'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

Leveraging the social networks of informal healthcare providers for universal health coverage: insights from the Indian Sundarbans

India's healthcare landscape is characterized by a multitude of public and private healthcare providers, yet its health systems remain weak in many areas. Informal healthcare providers (IHPs) bridge this gap, particularly in rural India, and are deeply embedded within local communities. While their importance is widely recognized, there is a knowledge gap regarding the specifics of their social networks with actors in health systems. The aim of this study was to map the social networks of IHPs to elucidate the type and nature of their relationships, in order to explore opportunities for intersectoral collaboration to achieve universal health coverage (UHC). We have adopted the social network analysis (SNA) approach using qualitative ego-network methodology to evaluate the types and strengths of ties in the Indian Sundarbans. A total of 34 IHPs participated in the study. Qualitative data were analysed using NVivo10 and Kumu.io was used to visualize the social networks. Results show that the 34 IHPs had a total of 1362 ties with diverse actors, spanning the government, private sector and community. The majority of the ties were strong, with various motivating factors underpinning the relationships. Most of these ties were active and have continued for over a decade. The robust presence of IHPs in the Indian Sundarbans is attributable to the numerous, strong and often mutually beneficial ties. The findings suggest a need to reconsider the engagement of IHPs within formal health systems. Rather than isolation, a nuanced approach is required based on intersectoral collaboration capitalizing on these social ties with other actors to achieve UHC in impoverished and underserved regions globally.

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.

Burnout and Associated Factors among Hospital-Based Nurses in Northern Uganda: A Cross-Sectional Survey

Background

Burnout is a public health problem that disproportionately affects nurses in sub-Saharan Africa because of the weak health systems that create an unconducive workplace environment. In Uganda, there is limited evidence on the burden of burnout among nurses in a manner that undermine advocacy and policy formulation. We aimed to assess the level of burnout and associated factors among nurses in northern Uganda.

Methods

This was a cross-sectional survey conducted among 375 randomly selected nurses from health facilities in northern Uganda. Data were collected using a self-administered questionnaire. Data analysis consisted of descriptive statistics and logistic regression at a 95% level of significance in SPSS version 25.

Results

Majority of the respondents were female 56.5% (n = 223). Nearly half, 49.1% (n = 194) of respondents had high levels of burnout, 36.2% (n = 143) reported average levels of burnout, and 14.7% (n = 58) reported low levels of burnout. Factors associated with burnout were age (AOR: 2.90; 95% CI: 1.28-6.58; p = 0.011), social support (AOR: 0.45; 95% CI: 0.22-0.94; p = 0.033), healthy eating (AOR: 0.06; 95% CI: 0.02-0.22; p < 0.001), workload (AOR: 0.31; 95% CI: 0.14-0.68; p = 0.004), and management responsibilities (AOR: 3.07; 95% CI: 1.54-6.12; p = 0.001).

Conclusion

Half of the nurses in northern Uganda experienced high levels of burnout. The Ministry of Health should consider recruiting more nurses to reduce workload and adjust working hours to prevent workplace-related burnout among nurses in the country.

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.

Health Worker Absenteeism in Selected Health Facilities in Enugu State: Do Internal and External Supervision Matter?

Background: Absenteeism is widespread in Nigerian health facilities and is a major barrier to achievement of effective Universal Health Coverage. We have examined the role of internal (by managerial staff within facilities) and external (by managers at a higher level) supervision arrangements on health worker absenteeism. Specifically, we sought to determine whether these forms of supervision have any role to play in reducing health worker absenteeism in health facilities in Enugu State Nigeria. Methods: We conducted interviews with 412 health workers in urban and rural areas of Enugu State, in South-Eastern Nigeria. We used binary logistic regression to estimate the role of different types of supervision on health worker absenteeism in selected health facilities in Enugu State. Results: Internal supervision arrangements significantly reduce health worker absenteeism (odds ratio = 0.516, p = 0.03). In contrast, existing external supervision arrangements were associated with a small but significant increase in absenteeism (OR = 1.02, 0.043). Those reporting a better financial situation were more likely to report being absent (OR = 1.36, p < 0.01) but there was no association with age and marital status of respondents. Our findings also pointed to the potential for alternative forms of supervision, provided in a supportive rather than punitive way, for example by community groups monitoring the activities of health workers but trying to understand what support these workers may need, within or beyond the work environment. Conclusion: The existing system of external supervision of absenteeism in health facilities in Nigeria is not working but alternatives that take a more holistic approach to the lived experiences of health workers might offer an alternative.

Prevalence and predictors of burnout among nurses during COVID-19: a cross-sectional study in hospitals in central Uganda

OBJECTIVE

To determine the prevalence of burnout and associated factors among nurses during COVID-19 in central Uganda.

DESIGN

A cross-sectional design.

SETTING

Nurse from one referral and four general hospitals. These were reception centres and cared for patients with COVID-19 in central Uganda.

PARTICIPANTS

395 nurses.

MAIN OUTCOME MEASURES

Burnout scores.

RESULTS

Of the total 395 participants, 65.1% (n=257) were female; 40% (n=158) had a diploma; 47.1% (n=186) were single; and 39.2% (n=155) had worked for 11-15 years. The results show that 40% (n=158), 41.77% (n=165) and 18.23% (n=77) reported high, average and low levels of burnout, respectively. The results show that the predictors of nurses' burnout were personal protective equipment (PPE) (OR: 7.1, 95% CI 4.08 to 12.31) and increased workload (OR 4.3, 95% CI 2.43 to 7.93).

CONCLUSION

This study of nurses working in hospitals dealing with patients with COVID-19 in central Uganda reported high rates of burnout, and it was associated with PPE and workload. Interventions like contracting new nurses to reduce workload, the WHO guidelines on PPE, adjusting working hours and ensuring hours of effective rest should be adapted.

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.

The impact of health worker absenteeism on patient health care seeking behavior, testing and treatment: A longitudinal analysis in Uganda

INTRODUCTION

Absenteeism of frontline health workers in public sector facilities is widespread in low-income countries. There is little quantitative evidence on how health worker absenteeism influences patient treatment seeking behavior, though low public sector utilization and heavy reliance on the informal sector are well documented in low-income settings.

METHODS

Using a unique panel dataset covering health facilities and households over a 10-month period in Uganda, we investigate the extent to which health worker absenteeism (defined as zero health workers present at a health facility) impacts patient care seeking behavior, testing, and treatment.

RESULTS

We find high rates of health worker absenteeism at public sector health facilities, with most of the absenteeism occurring at lower level public health clinics. On average, no health worker was present in 42% of all days monitored in lowest level public health clinics, whereas this number was less than 5% in high level public hospitals and private facilities. In our preferred empirical model with household fixed effects, we find that health worker absenteeism reduces the odds that a patient seeks care in the public sector (OR = 0.65, 95% CI = 0.44-0.95) and receives malaria testing (OR = 0.73, 95% CI = 0.53-0.99) and increases the odds of paying out-of-pocket for treatment (OR = 1.41, 95% CI = 1.10-1.80). The estimated differences in care-seeking are larger for children under-five than for the overall study population.

CONCLUSIONS

The impact of health worker absenteeism on the quality of care received as well as the financial burden faced by households in sub-Saharan Africa is substantial.

Task-sharing to support paediatric and child health service delivery in low- and middle-income countries: current practice and a scoping review of emerging opportunities

BACKGROUND

Demographic and epidemiological changes have prompted thinking on the need to broaden the child health agenda to include care for complex and chronic conditions in the 0-19 years (paediatric) age range. Providing such services will be undermined by general and skilled paediatric workforce shortages especially in low- and middle-income countries (LMICs). In this paper, we aim to understand existing, sanctioned forms of task-sharing to support the delivery of care for more complex and chronic paediatric and child health conditions in LMICs and emerging opportunities for task-sharing. We specifically focus on conditions other than acute infectious diseases and malnutrition that are historically shifted.

METHODS

We (1) reviewed the Global Burden of Diseases study to understand which conditions may need to be prioritized; (2) investigated training opportunities and national policies related to task-sharing (current practice) in five purposefully selected African countries (Kenya, Uganda, Tanzania, Malawi and South Africa); and (3) summarized reported experience of task-sharing and paediatric and child health service delivery through a scoping review of research literature in LMICs published between 1990 and 2019 using MEDLINE, Embase, Global Health, PsycINFO, CINAHL and the Cochrane Library.

RESULTS

We found that while some training opportunities nominally support emerging roles for non-physician clinicians and nurses, formal scopes of practices often remain rather restricted and neither training nor policy seems well aligned with probable needs from high-burden complex and chronic conditions. From 83 studies in 24 LMICs, and aside from the historically shifted conditions, we found some evidence examining task-sharing for a small set of specific conditions (circumcision, some complex surgery, rheumatic heart diseases, epilepsy, mental health).

CONCLUSION

As child health strategies are further redesigned to address the previously unmet needs careful strategic thinking on the development of an appropriate paediatric workforce is needed. To achieve coverage at scale countries may need to transform their paediatric workforce including possible new roles for non-physician cadres to support safe, accessible and high-quality care.

Opportunities and Challenges for Improving Anti-Microbial Stewardship in Low- and Middle-Income Countries; Lessons Learnt from the Maternal Sepsis Intervention in Western Uganda

This paper presents findings from an action-research intervention designed to identify ways of improving antimicrobial stewardship in a Ugandan Regional Referral Hospital. Building on an existing health partnership and extensive action-research on maternal health, it focused on maternal sepsis. Sepsis is one of the main causes of maternal mortality in Uganda and surgical site infection, a major contributing factor. Post-natal wards also consume the largest volume of antibiotics. The findings from the Maternal Sepsis Intervention demonstrate the potential for remarkable changes in health worker behaviour through multi-disciplinary engagement. Nurses and midwives create the connective tissue linking pharmacy, laboratory scientists and junior doctors to support an evidence-based response to prescribing. These multi-disciplinary 'huddles' form a necessary, but insufficient, grounding for active clinical pharmacy. The impact on antimicrobial stewardship and maternal mortality and morbidity is ultimately limited by very poor and inconsistent access to antibiotics and supplies. Insufficient and predictable stock-outs undermine behaviour change frustrating health workers' ability to exercise their knowledge and skill for the benefit of their patients. This escalates healthcare costs and contributes to anti-microbial resistance.