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      Perceptions of health stakeholders on task shifting and motivation of community health workers in different socio demographic contexts in Kenya (nomadic, peri-urban and rural agrarian)

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          Abstract

          Background

          The shortage of health professionals in low income countries is recognized as a crisis. Community health workers are part of a “task-shift” strategy to address this crisis. Task shifting in this paper refers to the delegation of tasks from health professionals to lay, trained volunteers. In Kenya, there is a debate as to whether these volunteers should be compensated, and what motivation strategies would be effective in different socio-demographic contexts, based type of tasks shifted. The purpose of this study was to find out, from stakeholders’ perspectives, the type of tasks to be shifted to community health workers and the appropriate strategies to motivate and retain them.

          Methods

          This was an analytical comparative study employing qualitative methods: key informant interviews with health policy makers, managers, and service providers, and focus group discussions with community health workers and service consumers, to explore their perspectives on tasks to be shifted and appropriate motivation strategies.

          Results

          The study found that there were tasks to be shifted and motivation strategies that were common to all three contexts. Common tasks were promotive, preventive, and simple curative services. Common motivation strategies were supportive supervision, means of identification, equitable allocation of resources, training, compensation, recognition, and evidence based community dialogue.

          Further, in the nomadic and peri-urban sites, community health workers had assumed curative services beyond the range provided for in the Kenyan task shifting policy. This was explained to be influenced by lack of access to care due to distance to health facilities, population movement, and scarcity of health providers in the nomadic setting and the harsh economic realities in peri-urban set up. Therefore, their motivation strategies included training on curative skills, technical support, and resources for curative care. Data collection was viewed as an important task in the rural site, but was not recognized as priority in nomadic and peri-urban sites, where they sought monetary compensation for data collection.

          Conclusions

          The study concluded that inclusion of curative tasks for community health workers, particularly in nomadic contexts, is inevitable but raises the need for accreditation of their training and regulation of their tasks.

          Translated abstract

          Résumé
          Contexte

          La pénurie de professionnels dans les pays à faible revenu constitue une crise. Les travailleurs en santé communautaire font partie d’une stratégie de « délégation de tâches » visant à résoudre cette crise. La « délégation de tâches » consiste à confier à des bénévoles formés certaines tâches incombant habituellement aux professionnels de la santé. Au Kenya, on se demande si les bénévoles doivent recevoir une forme de compensation et quelles seraient les stratégies de motivation efficaces en fonction du contexte sociodémographique et du type de tâche déléguée. Cette étude visait à recueillir les points de vue de divers intervenants à l’égard des types de tâches à déléguer aux travailleurs en santé communautaire et des stratégies appropriées pour les motiver et les maintenir en poste.

          Méthodes

          L’étude a pris la forme d’une analyse comparative fondée sur des méthodes qualitatives, à savoir, des entrevues réalisées auprès d’intervenants clés (notamment des responsables des politiques de santé, des gestionnaires et des fournisseurs) et des groupes de discussion réunissant des travailleurs de la santé et des prestataires de services visant à connaître leur opinion sur les tâches déléguées et sur les stratégies de motivation appropriées.

          Résultats

          L’étude a révélé que certaines tâches à déléguer et stratégies de motivation étaient les mêmes dans les trois contextes démographiques. Les tâches communes aux trois contextes étaient la promotion, la prévention et les services curatifs simples. Les stratégies de motivation communes aux trois contextes étaient la supervision empreinte de soutien, les outils de dépistage, l’affectation équitable des ressources, la formation, la rémunération, la reconnaissance et un dialogue communautaire fondé sur des données probantes.

          L’étude a en outre montré qu’au sein des populations nomades et périurbaines, les travailleurs en santé communautaire assument des tâches curatives qui dépassent la portée de la politique de délégation de tâches en vigueur au Kenya. Cette situation est attribuable au fait que l’accès aux soins est difficile compte tenu : de la distance que doivent parcourir certaines populations pour atteindre les établissements de santé; des mouvements des populations nomades et de la rareté des fournisseurs de soins de santé au sein de ces mêmes populations; de la réalité économique difficile dans les milieux périurbains. Les stratégies de motivation pour ces populations comprenaient : la formation aux tâches curatives; le soutien technique; l’affectation de ressources aux fins des traitements. L’étude a aussi révélé que la collecte de données, si elle est vue comme une tâche importante au sein des populations rurales, n’est pas jugée prioritaire par les populations nomades et périurbaines, qui réclament en échange une compensation financière.

          Conclusions

          L’étude a permis de conclure que l’ajout de tâches curatives aux fonctions des travailleurs en santé communautaire, particulièrement au sein des populations nomades, est inévitable, mais qu’il appelle la certification de leur formation et la réglementation de leurs tâches.

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          Most cited references 16

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          Evidence-based, cost-effective interventions: how many newborn babies can we save?

          In this second article of the neonatal survival series, we identify 16 interventions with proven efficacy (implementation under ideal conditions) for neonatal survival and combine them into packages for scaling up in health systems, according to three service delivery modes (outreach, family-community, and facility-based clinical care). All the packages of care are cost effective compared with single interventions. Universal (99%) coverage of these interventions could avert an estimated 41-72% of neonatal deaths worldwide. At 90% coverage, intrapartum and postnatal packages have similar effects on neonatal mortality--two-fold to three-fold greater than that of antenatal care. However, running costs are two-fold higher for intrapartum than for postnatal care. A combination of universal--ie, for all settings--outreach and family-community care at 90% coverage averts 18-37% of neonatal deaths. Most of this benefit is derived from family-community care, and greater effect is seen in settings with very high neonatal mortality. Reductions in neonatal mortality that exceed 50% can be achieved with an integrated, high-coverage programme of universal outreach and family-community care, consisting of 12% and 26%, respectively, of total running costs, plus universal facility-based clinical services, which make up 62% of the total cost. Early success in averting neonatal deaths is possible in settings with high mortality and weak health systems through outreach and family-community care, including health education to improve home-care practices, to create demand for skilled care, and to improve care seeking. Simultaneous expansion of clinical care for babies and mothers is essential to achieve the reduction in neonatal deaths needed to meet the Millennium Development Goal for child survival.
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            Health worker motivation in Africa: the role of non-financial incentives and human resource management tools

            Background There is a serious human resource crisis in the health sector in developing countries, particularly in Africa. One of the challenges is the low motivation of health workers. Experience and the evidence suggest that any comprehensive strategy to maximize health worker motivation in a developing country context has to involve a mix of financial and non-financial incentives. This study assesses the role of non-financial incentives for motivation in two cases, in Benin and Kenya. Methods The study design entailed semi-structured qualitative interviews with doctors and nurses from public, private and NGO facilities in rural areas. The selection of health professionals was the result of a layered sampling process. In Benin 62 interviews with health professionals were carried out; in Kenya 37 were obtained. Results from individual interviews were backed up with information from focus group discussions. For further contextual information, interviews with civil servants in the Ministry of Health and at the district level were carried out. The interview material was coded and quantitative data was analysed with SPSS software. Results and discussion The study shows that health workers overall are strongly guided by their professional conscience and similar aspects related to professional ethos. In fact, many health workers are demotivated and frustrated precisely because they are unable to satisfy their professional conscience and impeded in pursuing their vocation due to lack of means and supplies and due to inadequate or inappropriately applied human resources management (HRM) tools. The paper also indicates that even some HRM tools that are applied may adversely affect the motivation of health workers. Conclusion The findings confirm the starting hypothesis that non-financial incentives and HRM tools play an important role with respect to increasing motivation of health professionals. Adequate HRM tools can uphold and strengthen the professional ethos of doctors and nurses. This entails acknowledging their professionalism and addressing professional goals such as recognition, career development and further qualification. It must be the aim of human resources management/quality management (HRM/QM) to develop the work environment so that health workers are enabled to meet their personal and the organizational goals.
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              Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa.

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

                Contributors
                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central
                1472-6963
                2014
                12 May 2014
                : 14
                : Suppl 1
                : S4
                Affiliations
                [1 ]Great Lakes University of Kisumu P. O. Box 2224-40100 Kisumu, Kenya
                [2 ]University of Ottawa, Canada
                Article
                1472-6963-14-S1-S4
                10.1186/1472-6963-14-S1-S4
                4108867
                25079588
                Copyright © 2014 Ochieng et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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                Research

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