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Background: While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs. Methods: CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs' perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors' power to affect devolved decision-making. Results: CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall 'tripe-benefit' from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC. Conclusions: Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making. [ABSTRACT FROM AUTHOR]

Abstract Background There is a growing interest in using pay-for-performance mechanisms in low and middle-income countries in order to improve the performance of health care providers. However, at present there is a dearth of independent evaluations of such approaches which can guide understanding of their potential and risks in differing contexts. This article presents the results of an evaluation of a project managed by an international non-governmental organisation in one district of Pakistan. It aims to contribute to learning about the design and implementation of pay-for-performance systems and their impact on health worker motivation. Methods Quantitative analysis was conducted of health management information system (HMIS) data, financial records, and project documents covering the period 2007-2010. Key informant interviews were carried out with stakeholders at all levels. At facility level, in-depth interviews were held, as were focus group discussions with staff and community members. Results The wider project in Battagram had contributed to rebuilding district health services at a cost of less than US$4.5 per capita and achieved growth in outputs. Staff, managers and clients were appreciative of the gains in availability and quality of services. However, the role that the performance-based incentive (PBI) component played was less clear--PBI formed a relatively small component of pay, and did not increase in line with outputs. There was little evidence from interviews and data that the conditional element of the PBIs influenced behaviour. They were appreciated as a top-up to pay, but remained low in relative terms, and only slightly and indirectly related to individual performance. Moreover, they were implemented independently of the wider health system and presented a clear challenge for longer term integration and sustainability. Conclusions Challenges for performance-based pay approaches include the balance of rewarding individual versus team efforts; reflecting process and outcome indicators; judging the right level of incentives; allowing for very different starting points and situations; designing a system which is simple enough for participants to comprehend; and the tension between independent monitoring and integration in a national system. Further documentation of process and cost-effectiveness, and careful examination of the wider impacts of paying for performance, are still needed.

Abstract Background Motivation and retention of health workers, particularly in rural areas, is a question of considerable interest to policy-makers internationally. Many countries, including Vietnam, are debating the right mix of interventions to motivate doctors in particular to work in remote areas. The objective of this study was to understand the dynamics of the health labour market in Vietnam, and what might encourage doctors to accept posts and remain in-post in rural areas. Methods This study forms part of a labour market survey which was conducted in Vietnam in November 2009 to February 2010. The study had three stages. This article describes the findings of the first stage - the qualitative research and literature review, which fed into the design of a structured survey (second stage) and contingent valuation (third stage). For the qualitative research, three tools were used - key informant interviews at national and provincial level (6 respondents); in-depth interviews of doctors at district and commune levels (11 respondents); and focus group discussions with medical students (15 participants). Results The study reports on the perception of the problem by national level stakeholders; the motivation for joining the profession by doctors; their views on the different factors affecting their willingness to work in rural areas (including different income streams, working conditions, workload, equipment, support and supervision, relationships with colleagues, career development, training, and living conditions). It presents findings on their overall satisfaction, their ranking of different attributes, and willingness to accept different kinds of work. Finally, it discusses recent and possible policy interventions to address the distribution problem. Conclusions Four typical 'directions of travel' are identified for Vietnamese doctors - from lower to higher levels of the system, from rural to urban areas, from preventive to curative health and from public to private practice. Substantial differences in income from formal and informal sources all reinforce these preferences. While non-financial attributes are also important for Vietnamese doctors, the scale of the difference of opportunities presents a considerable policy challenge. Significant salary increases for doctors in hard-to-staff areas are likely to have some impact. However, addressing the differentials is likely to require broader market reforms and regulatory measures.

Correction: Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district Lucia D'Ambruoso and Nana Akua Abruquah have contributed equally to this work. Reference 1 D'Ambruoso L, Abruquah NA, Mabetha D, Van Der Merwe M, Goosen G, Sigudla J, Witter S. Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district. [Extracted from the article]

Abstract Background This article describes a survey of health workers and traditional birth attendants (TBAs) which was carried out in 2005 in two regions of Ghana. The objective of the survey was to ascertain the impact of the introduction of a delivery fee exemption scheme on both health workers and those providers who were excluded from the scheme (TBAs). This formed part of an overall evaluation of the delivery fee exemption scheme. The results shed light not only on the scheme itself but also on the general productivity of a range of health workers in Ghana. Methods A structured questionnaire was developed, covering individual and household characteristics, working hours and practices, sources of income, and views of the exemptions scheme and general motivation. After field testing, this was administered to 374 respondents in 12 districts of Central and Volta regions. The respondents included doctors, medical assistants (MAs), public and private midwives, nurses, community health nurses (CHNs), and traditional birth attendants, both trained and untrained. Results Health workers were well informed about the delivery fee exemptions scheme and their responses on its impact suggest a realistic view that it was a good scheme, but one that faces serious challenges regarding financial sustainability. Concerning its impact on their morale and working conditions, the responses were broadly neutral. Most public sector workers have seen an increased workload, but counterbalanced by increased pay. TBAs have suffered, in terms of client numbers and income, while the picture for private midwives is mixed. The survey also sheds light on pay and productivity. The respondents report long working hours, with a mean of 54 hours per week for community nurses and up to 129 hours per week for MAs. Weekly reported client loads in the public sector range from a mean of 86 for nurses to 269 for doctors. Over the past two years, reported working hours have been increasing, but so have pay and allowances (for doctors, allowances now make up 66% of their total pay). The lowest paid public health worker now earns almost ten times the average gross national income (GNI) per capita, while the doctors earn 38.5 times GNI per capita. This compares well with average government pay of four times GNI per capita. Comparing pay with outputs, the relatively high number of clients reported by doctors reduces their pay differential, so that the cost per client – $1.09 – is similar to a nurse's (and lower than a private midwife's). Conclusion These findings show that a scheme which increases demand for public health services while also sustaining health worker income and morale, is workable, if well managed, even within the relatively constrained human resources environment of countries like Ghana. This may be linked to the fact that internal comparisons reveal Ghana's health workers to be well paid from public sector sources.

Background: The objectives of this study were to understand the labour market dynamics among health workers, including their preferences and concerns, and to assess the skills, competence and performance (i.e. the 'know-do gap') of doctors working in Timor-Leste. Methods: This cross-sectional survey was implemented in all 13 districts of Timor-Leste in 2014. We surveyed 443 health workers, including 175 doctors, 150 nurses and 118 midwives (about 20% of the health workers in the country). We also observed 632 clinical consultations with doctors, including 442 direct clinical observations, and tested 190 vignettes. Results: The study highlights some positive findings, including the gender balance of health workers overall, the concentration of doctors in rural areas, the high overall reported satisfaction of staff with their work and high motivation, the positive intention to stay in the public sector, the feeling of being well prepared by training for work, the relatively frequent and satisfactory supervisions, and the good attitudes towards patients as identified in observations and vignettes. However, some areas require more investigations and investments. The overall clinical performance of the doctors was very good in terms of attitude and moderate in regard to history taking, health education and treatment. However, the average physical examination performance score was low. Doctors performed better with simulated cases than the real cases in general, which means they have better knowledge and skills than they actually demonstrated. The factors that were significantly associated with the clinical performance of doctors were location of the health facility (urban doctors were better) and consultation time (cases with more consultation time were better). Regression analysis suggests that lack of knowledge was significantly associated with lack of performance, while lack of motivation and equipment were not significant. Conclusions: The survey provides essential information for workforce planning and for developing training policies and terms and conditions that will attract and retain health workers in rural service. Improving the work environment and performance of doctors working in rural health facilities and ensuring compliance with clinical protocols are two priority areas needed to improve the performance of doctors in Timor-Leste. [ABSTRACT FROM AUTHOR]

Background: Although human resources for health (HRH) represent a critical element for health systems, many countries still face acute HRH challenges. These challenges are compounded in conflict-affected settings where health needs are exacerbated and the health workforce is often decimated. A body of research has explored the issues of recruitment of health workers, but the literature is still scarce, in particular with reference to conflict-affected states. This study adds to that literature by exploring, from a central-level perspective, how the HRH recruitment policies changed in Timor-Leste (1999-2018), the drivers of change and their contribution to rebuilding an appropriate health workforce after conflict.Methods: This research adopts a retrospective, qualitative case study design based on 76 documents and 20 key informant interviews, covering a period of almost 20 years. Policy analysis, with elements of political economy analysis was conducted to explore the influence of actors and structural elements.Results: Our findings describe the main phases of HRH policy-making during the post-conflict period and explore how the main drivers of this trajectory shaped policy-making processes and outcomes. While initially the influence of international actors was prominent, the number and relevance of national actors, and resulting influence, later increased as aid dependency diminished. However, this created a fragmented institutional landscape with diverging agendas and lack of inter-sectoral coordination, to the detriment of the long-term strategic development of the health workforce and the health sector.Conclusions: The study provides critical insights to improve understanding of HRH policy development and effective practices in a post-conflict setting but also looking at the longer term evolution. An issue that emerges across the HRH policy-making phases is the difficulty of reconciling the technocratic with the social, cultural and political concerns. Additionally, while this study illuminates processes and dynamics at central level, further research is needed from the decentralised perspective on aspects, such as deployment, motivation and career paths, which are under-regulated at central level. [ABSTRACT FROM AUTHOR]