessness among both health service providers and service users confronted by politically backed absentees as the power dynamics in the health sector resonate with experiences in other spheres of life in Nigeria. Health workers rationalised mundane, technical absenteeism, adjusted to it and felt it should be accommodated in the health system. Service users are often unsure about who is absent and why, but when they notice absenteeism, they often ascribe it to wider system malpractices that characterise public services.

Conclusion

Interventions to tackle absenteeism and other forms of health sector corruption should be sensitive to socio-cultural and political contexts that shape everyday lives in specific contexts. Challenging narratives/beliefs that normalise absenteeism should be part of reform plans.

Sustainability capacity and health worker normalisation of a successful non-communicable disease (NCD) health systems intervention within primary care settings in Uganda: a quantitative approach to a qualitative question

BACKGROUND

Interventions for non-communicable diseases are increasingly implemented and evaluated in sub-Saharan Africa, but little is known about their medium- to long-term sustainability beyond the end of research funding. A cluster randomised trial conducted between 2013 and 2016 in Uganda and Tanzania showed that an intervention package to improve hypertension (HT) and type-2 diabetes mellitus (DM) care was highly effective in increasing service readiness and quality of care. The present study assesses the sustainability of the intervention 4 years after the trial in Uganda.

METHODS

The study was conducted in 2020 in 22 primary care health facilities (HFs) (3 referrals and 19 lower-level units) that had received the intervention package until trial end (2016), to assess their current capacity and practice to sustain ongoing intervention activities for HT and DM care. Through a cross-sectional survey, 4 pre-defined domains (i.e., cognitive participation, coherence, collective action, and reflexive monitoring) were examined with regard to health worker (HW) normalization and 8 pre-defined domains for intervention sustainability (i.e., organisational capacity, local environment, funding stability, partnerships, communication, evaluation, adaptation, and strategic planning), using the normalisation tool and the program sustainability tool (PSAT). Summary scores were assessed by domains and facility level.

RESULTS

Overall normalization strength was adequate at 4.0 (IQR: 3.8, 4.2) of a possible 5 with no evidence of association with HF level (p = 0.40); cognitive participation (buy-in) and reflexive monitoring (appraisal) were strongest at > 4 across all HF levels. All HF levels were weak (< 4) on collective action (teamwork) and coherence (sense-making). Only collective action differed by level (p < 0.002). Overall intervention sustainability was suboptimal at 3.1 [IQR: 1.9, 4.1] of a possible 7 with weak scores on funding stability (2.0), supportive partnerships (2.2), and strategic planning (2.6). Domain differences by HF level were significant for environmental support (p = 0.02) and capacity in organisation (p = 0.01). Adequate strength at a cut-off mean of ≥5 did not differ by HF level for any domain.

CONCLUSIONS

Four years after their introduction, practice-dependent intervention elements e.g., local organisational context, HW knowledge or dedication were sustained, but external elements e.g., new funding support or attracting new partners to sustain intervention efforts were not. Whenever new interventions are introduced into an existing health service, their long-term sustainability including the required financial support should be ensured. The quality of services should be upheld by providing routine in-service training with dedicated support supervision.

Patient and health worker perspectives on quality of HIV care and treatment services in Haiti

BACKGROUND

Poor quality of care is a barrier to engagement in HIV care and treatment in low- and middle-income country settings. This study involved focus group discussions (FGD) with patients and health workers in two large urban hospitals to describe quality of patient education and psychosocial support services within Haiti's national HIV antiretroviral therapy (ART) program. The purpose of this qualitative study was to illuminate key gaps and salient "ingredients" for improving quality of care.

METHODS

The study included 8 FGDs with a total of 26 male patients and 32 female patients and 15 smaller FGDs with 57 health workers. The analysis used a directed content analysis method, with the goal of extending existing conceptual frameworks on quality of care through rich description.

RESULTS

Dimension of safety, patient-centeredness, accessibility, and equity were most salient. Patients noted risks to privacy with both clinic and community-based services as well as concerns with ART side effects, while health workers described risks to their own safety in providing community-based services. While patients cited examples of positive interactions with health workers that centered their needs and perspectives, they also noted concerns that inhibited trust and satisfaction with services. Health workers described difficult working conditions that challenged their ability to provide patient-centered services. Patients sought favored relationships with health workers to help them navigate the health care system, but this undermined the sense of fairness. Both patients and health workers described frustration with lack of resources to assist patients in dire poverty, and health workers described great pressure to help patients from their "own pockets."

CONCLUSIONS

These concerns reflected the embeddedness of patient - provider interactions within a health system marked by scarcity, power dynamics between patients and health workers, and social stigma related to HIV. Reinforcing a respectful and welcoming atmosphere, timely service, privacy protection, and building patient perception of fairness in access to support could help to build patient satisfaction and care engagement in Haiti. Improving working conditions for health workers is also critical to achieving quality.

Occupational stress and job performance among Iranian hospital nurses: A cross-sectional survey

BACKGROUND

Occupational stress is one of the most important factors affecting nurse performance. However, there is a lack of data about the association between occupational stress and performance.

OBJECTIVE

The aim of this study was to determine the occupational stress level and its association with job performance in hospital staff.

METHODS

This cross-sectional study was conducted among 400 hospital staff of Tehran University of medical sciences in 2018. Subjects completed the World Health Organization Health and Work Performance questionnaire (WHO HPQ) for demographic and occupational characteristics, and the Short Form of Copenhagen questionnaire.

RESULTS

The demand and individual interface domain received the highest and the lowest score of occupational stress respectively. We found that the median for absenteeism distribution was 16 hours and, in our study, less than 10 % of the nurses had low performance. Working in intensive care units, fewer night shifts, higher income, higher levels of vitality, and social support could decrease absenteeism. In addition, staff who felt more supported and reported lower emotional demands had higher performance.

CONCLUSION

Since higher levels of social support could have positive influences on reducing absenteeism and improving performance, it is recommended that hospital managers should be encouraged to use educational programs, coping behaviors, and effective interventions to improve social support. Financial incentives are a factor that could also be used to reduce absenteeism.

Leveraging mHealth usage logs to inform health worker performance in a Resource-Limited setting: Case example of mUzima use for a chronic disease program in Western Kenya

BACKGROUND

Health systems in low- and middle-income countries (LMICs) can be strengthened when quality information on health worker performance is readily available. With increasing adoption of mobile health (mHealth) technologies in LMICs, there is an opportunity to improve work-performance and supportive supervision of workers. The objective of this study was to evaluate usefulness of mHealth usage logs (paradata) to inform health worker performance.

METHODOLOGY

This study was conducted at a chronic disease program in Kenya. It involved 23 health providers serving 89 facilities and 24 community-based groups. Study participants, who already used an mHealth application (mUzima) during clinical care, were consented and equipped with an enhanced version of the application that captured usage logs. Three months of log data were used to determine work performance metrics, including: (a) number of patients seen; (b) days worked; (c) work hours; and (d) length of patient encounters.

PRINCIPAL FINDINGS

Pearson correlation coefficient for days worked per participant as derived from logs as well as from records in the Electronic Medical Record system showed a strong positive correlation between the two data sources (r(11) = .92, p < .0005), indicating mUzima logs could be relied upon for analyses. Over the study period, only 13 (56.3%) participants used mUzima in 2,497 clinical encounters. 563 (22.5%) of encounters were entered outside of regular work hours, with five health providers working on weekends. On average, 14.5 (range 1-53) patients were seen per day by providers.

CONCLUSIONS / SIGNIFICANCE

mHealth-derived usage logs can reliably inform work patterns and augment supervision mechanisms made particularly challenging during the COVID-19 pandemic. Derived metrics highlight variabilities in work performance between providers. Log data also highlight areas of suboptimal use, of the application, such as for retrospective data entry for an application meant for use during the patient encounter to best leverage built-in clinical decision support functionality.

Corruption in the health sector: A problem in need of a systems-thinking approach

Health systems are comprised of complex interactions between multiple different actors with differential knowledge and understanding of the subject and system. It is exactly this complexity that makes it particularly vulnerable to corruption, which has a deleterious impact on the functioning of health systems and the health of populations. Consequently, reducing corruption in the health sector is imperative to strengthening health systems and advancing health equity, particularly in low- and middle-income countries (LMICs). Although health sector corruption is a global problem, there are key differences in the forms of and motivations underlying corruption in health systems in LMICs and high-income countries (HICs). Recognizing these differences and understanding the underlying system structures that enable corruption are essential to developing anti-corruption interventions. Consequently, health sector corruption is a problem in need of a systems-thinking approach. Anti-corruption strategies that are devised without this understanding of the system may have unintended consequences that waste limited resources, exacerbate corruption, and/or further weaken health systems. A systems-thinking approach is important to developing and successfully implementing corruption mitigation strategies that result in sustainable improvements in health systems and consequently, the health of populations.

The Gendered Drivers of Absenteeism in the Nigerian Health System

The ability to deliver primary care in Nigeria is undermined by chronic absenteeism but an understanding of its drivers is needed if effective responses are to be developed. While there is a small but growing body of relevant research, the gendered dynamics of absenteeism remain largely unexplored. We apply a gendered perspective to understanding absenteeism and propose targeted strategies that appear likely to reduce it. We did so by means of a qualitative study that was part of a larger project examining corruption within the health system in six primary healthcare facilities across rural and urban regions in Enugu State, south-east Nigeria. We conducted thirty in-depth interviews with frontline health workers, healthcare managers, and community members of the health facility committee. Six Focus Group Discussions were held with male and female service users. Data were analysed using thematic analysis. Participants described markedly gendered differences in the factors contributing to health worker absenteeism that were related to gender norms. Absence by female health workers was attributed to domestic and caregiving responsibilities, including housekeeping, childcare, cooking, washing, and non-commercial farming used to support their families. Male health workers were most often absent to fulfil expectations related to their role as breadwinners, with dual practice and work in other sectors to generate additional income generation as their formal salaries were considered irregular and poor. Demands arising from sociocultural and religious events affected the attendance of both male and female health workers. Both men and women were subject to sanctions, but managers and facility chairs were more lenient with women when absence was due to caregiving and other domestic responsibilities. In summary, gender roles influence absenteeism amongst primary healthcare workers in Nigeria and thus should be taken into account in developing nuanced responses that take account of the social, economic, and cultural factors that underpin these roles.

Childhood acute lymphoblastic leukemia treatment in an academic hospital in Kenya: Treatment outcomes and health-care providers' perspectives

BACKGROUND

Early deaths and treatment nonadherence are major reasons for low childhood acute lymphoblastic leukemia (ALL) survival in low- and middle-income countries. This study assessed treatment outcomes of children presenting with ALL and evaluated perspectives of health-care providers (HCP) on ALL treatment at a Kenyan academic hospital.

METHODS

This was a combined retrospective medical records and cross-sectional questionnaire study. Treatment outcomes of 136 children diagnosed with ALL between 2010 and 2016 were collected. Questionnaires were completed by 245 HCP (response rate, 86%) between September and October 2016.

RESULTS

Childhood ALL treatment outcomes were death (30%), progressive or relapsed disease (26%), abandonment (24%), and event-free survival (20%). Of all deaths, 80% were early deaths (prior or during induction), whereas 20% occurred in remission. Probability of event-free survival at three years was 18%. Only 57% of HCP believed childhood ALL can be cured, with more doctors (96%) than other HCP (45%) believing in curability of ALL (P < 0.001). The majority of HCP (96%) thought that experienced doctors should put more time and effort into making parents understand the diagnosis and necessity to complete treatment. According to HCP, reasons for protocol nonadherence included parental financial difficulties (94%) and use of alternative treatment (79%).

CONCLUSIONS

Event-free survival for ALL in Kenya is low. The primary reason for treatment failure is early death from treatment-related complications. More efforts should be directed toward improving supportive care strategies. In the opinion of HCPs, improved communication with parents and supervision of junior staff will improve ALL treatment outcomes.

Paths towards Universal Health Coverage: beyond political commitments

The rapid economic growth in low and middle-income countries provides the opportunity of translating political commitment into action for achieving Universal Health Coverage. However, this is not straightforward. High donor dependence in low income countries; the lack of fiscal space; the inadequacy of attention to primary health care and under-developed pre-payment systems all pose challenges. Windows of political opportunity open up and ensuring that Universal Health Coverage makes it into the agenda of parties and subsequent holding them accountable by citizens can address political inertia. Not only is more money for health needed, but governments also need to gain more health for money through effective strategic purchasing and addressing the main drivers of inefficiency. Moving Universal Health Coverage from political aspiration to reality requires approaching it as a citizen's rights and entitlement to health, through full subsidies for the poor and vulnerable.

Corruption: An Impediment to Delivering Pathology and Laboratory Services in Resource-Limited Settings

OBJECTIVES

Corruption is a widely acknowledged problem in the health sector of low- and middle-income countries (LMICs). Yet, little is known about the types of corruption that affect the delivery of pathology and laboratory medicine (PALM) services. This review is a first step at examining corruption risks in PALM.

METHODS

We performed a critical review of medical literature focused on health sector corruption in LMICs. To provide context, we categorized cases of laboratory-related fraud and abuse in the United States.

RESULTS

Forms of corruption in LMICs that may affect the provision of PALM services include informal payments, absenteeism, theft and diversion, kickbacks, self-referral, and fraudulent billing.

CONCLUSIONS

Corruption represents a functional reality in many LMICs and hinders the delivery of services and distribution of resources to which individuals and entities are legally entitled. Further study is needed to estimate the extent of corruption in PALM and develop appropriate anticorruption strategies.

Prevalence and contextual factors associated with compassion fatigue among nurses in northern Uganda

BACKGROUND

Compassion fatigue is associated with negative consequences that undermine workplace performance. However, literature is scarce on compassion fatigue among nurses in the context of Uganda who are at higher risk of compassion fatigue owed to the nature of their occupation and the unfavorable work environment. We aimed to assess the prevalence and predictors of compassion fatigue among nurses in Northern Uganda.

METHODS

We conducted a cross-sectional survey among 395 randomly selected nurses from two referral and four general hospitals in Northern Uganda. Data was collected using a self-administered questionnaire. Data analysis consisted of descriptive statistics, cross-tabulations, and logistic regression at a 95% level of significance in SPSS version 25.

RESULTS

Of 395 nurses who took part in the study, 58.2% were female, 39.8% had a diploma, 47.1% were single, and 32.4% had worked for between 11-15 years. Close to 50% of the nurses experienced compassion fatigue. The predictors of compassion fatigue among the participants were; workplace bullying (AOR: 3.83; 95% CI: 1.99-7.36; p = <0.001) career enhancement opportunities (AOR: 9.16; 95% CI: 2.32-36.22; p = 0.002; and remuneration (AOR: 7.30; 95% CI: 2.73-19.49; p = <0.001).

CONCLUSION

More than 3 in 4 nurses in Northern Uganda experience compassion fatigue. The Ministry of Health together with other stakeholders should strive to increase career enhancement opportunities for nurses, improve nurses' remuneration and improve the overall workplace environment to prevent compassion fatigue among nurses in the country.

Provision of cervical cancer prevention services in Northern Uganda: a survey of health workers from rural health centres

Background

Cervical cancer is the leading cancer among Ugandan women, contributing to 40 % of all cancer cases recorded in the cancer registry. Having identified the substantial impact of cervical cancer among Ugandan women, the Ministry of Health in 2010 launched a Strategic Plan for Cervical Cancer prevention and control. This study was conducted to determine if health workers working in rural health centres (HCs) III and IV in Northern Uganda provide cervical cancer screening services as recommended in the Strategic Plan.

Methods

A cross-sectional survey using a structured questionnaire was conducted among nurses, midwives and clinical officers working in rural HC III and IV in Northern Uganda. Data were entered in Epidata 3.1 and analysed using Stata 16 statistical software. Univariate, bivariate, and multivariate analyses were performed. Any factor with p-value ≤ 0.05 was considered a significant predictor of outcome.

Results

We surveyed 286 health workers. Fifty-one (18 %) health workers were screening women for cervical cancer. Fifty-eight (21 %) health workers have guideline for cervical cancer screening in their HCs, 93 (33 %) participants were trained to screen women for cervical cancer. Two hundred sixty-two (92 %) participants provided HPV vaccination. Two hundred forty-six (87 %) participants were conducting health education about cervical cancer in their HCs. Factors associated with screening women for cervical cancer include: being a staff member from HCs III (AOR = 0.30, 95 % CI 0.13–0.68, p = 0.00), being staff of HCs that have organization to support cervical cancer screening services (AOR = 4.38, 95 % CI 1.99–9.63, p-=0.00), being a health worker who had been trained to screen for cervical cancer (AOR = 2.21, 95 % CI 1.00–4.90, p = 0.05) and staff from HCs that has guideline for cervical cancer screening (AOR = 2.89, 95 % CI 1.22–6.86, p = 0.02).

Conclusions

This study shows an overall structural problem related to the delivery of cervical cancer screening services in HC III and IV in Northern Uganda which the Strategic Plan has not addressed. These structural problems need urgent attention if the Uganda government and other sub-Saharan African (SSA) countries are to achieve the World Health Organization (WHO) 90–70–90 targets by 2030 to be on track for cervical cancer elimination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06795-5.

Towards an Explanation of the Social Value of Health Systems: An Interpretive Synthesis

BACKGROUND

Health systems are complex social systems, and values constitute a central dimension of their complexity. Values are commonly understood as key drivers of health system change, operating across all health systems components and functions. Moreover, health systems are understood to influence and generate social values, presenting an opportunity to harness health systems to build stronger, more cohesive societies. However, there is little investigation (theoretical, conceptual, or empirical) on social values in health policy and systems research (HPSR), particularly regarding the capacity of health systems to influence and generate social values. This study develops an explanatory theory for the 'social value of health systems.'

METHODS

We present the results of an interpretive synthesis of HPSR literature on social values, drawing on a qualitative systematic review, focusing on claims about the relationship between 'health systems' and 'social values.' We combined relational claims extracted from the literature under a common framework in order to generate new explanatory theory.

RESULTS

We identify four mechanisms by which health systems are considered to contribute social value to society: Health systems can: (1) offer a unifying national ideal and build social cohesion, (2) influence and legitimise popular attitudes about rights and entitlements with regard to healthcare and inform citizen's understanding of state responsibilities, (3) strengthen trust in the state and legitimise state authority, and (4) communicate the extent to which the state values various population groups.

CONCLUSION

We conclude that, using a systems-thinking and complex adaptive systems perspective, the above mechanisms can be explained as emergent properties of the dynamic network of values-based connections operating within health systems. We also demonstrate that this theory accounts for how HPSR authors write about the relationship between health systems and social values. Finally, we offer lessons for researchers and policy-makers seeking to bring about values-based change in health systems.

Retention of healthcare workers 1 year after recruitment and deployment in rural settings: an experience post-Ebola in five health districts in Guinea

BACKGROUND

Guinea undertook health workforce reform in 2016 following the Ebola outbreak to overcome decades-long shortages and maldistribution of healthcare workers (HCWs). Specifically, over 5000 HCWs were recruited and deployed to rural health districts and with a signed 5-year commitment for rural medical practice. Governance structures were also established to improve the supervision of these HCWs. This study assessed the effects of this programme on local health systems and its influence on HCWs turnover in rural Guinea.

METHODS

An exploratory study design using a mixed-method approach was conducted in five rural health districts. Data were collected through semi-structured questionnaires, in-depth interview guides, and documentary reviews.

RESULTS

Of the 611 HCWs officially deployed to the selected districts, 600 (98%) took up duties. Female HCWs (64%), assistant nurses (39%), nurses (26%), and medical doctors (20%) represented the majority. Findings showed that 69% of HCWs were posted in health centres and the remaining in district hospitals and the health office (directorate); the majority of which were medical doctors, nurses, and midwives. The deployment has reportedly enhanced quality and timely data reporting. However, challenges were faced by local health authorities in the posting of HCWs including the unfamiliarity of some with primary healthcare delivery, collaboration conflicts between HCWs, and high feminization of the recruitment. One year after their deployment, 31% of the HCWs were absent from their posts. This included 59% nurses, 29% medical doctors, and 11% midwives. The main reasons for absenteeism were unknown (51%), continuing training (12%), illness (10%), and maternity leave (9%). Findings showed a confusion of roles and responsibilities between national and local actors in the management of HCWs, which was accentuated by a lack of policy documents.

CONCLUSION

The post-Ebola healthcare workers policy appears to have been successfully positive in the redistribution of HCWs, quality improvement of staffing levels in peripheral healthcare facilities, and enhancement of district health office capacities. However, greater attention should be given to the development of policy guidance documents with the full participation of all actors and a clear distinction of their roles and responsibilities for improved implementation and efficacy of this programme.

Infant malnutrition treatment in Kenya: Health worker and breastfeeding peer supporter experiences

Acute malnutrition in infants under 6 months (u6m) is increasingly recognised as a global public health problem. The World Health Organisation (WHO) guidelines for inpatient nutritional rehabilitation of infants u6m is re-lactation: the re-establishment of exclusive breastfeeding. Evidence suggests these guidelines are rarely followed in many low-income settings. Two studies of infant nutritional rehabilitation undertaken in three public hospitals in coastal Kenya employed breastfeeding peer supporters (BFPSs) to facilitate WHO guideline implementation. To explore the acceptability of the strategy to health workers (HWs) and the BFPSs, in-depth interviews were conducted with 20 HWs and five BFPSs in the three study hospitals. The HWs reported that the presence of the BFPSs changed the way infant nutritional rehabilitation was managed, increasing efforts at relactation and decreasing reliance on supplemental milk. BFPSs were said to help address staff shortages and had dedicated time to support and assist the mothers. Key to the success of the BFPSs was the social relationships they were able to establish with the mothers due to the similarity in their experiences and backgrounds. Despite the success of the BFPSs, human resource management and infrastructure challenges remained. BFPSs can successfully be employed to facilitate the implementation of the WHO guidelines for the nutritional rehabilitation of acutely malnourished infants u6m in hospitals in Kenya, establishing supportive social relationships and trust with the mothers of the acutely malnourished infants and helping to address the issue of human resource shortages.

Towards achieving the family planning targets in the African region: a rapid review of task sharing policies

Background

Expanding access and use of effective contraception is important in achieving universal access to reproductive healthcare services, especially in low- and middle-income countries (LMICs), such as those in sub-Saharan Africa (SSA). Shortage of trained healthcare providers is an important contributor to increased unmet need for contraception in SSA. The World Health Organization (WHO) recommends task sharing as an important strategy to improve access to sexual and reproductive healthcare services by addressing shortage of healthcare providers. This study explores the status, successes, challenges and impacts of the implementation of task sharing for family planning in five SSA countries. This evidence is aimed at promoting the implementation and scale-up of task sharing programmes in SSA countries by WHO.

Methodology and findings

We employed a rapid programme review (RPR) methodology to generate evidence on task sharing for family planning programmes from five SSA countries namely, Burkina Faso, Cote d’Ivoire, Ethiopia, Ghana, and Nigeria. This involved a desk review of country task sharing policy documents, implementation plans and guidelines, annual sexual and reproductive health programme reports, WHO regional meeting reports on task sharing for family planning; and information from key informants on country background, intervention packages, impact, enablers, challenges and ways forward on task sharing for family planning. The findings indicate mainly the involvement of community health workers, midwives and nurses in the task sharing programmes with training in provision of contraceptive pills and long-acting reversible contraceptives (LARC). Results indicate an increase in family planning indicators during the task shifting implementation period. For instance, injectable contraceptive use increased more than threefold within six months in Burkina Faso; contraceptive prevalence rate doubled with declines in total fertility and unmet need for contraception in Ethiopia; and uptake of LARC increased in Ghana and Nigeria. Some barriers to successful implementation include poor retention of lower cadre providers, inadequate documentation, and poor data systems.

Conclusions

Task sharing plays a role in increasing contraceptive uptake and holds promise in promoting universal access to family planning in the SSA region. Evidence from this RPR is helpful in elaborating country policies and scale-up of task sharing for family planning programmes.

From twisting to settling down as a nurse in China: a qualitative study of the commitment to nursing as a career

Background

The nurse workforce shortage, partially caused by high work turnover, is an important factor influencing the quality of patient care. Because previous studies concerning Chinese nurse work turnover were predominantly quantitative, they lacked insight into the challenges faced by nurses as they transition from university to their career. A successful transition can result in new nurses' commitment to the career. As such, this study sought to understand how new nurses commit to the career, and focused on identifying facilitators and barriers to such commitment.

Methods

This was a qualitative study using a grounded theory design. Through purposive sampling, clinical nurses were recruited from hospitals in Western China to participate in semi-structured interviews. The data was analyzed through coding to develop categories and themes.

Results

Theoretical saturation was achieved after interviewing 25 participants. The data revealed the 'zigzag journey' of committing to the nursing career. The emerging core theme was "getting settled", indicating that new nurses needed to acclimate to the work reality in the nursing career. By analyzing the data provided by the participants, the researchers concluded that the journey to getting settled in nursing compassed four stages:1) "sailing out with mixed feelings", 2) "contemplating to leave", 3) "struggling to stay", and 4) "accepting the role". For most participants, nursing was described as a way to earn a living for their family, not as a career about which they felt passionate.

Conclusions

Committing to the nursing career is a complicated long-term process. There seems to be a lack of passion for nursing among the Chinese clinical nurses participating in this study. Thus, the nurses may need continued support at different career stages to enhance their ability to remain a nurse for more than economic reasons.

Private money-making indulgence and inefficiency of primary healthcare in Nigeria: a qualitative study of health workers' absenteeism

Objectives

Generating additional personal income is common with primary healthcare (PHC) workforce in Nigeria, which could be because of the inconsistencies marring their monthly salaries. Therefore, this study investigates the drivers of private economic activities of PHC providers in the public sector, and the links to absenteeism, as well as inefficiency of PHC facilities in Nigeria.

Methods

A qualitative study design was used to collect data from 30 key-informants using in-depth interviews. They were selected from 5 PHC facilities across three local government areas in Enugu state, south-eastern Nigeria. Data were analysed thematically, and guided by phenomenology.

Results

Findings showed that majority of the health workers were involved in different private money-making activities. A main driver was inconsistencies in salaries, which makes it difficult for them to routinely meet their personal and household needs. As a result, PHC facilities were found less functional.

Conclusions

Absenteeism of PHC providers can be addressed if efforts are made to close justifiable gaps that cause health workers to struggle informally. Such lesson can be instructive to low- and middle-income countries in strengthening their health systems.

Financial cost analysis of a strategy to improve the quality of administrative vaccination data in Uganda

BACKGROUND

High-quality vaccination data are critical to planning, implementation and evaluation of immunization programs. However, sub-optimal administrative vaccination data quality in low- and middle-income countries persist for heterogeneous reasons, though most relate to organizational factors and human behavior. The nationwide Data Improvement Team (DIT) strategy in Uganda aimed to strengthen human resource capacity to generate quality administrative vaccination data at the health facility.

METHODS

A financial cost analysis of the Uganda DIT strategy (2014-2016) was conducted from the program funder perspective. Activity-based micro-costing from funder financial and program monitoring records was used to estimate total and unit costs by program area (in 2016 US dollars). Hypothetical scenarios were developed to illustrate potential approaches to reducing costs.

RESULTS

Over 25 months the DIT strategy was implemented in all 116 operational districts and 3443 (89%) health facilities in Uganda at a total financial cost of US $575 275. Training and deployment of DITs accounted for the highest proportion of expenditure across program areas (69%). Transport, per diems, lodging, and honoraria for DIT members and national supervisors were the main cost drivers of the strategy. Deployment of 557 DIT members cost US $839 per DIT member, US $4 030 per district, and US $136 per health facility. The estimated opportunity cost of government staff time wasn't a major cost driver (2.5%) of total cost.

CONCLUSION

The results provide the first estimates of the magnitude and drivers of cost to implement a national workforce capacity building strategy to improve administrative vaccination data quality in a low- or middle-income country. Financial costs are a critical input to combine with future outcome data to describe the cost of strategies relative to performance outcomes. The operational costs of the strategy were modest (0.5-1.6%) relative to the estimated operational costs of Uganda's national immunization program.

'I have no love for such people, because they leave us to suffer': a qualitative study of health workers' responses and institutional adaptations to absenteeism in rural Uganda

BACKGROUND

Achieving positive treatment outcomes and patient safety are critical goals of the healthcare system. However, this is greatly undermined by near universal health workforce absenteeism, especially in public health facilities of rural Uganda. We investigated the coping adaptations and related consequences of health workforce absenteeism in public and private not-for-profit (PNFP) health facilities of rural Uganda.

METHODS

An empirical qualitative study involving case study methodology for sampling and principles of grounded theory for data collection and analysis. Focus groups and in-depth interviews were used to interview a total of 95 healthcare workers (11 supervisors and 84 frontline workers). The NVivo V.10 QSR software package was used for data management.

RESULTS

There was tolerance of absenteeism in both the public and PNFP sectors, more so for clinicians and managers. Coping strategies varied according to the type of health facility. A majority of the PNFP participants reported emotion-focused reactions. These included unplanned work overload, stress, resulting anger directed towards coworkers and patients, shortening of consultation times and retaliatory absence. On the other hand, various cadres of public health facility participants reported ineffective problem-solving adaptations. These included altering weekly schedules, differing patient appointments, impeding absence monitoring registers, offering unnecessary patient referrals and rampant unsupervised informal task shifting from clinicians to nurses.

CONCLUSION

High levels of absenteeism attributed to clinicians and health service managers result in work overload and stress for frontline health workers, and unsupervised informal task shifting of clinical workload to nurses, who are the less clinically skilled. In resource-limited settings, the underlying causes of absenteeism and low staff morale require attention, because when left unattended, the coping responses to absenteeism can be seen to compromise the well-being of the workforce, the quality of healthcare and patients' access to care.