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1.  Negotiating markets for health: an exploration of physicians’ engagement in dual practice in three African capital cities 
Health Policy and Planning  2013;29(6):774-783.
Scarce evidence exists on the features, determinants and implications of physicians’ dual practice, especially in resource-poor settings. This study considered dual practice patterns in three African cities and the respective markets for physician services, with the objective of understanding the influence of local determinants on the practice. Forty-eight semi-structured qualitative interviews were conducted in the three cities to understand features of the practice and the respective markets. A survey was carried out in a sample of 331 physicians to explore their characteristics and decisions to work in public and private sectors. Descriptive analysis and inferential statistics were employed to explore differences in physicians’ engagement in dual practice across the three locations. Different forms of dual practice were found to exist in the three cities, with public physicians engaging in private practice outside but also inside public facilities, in regulated as well as unregulated ways. Thirty-four per cent of the respondents indicated that they worked in public practice only, and 11% that they engaged exclusively in private practice. The remaining 55% indicated that they engaged in some form of dual practice, 31% ‘outside’ public facilities, 8% ‘inside’ and 16% both ‘outside’ and ‘inside’. Local health system governance and the structure of the markets for physician services were linked to the forms of dual practice found in each location, and to their prevalence. Our analysis suggests that physicians’ decisions to engage in dual practice are influenced by supply and demand factors, but also by how clearly separated public and private markets are. Where it is possible to provide little-regulated services within public infrastructure, less incentive seems to exist to engage in the formal private sector, with equity and efficiency implications for service provision. The study shows the value of analysing health markets to understand physicians’ engagement in professional activities, and contributes to an evidence base for its regulation.
doi:10.1093/heapol/czt071
PMCID: PMC4153303  PMID: 24077880
Dual practice; multiple job-holding; human resources for health; physicians in Africa; Cape Verde; Guinea Bissau; Mozambique; health system research in low-income countries
2.  Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources for health 
Background
The last decade has seen widespread retreat from user fees with the intention to reduce financial constraints to users in accessing health care and in particular improving access to reproductive, maternal and newborn health services. This has had important benefits in reducing financial barriers to access in a number of settings. If the policies work as intended, service utilization rates increase. However this increases workloads for health staff and at the same time, the loss of user fee revenues can imply that health workers lose bonuses or allowances, or that it becomes more difficult to ensure uninterrupted supplies of health care inputs.
This research aimed to assess how policies reducing demand-side barriers to access to health care have affected service delivery with a particular focus on human resources for health.
Methods
We undertook case studies in five countries (Ghana, Nepal, Sierra Leone, Zambia and Zimbabwe). In each we reviewed financing and HRH policies, considered the impact financing policy change had made on health service utilization rates, analysed the distribution of health staff and their actual and potential workloads, and compared remuneration terms in the public sectors.
Results
We question a number of common assumptions about the financing and human resource inter-relationships. The impact of fee removal on utilization levels is mostly not sustained or supported by all the evidence. Shortages of human resources for health at the national level are not universal; maldistribution within countries is the greater problem. Low salaries are not universal; most of the countries pay health workers well by national benchmarks.
Conclusions
The interconnectedness between user fee policy and HRH situations proves difficult to assess. Many policies have been changing over the relevant period, some clearly and others possibly in response to problems identified associated with financing policy change. Other relevant variables have also changed.
However, as is now well-recognised in the user fee literature, co-ordination of health financing and human resource policies is essential. This appears less well recognised in the human resources literature. This coordination involves considering user charges, resource availability at health facility level, health worker pay, terms and conditions, and recruitment in tandem. All these policies need to be effectively monitored in their processes as well as outcomes, but sufficient data are not collected for this purpose.
doi:10.1186/1478-4491-11-46
PMCID: PMC3849922  PMID: 24053731
User fees; Human resources for health; Policy co-ordination; Distribution; Workload; Pay
3.  The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe 
Background
A paradigm shift in global health policy on user fees has been evident in the last decade with a growing consensus that user fees undermine equitable access to essential health care in many low and middle income countries. Changes to fees have major implications for human resources for health (HRH), though the linkages are rarely explicitly examined. This study aimed to examine the inter-linkages in Zimbabwe in order to generate lessons for HRH and fee policies, with particular respect to reproductive, maternal and newborn health (RMNH).
Methods
The study used secondary data and small-scale qualitative fieldwork (key informant interview and focus group discussions) at national level and in one district in 2011.
Results
The past decades have seen a shift in the burden of payments onto households. Implementation of the complex rules on exemptions is patchy and confused. RMNH services are seen as hard for families to afford, even in the absence of complications. Human resources are constrained in managing current demand and any growth in demand by high external and internal migration, and low remuneration, amongst other factors. We find that nurses and midwives are evenly distributed across the country (at least in the public sector), though doctors are not. This means that for four provinces, there are not enough doctors to provide more complex care, and only three provinces could provide cover in the event of all deliveries taking place in facilities.
Conclusions
This analysis suggests that there is a strong case for reducing the financial burden on clients of RMNH services and also a pressing need to improve the terms and conditions of key health staff. Numbers need to grow, and distribution is also a challenge, suggesting the need for differentiated policies in relation to rural areas, especially for doctors and specialists. The management of user fees should also be reviewed, particularly for non-Ministry facilities, which do not retain their revenues, and receive limited investment in return from the municipalities and district councils. Overall public investment in health needs to grow.
doi:10.1186/1472-6963-13-197
PMCID: PMC3671956  PMID: 23714143
Human resources for health; Zimbabwe; Reproductive; Maternal and newborn health; Financial access; User fees
4.  Healthcare-seeking Behaviour among the Tribal People of Bangladesh: Can the Current Health System Really Meet Their Needs? 
Despite the wealth of studies on health and healthcare-seeking behaviour among the Bengali population in Bangladesh, relatively few studies have focused specifically on the tribal groups in the country. This study aimed at exploring the context, reasons, and choices in patterns of healthcare-seeking behaviour of the hill tribal population of Bangladesh to present the obstacles and challenges faced in accessing healthcare provision in the tribal areas. Participatory tools and techniques, including focus-group discussions, in-depth interviews, and participant-observations, were used involving 218 men, women, adolescent boys, and girls belonging to nine different tribal communities in six districts. Data were transcribed and analyzed using the narrative analysis approach. The following four main findings emerged from the study, suggesting that the tribal communities may differ from the predominant Bengali population in their health needs and priorities: (a) Traditional healers are still very popular among the tribal population in Bangladesh; (b) Perceptions of the quality and manner of treatment and communication can override costs when it comes to provider-preference; (c) Gender and age play a role in making decisions in households in relation to health matters and treatment-seeking; and (d) Distinct differences exist among the tribal people concerning their knowledge on health, awareness, and treatment-seeking behaviour. The findings challenge the present service-delivery system that has largely been based on the needs and priorities of the plainland population. The present system needs to be reviewed carefully to include a broader approach that takes the sociocultural factors into account, if meaningful improvements are to be made in the health of the tribal people of Bangladesh.
PMCID: PMC3489951  PMID: 23082637
Healthcare-seeking behaviour; Health services; Perceptions; Service delivery; Tribal people; Bangladesh
5.  Global Health Initiatives and aid effectiveness: insights from a Ugandan case study 
Background
The emergence of Global Health Initiatives (GHIs) has been a major feature of the aid environment of the last decade. This paper seeks to examine in depth the behaviour of two prominent GHIs in the early stages of their operation in Uganda as well as the responses of the government.
Methods
The study adopted a qualitative and case study approach to investigate the governance of aid transactions in Uganda. Data sources included documentary review, in-depth and semi-structured interviews and observation of meetings. Agency theory guided the conceptual framework of the study.
Results
The Ugandan government had a stated preference for donor funding to be channelled through the general or sectoral budgets. Despite this preference, two large GHIs opted to allocate resources and deliver activities through projects with a disease-specific approach. The mixed motives of contributor country governments, recipient country governments and GHI executives produced incentive regimes in conflict between different aid mechanisms.
Conclusion
Notwithstanding attempts to align and harmonize donor activities, the interests and motives of the various actors (GHIs and different parts of the government) undermine such efforts.
doi:10.1186/1744-8603-7-20
PMCID: PMC3148970  PMID: 21726431
6.  Two-tier charging in Maputo Central Hospital: Costs, revenues and effects on equity of access to hospital services 
Background
Special services within public hospitals are becoming increasingly common in low and middle income countries with the stated objective of providing higher comfort services to affluent customers and generating resources for under funded hospitals. In the present study expenditures, outputs and costs are analysed for the Maputo Central Hospital and its Special Clinic with the objective of identifying net resource flows between a system operating two-tier charging, and, ultimately, understanding whether public hospitals can somehow benefit from running Special Clinic operations.
Methods
A combination of step-down and bottom-up costing strategies were used to calculate recurrent as well as capital expenses, apportion them to identified cost centres and link costs to selected output measures.
Results
The results show that cost differences between main hospital and clinic are marked and significant, with the Special Clinic's cost per patient and cost per outpatient visit respectively over four times and over thirteen times their equivalent in the main hospital.
Discussion
While the main hospital cost structure appeared in line with those from similar studies, salary expenditures were found to drive costs in the Special Clinic (73% of total), where capital and drug costs were surprisingly low (2 and 4% respectively). We attributed low capital and drug costs to underestimation by our study owing to difficulties in attributing the use of shared resources and to the Special Clinic's outsourcing policy. The large staff expenditure would be explained by higher physician time commitment, economic rents and subsidies to hospital staff. On the whole it was observed that: (a) the flow of capital and human resources was not fully captured by the financial systems in place and stayed largely unaccounted for; (b) because of the little consideration given to capital costs, the main hospital is more likely to be subsidising its Special Clinic operations, rather than the other way around.
Conclusion
We conclude that the observed lack of transparency may create scope for an inequitable cross subsidy of private customers by public resources.
doi:10.1186/1472-6963-11-143
PMCID: PMC3127984  PMID: 21635752
7.  International flow of Zambian nurses 
This commentary paper highlights changing patterns of outward migration of Zambian nurses. The aim is to discuss these pattern changes in the light of policy developments in Zambia and in receiving countries.
Prior to 2000, South Africa was the most important destination for Zambian registered nurses. In 2000, new destination countries, such as the United Kingdom, became available, resulting in a substantial increase in migration from Zambia. This is attributable to the policy of active recruitment by the United Kingdom's National Health Service and Zambia's policy of offering Voluntary Separation Packages: early retirement lump-sum payments promoted by the government, which nurses used towards migration costs.
The dramatic decline in migration to the United Kingdom since 2004 is likely to be due to increased difficulties in obtaining United Kingdom registration and work permits. Despite smaller numbers, enrolled nurses are also leaving Zambia for other destination countries, a significant new development.
This paper stresses the need for nurse managers and policy-makers to pay more attention to these wider nurse migration trends in Zambia, and argues that the focus of any migration strategy should be on how to retain a motivated workforce through improving working conditions and policy initiatives to encourage nurses to stay within the public sector.
doi:10.1186/1478-4491-7-83
PMCID: PMC2778636  PMID: 19906301
8.  Does a code make a difference – assessing the English code of practice on international recruitment 
Background
This paper draws from research completed in 2007 to assess the effect of the Department of Health, England, Code of Practice for the international recruitment of health professionals.
The Department of Health in England introduced a Code of Practice for international recruitment for National Health Service employers in 2001. The Code required National Health Service employers not to actively recruit from low-income countries, unless there was government-to-government agreement. The Code was updated in 2004.
Methods
The paper examines trends in inflow of health professionals to the United Kingdom from other countries, using professional registration data and data on applications for work permits. The paper also provides more detailed information from two country case studies in Ghana and Kenya.
Results
Available data show a considerable reduction in inflow of health professionals, from the peak years up to 2002 (for nurses) and 2004 (for doctors). There are multiple causes for this decline, including declining demand in the United Kingdom.
In Ghana and Kenya it was found that active recruitment was perceived to have reduced significantly from the United Kingdom, but it is not clear the extent to which the Code was influential in this, or whether other factors such as a lack of vacancies in the United Kingdom explains it.
Conclusion
Active international recruitment of health professionals was an explicit policy intervention by the Department of Health in England, as one key element in achieving rapid staffing growth, particularly in the period 2000 to 2005, but the level of international recruitment has dropped significantly since early 2006. Regulatory and education changes in the United Kingdom in recent years have also made international entry more difficult.
The potential to assess the effect of the Code in England is constrained by the limitations in available databases. This is a crucial lesson for those considering a global code: without a clear link between explicit objectives of a code, and relevant monitoring capacity, it is not possible to judge the actual impact of a code.
A second message for policy-makers is that attempts to use a single country code in other countries where there are a multiplicity of independent, private-sector health care employers, or where there is a federated political and regulatory structure, will be a much more challenging and complex issue than in England, which has one major public sector health care employer and one national point of entry for regulated health professionals.
Finally, there is a message about the importance of the "visibility" of any recruitment code – for policy-makers, employers and potential recruits. The Department of Health Code has a good level of recognition in the National Health Service, but would benefit from better dissemination in low-income countries, particularly in Africa, together with further consultation on the appropriateness of its provisions in specific countries. To achieve high visibility and recognition of any global code will be a much bigger challenge.
doi:10.1186/1478-4491-7-33
PMCID: PMC2678075  PMID: 19358727
9.  Improving Maternal Survival in South Asia—What Can We Learn from Case Studies? 
Technical interventions for maternal healthcare are implemented through a dynamic social process. Peoples' behaviours—whether they be planners, managers, providers, or potential users—influence the outcomes. Given the complexity and unpredictability inherent in such dynamic processes, the proposed cause-and-effect relationships in any one context cannot be directly transferred to another. While this is true of all health services, its importance is magnified in maternal healthcare because of the need to involve multiple levels of the health system, multiple types of care providers from the highly skilled specialist to community-level volunteers, and multiple technical interventions, without the ability to measure significant change in the outcome, the maternal mortality ratio. Patterns can be followed however, in terms of outcomes in response to interventions. From these case studies of implementation of maternal health programmes across five states of India, Pakistan, and Bangladesh, some patterns stand out and seem to apply virtually everywhere (e.g. failure of systems to post staff in difficult areas) while others require more data to understand the observed patterns (e.g. response to financial incentives for improving maternal health systems; instituting available accessible safe blood). The patterns formed can provide guidance to programme managers as to what aspects of the process to track and micro-manage, to policy-makers as to what features of a context may particularly influence impacts of alternative maternal health strategies, and to governments more broadly as to the factors shaping dynamic responses that might themselves warrant intervention.
PMCID: PMC2761770  PMID: 19489409
Maternal health; Maternal mortality; Case studies; Asia, South; Bangladesh; India; Pakistan
10.  Equity in community health insurance schemes: evidence and lessons from Armenia 
Health Policy and Planning  2009;24(3):209-216.
Introduction Community health insurance (CHI) schemes are growing in importance in low-income settings, where health systems based on user fees have resulted in significant barriers to care for the poorest members of communities. They increase revenue, access and financial protection, but concerns have been expressed about the equity of such schemes and their ability to reach the poorest. Few programmes routinely evaluate equity impacts, even though this is usually a key objective. This lack of evidence is related to the difficulties in collecting reliable data on utilization and socio-economic status. This paper describes the findings of an evaluation of the equity of Oxfam's CHI schemes in rural Armenia.
Methods Members of a random sample of 506 households in villages operating insurance schemes in rural Armenia were interviewed using a structured questionnaire. Household wealth scores based on ownership of assets were generated using principal components analysis. Logistic and Poisson regression analyses were performed to identify the determinants of health facility utilization, and equity of access across socio-economic strata.
Results The schemes have achieved a high level of equity, according to socio-economic status, age and gender. However, although levels of participation compare favourably with international experience, they remain relatively low due to a lack of affordability and a package of primary care that does not include coverage for chronic disease.
Conclusion This paper demonstrates that the distribution of benefits among members of this community-financing scheme is equitable, and that such a degree of equity in community insurance can be achieved in such settings, possibly through an emphasis on accountability and local management. Such a scheme presents a workable model for investing in primary health care in resource-poor settings.
doi:10.1093/heapol/czp001
PMCID: PMC2670975  PMID: 19237388
Community-based health insurance; equity; health care utilization; Former Soviet Union; Armenia
11.  The double burden of human resource and HIV crises: a case study of Malawi 
Two crises dominate the health sectors of sub-Saharan African countries: those of human resources and of HIV. Nevertheless, there is considerable variation in the extent to which these two phenomena affect sub-Saharan countries, with a few facing extreme levels of both: Lesotho, Zimbabwe, Zambia, Mozambique, the Central African Republic and Malawi.
This paper reviews the continent-wide situation with respect to this double burden before considering the case of Malawi in more detail. In Malawi, there has been significant concurrent investment in both an Emergency Human Resource Programme and an antiretroviral therapy programme which was treating 60,000 people by the end of 2006. Both areas of synergy and conflict have arisen, as the two programmes have been implemented. These highlight important issues for programme planners and managers to address and emphasize that planning for the scale-up of antiretroviral therapy while simultaneously strengthening health systems and the human resource situation requires prioritization among compelling cases for support, and time (not just resources).
doi:10.1186/1478-4491-6-16
PMCID: PMC2533352  PMID: 18699994
12.  Health sector reforms and human resources for health in Uganda and Bangladesh: mechanisms of effect 
Background
Despite the expanding literature on how reforms may affect health workers and which reactions they may provoke, little research has been conducted on the mechanisms of effect through which health sector reforms either promote or discourage health worker performance. This paper seeks to trace these mechanisms and examines the contextual framework of reform objectives in Uganda and Bangladesh, and health workers' responses to the changes in their working environments by taking a 'realistic evaluation' approach.
Methods
The study findings were generated by triangulating both qualitative and quantitative methods of data collection and analysis among policy technocrats, health managers and groups of health providers. Quantitative surveys were conducted with over 700 individual health workers in both Bangladesh and Uganda and supplemented with qualitative data obtained from focus group discussions and key interviews with professional cadres, health managers and key institutions involved in the design, implementation and evaluation of the reforms of interest.
Results
The reforms in both countries affected the workforce through various mechanisms. In Bangladesh, the effects of the unification efforts resulted in a power struggle and general mistrust between the two former workforce tracts, family planning and health. However positive effects of the reforms were felt regarding the changes in payment schemes. Ugandan findings show how the workforce responded to a strong and rapidly implemented system of decentralisation where the power of new local authorities was influenced by resource constraints and nepotism in recruitment. On the other hand, closer ties to local authorities provided the opportunity to gain insight into the operational constraints originating from higher levels that health staff were dealing with.
Conclusion
Findings from the study suggest that a) reform planners should use the proposed dynamic responses model to help design reform objectives that encourage positive responses among health workers b) the role of context has been underestimated and it is necessary to address broader systemic problems before initiating reform processes, c) reform programs need to incorporate active implementation research systems to learn the contextual dynamics and responses as well as have inbuilt program capacity for corrective measures d) health workers are key stakeholders in any reform process and should participate at all stages and e) some effects of reforms on the health workforce operate indirectly through levels of satisfaction voiced by communities utilising the services.
doi:10.1186/1478-4491-5-3
PMCID: PMC1800303  PMID: 17270042
13.  the devil is in the detail 
BMJ : British Medical Journal  2004;329(7475):1175-1176.
PMCID: PMC527705  PMID: 15539679

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