Determining the causes for the shortage of human resources for primary health care in Botswana and developing a pilot intervention to address the problem

[摘要] ENGLISH SUMMARY : The global policy on universal health coverage is a commitment to ensuring that all people have access to comprehensive health services without suffering financial hardship. Furthermore, primary healthcare has been recognised as a vehicle to achieving equitable access to comprehensive and cost effective health services. Effective primary healthcare services in many low– and middle-income countries, however, have been hampered by severe shortages and inequitable distribution of the health workforce. Internal migration of health workers from rural to urban areas and from public to private or non-governmental organisations, coupled with regional and international migrations, have exacerbated the shortage and inequity in many of these countries.Multiple strategies have been employed to address the shortage of healthcare workers with varying degrees of success. These include training, fiscal, regulatory and professional or personal support. Thse strategies concur with the World Health Organisation's policy recommedations for the retention of healthcare workers in rural and remote areas.The causes of shortages in human resources for health are many and complex and effective mitigating strategies should therefore be comprehensive and context-specific and derived from an adequate understanding of the context. Although Botswana is reported to have a shortage of human resources for health, which is worse in rural areas and primary health care, there is a paucity of readily-accessible, integrated and comprehensive information on human resources for health. Moreover, there has not been any research to determine the cause(s) of the shortage which negates evidence based interventions.A situational analysis of the human resources for primary health care in Botswana was conducted using an analysis of the existing databases as well as conducting focus group discussions with health care workers, the community and policy makers in three health districts. The findings of the situational analysis then informed the subsequent intervention: creating more supportive health management for primary healthcare workers using a cooperative inquiry group method. The cooperative inquiry group, based on what they learnt from the inquiry, developed a consensus on the prerequisites for effective supportive supervision.This thesis has quantified the numbers of healthcare workers in the primary and hospital care as well as rural and urban areas. It has elucidated the perceived causes of the shortage of healthcare workers as well as potential solutions. It has also highlighted the need for Botswana to explore how to implement the World Health Organisation's policy recommendations for retention of healthcare workers which were deemed to be inadequately addressed.This is a thesis by publication.The abstracts of the four articles are given below:Article number 1: Human resources for health in Botswana: the results of in-country database and reports analysisBackground: Botswana is a large middle-income country in Southern Africa with a population of just over two million. Shortage of human resources for health is blamed for the inability to provide high quality accessible health services. There is however a lack of integrated, comprehensive and readily-accessible data on the health workforce.Aim: The aim of this study was to analyse the existing databases on health workforce in Botswana in order to quantify the human resources for health.Method: The Department of Policy, Planning, Monitoring and Evaluation at the Ministry of Health, Ministry of Education and Skills Development, the Botswana Health Professions Council, the Nursing and Midwifery Council of Botswana and the in-country World Health Organization office provided raw data on human resources for health in Botswana.Results: The densities of doctors and nurses per 10 000 population were four and 42, respectively; three and 26 for rural districts; and nine and 77 for urban districts. The average vacancy rate in 2007/2008 was 5% and 13% in primary and hospital care, respectively, but this is projected to increase to 53% and 43%, respectively, in 2016. Only 21% of the doctors registered with the Botswana Health Professions Council were from Botswana, the rest being mainly from other African countries. Before 2009 doctors were trained at regional and international medical schools. Nonetheless Botswana trained 77% of its health workforce locally.Conclusion: Although the density of health workers is relatively high compared to the region, they are concentrated in urban areas, insufficient to meet the projected requirements and reliant on migrant professionals.Article number 2: Stakeholders' perceptions on shortage of healthcare workers in primary healthcare in Botswana: focus group discussionsBackground: An adequate health workforce force is central to universal health coverage and positive public health outcomes. However many African countries, including Botswana, have critical shortages of healthcare workers, which are worse in primary healthcare. The aim of this study was to explore the perceptions of healthcare workers, policy makers and the community on the shortage of healthcare workers in Botswana.Method: Fifteen focus group discussions were conducted with three groups of policy makers, six groups of healthcare workers and six groups of community members in rural, urban and remote rural health districts of Botswana. All the participants were 18 years and older. Recruitment was purposive and the framework method was used to inductively analyse the data.Results: There was a perceived shortage of healthcare workers in primary healthcare, which was believed to result from an increased need for health services, inequitable distribution of healthcare workers, migration and too few such workers being trained. Migration was mainly the result of unfavourable personal and family factors, weak and ineffective healthcare and human resources management, low salaries and inadequate incentives for rural and remote area service.Conclusions: Botswana has a perceived shortage of healthcare workers, which is worse in primary healthcare and rural areas, as a result of multiple complex factors. To address the scarcity the country should train adequate numbers of healthcare workers and distribute them equitably to sufficiently resourced healthcare facilities.Article number 3: Understanding the organisational culture of district health services: Mahalapye and Ngamiland Health Districts of BotswanaBackground: Botswana has a shortage of healthcare workers, especially in primary health care. Retention and high performance of employees however is closely linked to job satisfaction and motivation which are both highest where employees' personal values and goals are realised.Aim: The aim of the study was to evaluate the organisational culture of the district health services as experienced by the primary healthcare workers.Setting: The study was conducted in the Ngamiland and Mahalapye health districtsMethod: This was a cross-sectional survey. The participants were asked to select ten values that best described their personal, current organisational and desired organisational values from a predetermined list.Results: 60 and 67 healthcare workers completed the survey in Mahalapye and Ngamiland districts, respectively. Eight of the top ten prevalent organisational values were common to both districts: teamwork, blame, patient satisfaction, blame, confusion, job insecurity, not sharing information and manipulation. When all the current values were assessed 32% (Mahalapye) and 36% (Ngamiland) selected by healthcare workers, were potentially limiting organisational effectiveness. The organisational values desired by healthcare workers in both districts were: transparency, professional growth, staff recognition, shared decision-making, accountability, productivity, leadership development and teamwork.Conclusions: The experience of the primary healthcare workers in the two health districts were overwhelmingly negative which is likely to contribute to low levels of motivation, job satisfaction, productivity and high attrition rates. There is an urgent need for organisational transformation with a focus on staff experience and leadership development at all levels of the health system in Botswana.Article number 4: How to create more supportive supervision for primary healthcare: lessons from Ngamiland district of Botswana: Co-operative inquiry group Background: Supportive supervision is a way to foster performance, productivity, motivation and retention of health workforce. Nevertheless there is a dearth of evidence of the impact and acceptability of supportive supervision in low- and middle-income countries. This article describes a participatory process of transforming the supervisory practice of district health managers to create a supportive environment for primary healthcare workers.Objective: The objective of the study was to explore how district health managers can change their practice to create a more supportive environment for primary healthcare providers.Methods: A facilitated cooperative inquiry group was formed with Ngamiland health district managers. Cooperative inquiry group belongs to the participatory action research paradigm and is characterised by a cyclic process of observation, reflection, planning and action. The cooperative inquiry group went through three cycles between March 2013 and March 2014.Results: 12 district health managers participated in the inquiry group. The major insights and learning that emerged from the inquiry process included inadequate supervisory practice, perceptions of healthcare workers' experiences; change in the managers' supervision paradigm, recognition of the supervisors' inadequate supervisory skills and barriers to supportive supervision. Finally, the group developed a 10-point consensus on what they had learnt regarding supportive supervision.Conclusion: Ngamiland health district managers have come to appreciate the value of supportive supervision and changed their management style to be more supportive of their subordinates. They also developed a consensus on supportive supervision that could be adapted for use nationally. Supportive supervision should be prioritised at all levels of the health system and it should be adequately resourced.

[发布机构] Stellenbosch University