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1.  Estimating the costs of school closure for mitigating an influenza pandemic 
BMC Public Health  2008;8:135.
School closure is a key component of many countries' plans to mitigate the effect of an influenza pandemic. Although a number of studies have suggested that such a policy might reduce the incidence, there are no published studies of the cost of such policies. This study attempts to fill this knowledge gap
School closure is expected to lead to significant work absenteeism of working parents who are likely to be the main care givers to their dependent children at home. The cost of absenteeism due to school closure is calculated as the paid productivity loss of parental absenteeism during the period of school closure. The cost is estimated from societal perspective using a nationally representative survey.
The results show that overall about 16% of the workforce is likely to be the main caregiver for dependent children and therefore likely to take absenteeism. This rises to 30% in the health and social care sector, as a large proportion of the workforce are women. The estimated costs of school closure are significant, at £0.2 bn – £1.2 bn per week. School closure is likely to significantly exacerbate the pressures on the health system through staff absenteeism.
The estimates of school closure associated absenteeism and the projected cost would be useful for pandemic planning for business continuity, and for cost effectiveness evaluation of different pandemic influenza mitigation strategies.
PMCID: PMC2377259  PMID: 18435855
2.  Registered nurses in Israel - workforce employment characteristics and projected supply 
Surveys of nursing supplies around the world have furnished a better understanding of the structure of the workforce, helped identify shortages, and plan professional training. This study aimed to examine the employment and workforce characteristics of registered nurses and the projected supply in Israel as a tool for planning.
1. A survey of a national sample of 10% of the RNs of working age (3,200 nurses). 2. Analysis of administrative data from the Ministry of Health' Nursing Division and the Central Bureau of Statistics.
Most registered nurses are employed (89%) - 67% work full time. The workforce is mature (45% are above 45), trained (55% qualified beyond the basic course, 48% hold a BA, 18% hold an MA or PhD), and stable: few quit the profession altogether. The likelihood of "survival" in the profession after 10 years is 93%; after 20 years - 88%. 23% have made some transition in the last 10 years (most - a single transition). Most of the transitions are from hospital to community work. Supply projections show a decrease in the total number of RNs in the nursing workforce from 28,500 in 2008 to 21,201 in 2028 - i.e., of 25% by the end of the period. As for the ratio per 1,000 population, the drop is from 4 registered nurses/1,000 in 2008 to 2/1,000 in 2028.
The study findings provide more rigorous projections of supply than in the past on the declining rates of the nursing workforce in the coming decades, and contribute to decision making about the scope of training and recruitment. The study also points to the implications for policy decisions regarding the findings that the young nursing workforce is less stable, that there are advantages to recruiting a more mature workforce, and that post-basic education is connected with workforce stability.
PMCID: PMC3424825  PMID: 22913612
3.  Current dilemmas in overseas doctors' training 
Postgraduate Medical Journal  2005;81(952):79-82.
International medical graduates (IMGs) are a remarkably successful professional group in the United Kingdom making up to 30% of the NHS work force. Their very success and media publicity about general practice and consultant shortages, has led to a large influx of inexperienced doctors seeking training opportunities in competitive specialties. In 2003 a record 15 549 doctors joined the medical register of which 9336 doctors were non-European Economic Area citizens. The number of candidates sitting PLAB part 1 and part 2 in 2003 rose by 267% and 283% respectively compared with 2001. Changes to Department of Health, Home Office, and deanery regulations with expansion of medical schools, implementation of European Working Time Directive, Modernising Medical Careers, and the future role of the Postgraduate Medical Education and Training Board, will have an important impact on IMGs' training. Dissemination of realistic information about postgraduate training opportunities is important as the NHS for some time will continue to rely on IMGs.
PMCID: PMC1743197  PMID: 15701736
4.  Ten years of health workforce planning in the Netherlands: a tentative evaluation of GP planning as an example 
In many countries, health-care labour markets are constantly being challenged by an alternation of shortage and oversupply. Avoiding these cyclic variations is a major challenge. In the Netherlands, a workforce planning model has been used in health care for ten years.
Case description
Since 1970, the Dutch government has explored different approaches to determine the inflow in medical schools. In 2000, a simulation model for health workforce planning was developed to estimate the required and available capacity of health professionals in the Netherlands. In this paper, this model is explained, using the Dutch general practitioners as an example. After the different steps in the model are clarified, it is shown how elements can be added to arrive at different versions of the model, or ‘scenarios’. A comparison is made of the results of different scenarios for different years. In addition, the subsequent stakeholder decision-making process is considered.
Discussion and evaluation
Discussion of this paper shows that workforce planning in the Netherlands is a complex modelling task, which is sensitive to different developments influencing the balance between supply and demand. It seems plausible that workforce planning has resulted in a balance between supply and demand of general practitioners. Still, it remains important that the modelling process is accepted by the different stakeholders. Besides calculating the balance between supply and demand, there needs to be an agreement between the stakeholders to implement the advised training inflow.
The Dutch simulation model was evaluated using six criteria to be met by models suitable for policy objectives. This model meets these criteria, as it is a comprehensive and parsimonious model that can include all relevant factors.
Over the last decade, health workforce planning in the Netherlands has become an accepted instrument for calculating the required supply of health professionals on a regular basis. One of the strengths of the Dutch model is that it can be used for different types of medical and allied health professionals. A weakness is that the model is not yet fully capable of including substitutions between different medical professions to plan from a skill-mix perspective. Several improvements remain possible.
PMCID: PMC3465184  PMID: 22888974
5.  Current Status of Cardiac Surgery Allied Health Professionals in Asia 
More and more allied health professions are getting involved in clinical health care. One estimate reported allied health personnel makes up 60 percent of the total health workforce. In Asia, in the field of cardiothoracic surgery, allied health personnel includes perfusionists, physician assistants, physiotherapist, intensivists, rehabilitation therapists, nutritionists and social workers. They work in collaboration with surgeons to provide a range of diagnostic, technical, therapeutic, cardiac care and support services to the patients and their families.
Some allied health professions are more specialized. They must adhere to national training and education standards and their professional scope of practice. For example, the training of perfusionists consists of at least five years of academic in medical schools and another three-year-long clinical training in the hospital. The cardiac intensivists usually are medical doctors with a background in cardiology. They spend 3-4 years rotating in Internal Medicine, Anesthesiology, Emergency Rooms and Intensive Care Units. There have specialized medical societies to grant certified credentials and to provide continuing education. Other allied health professions require no special training or credentials and are trained for their work by the hospitals through on-the-job training.
Many young health care providers are getting involved in the allied health personnel projects. They consider this as a career ladder because of the opportunities for advancement within specific fields.
PMCID: PMC3563439  PMID: 23440019
cardiac surgery; allied health professionals; perfusion; nursing
6.  Balancing Risk Prevention and Health Promotion: Towards a Harmonizing Approach in Care for Older People in the Community 
Health Care Analysis  2012;22:82-102.
Many older people in western countries express a desire to live independently and stay in control of their lives for as long as possible in spite of the afflictions that may accompany old age. Consequently, older people require care at home and additional support. In some care situations, tension and ambiguity may arise between professionals and clients whose views on risk prevention or health promotion may differ. Following Antonovsky’s salutogenic framework, different perspectives between professionals and clients on the pathways that lead to health promotion might lead to mechanisms that explain the origin of these tensions and how they may ultimately lead to reduced responsiveness of older clients to engage in care. This is illustrated with a case study of an older woman living in the community, Mrs Jansen, and her health and social care professionals. The study shows that despite good intentions, engagement, clear division of tasks and tailored care, the responsiveness to receive care can indeed not always be taken for granted. We conclude that to harmonize differences in perspectives between professionals and older people, attention should be given to the way older people endow meaning to the demanding circumstances they encounter (comprehensibility), their perceived feelings of control (manageability), as well as their motivation to comprehend and manage events (meaningfulness). Therefore, it is important that both clients and professionals have an open mind and attempt to understand each others’ perspective, and have a dialogue with each other, taking the life narrative of clients into account.
PMCID: PMC3921446  PMID: 22228192
Health promotion; Risk prevention; Narratives; Older people; Salutogenesis; Sense of coherence
7.  Sick but yet at work. An empirical study of sickness presenteeism 
STUDY OBJECTIVE—The study is an empirical investigation of sickness presenteeism in relation to occupation, irreplaceability, ill health, sickness absenteeism, personal income, and slimmed down organisation.
DESIGN—Cross sectional design.
SETTING—Swedish workforce.
PARTICIPANTS—The study group comprised a stratified subsample of 3801 employed persons working at the time of the survey, interviewed by telephone in conjunction with Statistics Sweden's labour market surveys of August and September 1997. The response rate was 87 per cent.
MAIN RESULTS—A third of the persons in the total material reported that they had gone to work two or more times during the preceding year despite the feeling that, in the light of their perceived state of health, they should have taken sick leave. The highest presenteeism is largely to be found in the care and welfare and education sectors (nursing and midwifery professionals, registered nurses, nursing home aides, compulsory school teachers and preschool/primary educationalists. All these groups work in sectors that have faced personnel cutbacks during the 1990s). The risk ratio (odds ratio (OR)) for sickness presenteeism in the group that has to re-do work remaining after a period of absence through sickness is 2.29 (95% CI 1.79, 2.93). High proportions of persons with upper back/neck pain and fatigue/slightly depressed are among those with high presenteeism (p< 0.001). Occupational groups with high sickness presenteeism show high sickness absenteeism (ρ = 0.38; p<.01) and the hypothesis on level of pay and sickness presenteeism is also supported (ρ = −0.22; p<0.01).
CONCLUSIONS—Members of occupational groups whose everyday tasks are to provide care or welfare services, or teach or instruct, have a substantially increased risk of being at work when sick. The link between difficulties in replacement or finding a stand in and sickness presenteeism is confirmed by study results. The categories with high sickness presenteeism experience symptoms more often than those without presenteeism. The most common combination is low monthly income, high sickness absenteeism and high sickness presenteeism.

Keywords: sickness presenteeism; sickness absenteeism; ill health
PMCID: PMC1731716  PMID: 10846192
8.  Are residential and nursing homes adequately screening overseas healthcare workers? 
BMC Research Notes  2008;1:62.
There has been significant growth in the number of healthcare workers born outside the UK or recruited to the UK from countries with a high prevalence of TB, Hepatitis and other blood borne infections. Government policy recognises the need for occupational health procedures to facilitate treatment for these individuals and to reduce the risk of transmission of disease to patients.
The aim of this study was to undertake a survey of nursing and residential homes in South East England, to assess whether homes had occupational health screening policies for healthcare workers who have originated from overseas, and what level of occupational health screening had been undertaken on these employees.
An anonymous survey was sent to all 500 homes in West Sussex assessing occupational health practices for "overseas health care workers", defined as health care workers who had been born outside the UK.
Only one employer (0.8%) reported they had an occupational health screening policy specific for healthcare workers who originate from overseas. Over 80% of homes who had recruited directly had no evidence of screening results for HIV, TB, Hepatitis B and C. The commonest countries of origin for staff were the UK, Philippines, Poland, South Africa, Zimbabwe, and India.
This study suggests that screening of overseas healthcare workers is not routine practice for residential or nursing care homes and requires further input from Primary Care Trust's, Health Care Commission, Commission for Social Care Inspection, and Professional bodies.
PMCID: PMC2527002  PMID: 18710515
9.  Issues facing the future health care workforce: the importance of demand modelling 
This article examines issues facing the future health care workforce in Australia in light of factors such as population ageing. It has been argued that population ageing in Australia is affecting the supply of health care professionals as the health workforce ages and at the same time increasing the demand for health care services and the health care workforce.
However, the picture is not that simple. The health workforce market in Australia is influenced by a wide range of factors; on the demand side by increasing levels of income and wealth, emergence of new technologies, changing disease profiles, changing public health priorities and a focus on the prevention of chronic disease. While a strong correlation is observed between age and use of health care services (and thus health care workforce), this is mediated through illness, as typified by the consistent finding of higher health care costs in the months preceding death.
On the supply side, the health workforce is highly influenced by policy drivers; both national policies (eg funded education and training places) and local policies (eg work place-based retention policies). Population ageing and ageing of the health workforce is not a dominant influence. In recent years, the Australian health care workforce has grown in excess of overall workforce growth, despite an ageing health workforce. We also note that current levels of workforce supply compare favourably with many OECD countries. The future of the health workforce will be shaped by a number of complex interacting factors.
Market failure, a key feature of the market for health care services which is also observed in the health care labour market – means that imbalances between demand and supply can develop and persist, and suggests a role for health workforce planning to improve efficiency in the health services sector. Current approaches to health workforce planning, especially on the demand side, tend to be highly simplistic. These include historical allocation methods, such as the personnel-to-population ratios which are essentially circular in their rationale rather than evidence-based. This article highlights the importance of evidence-based demand modelling for those seeking to plan for the future Australian health care workforce. A model based on population health status and best practice protocols for health care is briefly outlined.
PMCID: PMC2685808  PMID: 19422686
10.  Nongovernmental Organizations in Musculoskeletal Care: Orthopaedics Overseas 
Injuries are a major worldwide contributor to morbidity and mortality. The negative impact caused by such injuries is disproportionately heavy in developing countries. Such disparities are caused by a complex array of problems, including a lack of physical resources, poor infrastructure, and a shortage of trained health professionals. Overcoming such deficits in care will require the involvement of organizations that can offer broad-based solutions. These organizations must bridge the gap between private and public institutions to establish a systems-based approach to program development and institution-building. They must provide not just an adequate level of care, but a transfer of knowledge that leads to sustainable and cost-effective intervention. Orthopedics Overseas is an example of such an organization. We examine the development of Orthopedics Overseas and describe their interventions in Uganda as a case-study to show the unique position they have to affect change.
PMCID: PMC2584283  PMID: 18685907
11.  Analysis of the Literature Pertaining to the Education of Public Health Professionals 
A well-educated workforce is essential to the infrastructure of a public health system (1). At a time when global focus on public health is increasing, a severe shortage of public health professionals is projected (2). A strong educational framework is thus imperative to ensure the capacity and capability of the worldwide public health workforce for the future. The education of those who work in public health is spread across disciplines, subject-specific training programs and types of academic institutions. In the 2011 report on the Health Professionals for a New Century, Frenk and Chen comment that, compared to medicine and nursing, public health has done the least to examine what and how it teaches (3). This does not bode well for meeting the demands of the public health workforce for the future. The purpose of the study reported here is to analyze the state of pedagogy pertaining to the education of the public health workforce as evidenced by published literature. The focus is on “professionals,” defined as those who have formal education, are self-governing, and can work independently.
PMCID: PMC3859983  PMID: 24350216
education of the public health workforce; public health workforce pedagogy; literature on public health pedagogy; literature on education of public health professionals; public health professionals’ education
12.  Tracking the Workforce: The American Society of Clinical Oncology Workforce Information System 
Reports generated by the workforce information system can be used by ASCO and others in the oncology community to advocate for needed health care system and policy changes to help offset future workforce shortages.
In anticipation of oncologist workforce shortages projected as part of a 2007 study, the American Society of Clinical Oncology (ASCO) worked with a contractor to create a workforce information system (WIS) to assemble the latest available data on oncologist supply and cancer incidence and prevalence. ASCO plans to publish findings annually, reporting on new data and tracking trends over time.
The WIS report is composed of three sections: supply, new entrants, and cancer incidence and prevalence. Tabulations of the number of oncologists in the United States are derived mainly from the American Medical Association Physician Masterfile. Information on fellows and residents in the oncology workforce pipeline come from published sources such as Journal of the American Medical Association. Incidence and prevalence estimates are published by the American Cancer Society and National Cancer Institute.
The WIS reports a total of 13,084 oncologists working in the United States in 2011. Oncologists are defined as those physicians who designate hematology, hematology/oncology, or medical oncology as their specialty. The WIS compares the characteristics of these oncologists with those of all physicians and tracks emerging trends in the physician training pipeline.
Observing characteristics of the oncologist workforce over time allows ASCO to identify, prioritize, and evaluate its workforce initiatives. Accessible figures and reports generated by the WIS can be used by ASCO and others in the oncology community to advocate for needed health care system and policy changes to help offset future workforce shortages.
PMCID: PMC3545660  PMID: 23633965
13.  Retention of allied health professionals in rural New South Wales: a thematic analysis of focus group discussions 
Uneven distribution of the medical workforce is globally recognised, with widespread rural health workforce shortages. There has been substantial research on factors affecting recruitment and retention of rural doctors, but little has been done to establish the motives and conditions that encourage allied health professionals to practice rurally. This study aims to identify aspects of recruitment and retention of rural allied health professionals using qualitative methodology.
Six focus groups were conducted across rural NSW and analysed thematically using a grounded theory approach. The thirty allied health professionals participating in the focus groups were purposively sampled to represent a range of geographic locations, allied health professions, gender, age, and public or private work sectors.
Five major themes emerged: personal factors; workload and type of work; continuing professional development (CPD); the impact of management; and career progression. ‘Pull factors’ favouring rural practice included: attraction to rural lifestyle; married or having family in the area; low cost of living; rural origin; personal engagement in the community; advanced work roles; a broad variety of challenging clinical work; and making a difference. ‘Push factors’ discouraging rural practice included: lack of employment opportunities for spouses; perceived inadequate quality of secondary schools; age related issues (retirement, desire for younger peer social interaction, and intention to travel); limited opportunity for career advancement; unmanageable workloads; and inadequate access to CPD. Having competent clinical managers mitigated the general frustration with health service management related to inappropriate service models and insufficient or inequitably distributed resources. Failure to fill vacant positions was of particular concern and frustration with the lack of CPD access was strongly represented by informants.
While personal factors affecting recruitment and retention of allied health study participants were similar to doctors, differences also existed. Allied health professionals were attracted by advanced work roles in a context of generalist practice. Access to CPD and inequitable resource distribution were strong ‘push’ factors in this group. Health policy based on the assumption of transferability between professions may be misguided.
PMCID: PMC3479013  PMID: 22726758
14.  The role of wages in the migration of health care professionals from developing countries 
Several countries are increasingly relying on immigration as a means of coping with domestic shortages of health care professionals. This trend has led to concerns that in many of the source countries – especially within Africa – the outflow of health care professionals is adversely affecting the health care system. This paper examines the role of wages in the migration decision and discusses the likely effect of wage increases in source countries in slowing migration flows.
This paper uses data on wage differentials in the health care sector between source country and receiving country (adjusted for purchasing power parity) to test the hypothesis that larger wage differentials lead to a larger supply of health care migrants. Differences in other important factors affecting migration are discussed and, where available, data are presented.
There is little correlation between the supply of health care migrants and the size of the wage differential between source and destination country. In cases where data are available on other factors affecting migration, controlling for these factors does not affect the result.
At current levels, wage differentials between source and destination country are so large that small increases in health care wages in source countries are unlikely to affect significantly the supply of health care migrants. The results suggest that non-wage instruments might be more effective in altering migration flows.
PMCID: PMC419378  PMID: 15115549
15.  The contribution of Physician Assistants in primary care: a systematic review 
Primary care provision is important in the delivery of health care but many countries face primary care workforce challenges. Increasing demand, enlarged workloads, and current and anticipated physician shortages in many countries have led to the introduction of mid-level professionals, such as Physician Assistants (PAs). Objective: This systematic review aimed to appraise the evidence of the contribution of PAs within primary care, defined for this study as general practice, relevant to the UK or similar systems.
Medline, CINAHL, PsycINFO, BNI, SSCI and SCOPUS databases were searched from 1950 to 2010. Eligibility criteria: PAs with a recognised PA qualification, general practice/family medicine included and the findings relevant to it presented separately and an English language journal publication. Two reviewers independently identified relevant publications, assessed quality using Critical Appraisal Skills Programme tools and extracted findings. Findings were classified and synthesised narratively as factors related to structure, process or outcome of care.
2167 publications were identified, of which 49 met our inclusion criteria, with 46 from the United States of America (USA). Structure: approximately half of PAs are reported to work in primary care in the USA with good support and a willingness to employ amongst doctors. Process: the majority of PAs’ workload is the management of patients with acute presentations. PAs tend to see younger patients and a different caseload to doctors, and require supervision. Studies of costs provide mixed results. Outcomes: acceptability to patients and potential patients is consistently found to be high, and studies of appropriateness report positively. Overall the evidence was appraised as of weak to moderate quality, with little comparative data presented and little change in research questions over time.
Limitations: identification of a broad range of studies examining ‘contribution’ made meta analysis or meta synthesis untenable.
The research evidence of the contribution of PAs to primary care was mixed and limited. However, the continued growth in employment of PAs in American primary care suggests that this professional group is judged to be of value by increasing numbers of employers. Further specific studies are needed to fill in the gaps in our knowledge about the effectiveness of PAs’ contribution to the international primary care workforce.
PMCID: PMC3698179  PMID: 23773235
Physician assistants; Family practice; Physicians; Family; General practice; Primary health care; Review
16.  The AHEC contribution to social work education. 
Public Health Reports  1986;101(2):187-191.
The Area Health Education Center (AHEC) Program is a Federal initiative funded by the Public Health Service. The goal of the program is to improve the distribution and quality of training for health professionals. Funds are awarded to schools of medicine or osteopathy which in turn subcontract with at least two other health professional schools. Each project recipient must establish an AHEC center to plan and coordinate community-based educational experiences for health professions students in designated health shortage areas. The AHEC program fosters interdisciplinary training among health professionals. As part of the basic program thrust, some AHECs have included the social work profession in their program design. The Massachusetts AHEC, through Boston University's School of Social Work, established a health care concentration and interdisciplinary rotation that included students from social work, psychology, nursing, and medicine. Other examples of AHEC-sponsored training are presented from Baltimore, the eastern shore of Virginia, and several centers in Massachusetts. Through the AHEC training mechanism, social work students as well as practitioners in the field have the opportunity to encounter the most current and urgent issues in health care practice.
PMCID: PMC1477786  PMID: 3083474
17.  Nurses on the Move: A Global Overview 
Health Services Research  2007;42(3 Pt 2):1281-1298.
To look at nurse migration flows in the light of national nursing workforce imbalances, examine factors that encourage or inhibit nurse mobility, and explore the potential benefits of circular migration.
Principal Findings
The number of international migrants has doubled since 1970 and nurses are increasingly part of the migratory stream. Critical nursing shortages in industrialized countries are generating a demand that is fueling energetic international recruitment campaigns. Structural adjustments in the developing countries have created severe workforce imbalances and shortfalls often coexist with large numbers of unemployed health professionals. A nurse's motivation to migrate is multifactorial, not limited to financial incentives, and barriers exist that discourage or slow the migration process. The migration flows vary in direction and magnitude over time, responding to socioeconomic factors present in source and destination countries. The dearth of data on which to develop international health human resource policy remains. There is growing recognition, however, that migration will continue and that temporary migration will be a focus of attention in the years to come.
Today's search for labor is a highly organized global hunt for talent that includes nurses. International migration is a symptom of the larger systemic problems that make nurses leave their jobs. Nurse mobility becomes a major issue only in a context of migrant exploitation or nursing shortage. Injecting migrant nurses into dysfunctional health systems—ones that are not capable of attracting and retaining staff domestically—will not solve the nursing shortage.
PMCID: PMC1955376  PMID: 17489915
Nurse; migration; shortage
18.  Stakeholder perceptions of a nurse led walk-in centre 
As many countries face primary care medical workforce shortages and find it difficult to provide timely and affordable care they seek to find new ways of delivering first point of contact health care through developing new service models. In common with other areas of rural and regional Australia, the Australian Capital Territory (ACT) is currently experiencing a general practitioner (GP) workforce shortage which impacts significantly on the ability of patients to access GP led primary care services. The introduction of a nurse led primary care Walk-in Centre in the ACT aimed to fulfill an unmet health care need in the community and meet projected demand for health care services as well as relieve pressure on the hospital system. Stakeholders have the potential to influence health service planning and policy, to advise on the potential of services to meet population health needs and to assess how acceptable health service innovation is to key stakeholder groups. This study aimed to ascertain the views of key stakeholders about the Walk-in Centre.
Stakeholders were purposively selected through the identification of individuals and organisations which had organisational or professional contact with the Walk-in Centre. Semi structured interviews around key themes were conducted with seventeen stakeholders.
Stakeholders were generally supportive of the Walk-in Centre but identified key areas which they considered needed to be addressed. These included the service's systems, full utilisation of the nurse practitioner role and adequate education and training. It was also suggested that a doctor could be available to the Centre as a source of referral for patients who fall outside the nurses' scope of practice. The location of the Centre was seen to impact on patient flows to the Emergency Department.
Nurse led Walk-in Centres are one response to addressing primary health care medical workforce shortages. Whilst some stakeholders have reservations about the model others are supportive and see the potential the model has to provide accessible primary health care. Any further developments of nurse-led Walk-in Centres need to take into account the views of key stakeholders so as to ensure that the model is acceptable and sustainable.
PMCID: PMC3529673  PMID: 23126431
19.  Measuring and managing the work environment of the mid-level provider – the neglected human resource 
Much has been written in the past decade about the health workforce crisis that is crippling health service delivery in many middle-income and low-income countries. Countries having lost most of their highly qualified health care professionals to migration increasingly rely on mid-level providers as the mainstay for health services delivery. Mid-level providers are health workers who perform tasks conventionally associated with more highly trained and internationally mobile workers. Their training usually has lower entry requirements and is for shorter periods (usually two to four years). Our study aimed to explore a neglected but crucial aspect of human resources for health in Africa: the provision of a work environment that will promote motivation and performance of mid-level providers. This paper explores the work environment of mid-level providers in Malawi, and contributes to the validation of an instrument to measure the work environment of mid-level providers in low-income countries.
Three districts were purposively sampled from each of the three geographical regions in Malawi. A total of 34 health facilities from the three districts were included in the study. All staff in each of the facilities were included in the sampling frame. A total of 153 staff members consented to be interviewed. Participants completed measures of perceptions of work environment, burnout and job satisfaction.
The Healthcare Provider Work Index, derived through Principal Components Analysis and Rasch Analysis of our modification of an existing questionnaire, constituted four subscales, measuring: (1) levels of staffing and resources; (2) management support; (3) workplace relationships; and (4) control over practice. Multivariate analysis indicated that scores on the Work Index significantly predicted key variables concerning motivation and attrition such as emotional exhaustion, job satisfaction, satisfaction with the profession and plans to leave the current post within 12 months. Additionally, the findings show that mid-level medical staff (i.e. clinical officers and medical assistants) are significantly less satisfied than mid-level nurses (i.e. enrolled nurses) with their work environments, particularly their workplace relationships. They also experience significantly greater levels of dissatisfaction with their jobs and with their profession.
The Healthcare Provider Work Index identifies factors salient to improving job satisfaction and work performance among mid-level cadres in resource-poor settings. The extent to which these results can be generalized beyond the current sample must be established. The poor motivational environment in which clinical officers and medical assistants work in comparison to that of nurses is of concern, as these staff members are increasingly being asked to take on leadership roles and greater levels of clinical responsibility. More research on mid-level providers is needed, as they are the mainstay of health service delivery in many low-income countries. This paper contributes to a methodology for exploring the work environment of mid-level providers in low-income countries and identifies several areas needing further research.
PMCID: PMC2655277  PMID: 19228391
20.  Assisting role redesign: a qualitative evaluation of the implementation of a podiatry assistant role to a community health setting utilising a traineeship approach 
Increasing demands for podiatry combined with workforce shortages due to attrition, part-time working practices and rural healthcare shortages means that in some geographic areas in Australia there are insufficient professionals to meet service demand. Although podiatry assistants have been introduced to help relieve workforce shortages there has been little evaluation of their impact on patient, staff and/or service outcomes. This research explores the processes and outcomes of a ‘trainee’ approach to introducing a podiatry assistant (PA) role to a community setting in the Australian Capital Territory (ACT) Government Health Service Directorate.
A qualitative methodology was employed involving interviews and focus groups with service managers, qualified practitioners, the assistant, service users and consumer representatives. Perspectives of the implementation process; the traineeship approach; the underlying mechanisms that help or hinder the implementation process; and the perceived impact of the role were explored. Data were analysed using the Richie and Spencer Framework approach.
Although the impact of the PA role had not been measured at the time of the evaluation, the implementation of the PA traineeship was considered a success in terms of enabling the transfer of a basic foot-care service from nursing back to podiatry; releasing Enrolled Nurses (ENs) from foot-care duties; an increase in the number of treatments delivered by the podiatry service; and high levels of stakeholder satisfaction with the role. It was perceived that the transfer of the basic foot-care role from nursing to podiatry through the use of a PA impacted on communication and feedback loops between the PA and the podiatry service; the nursing-podiatry relationship; clinical governance around the foot-care service; and continuity of care for clients through the podiatry service. The traineeship was considered successful in terms of producing a PA whose skills were shaped by and directly met the needs of the practitioners with whom they worked. However, the resource intensiveness of the traineeship model was acknowledged by most who participated in the programme.
This research has demonstrated that the implementation of a PA using a traineeship approach requires good coordination and communication with a number of agencies and staff and substantial resources to support training and supervision. There are added benefits of the new role to the podiatry service in terms of regaining control over podiatric services which was perceived to improve clinical governance and patient pathways.
PMCID: PMC3544652  PMID: 23181834
21.  Measuring inequalities in the distribution of health workers: the case of Tanzania 
The overall human resource shortages and the distributional inequalities in the health workforce in many developing countries are well acknowledged. However, little has been done to measure the degree of inequality systematically. Moreover, few attempts have been made to analyse the implications of using alternative measures of health care needs in the measurement of health workforce distributional inequalities. Most studies have implicitly relied on population levels as the only criterion for measuring health care needs. This paper attempts to achieve two objectives. First, it describes and measures health worker distributional inequalities in Tanzania on a per capita basis; second, it suggests and applies additional health care needs indicators in the measurement of distributional inequalities.
We plotted Lorenz and concentration curves to illustrate graphically the distribution of the total health workforce and the cadre-specific (skill mix) distributions. Alternative indicators of health care needs were illustrated by concentration curves. Inequalities were measured by calculating Gini and concentration indices.
There are significant inequalities in the distribution of health workers per capita. Overall, the population quintile with the fewest health workers per capita accounts for only 8% of all health workers, while the quintile with the most health workers accounts for 46%. Inequality is perceptible across both urban and rural districts. Skill mix inequalities are also large. Districts with a small share of the health workforce (relative to their population levels have an even smaller share of highly trained medical personnel. A small share of highly trained personnel is compensated by a larger share of clinical officers (a middle-level cadre) but not by a larger share of untrained health workers. Clinical officers are relatively equally distributed. Distributional inequalities tend to be more pronounced when under-five deaths are used as an indicator of health care needs. Conversely, if health care needs are measured by HIV prevalence, the distributional inequalities appear to decline.
The measure of inequality in the distribution of the health workforce may depend strongly on the underlying measure of health care needs. In cases of a non-uniform distribution of health care needs across geographical areas, other measures of health care needs than population levels may have to be developed in order to ensure a more meaningful measurement of distributional inequalities of the health workforce.
PMCID: PMC2655278  PMID: 19159443
22.  Wrong schools or wrong students? The potential role of medical education in regional imbalances of the health workforce in the United Republic of Tanzania 
The United Republic of Tanzania, like many other countries in sub-Saharan Africa, faces a human resources crisis in its health sector, with a small and inequitably distributed health workforce. Rural areas and other poor regions are characterised by a high burden of disease compared to other regions of the country. At the same time, these areas are poorly supplied with human resources compared to urban areas, a reflection of the situation in the whole of Sub-Saharan Africa, where 1.3% of the world's health workforce shoulders 25% of the world's burden of disease. Medical schools select candidates for training and form these candidates' professional morale. It is therefore likely that medical schools can play an important role in the problem of geographical imbalance of doctors in the United Republic of Tanzania.
This paper reviews available research evidence that links medical students' characteristics with human resource imbalances and the contribution of medical schools in perpetuating an inequitable distribution of the health workforce.
Existing literature on the determinants of the geographical imbalance of clinicians, with a special focus on the role of medical schools, is reviewed. In addition, structured questionnaires collecting data on demographics, rural experience, working preferences and motivational aspects were administered to 130 fifth-year medical students at the medical faculties of MUCHS (University of Dar es Salaam), HKMU (Dar es Salaam) and KCMC (Tumaini University, Moshi campus) in the United Republic of Tanzania. The 130 students represented 95.6% of the Tanzanian finalists in 2005. Finally, we apply probit regressions in STATA to analyse the cross-sectional data coming from the aforementioned survey.
The lack of a primary interest in medicine among medical school entrants, biases in recruitment, the absence of rural related clinical curricula in medical schools, and a preference for specialisation not available in rural areas are among the main obstacles for building a motivated health workforce which can help correct the inequitable distribution of doctors in the United Republic of Tanzania.
This study suggests that there is a need to re-examine medical school admission policies and practices.
PMCID: PMC2837610  PMID: 20187942
23.  Nurse Migration: A Canadian Case Study 
Health Services Research  2007;42(3 Pt 2):1336-1353.
To synthesize information about nurse migration in and out of Canada and analyze its role as a policy lever to address the Canadian nursing shortage.
Principal Findings
Canada is both a source and a destination country for international nurse migration with an estimated net loss of nurses. The United States is the major beneficiary of Canadian nurse emigration resulting from the reduction of full-time jobs for nurses in Canada due to health system reforms. Canada faces a significant projected shortage of nurses that is too large to be ameliorated by ethical international nurse recruitment and immigration.
The current and projected shortage of nurses in Canada is a product of health care cost containment policies that failed to take into account long-term consequences for nurse workforce adequacy. An aging nurse workforce, exacerbated by layoffs of younger nurses with less seniority, and increasing demand for nurses contribute to a projection of nurse shortage that is too great to be solved ethically through international nurse recruitment. National policies to increase domestic nurse production and retention are recommended in addition to international collaboration among developed countries to move toward greater national nurse workforce self sufficiency.
PMCID: PMC1955372  PMID: 17489918
Nurse migration; nurse shortage; nursing workforce
24.  Global Anesthesia Workforce Crisis: A Preliminary Survey Revealing Shortages Contributing to Undesirable Outcomes and Unsafe Practices 
World Journal of Surgery  2009;34(3):438-444.
The burden of disease, disability, and mortality that could be averted by surgery is growing. However, few low and middle income countries (LMICs) have the infrastructure or capacity to provide surgical services to meet this growing need. Equally, few of these countries have been assessed for key infrastructural capacity including surgical and anesthesia providers, equipment, and supplies. These assessments are critical to revealing magnitude of the evolving surgical and anesthesia workforce crisis, related morbidity and mortality, and necessary steps to mitigate the impact of the crisis.
A pilot Internet-based survey was conducted to estimate per-capita anesthesia providers in LMICs. Information was obtained from e-mail respondents at national health care addresses, and from individuals working in-country on anesthesia-related projects.
Workers from 6 of 98 countries responded to direct e-mail inquiries, and an additional five responses came from individuals who were working or had worked in-country at the time of the survey. The data collected revealed that the per-capita anesthesia provider ratio in the countries surveyed was often 100 times lower than in developed countries.
This pilot study revealed that the number of anesthesia providers available per capita of population is markedly reduced in low and lower middle income countries compared to developed countries. As anesthesia providers are an integral part of the delivery of safe and effective surgical care, it is essential that more data is collected to fully understand the deficiencies in workforce and capacity in low and middle income countries.
PMCID: PMC2816796  PMID: 19795163
25.  An economic perspective on Malawi's medical "brain drain" 
The medical "brain drain" has been described as rich countries "looting" doctors and nurses from developing countries undermining their health systems and public health. However this "brain-drain" might also be seen as a success in the training and "export" of health professionals and the benefits this provides. This paper illustrates the arguments and possible policy options by focusing on the situation in one of the poorest countries in the world, Malawi.
Many see this "brain drain" of medical staff as wrong with developed countries exploiting poorer ones. The effects are considerable with Malawi facing high vacancy rates in its public health system, and with migration threatening to outstrip training despite efforts to improve pay and conditions. This shortage of staff has made it more challenging for Malawi to deliver on its Essential Health Package and to absorb new international health funding.
Yet, without any policy effort Malawi has been able to demonstrate its global competitiveness in the training ("production") of skilled health professionals. Remittances from migration are a large and growing source of foreign exchange for poor countries and tend to go directly to households. Whilst the data for Malawi is limited, studies from other poor countries demonstrate the power of remittances in significantly reducing poverty.
Malawi can benefit from the export of health professionals provided there is a resolution of the situation whereby the state pays for training and the benefits are gained by the individual professional working abroad. Solutions include migrating staff paying back training costs, or rich host governments remitting part of a tax (e.g. income or national insurance) to the Malawi government. These schemes would allow Malawi to scale up training of health professionals for local needs and to work abroad.
There is concern about the negative impacts of the medical "brain-drain". However a closer look at the evidence for and against the medical "brain-drain" in Malawi suggests that there are potential gains in managing medical migration to produce outcomes that are beneficial to individuals, households and the country. Finally we present several policy options.
PMCID: PMC1769362  PMID: 17176457

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