Governing human resources for health in a global context - the case of the Republic of Malawi

Bredehorst M. Governing human resources for health in a global context - the case of the Republic of Malawi. Bielefeld: Universität Bielefeld; 2015.Background: At the beginning of the new millennium, Malawi receives international attention for its Human Resources for Health (HRH) crisis, together with 57 other developing countries identified in the World Health Report 2006. Poverty-related diseases including HIV/AIDS have added to the workload and perpetuated attrition from the Malawian health workforce. After president H.K. Banda’s 30 years of autocratic rule ended in 1994, the health labour market has also become increasingly international. Opportunities have opened up to find work and better payment either abroad or with private and non-governmental organisations. By 2009, a large-scale intervention of international donors is underway to re-strengthen HRH as a basis for delivering an essential health package to the Malawian population and reducing poverty. Starting from the idea of sustainable development that has evolved since the Rio Declaration 1994, the underlying assumption of this study is that qualified health work can be seen as a common-pool resource system. Commons theory suggests that self-organization and rule-setting by relevant actors could help to balance the appropriation and (re)production of a resource in a circumscribed system. This study investigates how the cooperation of Malawian and international employers can be regulated to achieve a well-performing and sustainable health workforce. Methodology: Malawi has been selected as the research site for a country case study based on qualitative and quantitative, primary and secondary data. A field research phase of six months in 2009 has been used for collecting text documents and statistics, and for conducting 25 expert interviews. Secondary data has been analysed to reconstruct the historically grown structures and conditions of HRH and international cooperation. Interview data has first been subjected to thematic analysis, with themes deducted from the UNDP capacity development framework. Relevant findings feed into an institutional analysis (Oakerson 2003; Ostrom 2005), looking at strategies, norms and rules applied to HRH in Malawi. The focus is on the district health system as an action arena, but other linked arenas are also considered. Results: The HRH system in Malawi shows warning signs of depletion, as reproduction through training cannot meet the domestic demand and compensate for attrition. Expectations to revert this trend are focused on the government and the Christian Health Association of Malawi (CHAM) as those who have historically been in charge of securing the availability of different cadres of health workers. At the same time, the appropriators of HRH (organisations acting as employers or contractors) have multiplied and diversified. This group is characterized by striking asymmetries regarding their dependence on HRH, their financial and technological endowments and their autonomy in decision making. International actors’ entry to and exit from the system is weakly regulated. As for the level of the health district, three basic strategies of international aid agencies emerge: (1) direct implementation of health-related activities, (2) implementation through the District Health Office as a governmental structure, (3) implementation through other Malawian organisations or consultants. Although HRH is a cross-cutting issue in health service provision, the interview statements hardly convey explicit rules concerning the inter-organisational cooperation on HRH appropriation and/or reproduction. Concepts of staff supervision and professional development continue to be geared towards control and hierarchy. Even when it comes to the zonal or national level, the special features of HRH - such as individual decision-making and mobility of health workers, their socio-cultural embeddedness and their capacity to organize – only begin to be addressed. Discussion: Human resources largely meet the economic attributes of a common-pool resource, namely subtractability, indivisibility and limited excludability. As such, it appears promising to apply governance concepts to HRH which have originally been devised for sustaining natural resources. However, compared against the sustainability criteria named in commons theory, the findings for Malawi (together with the political developments since 2009) do not give rise to optimism. New forms of governance in this field are likely to be inhibited by the degree of deterioration of the HRH system and the existing incentive structures, the difficulties of monitoring, a lack of trust and reciprocity among the different actors and low levels of autonomy from external forces. At the same time, the study has revealed some potential points of intervention if collective rule setting at the level of the health district is to be enabled, involving local and global, governmental and non-governmental actors. Political decentralisation appears to have reached a new phase in Malawi, with the local elections finally conducted in 2014. The district assemblies and the Zonal Health Support Offices may take responsibilities with regard to monitoring and conflict resolution in the HRH system. The increasing frequency of strikes among health workers also underlines the need for clearer regulative frameworks at the constitutional level in Malawi, providing for new actor constellations and a new understanding of HRH

Correlates of depressive symptoms among Latino and Non-Latino White adolescents: Findings from the 2003 California Health Interview Survey

BACKGROUND: The prevalence of depression is increasing not only among adults, but also among adolescents. Several risk factors for depression in youth have been identified, including female gender, increasing age, lower socio-economic status, and Latino ethnic background. The literature is divided regarding the role of acculturation as risk factor among Latino youth. We analyzed the correlates of depressive symptoms among Latino and Non-Latino White adolescents residing in California with a special focus on acculturation. METHODS: We performed an analysis of the adolescent sample of the 2003 California Health Interview Survey, which included 3,196 telephone-interviews with Latino and Non-Latino White adolescents between the ages of 12 and 17. Depressive symptomatology was measured with a reduced version of the Center for Epidemiologic Studies Depression Scale. Acculturation was measured by a score based on language in which the interview was conducted, language(s) spoken at home, place of birth, number of years lived in the United States, and citizenship status of the adolescent and both of his/her parents, using canonical principal component analysis. Other variables used in the analysis were: support provided by adults at school and at home, age of the adolescent, gender, socio-economic status, and household type (two parent or one parent household). RESULTS: Unadjusted analysis suggested that the risk of depressive symptoms was twice as high among Latinos as compared to Non-Latino Whites (10.5% versus 5.5 %, p < 0.001). The risk was slightly higher in the low acculturation group than in the high acculturation group (13.1% versus 9.7%, p = 0.12). Similarly, low acculturation was associated with an increased risk of depressive symptoms in multivariate analysis within the Latino subsample (OR 1.54, CI 0.97–2.44, p = 0.07). Latino ethnicity emerged as risk factor for depressive symptoms among the strata with higher income and high support at home and at school. In the disadvantaged subgroups (higher poverty, low support at home and at school) Non-Latino Whites and Latinos had a similar risk of depressive symptoms. CONCLUSION: Our findings suggest that the differences in depressive symptoms between Non-Latino Whites and Latino adolescents disappear at least in some strata after adjusting for socio-demographic and social support variables

Challenges of audit of care on clinical quality indicators for hypertension and type 2 diabetes across four European countries

BACKGROUND: The purpose of the study was to measure clinical quality by doing an audit of clinical records and to compare the performance based on clinical quality indicators (CQI) for hypertension and type 2 diabetes across seven European countries: Estonia, Finland, Germany, Hungary, Italy, Lithuania and Spain. METHODS: Two common chronic conditions in primary care (PC), hypertension and type 2 diabetes, were selected for audit. The assessment of CQI started with a literature review of different databases: Organization for Economic Co-operation and Development, World Health Organization, European Commission European Community Health Indicators, US National Library of Medicine. Data were collected from clinical records. RESULTS: Although it was agreed to obtain the clinical indicators in a similar way from each country, the specific data collection process in every country varied greatly, due to different traditions in collecting and keeping the patients' data, as well as differences in regulation regarding access to clinical information. Also, there was a huge variability across countries in the level of compliance with the indicators. CONCLUSIONS: Measurement of clinical performance in PC by audit is methodologically challenging: different databases provide different information, indicators of quality of care have insufficient scientific proof and there are country-specific regulations. There are large differences not only in quality of health care across Europe but also in how it is measured.EU primecare project was funded under the European Commission’s 7th Framework Programme (grant no. 241595).S

Recommendations for the primary prevention of atherosclerotic cardiovascular disease in primary care: study protocol for a systematic guideline review

Schürmann L, Bredehorst M, González González AI, et al. Recommendations for the primary prevention of atherosclerotic cardiovascular disease in primary care: study protocol for a systematic guideline review. BMJ Open. 2023;13(12): e074788.INTRODUCTION: Atherosclerotic cardiovascular disease (ASCVD) was the main cause of death in Germany in 2021, with major risk factors (ie, hypertension, diabetes, dyslipidaemia, obesity and certain lifestyle factors) being highly prevalent. Preventing ASCVD by assessment and modification of these risk factors is an important challenge for general practitioners. This study aims to systematically review and synthesise recent recommendations of national and international guidelines regarding the primary prevention of ASCVD in adults in primary care.; METHODS AND ANALYSIS: We will conduct a systematic review of clinical practice guidelines (CPGs) to evaluate primary prevention strategies for ASCVD. CPGs will be retrieved from MEDLINE and the Turning Research Into Practice database, guideline-specific databases and websites of guidelines-producing societies, with searches limited to publications from 2016 onwards. We will include CPGs in English, Spanish, German or Dutch languages that provide evidence-based recommendations for ASCVD prevention. The study population will include adults without diagnosed ASCVD. Two independent reviewers will assess guideline eligibility and quality by means of the mini-checklist MiChe, and extract study characteristics and relevant recommendations for further consistency analysis. A third reviewer will resolve disagreements. Findings will be presented as a narrative synthesis and in tabular form.; ETHICS AND DISSEMINATION: This review does not require ethical approval. Our systematic review will inform the CPG of the German College of General Practitioners and Family Physicians on the primary prevention of ASCVD. The review results will also be disseminated through publications in peer-reviewed journals and presentations at local, national and international conferences.; PROSPERO REGISTRATION NUMBER: CRD42023394605. © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ