Task shifting refers to the strategic redistribution and decentralization of health care tasks from one group to another(including lay workers), the latter usually deemed as having lesser training and qualifications, and is an approach that isutilized to address the shortage and imbalance of the health workforce within a certain geographic area, thereby ensuring apopulationâs access to care.1 Task shifting can involve extending the role of a particular group (enhancement), exchanging workbetween groups (substitution/delegation), or creation of new jobs (innovation).2 While the primary conceptualization of taskshifting is from professional to lay health workers, it must be stated that task shifting can also involve shifting of tasks fromprofessionals to patients; from health workers to technology; and between different types of health workers.2 Task shifting hasbeen implemented in a variety of settings and for different programs/conditions, such as HIV/AIDS treatment3, cancer care4,mental health5, ultrasonography for antenatal care6, surgical care7, and non-communicable disease management8, similar to thecontext of the report by Tamayo and Reyes9 in this issue of Acta Medica Philippina. In addition to bridging the health humanresources gap, it has been proposed that task shifting may address health equity by broadening access to essential health services,contribute to enhancing the quality of care that is aligned with the changing societal needs, and yield cost savings particularlyfor the delivery of routine activities.10,11 Despite its widespread application, touted benefits, and the seeming preference of many organizations to use task shiftinga default solution to the health workforce challenge, three things must be pointed out. First, task shifting should be properly seen as a temporary solution to the health workforce challenge confronting countriesand health systems.12,13 Better and more comprehensive planning and management of human resources for health at the systemlevel is needed so that we can address the underlying problems that resulted to the implementation of task shifting in the firstplace â shortage, maldistribution, skill-mix balance, and sub-optimal working conditions that are, in turn, driven, by both healthsystem and contextual factors.14 Second, in situations where task shifting is perceived to be the better policy alternative, the program should be implementedin an ethical manner, considering respect for persons (i.e., free and informed decision making to take part in task shifting,recognition of recipients of tasks as critical contributors to the health program), justice (i.e., adequate guidance and supervision,fair remuneration, minimization of undue burden), beneficence (i.e., promoting health and welfare of workers, minimizingharm to workers and communities), proportionality (i.e., assignment of workload and responsibility commensurate to skillsand resources available), and cultural humility (i.e., cultural competency and humility on the part of dominant institutions),especially when the recipient of tasks are volunteer community health workers.15 Lastly, task shifting should be implemented as a comprehensive package of interventions, rather than a single activity.At the outset, the necessary conditions and important considerations for launching a task shifting program should be present,as outlined in the Concepts and Opportunities to Advance Task Shifting and Task Sharing (COATS) Framework.16 The keyelements for successful implementation (i.e., collaboration and coordinated care, financing, patient preference, shared decisionmaking,provider empowerment, training and competency, clear process outcomes, and supportive organizational system) oftask shifting should also be present.17 Recommendations on how and when to adopt task shifting as a strategy have also beenpublished by various organizations such as the World Health Organization1 and the World Medical Association18. The success of a task shifting strategy will require, among others, that health workers be actively engaged in the process,ensuring that the planned task shifting is aligned with their personal values, and creating an enabling environment19 that willallow them to carry out their tasks effectively, efficiently, and in a safe manner. In short, one of the requirements is that, aspointed out in the paper by Tamayo and Reyes9, stakeholders find task shifting an acceptable strategy.
BACKGROUND The Durban University of Technology (DUT) Faculty of Health Sciences (FHS) in KwaZulu-Natal, South Africa, is embarking on a project to implement a Decentralized Clinical Training Program (DCTP). The DUT FHS DCTP project is being conducted in response to the growing demands of students requiring clinical service placements as part of work-integrated learning. The project is also geared toward responding to existing gaps in current practices related to the implementation of a DCTP, which has mainly been through traditional universities providing training to medical, optometry, occupational therapy, and physiotherapy students. In South Africa, a DCTP is yet to be implemented within the context of a university of technology; it is yet to be implemented within health science faculties that offer undergraduate health science programs in mainstream biomedicine and alternative and complementary disciplines. OBJECTIVE We aim to design, pilot, and establish an effective DCTP at the DUT FHS in KwaZulu-Natal, South Africa. METHODS Participatory action research comprising various designsânamely, appreciative inquiry, qualitative case study design, phenomenography, and descriptive qualitative study designâwill be used to conduct the study. Data will be collected using individual interviews, focus group discussions, nominal group technique, consensus methodology, and narrative inquiry. Study participants will include various internal and external stakeholders of the DUT, namely, academic staff; students; key informants from universities currently using successfully established DCTPs; academic support staff; staff working in human resources, finance, procurement, and accounting; and experts in other disciplines such as engineering and information systems. Overall, 4 undergraduate health science programsânamely, Radiography, Medical Orthotics and Prosthetics, Clinical Technology, and Emergency Medical Care and Rescueâwill be part of the projectâs pilot phase. Findings from the projectâs pilot phase will be used to inform scale-up in the other undergraduate programs in the DUT FHS. The project is being implemented as part of the universityâs strategic objective of devising innovative curricula and pedagogical practices to improve the mastery, skill set, and competence of health science graduates. RESULTS The study has currently commenced with the situational analysis, consisting of engagement with external stakeholders implementing DCTPs. The data to be generated from the completion of the situational analysis are anticipated to be published in 2024. CONCLUSIONS This project is envisioned to facilitate collaboration among the universities of technology, traditional universities, Ministry of Health, and private sector for clinical placement of undergraduate health science students in health establishments that are away from the university, thereby exposing them to real-life experiences related to health care. This will facilitate authentic learning experiences that will contribute to improved competencies of graduates in relation to the health needs of society and the multiple realities of the South African health system. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/52243
To say that we live in turbulent times is a massive understatement. COVID-19 ruthlessly exposes the fault lines of health services and systems, and the responses put in place to prevent its spread or mitigate its effects may affect people more than the actual infection. The outbreak in Wuhan quickly grew to a pandemic that has affected countries and regions all over the world in many, and as of yet, little understood ways. This is a global infectious disease outbreak of a scale not seen since the Spanish Flu. For many countries, it is an extreme stress test of the health system and of society at large. All over the world, people, patients, providers, health service managers, health and other sectoral policymakers and politicians, are dealing with high levels of uncertainty and severe challenges to the resilience of their systems. The governance not only of health, at national and global levels, but also of trade, communication and globalization itself is under scrutiny. The virus exposes, yet again, the structural determinants that lead to health inequalities (Shadmi et al., 2020), including racism and colonial legacies. Many see this as a key moment of reckoning, nationally and globally: the pandemic and its responses have precipitated unprecedented economic, social and health crises that may shape the decades ahead. At the same time, the role of health systems in responding to COVID-19 and the need to (re-)invest in these systems through the state offers transformative opportunities. In the light of this, we outline how health policy and systems research (HPSR) can both address current short-term challenges, and support the system transformations needed to strengthen people-centred and equitable health systems over the long term. The HPSR community has responded to the COVID-19 pandemic quickly, following the wave of publications on epidemiological and clinical aspects of the disease. Initial studies have included those describing the capacity of hospitals, intensive care units and first line health services required to respond to the disease, and those reporting specific experiences at community and local levels, including the denial of care and the inequitable effects of disease control measures. Many commentaries and calls for action have been published (COVID-19 Clinical Research Coalition, 2020; English et al., 2020; Shamasunder et al., 2020). Inevitably, however, due to the acute nature of the crisis, few papers have yet focused on how health systems are coping with or adapting to the pandemic, or how health policy-making and decision-making has (or has not) changed in this time of crisis. Yet, there is an urgent need to develop a structured research agenda to inform health policy and system responses to COVID-19 that can move us beyond the current crisis, and into the future. This commentary makes proposals towards such an agenda. In line with the audience of Health Policy and Planning, we specifically focus on low- and middle-income country (LMIC) HPSR needs, drawing on our collective experience as a group of HPS researchers based around the world. The Health System Research and Health Policy Processes section editors initiated the process and purposefully sought inputs from HPS researchers in a range of LMICs . The process was also supported by both the Alliance for Health Policy and Systems Research and Health System Global. We organized an online consultation process, whereby the first authors invited the co-authors to identify research priorities, questions and themes. In a second round, these were compiled and categorized in themes and sent out for further comment. In a final round, the issues and questions within each theme were examined and gaps and overlaps eliminated. We consider, first, key dimensions of the overall approach of HPSR to frame the further work needed, and second, in an annex, we suggest an initial categorization and listing of possible research topics. We present these ideas to prompt wider reflectionâand we conclude by proposing ways of engaging further with these ideas, acknowledging the fast-changing nature of the pandemic and the need to review research priorities regularly. We start by reviewing how the defining features of HPSR, including the systems approach, multi-disciplinarity and the emphasis on policy and power may be applied to the pandemic. One defining feature of HPSR is its systems approach. This frames COVID-19 and the responses to it in a criticalâanalytical perspective, zooming out from specific experiences to seek the root causes of the differential impact of the pandemic across individuals and population groups as a function of societyâs power structures and dominant culturesâas reflected in their social, political and economic position, and their race, gender, caste, class and more. Groups that become vulnerable due to systemic and structural inequities include those living in informal settlements in cities or in geographically isolated areas, informal workers, migrant and refugee communities, people without citizenship rights, sex workers, single-women households, LGBTQI+ communities and indigenous peoples. The systems lens equips HPS researchers to understand how, for such groups, health system fault lines interact with the histories of discrimination and disenfranchisement that underpin other determinants of vulnerability, risks and infection. Some people have already faced worse effects from COVID-19 responses than from (the possibility of) infection itself, due to social exclusion, racism and human rights abuse. Meanwhile, privilege and social networks have largely allowed wealthy elites to avoid the negative social and economic effects of lockdowns, deepening inequalities. Health systems have, in turn, generally been poorly equipped to respond fast enough either to the medical and psychological demands of the pandemic or to the wider public and social action needed to address multiple disadvantage and vulnerability. HPSR is well placed to contribute in understanding the layered causes and effects of the pandemic on people and systems. Identifying how health system gaps and weaknesses interact with the root causes of vulnerability to COVID-19 is a vital responsibility that HPSR needs to shoulderânot only as an obligation of itself (referring to HPSRâs social justice agenda), but also as an opportunity to strengthen health systems in more just and inclusive ways than before. The multi-disciplinary approach of HPSR will be key to this task because of the complex nature of health and its determinants, as well as of health policies and health systems. This multi-disciplinary approach supports consideration of how agents and systems interact and of the inter-connections among the systems relevant to health. These include community, workplace and government systems; health and other government sectors; local, national and global systems and markets, corporate actors and the private sector in its full heterogeneity. HPSR can assist in distinguishing COVID-19-related challenges that are simple problems, from those that are better considered as complex problems and that demand appropriate context-sensitive response strategies. It can also nurture and sustain the systemic responses to COVID-19 and its impacts that are vital for the long-term. It supports a system-based approach in anticipating the collateral effects of policies aimed at responding to the pandemic, generating ideas about how mitigate the damages and optimize the gains. The pandemic specifically demands recognition of the interactions of human, animal and ecological systems. The spill-over of the virus from animal to human reservoirs inevitably calls for a critical exploration of how humans continue to interfere with fragile equilibria in the natural world through urbanization, deforestation and more. Beyond âone healthâ research, attention should be paid to the dominant economic growth paradigm on health, development, trade, society and the natural world and the role of populist and isolationist ideologies in framing the response. Another defining feature of HPSR is its focus on policy, policy-making and how health systems are nested in and influenced by power dynamics and political forces, histories and cultures: the âpâ in HPSR. This is another vital lens for research in the time of COVID-19. It supports inquiry into governance, decision-making and health policy responses in times of crisis, as well as how both to inform and strengthen system change. It encourages consideration of the values driving decision-making and the ethical demands of leadership. In addition, this lens underpins investigation of the political economy of the pandemic response and whether and how health systems and political action align to address the structural determinants of ill health and inequity which COVID-19 exposes. It can expose the lack of accountability towards some marginalized groups and the focus on politically important constituencies, the lack of stewardship/leadership at multiple levels and how efforts towards decentralizing and commercializing health system responsibilities lead to fragmented health systems. It could focus on new forms of sub-national and national governance arrangements and investigate how that deepens community-level and inter-sectoral action for health and societal development. The pandemic forces us to consider governance not only at national level, but also at global level: Should we redefine global health? How can we promote better global leadership to coordinate and enforce efforts across countries, including the need for consideration of global public goods and global health ethics? Drawing on well-established bodies of knowledge and evidence from other disciplines (e.g. political science, policy studies, public administration, sociology, complexity theory, critical studies), HPSR can make major contributions to learning how better to deal with pandemics. But HPSR must also do more than help systems absorb future shocks. It must help establish the foundations of more just, equitable and better health systemsâhealth systems that demonstrate resilience through their capacity to be transformative as they respond to shock and stress. Crucial in this effort will be research around how health systems can be transformed for the better during or in the wake of the pandemic. This includes work around adaptive governance as well as on other fundamental system driversâsuch as the health workforce, and information and financing systems. Prioritizing among research topics is not straightforward. Such prioritization must, first, be informed by the views of vulnerable groups, community groups, health system decision-makers and health policymakers in the broadest sense and be situated in specific settings. Below, we discuss a few waypoints that may help in thinking about HPSR priorities in relation to COVID-19. As Marquette (2020) has argued for social science more generally, more immediate needs for research are likely to include understanding the root causes of vulnerability to support response activities and limit their negative effects. However, she notes that even mid- to longer-term research to understand secondary effects and long-term impacts and recovery must start now, accompanied by political analysis, and this will be needed to sustain recovery and support the emergence of new and better systems. Critical to this work will be revealing opportunity, agency and resilience, even in the midst of multi-layered challenges. For HPSR, we can also be guided by our understanding of people-centred health systems. This points, e.g. to the importance of understanding community-level COVID-19 experiences, including the experience of marginalized groups, and considering how system software (including power, trust and values) interacts with other system changes to influence the impacts of COVID-19; examining how health systems and COVID-19 responses may exclude people on the basis of their gender, race, income and other characteristics, and how histories of colonialism and racism underpin such exclusion; analysing the power and influence of ideas and framing, and the role of communication in decision-making at every level; and finally, purposefully considering the political economy influences driving COVID-19 and responses to it . Our research must offer new ideas for future health systemsâbuilding evidence around new ways of organizing, new ways of caring, new strategies of health development. In responding to COVID-19 and offering new ideas for future health systems, the HPSR community must also consider how to go about doing research. Issues to be reflected upon include the distribution of power within HPSR communities, the balance between global concerns and priorities on one hand and context-sensitivity on the other hand, the challenge of researching what is essentially a fast moving target, the practical problems induced by the control measures (such as social distancing) when collecting data, and finally the issue of research governance. Power-balancing strategies must be reflected in how the research is doneâconsidering, e.g. with whom and how we collaborate, and what forms of knowledge are valued and enhanced through this work. Research responding to COVID-19 must also be relevant to the contexts in which it is located, and acknowledge the imperatives of this moment. In the short term, then, it must be conducted quickly to address immediate needs, and be fed-back into decision-making rapidly. Innovative knowledge translation efforts and new models of collaborations between research, policymaking and stakeholder organizations are of special interest. Being systematic and rigorous will always be important, but we must capture current experience even as we also develop longer-term research activities. To support such HPSR can on and new ways of doing research. These include research et al., action research et al., action learning 2020), research and policy and All multiple forms of knowledge and for researchers to through with in the response in ways of that for HPSR to help shape the world COVID-19. At the same time, in the response to COVID-19 it always important to consider the ethical dimensions and of ethical and In the we will also need to about research and that can be to and vulnerable groups by online and online from experiences, as they their is and social could be a relevant research forms offer other new ways of and such experience et al., other an online of and studies could be to support the HPSR of secondary and simple work can also important, immediate about social and among other evidence drawing on both and and is into the and process research will be important to out the of is also needed both to understand the current experience and from experience and work can offer into the experience of groups and into responses to inform future action 2020). The of will support understanding of system sub-national or can e.g. on critical governance influences over of experience will also always be important to understand the layered vulnerability of people and systems, and the agency and to and must become a of HPSR et al., it is critical to and research governance at all levels to important, research that supports social justice is possible and is and to identify and limit research. We must also and how research governance and the research that is are by COVID-19 and responses to the research of and is for it is of this will not only work but also papers by and by At another level, how can we contribute to global health for whom in the current research on COVID-19 challenges HPS researchers to and in research that to new health systems for the future. HPSR that current needs and experiences will offer important and both about how COVID-19 impacts on our and about the responses to the pandemic. It can help how these responses and or new for just health systems. The HPSR in LMICs must support in the place and capacity for and nationally research, with appropriate Health and research in LMICs must as needed, be to do Research for must also include communities, patients, providers, health service and health and other policy in to society and HPSR must be an as it is for global health more and these are in that the current a new COVID-19 has just been for the on Health Systems Research the of the HPSR are within its theme of health systems for better health and social and for of the political social, economic and forces and and social In the annex, we also present a of HPSR themes and topics the of importance we have already These range from studies the differential impact on people, disadvantage and to those focused on the impacts on health systems, including studies on governance and system of health system towards better and just health systems. We responses to our ideas and proposals for a HPSR in the of to be published in Health Policy and We also a future for papers for a special issue of this that may and the COVID-19 pandemic and the responses at sub-national and as well as responses by people, communities health and social providers, decision-makers including community and from a analysing COVID-19 responses in of health and social including and on the of decision-making in a time of to the impact of the pandemic and the responses at sub-national and through e.g. studies, policy and decision-making analysis, of is a of the Health and is for the views in the which do not the or policies of the Health ethical was required for this is the of the pandemic and the response on the and of first line services for and by vulnerable groups people with and the and health response services for and LGBTQI+ service is the differential impact of COVID-19 on and how it affect the health of people, and people work from are the impacts of COVID-19 How to sex in and systems to understand the of How to COVID-19 measures to impacts on vulnerable groups, such as those living in informal refugee the and the are the of and how can of those test for COVID-19 and those have from COVID-19 (including health be How in is to trust and of response to a disease How power out in the governance of COVID-19 responses and within new forms of governance and that How do power and the COVID-19 and evidence and knowledge is in decision-making around is the balance of political and and how do governance histories and structures shape this and how and or limit over the and how to address this COVID-19 global health in e.g. more emphasis on global health and from health will COVID-19 in the global political economy of health? 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AbuYusuf Aminu-Ibrahim, John Chinemerem Ogbete, Kazeem Babatunde Ambali
Expanding diagnostic access across underserved and rural healthcare regions remains a critical determinant of health equity, early disease detection, and system-wide resilience. Infrastructure-driven approaches offer a pragmatic pathway to closing persistent diagnostic gaps caused by geographic isolation, workforce shortages, fragmented referral networks, and underinvestment in health facilities. This paper examines how strategic development of physical, digital, and organizational infrastructure can enable scalable, sustainable diagnostic services in low-resource and rural settings. It synthesizes evidence from health systems strengthening, rural health planning, and diagnostic network design to identify core infrastructure enablers that improve access, quality, and continuity of care. Key infrastructure components include decentralized laboratory hubs, modular and prefabricated diagnostic facilities, reliable power and water systems, cold-chain and specimen transport logistics, and interoperable health information systems. When combined with digital connectivity, telepathology, and point-of-care diagnostics, these assets reduce turnaround times, minimize patient travel burdens, and support timely clinical decision-making. The paper further highlights the role of workforce-aligned infrastructure, emphasizing training-centered facility design, task-shifting support spaces, and remote supervision platforms that extend specialist expertise into rural contexts. From a policy and financing perspective, infrastructure-driven expansion requires coordinated investment models that align capital planning with service delivery objectives. Publicâprivate partnerships, performance-based financing, and regional diagnostic networks are discussed as mechanisms to de-risk infrastructure investment while ensuring affordability and long-term operability. Governance frameworks that integrate maintenance planning, quality assurance, biosafety, and regulatory compliance are identified as essential to preventing infrastructure decay and service fragmentation. The papaer concludes that infrastructure is not merely a physical input but a systems-level enabler of equitable diagnostic access. By embedding diagnostics within resilient infrastructure ecosystems that integrate technology, logistics, workforce capacity, and governance, health systems can extend high-quality diagnostic services to underserved and rural populations. Such infrastructure-driven strategies are foundational to universal health coverage, pandemic preparedness, and the reduction of avoidable morbidity and mortality in marginalized regions. Importantly, infrastructure planning must be context-sensitive, data-informed, and community-engaged, ensuring that diagnostic expansion aligns with local disease burdens, cultural practices, referral pathways, and sustainability constraints while promoting trust, utilization, and long-term health system integration across diverse rural geographies globally and fragile health markets.
Frank W. Garrison, Valorie Dearmon, Rebecca Graves
FigureA nursing shortage, whether at the individual market level or the national level, profoundly impacts healthcare delivery.1 Nurse administrators continually seek ways to address nursing shortages by attracting new nurses to the profession and supporting their success as novice practitioners. Nurse residency programs (NRPs) are commonly employed to develop and support new graduate RNs (NGRNs), reducing vacancy and turnover.2-4 Putting an effective NRP into practice can be challenging in any setting, but particularly so for smaller hospitals where resources are seriously limited. In 2015, our 100-bed community hospital hurriedly implemented an NRP to address the facility's critical nursing shortage. Predictably, we identified opportunities for improvement of the newly developed NRP soon after implementation. Here, we explain how we optimized our NRP at minimal cost to achieve sustained improvements in nursing vacancy and turnover. A quick fix Our hospital implemented its original NRP in response to a 2014 nursing vacancy rate of 17% and a turnover rate of 37%. We needed a solution to provide immediate relief from our nursing shortage, but a policy was in place that prohibited hiring nurses with less than 2 years of experience. The CNO and management team decided to revise the policy to allow the hiring of NGRNs contingent on their completion of an NRP, which the hospital quickly developed and implemented. Although the NRP brought significant relief to the nursing vacancy crisis, the CNO and nurse managers feared that the program was only a quick fix. They wanted to replace it with a well-developed and evidence-based solution able to sustain vacancy reduction and prevent future turnover. For the NRP to be most effective, the team believed that it needed greater emphasis on competence development of NGRNs and preceptors alike to support the hospital's mission of excellence. However, with substantial capital already investedâapproximately $20,000 per NGRN over traditional orientation, predominantly for salary dollarsârequesting further funds to enhance the NRP presented a challenge. Identifying best practices The CNO and project team, which included nurse managers, nurse educators, and recent graduates from the hospital's NRP, conducted a comprehensive literature review to identify NRP best practices. The use of NRPs to improve competence and reduce vacancy and turnover is well documented in the literature, but program variations make it difficult to define best-practice strategies.4,5 Agencies such as the American Association of Colleges of Nursing have established guidelines for NRPs, and accreditation status is awarded for a fee to organizations meeting the established guidelines.6 However, as with our organization, resource limitations prevent some facilities from seeking accreditation. Nonetheless, criteria found within the accreditation standards underscore best practices and can guide the selection of evidence-based strategies within the context and constraints of any organization. Our literature review identified that competent preceptors are essential to NGRN development.2,7 The preceptor-NGRN bond is vital to NGRN confidence and skill building.8 Effective preceptors possess clinical expertise combined with the knowledge and ability to facilitate another's competence.2,7 Interprofessional collaboration is also key to NGRN success.9,10 Engaging NGRNs in collaborative work promotes decision making, confidence, and communication.9-11 Simulation can facilitate competence and help develop collaborative skills.8,9,12 It allows novice nurses to practice skills without fear or risk of hurting patients, honing critical-thinking and decision-making abilities.12-14 A recent landmark study validated the effectiveness of high-fidelity simulation as a substitute for up to half of traditional clinical hours for nursing students.14 Lastly, studies repeatedly find that socialization and long-term support are vital to NGRN competence, retention, and professional commitment.2,5,7 Other strategies, such as extending the duration of NRP class time, are recommended, but these were eliminated by our team due to prohibitive cost. The project team carefully examined the evidence and selected best practices appropriate to our setting and circumstances. Three measurable objectives guided NRP improvement: 1) increase NGRN competence through practical skill-building methods; 2) increase preceptor competence, with NGRN competence correlating with preceptors' teaching and mentoring skills; and 3) develop a social and professional support system for NGRNs to promote competence and foster professional and organizational loyalty. Getting to work The project team formalized the competence development plan, obtained institutional review board approval, and set out to implement the NRP improvements for an incoming 2016 class of NGRNs (N = 6). The team began the implementation process by partnering with a local university's school of nursing for simulation lab use with faculty instruction. Next, the team purchased validated assessment tools from a national company for NGRN and preceptor pre- and posttraining competence assessment. The instruments consisted of an NGRN clinical competence assessment tool and a preceptor clinical and precepting competence tool. Assessment findings were analyzed by the contracted company, providing detailed reporting of each individual's strengths and weaknesses. A group of seven preceptor nurses within the facility completed the nurse preceptor competence assessments; the project team used the assessment results to tailor the preceptors' education to areas of needed improvement. The hospital hadn't previously assessed preceptor competence, and the new approach allowed for customized education to improve preceptors' abilities. The hospital's education department conducted the training; afterward, the preceptors took a posttraining assessment. During the course of the project, three of the preceptors had to be replaced due to unforeseen circumstances. The substitute preceptors received training but weren't in the initial preassessment group, so only the assessments of the remaining four preceptors from the original group were considered as part of the study results. The costs for assessments for both the preceptors and NGRNs were minimal, as shown in Table 1.Table 1:: Annual NRP improvement project expensesThe enhanced NRP commenced a few weeks after the preceptors completed training. Each of the six NGRNs took nationally validated NGRN-specific nursing competence assessments aligned to clinical specialty areas of interest to establish pre- and posttraining competence; three of the six NGRNs took an additional pre- and posttraining competence assessment necessary for the combined clinical focus of their selected department. The NGRNs completed an initial hospital orientation and then began the competence development curriculum consisting of simulation lab training, didactic interprofessional collaboration training, preceptor-guided nursing shifts, and social and professional support group meetings. (See Table 2.) Many of the simulation scenarios and the didactic interprofessional collaboration lessons were based on findings from the NGRNs' baseline competence assessments and feedback from the hospital's recent NRP graduates. The project team analyzed this information to identify areas of needed improvement and allocated didactic instruction time accordingly to those areas.Table 2:: NGRN competence development curriculum examplesCollaborative skills were practiced during interprofessional simulation scenarios. Furthermore, numerous NGRN classes were taught by various hospital leaders, again focusing on improvement areas identified from the baseline assessments and the previous NRP class feedback. Class time included a variety of role-play scenarios, allowing the NGRNs to practice the skills necessary to communicate accurately, effectively, and collaboratively. Faculty from the nursing school also taught classes on time management skills and the impact of effective collaboration on overall time management. The NGRNs worked scheduled shifts to care for patients under the direction and guidance of their preceptors, observing and/or participating in all nursing activities, including multidisciplinary rounds. As the NRP progressed, the amount of nursing work performed independently by the NGRNs increased steadily as preceptors observed improvement in the NGRNs' skills and readiness. The importance of socialization and professional support to the NGRNs' success can't be understated. Providing social and professional support requires a time investment as opposed to capital. During each NRP class day, a 1-hour catered lunch was scheduled as social and professional support time. Some of these lunch meetings focused on strengthening NGRN peer relationships, whereas others included preceptors and managers for fostering social and professional networks outside of the NGRNs' peer group. When the didactic portion of the NRP was complete, the social and professional functions were changed to a breakfast meeting at morning shift change. The breakfast meetings continue for a full year to provide time for NGRNs to engage with each other, their preceptors, the CNO, and other nurse leaders by asking questions, resolving challenges, making suggestions, and sharing successes in their transition to professional practice. Success! The project was an enormous success from the perspective of the project team and hospital administration. The best practices integrated into the existing NRP markedly strengthened the program. Incorporating simulation lab training was highly valuable, but even more efficacious was the relationship between our hospital and the university. Developing the infrastructure for the partnership between the hospital and university required a significant time commitment for both parties because a number of meetings were required to understand each other's needs and goals. As the parties grew to understand what each had to offer, a mutually beneficial contractual agreement for simulation training was formalized. The contract established a partnership with the school for use of its high-fidelity simulation lab and faculty instruction in the lab to facilitate NGRN skill building. The fees for simulation training required an investment that was significant to the hospital's budget, but the resulting partnership between the hospital and university was well worth it. The relationship helped meet the hospital's need for nursing staff and the school's need for NGRN placement in the workforce. Faculty also volunteered a significant amount of time, at no additional cost to the hospital, to assist the project team in educating the NGRNs during the NRP didactic class times. The partnership led to an agreement for the school's family NP students to perform clinical rotations in the hospital and its clinics, and for the hospital to be the school's sole provider for women's services clinical rotations. The relationship even resulted in the CNO's placement on a university advisory council. Competence assessment data also revealed project success. Pre- and posttraining assessment data were analyzed using statistics software. Measures of central tendency and variance were evaluated and, because of the normal distribution of all variables, differences in the means were analyzed by paired-samples t tests. The itemized score reports from the preceptors' initial competence assessments revealed opportunities for improvement in the areas of communication, critical thinking and problem solving, and orientation plans. The competence assessment group mean score for the four preceptors who participated in the entire project increased from a pretraining score of 77.00 (SD = 2.94) to a posttraining score of 79.00 (SD = 4.55); however, statistical significance wasn't found (t(3) = -.608, P = .586). Also, the reassessment itemized score reports for the individual preceptors revealed an improvement in the pre- and posttraining mean score in the three identified areas of need. Similarly, the NGRN competence development curriculum, as informed by the NGRNs' baseline assessments and feedback from the hospital's recent NRP graduates, led to improved NGRN competence. The posttraining assessments demonstrated a statistically significant improvement in overall NGRN competence. The mean for the nine baseline tests was 72.11 (SD = 6.03) and for the nine reassessment tests, 81.22 (SD = 3.59). A significant increase from the baseline assessment to the reassessment was found (t(8) = -3.833, P = .005). The NGRNs also completed the Casey-Fink Graduate Nurse Experience Survey at the end of didactic training. The Casey-Fink survey is a valid and reliable self-assessment of NGRN competence, with content validity established by expert review and a Cronbach's alpha coefficient of 0.89 after repeated measures.15,16 The survey findings provided additional insight into project effectiveness by revealing the NGRNs' self-perceptions of nursing competence after the NRP. For example, in the 24-question Likert scale portion of the survey, 83.3% of the responses from the six NGRNs demonstrated a favorable view of the transition experience. The survey results were also useful in departmental placement of the NGRNs at the end of didactic training and for planning additional education for individual NGRNs in areas of self-perceived need. The hospital's nursing vacancy continued to improve during the enhanced NRP. The current vacancy rate dropped from 17% at the end of 2014 to 7.5% by mid-2016, and that reduction has occurred even as the hospital has increased nursing positions by 20% to account for growth since the inception of the NRP. The vacancy rate is impacted by a variety of factors; implementation of an NRP is one such factor. In our case, the NRP resulted in an impactful reduction in vacancies. Although the small cohort size for the NRP improvement project limits the generalizability of our study, the improvements significantly increased NGRN competence, which has been linked to increased retention.3 Whether improvements in the NRP will impact nurse retention and sustain lower vacancy rates downstream is yet to be determined, but early findings are promising. In summary, at the onset of the NRP, a valuable partnership was established benefitting all parties involved. Areas of preceptor weakness were identified and successfully addressed in preparation for the NRP, although the improvement in preceptor competence wasn't statistically significant. However, NGRN competence did significantly improve from baseline after the NRP. The Casey-Fink survey indicated a favorable view of the NGRNs' transition experience and identified areas to target individualized education going forward. Finally, the facility's nursing vacancy rate improved, decreasing by more than half. In progress The costs of implementing and operating an NRP are considerable, but the expenses required to make impactful best-practice improvements to an existing NRP are far less substantial. With the exception of the simulation lab fees, the overall costs of the improvement project were minimal. Although simulation added to the costs, the long-term benefits of the relationship between the hospital and university, along with improved NGRN competence, were deemed a solid return on investment. The expense for the competence assessment tools and analysis of findings wasn't an additional cost to the improvement project because our parent company was already requiring us to use an outside company to measure new employee competence. A hospital interested in NGRN competence assessment but lacking the resources to engage an outside company can use other assessment instruments free of charge, such as the Casey-Fink survey or an internally developed tool. Nurse leaders in community hospitals with limited capital for NGRN recruitment and retention need to evaluate the in-house resources available to support NGRNs and strategize ways to optimize those resources. For example, the project team realized that a tactic as simple as involving various hospital departments in NGRNs' education can improve their interdepartmental knowledge and collaboration. We also learned that purposefully designed social and professional support activities are a far more productive use of lunch and breakfast hours than unstructured break times. Nurse leaders also need to consider looking beyond the four walls of the hospital for any available resources.7 Not every community hospital has access to a nearby university or nursing school, but other community resources may be available. For example, a long-term acute care facility may be willing to conduct educational in-services for NGRNs on how the facilities work collaboratively for safe care transitions. Learning from and partnering with sister hospitals can also serve as an excellent NRP improvement resource. Perhaps partnering with a sister hospital can allow for specialty training of NGRNs that one facility's NRP isn't equipped to provide. Even pharmaceutical and medical representatives may be willing to provide in-services on medications and equipment to increase NGRNs' knowledge about the nursing care they provide and further their understanding of how hospitals work with these entities. By identifying both the internal and external resources available, hospitals with limited capital to direct toward recruitment and retention of NGRNs can work smarter to increase nursing competence and support long-term retention.
<p>Background </p><p> Human resources for health are crucial for health system strengthening and achieving sustainable development goals and universal health coverage, but the shortage and maldistribution of health workers have been critical concerns in the Asia Pacific region. This study aimed to identify the key interventions on attracting and retaining rural health workers, understand their management structure, examine the effectiveness and analyze the contexts in the Asia Pacific region.</p><p>Methods </p><p> This mixed-method study used systematic review and country case studies to synthesize and analyze the available data. A systematic review on attraction and retention of rural health workers in the Asia Pacific region was conducted. Thirty-five, fourteen and nineteen studies were included for the interventions and their management structure, effectiveness and contexts, respectively. In-depth interviews of twenty-two key informants and gray literature recommended from the key informants in China, Vietnam and Cambodia were used to gather information for the country case studies. Narrative synthesis was applied to review and synthesize the extracted data from the systematic review and qualitative analysis using Nvivo 11 was conducted for the interviews.</p><p>Results </p><p> Five categories of interventions, involving education, regulation, financial incentives, personal and professional support and bundled interventions were implemented to attract and retain rural health workers in the Asia Pacific region. Regulatory interventions, such as MRBS, task shifting and compulsory rural services, were the key interventions reported in the systematic review. Although financial incentives were scarce in the systematic review, they were the key strategies in the country case studies of China, Vietnam and Cambodia. Asian Pacific countries also had their distinctive interventions, such as a system of compulsory rural services in Thailand, training on community health workers in Afghanistan, and a government midwifery incentive scheme in Cambodia. Geographically, the Pacific island countries were neglected. </p><p> Six categories of management structure of implementation were summarized. Decentralization from the central to the regional government was the dominant management structure. The regional government was responsible for program implementation in the decentralized programs, program development and implementation in the regional initiatives, which were more likely to be discovered in the countries and regions with strong economies. International donors were significant stakeholders for the low-income and post-conflict countries through providing financial and technical assistance. Several challenges emerged during implementation, including lack of rural eligible candidates, low and unsustainable financial incentives, complicated recruitment, poor management and deployment of HRH.</p><p> Although the majority of interventions lacked rigorous effectiveness evaluation or were without evaluation, most evaluated interventions demonstrated effectiveness in attracting and retaining rural health professionals. Some of the interventions also reported effectiveness in expanding health service coverage and improving health status. The regulatory interventions seemed to be more effective in attracting and retaining rural health workers through administrative and legislative enforcement. Bundled interventions were expected to be more effective and be more often recommended by the researchers and interviewees. </p><p> Various contexts, including political, economic and social factors and health system related issues, directly and indirectly impacted the attraction and retention of rural health workers. The political issues, economic development and social culture influenced rural HRH strengthening at the macro level while the health system reform pulled or pushed rural health workers. The promotion of rural health workers to be civil servants in Vietnam and Cambodia was a good motivation for rural health workers. The post mechanism in China, abolition of the referral system and increasing financial autonomy in the hospitals in Vietnam, the popular private sector, limited physical and human resources all served to push the health workers out of rural positions.</p><p>Conclusion </p><p> Due to great variation in economic development, Asian Pacific countries implemented three different patterns of interventions: 1) comprehensive packages in the high-income countries; 2) one or two categories of interventions in the low- and middle-income countries; and 3) training of community health workers in the post-conflict countries. Economic variation was also reflected in the differences of the management structure of implementation. The upper-middle- and high-income countries were likely to initiate regional interventions while the low-income countries partly relied on donations for HRH development and implementation, especially for the post-conflict countries. Although decentralization was widely applied to implementation, its implications were neglected and unclear. Based on the exclusive mechanism, effectiveness of each category of interventions varied. However, the regulatory interventions seemed be better. The socio-economic development significantly influenced interventions on attracting and retaining rural health workers. Rural HRH strengthening required strong economic support. Health financing reform for universal health coverage did impact the capacity building of rural health workforce. Further research was needed.</p>
Xiaoyun Liu, Lixia Dou, Huan Zhang, Yang Sun · 5 authors
BACKGROUND: Current literature systematically reports that interventions to attract and retain health workers in underserved areas need to be context specific but rarely defines what that means. In this systematic review, we try to summarize and analyse context factors influencing the implementation of interventions to attract and retain rural health workers. METHODS: We searched online databases, relevant websites and reference lists of selected literature to identify studies on compulsory rural service programmes and financial incentives. Forty studies were selected. Information regarding context factors at macro, meso and micro levels was extracted and synthesized. RESULTS: Macro-level context factors include political, economic and social factors. Meso-level factors include health system factors such as maldistribution of health workers, growing private sector, decentralization and health financing. Micro-level factors refer to the policy implementation process including funding sources, administrative agency, legislation process, monitoring and evaluation. CONCLUSIONS: Macro-, meso- and micro-level context factors can play different roles in agenda setting, policy formulation and implementation of health interventions to attract and retain rural health workers. These factors should be systematically considered in the different stages of policy process and evaluation.
James Kiarie, Carey Farquhar, Robert Redfield, Kefa O Bosire · 8 authors
Background: Lack and inequitable distribution of human resources for health (HRH) is a major health systems challenge in Sub-Saharan Africa.1,2 The Partnership for Innovative Medical Education for Kenya (PRIME-Kenya) is an innovative approach that seeks to strengthen health systems by increasing linkages and collaborations in health care, health education, and health research. This approach was informed by concerns of inadequate clinical exposure with increasing undergraduate student enrollment at a tertiary hospital; increasing demand for locally relevant health research; and the desire to retain health workers at nontertiary facilities during and after training. Intervention: We focused on three interventions as part of the PRIME-Kenya initiative: decentralized training of undergraduate students, building research capacity at 14 nontertiary health facilities, and a nurse training program based on an eLearning platform. Decentralized Training. We sought to improve medical education capacity at selected nontertiary health facilities by training facility staff that already had postgraduate clinical training by using e-resources (textbooks, guidelines, and online lectures). Staff that completed the training were appointed as adjunct faculty at the University of Nairobi (UoN). Building Research Capacity. We conducted two phases of implementation science research training. First, between December 2012 and August 2013, 354 staff (30â60 per facility) received three days of instruction at their facilities on how to develop research questions, write research proposals, and collect data. Second, in October and November 2013, 35 adjunct faculty (3â5 per facility) received two additional days of training during which they developed research proposals based on research questions developed during the first phase. These adjunct faculty will be mentored by UoN faculty to help them submit their proposals for ethics review, collect and analyze data, and disseminate results. eLearning. In 2012, the School of Nursing Sciences introduced an eLearning Bachelor of Nursing (eBScN) upgrading course for diploma-level nurses. Training is conducted in accredited county hospitals where students are supervised by UoN adjunct faculty. Outcomes: At 14 nontertiary health facilities, 182 adjunct faculty have been trained and 306 students have rotated. Adjunct faculty at 9 health facilities have developed draft research proposals covering various areas including the impact of national health financing policies, staff retention, and quality of services. At 28 county hospitals, 148 students are enrolled in the eBScN program, and initial exam results indicate that trainees are gaining expected knowledge and skills. Comment: According to the interviews, the students felt they had more opportunities to practice clinical skills, closer mentoring, and closer interactions with patients at the nontertiary facilities than at the tertiary hospital. Health workers at the nontertiary hospitals also reported improved quality of patient care, increased job satisfaction, and greater interest in research. Those working in the nontertiary health facilities prioritized research that was highly relevant to local practice and policy. In the eBScN training program, county hospitals have retained employees, and the nurses are upgrading their skills without losing income. This innovative approach is successfully addressing some of the HRH challenges in medical education, health care, and research. Acknowledgments: PRIME-Kenya Secretariat staff members included Collins Owek, Francis Njiri, Raphael Kinuthia, Samuel Runo, James Macharia, Wycliffe Ndege, Juliet Mwangi, Minnie Kibore, Linda Nyaga, Wycliffe Khaemba, Susan Wanja, and Luke D. Davies.
BACKGROUND: The Brazilian health reform process, following the establishment of the Unified Health System (SUS), has had a strong emphasis on decentralization, with a special focus on financing, management and inter-managerial agreements. Brazil is a federal country and the Ministry of Health (MoH), through the Secretary of Labour Management and Health Education, is responsible for establishing national policy guidelines for health labour management, and also for implementing strategies for the decentralization of management of labour and education in the federal states. This paper assesses whether the process of decentralizing human resources for health (HRH) management and organization to the level of the state and municipal health departments has involved investments in technical, political and financial resources at the national level. METHODS: The research methods used comprise a survey of HRH managers of states and major municipalities (including capitals) and focus groups with these HRH managers - all by geographic region. The results were obtained by combining survey and focus group data, and also through triangulation with the results of previous research. RESULTS: The results of this evaluation showed the evolution policy, previously restricted to the field of 'personnel administration', now expanded to a conceptual model for health labour management and education-- identifying progress, setbacks, critical issues and challenges for the consolidation of the decentralized model for HRH management. The results showed that 76.3% of the health departments have an HRH unit. It was observed that 63.2% have an HRH information system. However, in most health departments, the HRH unit uses only the payroll and administrative records as data sources. Concerning education in health, 67.6% of the HRH managers mentioned existing cooperation with educational and teaching institutions for training and/or specialization of health workers. Among them, specialization courses account for 61.4% and short courses for 56.1%. CONCLUSIONS: Due to decentralization, the HRH area has been restructured and policies beyond traditional administrative activities have been developed. However, twenty years on from the establishment of the SUS, there remains a low level of institutionalization in the HRH area, despite recent efforts of the MoH.
Abstract Papua New Guinea decentralized a wide range of health functions to provincial governments between 1977 and 1983. The national Department of Health (DOH) was given no role in provincial budget and staffing decisions, and the national health budget was fragmented into the health components of provincial budgets. The impact of decentralization on health workforce development was particularly severe and largely unforeseen. Many difficulties were inherent in the manner in which decentralization regulations structured power relationships. Others arose as a result of the administrative confusion and inflamed relationships that accompanied the forceful transfer of power from a very reluctant national DOH to the provinces. Even though policy formulation and planning were retained as national functions, decentralization hampered their effective execution. Human resource data bases deteriorated, responsibility for planning became confused, and the ability of the DOH to implement its planning decisions was compromised. In reality, health workforce planning was carried out by the Departments of Finance and Planning, and Personnel Management through the annual budgetary process of provincial financial limits and staff ceilings, without any attempt to assess health service needs, either in the country as a whole or between the provinces. Decentralization brought a need for new management skills, and it complicated administrative relationships between training institutions and the provinces. The Papua New Guinea experience has shown that in a decentralized health service, there is a great potential for conflict between national goals and the aspirations of individual provinces. To achieve an equitable, appropriate and effective staffing of services, standards must be formulated as the basis for planning and conflict resolution. Effective linkages between central government departments and between the national and provincial health authorities must be developed, and management and technical skills of health managers improved.