Increasing access to health workers in underserved areas: a conceptual framework for measuring results.

Many countries have developed strategies to attract and retain qualified health workers in underserved areas, but there is only scarce and weak evidence on their successes or failures. It is difficult to compare lessons and measure results from the few evaluations that are available. Evaluation faces several challenges, including the heterogeneity of the terminology, the complexity of the interventions, the difficulty of assessing the influence of contextual factors, the lack of baseline information, and the need for multi-method and multi-disciplinary approaches for monitoring and evaluation. Moreover, the social, political and economic context in which interventions are designed and implemented is rarely considered in monitoring and evaluating interventions for human resources for health. This paper proposes a conceptual framework that offers a model for monitoring and evaluation of retention interventions taking into account such challenges. The conceptual framework is based on a systems approach and aims to guide the thinking in evaluating an intervention to increase access to health workers in underserved areas, from its design phase through to its results. It also aims to guide the monitoring of interventions through the routine collection of a set of indicators, applicable to the specific context. It suggests that a comprehensive approach needs to be used for the design, implementation, monitoring, evaluation and review of the interventions. The framework is not intended to be prescriptive and can be applied flexibly to each country context. It promotes the use of a common understanding on how attraction and retention interventions work, using a systems perspective

Realizing universal health coverage for maternal health services in the Republic of Guinea: the use of workforce projections to design health labor market interventions

BACKGROUND: Universal health coverage requires a health workforce that is available, accessible, and well-performing. This article presents a critical analysis of the health workforce needs for the delivery of maternal and neonatal health services in Guinea, and of feasible and relevant interventions to improve the availability, accessibility, and performance of the health workforce in the country. METHODS: A needs-based approach was used to project human resources for health (HRH) requirements. This was combined with modeling of future health sector demand and supply. A baseline scenario with disaggregated need and supply data for the targeted health professionals per region and setting (urban or rural) informed the identification of challenges related to the availability and distribution of the workforce between 2014 and 2024. Subsequently, the health labor market framework was used to identify interventions to improve the availability and distribution of the health workforce. These interventions were included in the supply side modeling, in order to create a "policy rich" scenario B which allowed for analysis of their potential impact. RESULTS: In the Republic of Guinea, only 44% of the nurses and 18% of the midwives required for maternal and neonatal health services are currently available. If Guinea continues on its current path without scaling up recruitment efforts, the total stock of HRH employed by the public sector will decline by 15% between 2014 and 2024, while HRH needs will grow by 22% due to demographic trends. The high density of HRH in urban areas and the high number of auxiliary nurses who are currently employed pose an opportunity for improving the availability, accessibility, and performance of the health workforce for maternal and neonatal health in Guinea, especially in rural areas. CONCLUSION: Guinea will need to scale up its recruitment efforts in order to improve health workforce availability. Targeted labor market interventions need to be planned and executed over several decades to correct entrenched distortions and mismatches between workforce need, supply, and demand. The case of Guinea illustrates how to design and operationalize HRH interventions based on workforce projections to accompany and facilitate universal health coverage reforms

How to recruit and retain health workers in underserved areas: the Senegalese experience

PROBLEM: Significant regional disparities in human resources for health deployment in Senegal weaken the country's health system and compromise population health. APPROACH: In recent years, the Ministry of Health adopted measures to improve the posting, recruitment and retention of health workers in rural and remote areas. One was the introduction of a special contracting system to recruit health workers. LOCAL SETTING: Health workers in Senegal are concentrated in specific urban centres, particularly Dakar. Whereas the Dakar region has 0.2 physicians per 1000 population, the Fatick, Kaolack, Kolda and Matam regions have fewer than 0.04. The density of midwives and, to a lesser extent, of nurses also varies considerably among different regions in Senegal. RELEVANT CHANGES: Between 2006 and 2008, the introduction of the special contracting system contributed to the successful recruitment of health workers in remote and rural regions and the reopening of health outposts. LESSONS LEARNT: The introduction of a special contracting system for health workers was a successful approach to reopening health posts in regions with low health workforce density in Senegal. However, the long-term sustainability of such an approach, particularly in fiscal terms, must be considered, as a single policy intervention may not be enough to address the diverse and complex challenges in human resources for health facing different regions of Senegal

Career mobility of maternal care providers in Mali:a mixed method study on midwives and obstetric nurses

BACKGROUND: An important strategy to reduce maternal and child mortality in Mali is to increase the number of deliveries assisted by qualified personnel in primary care facilities, especially in rural areas. However, placements and retention of healthcare professionals in rural areas are a major problem, not only in Mali but worldwide, and are a challenge to the health sector. The purpose of this study was to map the mobility of midwives and obstetric nurses during their work lives, in order to better understand their career paths and the role that working in rural areas plays. This article contributes to the understanding of career mobility as a determinant of the retention of rural health professionals. METHODS: A mixed method study was conducted on 2005, 2010, and 2015 cohorts of midwives and obstetric nurses. The cohorts have been defined by their year of graduation. Quantitative data were collected from 268 midwives and obstetric nurses through questionnaires. Qualitative data had been gathered through semi-structured interviews from 25 midwives and stakeholders. A content analysis was conducted for the qualitative data. RESULTS: Unemployment rate was high among the respondents: 39.4% for midwives and 59.4% for obstetric nurses. Most of these unemployed nurses and midwives are working, but unpaid. About 80% of the employed midwives were working in urban facilities compared to 64.52% for obstetric nurses. Midwives were employed in community health centers (CSCom) (43%), referral health centers (CSRef) (20%), and private clinics and non-governmental organizations (NGO) (15%). The majority of midwives and obstetric nurses were working in the public sector (75.35%) and as civil servants (65.5%). The employment status of midwives and obstetric nurses evolved from private to public sector, from rural to urban areas, and from volunteer/unpaid to civil servants through recruitment competitions. Qualitative data supported the finding that midwives and obstetric nurses prefer to work as civil servant and preferably in urban areas and CSRef. CONCLUSION: The current mobility pattern of midwives and obstetric nurses that brings them from rural to urban areas and towards a civil servant status in CSRef shows that it is not likely to increase their numbers in the short term in places where qualified midwives are most needed

CORE GROUP Coordinator: Luc de Bernis

Country contributions: Many thanks to the heads of the UNFPA and WHO country offices, their staff, and the people that coordinated, completed, and verified responses to the State of the World’s Midwifery country survey. In particular, thanks to the country focal points

Assessment of Factors Associated with Morbidity and Textbook Outcomes of Laparoscopic Liver Resection in Obese Patients. A French Nationwide Study

BACKGROUND: Liver surgeons need to know the expected outcomes of laparoscopic liver resection (LLR) in obese patients.OBJECTIVE: The purpose of the present study is to assess morbidity, mortality and textbook outcomes (TO) after LLR in obese patients.METHODS: This is a French multicenter study of patients undergoing LLR between 1996 and 2018. Obesity was defined by a BMI at or above 30 kg/m(2). Short-term outcomes and TO were compared between obese (ob) and nonobese (non-ob) patients. Factors associated with severe morbidity and TO were investigated.RESULTS: Of 3,154 patients included, 616 (19.5%) were obese. Ob-group patients had significantly higher American Society of Anesthesiologists (ASA) score and higher incidence of metabolic syndrome and chronic liver disease and were less likely to undergo major hepatectomy. Mortality rates were similar between ob and non-ob groups (0.8 vs 1.1%; p = 0.66). Overall morbidity and hospital stay were significantly increased in the ob group compared with the non-ob group (39.4 vs 34.7%, p = 0.03; and 9.5 vs 8.6 days, p = 0.02), whereas severe 90-day morbidity (at or above Clavien-Dindo grade III) was similar between groups (8% in both groups; p = 0.90). TO rate was significantly lower for the ob group than the non-ob group (58.3 vs 63.7%; p = 0.01). In multivariate analysis, obesity did not emerge as a risk factor for severe 90-day morbidity but was associated with a lower TO rate after LLR (odds ratio = 0.8, 95% CI 0.7-1.0; p = 0.03).CONCLUSIONS: LLR in obese patients is safe and effective with acceptable mortality and morbidity. Obesity had no impact on severe morbidity but was a factor for failing to achieve TO after LLR. (C) 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved