Health ramifications and recovery avenues for Sudan's April 2023 armed conflict: A review

Background: Sudan's history is marred by ongoing sociopolitical challenges, with deep cultural divisions fueling numerous wars. A new conflict erupted on April 15, 2023, pushing the country closer to a full-scale civil war. This war has severely crippled Sudan's already fragile healthcare system, rendering 70% of hospitals in combat zones nonoperational, causing 12,000 deaths, thousands of injuries, and leaving 11 million in dire need of healthcare. More than seven million people are displaced, half of which are children, and are facing severe health challenges, especially vulnerable groups. Heath situation is threatening with unchecked spread of outbreaks of communicable diseases that were previously controlled and marked failure in meeting the health demands of patients with noncommunicable diseases, reproductive and child health issues, and people with serious conditions that require adequate follow-up. Moreover, the projections threaten with more catastrophic consequences including famine, environmental destruction, and further displacement of people. This review article highlights the urgency of the situation and explores potential solutions to enrich global understanding of crisis management. Methods: To comprehensively assess the impact of the crisis and propose a way forward, we drew data by exploring search engines and databases such as Google, Humanitarian Agencies Websites, Google Scholer, and PubMed along with some relevant reports. The search terms included are "Sudan's war", "impact of war on healthcare systems", and "Sudan's armed conflicts". Results: More than 19 publications on the impact of the war on health in addition to periodic reports from international organizations and governmental authorities were reviewed. Conclusion: Although all publications point to the gravity of the situation and the need for prompt response, this crisis offers a unique opportunity to rebuild Sudan's struggling healthcare system with the principles of social accountability. Through domestic and international collaboration, this sector can become a model for similar nations, meeting the needs of its people and promoting sustainable development.

Nigeria in the COVID era: Health system strengthening for national security and prosperity

The coronavirus disease­19 pandemic has spread to all parts of the world. As of 20 May 2022, over 500 million confirmed cases have occurred with over 6 million deaths. In Nigeria, over 255,000 cases have occurred with more than 3000 deaths. The pandemic has adversely affected virtually all aspects of human endeavour, with a severe impact on the health system. The Nigerian health system was ill prepared for the pandemic, and this further weakened it. The impacts of the pandemic on the health system include disruption of health services, low motivation of the health workforce, unresponsive leadership and poor funding. The national response, though initially weak, was ramped up to expand capacity building, testing, public enlightenment, creation of isolation and treatment centres and research. The funding for the national response was from the government, private sector and multilateral donors. Nigeria must comprehensively strengthen its health system through motivating and building the capacity of its human resources for health, improved service delivery and provision of adequate funding, to be better prepared against future pandemics.

Strengthening the oral health system in Nigeria: A health systems building block approach

Aim: The present study aimed to describe the building blocks of the oral health system, including the role that the community plays in strengthening the oral health system in Nigeria. Methodology: This research was a scoping review of the existing literature retrieved from search engines and databases. Thus, we utilised grey literature, peer-reviewed literature, policy documents and websites. The oral health system was analysed using the World Health Organisation's Health systems framework, and we adapted this framework by introducing a seventh block, community participation. We also inserted the links between the oral health service delivery and oral health workforce blocks of the framework to improve the oral health outcomes. Results: More dental clinics are required to improve the availability and accessibility of oral health services. Dental workforce expansion is imperative. This can be approached by training of junior cadre dental professionals and incorporating community health practitioners to deliver basic oral care. There is an unregulated access to medication to treat dental conditions; hence, oral disease treatments need to be included in the country's treatment guidelines to improve standard of care. The government needs to improve on overall health spending and invariably increase oral health care allocation urgently. Furthermore, the country's stewardship of oral health care is hinged on well disseminated and implemented national policies on oral health. The oral health system can achieve its overall goals with community participation, engagement and ownership. Conclusion: Strengthening the oral health system in Nigeria requires urgent attention on each building block and cross-cutting interventions across the system's building blocks. The role of the community will need to be recognised because it is vital in sustaining any organisational change.

Establishing communities of practice to improve health policy, systems and reproductive, maternal, newborn, child and adolescent health in West Africa

Objectives: To explore and analyse factors that facilitate and inhibit the initiation and functioning of a national and transnational Community of Practice (CoP) for health policy and systems (HPS) and Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) in West Africa and to identify lessons for CoP interventions in similar multilingual low and middle-income contexts. Design: A case study, with the case defined as processes, enablers and barriers to the initiation and functioning of a national and transnational CoP for HSP and RMNCAH in West Africa and drawing on a review and analysis of secondary data from the program, workshop, country team and project reports, and training sessions. Setting: The Economic Community of West African States (ECOWAS). Participants: Professionals from two Anglophone (Ghana and Sierra Leone) and four Francophone (Burkina Faso, Cote d'Ivoire, Niger e Senegal) ECOWAS countries. Interventions: Training and mentoring of multi-disciplinary country teams supported by small research grants to undertake formative evaluation and advocacy of priority HPS and RMNCAH issues; support for CoP development within and across country teams. Results: The desire to learn from peers and mentors was a major enabler of the process. Human and financial resource availability, competing demands for time, communication in the context of a Francophone-Anglophone official language divide and the arrival of COVID-19 were all constraints. Conclusions: This study highlights the processes, achievements, and challenges of establishing country-level and transnational CoPs in West Africa. CoPs require sustained human and financial resource investments, communication and medium-to-long-term implementation support for sustainability and impact.

An assessment of Nigeria's health systems response to COVID-19

Objectives: This study aims to understand and report on selected health system interventions considered nationally and sub-nationally of particular significance both in terms of COVID-19 responses and in strengthening the health system for the future. Design: A review of published and grey literature, including journals, news/ media and official documents, was conducted from 1st December 2019 to 31st December 2020. The reviewers read and extracted relevant data using FACTIVA in a uniform data extraction template. Responses that related to service delivery were captured. Setting: The assessment considered responses at the national and two state levels: Lagos and Enugu, representing the epicentre and a low COVID-19 burden centre. Inclusion criteria: Documents and news that mentioned COVID-19 response, particularly service delivery aspects, were included in this review. Results: The identified interventions were mostly technical support targeted at health workers: including training of about 17,000 health workers, supervising and engaging more health workers, upgrading laboratories and building new ones to improve screening and diagnosis, and motivation of health workforce with incentives. Furthermore, the influx of philanthropic contributions improved the data and information systems supply of medicines, medical products and non-pharmaceutical protective materials through local production. The presence of political will and the government's efforts in health system's response to COVID-19 facilitated these interventions. Conclusions: Interventions of state and non-state actors have strengthened the health systems to some extent. However, more needs to be done to sustain these gains and make the health system resilient to absorb unprecedented shocks.

Management of Helicobacter pylori among medical doctors working in Khartoum, Sudan 2019: a cross-sectional study

Background: Various international guidelines have been developed regarding Helicobacter pylori (H. pylori) management, as it is infecting more than half of the world's population. Sudan's health system lacks guidelines regarding H. pylori management, leading to a discrepancy in practice. Investigating the current approach could be a step forward in the formulation of a national consensus in the management of H. pylori. Methods: A cross-sectional study was conducted among medical doctors currently working in Khartoum, Sudan. Participants were enrolled from platforms of medical associations through an online questionnaire. The questionnaire was scored out of 25 points, and scoring 13 or above considered a good approach. Data analysis was carried out using Statistical Package for Social Sciences (SPSS). Results: A total of 358 medical doctors participated in the study. The mean (±SD) score was 12.9(±4.5). Those who were using textbooks, campaigns, symposiums or general medical information to their primary Source of knowledge significantly scored higher. The most selected indication for both diagnosis (76.8%) and treatment (67.6%) was an active peptic ulcer. Stool antigen test (SAT) was the most preferred test (70.7%). The majority of respondents selected triple therapy (82.1%) as a first-line regimen. Only 37.7% confirmed the eradication after four weeks of stopping the treatment. They ensure eradication mainly through SAT (29%). Conclusion: A suboptimal approach was noted among medical doctors of Khartoum, Sudan, regarding H. pylori management. Efforts should be invested in forming national guidelines and the implementation of continuous medical education programs.

Roles of local healthcare workers in the humanitarian response in South Sudan: a literature review

Introduction: Armed conflict is devastating to the health system, is a public health concern and recovery is an enormous challenge. The independence of South Sudan in 2011 brought much hope. However, eight years later, the country is still at conflict with itself. Although rich in resources, it is ranked among the poorest in the world and depends on donor funding for most service delivery, especially health. In an international context, promoting the localisation of humanitarian aid and the integration of health services, there is a lot to learn from the roles being played by healthcare workers (HCWs) throughout the conflict in South Sudan. Method: A literature review was conducted to identify the roles of local HCWs in South Sudan since 2011. Four databases were searched, grey literature sourced, and snowballing done to capture additional documents for a comprehensive analysis. Questions were adapted from the Critical Appraisal Skills Programme for qualitative and systematic reviews guided appraisals of the articles. Results were systematically coded, synthesised and summarised using a priori and emergent themes. Results: The health system in South Sudan is very fragmented with heavy dependence on humanitarian aid. There is serious shortage in health workforce with heavy reliance on unskilled workers to fill in the gaps, mainly in rural settings. Although close collaboration exists among different stakeholders to deliver integrated services, poor infrastructure, insecurity, lack of capacity and donor dependency still poses a challenge towards localisation of aid and sustainability. Conclusions: The literature reviewed for this study indicates that the road towards localisation of health care is possible but will depend highly on continued collaboration between the different contributors, integration of services, building capacity of the nationals, increased government funding and infrastructural development. Local involvement of HCWs by international agencies is paramount in ownership and sustainability of services.

Atlas des statistiques sanitaires africaines 2022: analyse de la situation sanitaire de la Région africaine ­ rapport de synthèse

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Qualitative Analysis of One Primary Health Care per Ward in Ekiti State, Nigeria

The "One Primary Health Care (PHC) per Ward" policy is an important health care component for achieving health for all. This study assesses the functionality, successes and challenges in the implementation of 'one PHC per ward' policy in Ekiti State, Nigeria. In-depth and key informant interview guides serve as qualitative research instruments for data collection. Relevant information was sourced from different stakeholders, including the Executives of the State Primary Health Care Development Agency (SPHCDA), the Local Government Chairmen, the Heads of Departments in PHCs, Staff of PHCs and patients who visited PHC facilities, amounting to twenty-five in-depth and seven key informant interviews. Although all the wards assessed had at least one PHC facility, none of the PHC facilities visited met the minimum standards recommended by the National Primary Health Care Development Agency (NPHCDA). PHC facilities located in the rural areas had fewer infrastructural and human resources than those in the urban areas. Routine immunization exercises were improved across the PHC facilities as the Universal Drug Revolving Scheme adopted by the PHCs was successful, largely because of the re-investment of both principal and profit into the purchase of drugs. Results suggest that while routine immunization as an aspect of PHC services had received remarkable successes, the PHC facilities suffered from inadequate equipment and personnel. There is need for a political will and concerted actions that are designed to improve PHC facilities if PHCs are to realize the objectives for setting them up.

Health system strengthening for human capital development in Eswatini project. P168564

Description of the Strengthening the Health System and Nutrition for Human Capital Development in Eswatini Project The Government of the Kingdom of Eswatini is preparing a project, Health System Strengthening for Human Capital Development in Eswatini Project financed by an IBRD loan of US$20 million, using an Investment Project Financing (IPF) instrument, over a five-year period. The Project Development Objective (PDO) isto improve the coverage and quality of key reproductive, maternal, neonatal, child and adolescent health (RMNCAH), nutrition and NCD services (hypertension and diabetes) in Eswatini. To address key sector challenges and support the achievement of the PDO, the proposed project will focus on strengthening the health system and ramping up investments in RMNCAH services as well as nutrition and non-communicable diseases (hypertension and diabetes) to address critical human capital challenges, including stunting and child and adult mortality, applying a life course approach. The Ministry of Health will house the (PIU) the project implementing unit (PIU). The MOH will be supported by the Environmental Health Department (EHD) in the MOH.

COVID-19 in Sudan: Will the mitigation efforts win against the virus?

Background: The COVID-19 pandemic has hit hard both the affluent and poor countries. The objective of this article is to highlight the efforts of the Ministry of Health in Sudan in mitigating the pandemic and reflecting on counteracting factors. Methods: We traced the reports and plans of the Federal Ministry of Health and looked at the models projecting the pandemic in Sudan. Results: The fundamental plan of the government of Sudan to cope up with the pandemic included the control of the source of infection, blocking transmission, and preventing the spread. The response mechanism had a multi-sector approach with involvement of government, civil society organizations, and non-governmental organizations (NGOs). The action plans involved protocols for COVID-19 diagnosis and treatment, surveillance, epidemiological investigation, and management of case contacts. However, several factors continued to jeopardize the mitigation efforts of these plans. At the time of writing this article (at the end of the May 2020), there were about 4,000 confirmed cases, 300 recoveries, and 170 deaths. Although these numbers are below the projected numbers in many proposed models, in the light of the limited testing capacity, case identification and contact tracing, the exact situation might not be ascertained. Conclusion: Sudan has prepared a national plan to prevent and contain COVID19 pandemic. However, tremendous challenges are opposing these efforts. The poor health infrastructure, fragility of the health system, and the economic crisis are the major obstructions

Community perception of quality of health care received and client satisfaction in Lagos, Nigeria

Background: Quality of health care and client satisfaction are key elements in improving the performance of health systems. A community-based assessment was conducted to determine the level of client satisfaction and the perception of the quality of services received by citizens of Lagos State.Methods: A descriptive cross-sectional study using both quantitative and qualitative methods, was conducted in four local government areas of Lagos State. Respondents were selected by multi-stage sampling technique. The survey instruments included an interviewer-administered, pre-tested questionnaire and a 10-itemed focus group discussion guide.Results: Two thousand respondents with a mean age of 37.6±10.21 years were recruited. Almost all respondents (98%) rated the health facilities to be clean, 96% felt they received effective treatment from their providers. Six out of ten respondents rated the waiting time to be short and 60% felt that most drugs were available. Eight-five percent opined that the quality of care received was good and 95% were satisfied with the services received. There was a significant correlation between quality of care and client satisfaction (ρ=0.145, p=0.001). Short waiting time was predictive of client satisfaction (OR=13.9, 95%CI, 5.68-33.33, p<0.001) and confidence in health care providers was predictive of both client satisfaction (OR=3.489, 95%CI, 1.554-7.835, p<0.001) and perception of good service quality (OR=2.234, 95%CI, 1.509-3.308, p<0.001)

The weakest link: competence and prestige as constraints to referral by isolated nurses in rural Niger

Background: For a health district to function referral from health centres to district hospitals is critical. In many developing countries referral systems perform well below expectations. Niger is not an exception in this matter. Beyond obvious problems of cost and access this study shows to what extent the behaviour of the health worker in its interaction with the patient can be a barrier of its own.Methods: Information was triangulated from three sources in two rural districts in Niger: first; 46 semi-structured interviews with health centre nurses; second; 42 focus group discussions with an average of 12 participants - patients; relatives of patients and others; third; 231 semi-structured interviews with referred patients.Results: Passive patients without 'voice' reinforce authoritarian attitudes of health centre staff. The latter appear reluctant to refer because they see little added value in referral and fear loss of power and prestige. As a result staff communicates poorly and show little eagerness to convince reluctant patients and families to accept referral proposals.Conclusions: Diminishing referral costs and distance barriers is not enough to correct failing referral systems. There is also a need for investment in district hospitals to make referrals visibly worthwhile and for professional upgrading of the human resources at the first contact level; so as to allow for more effective referral patterns

A model for analysis; systemic planning and strategic synthesis for health science teaching in the Democratic Republic of the Congo: a vision for action

Background: The problem of training human resources in health is a real concern in public health in Central Africa. What can be changed in order to train more competent health professionals? This is of utmost importance in primary health care. Methods: Taking into account the level of training of secondary-level nurses in the Democratic Republic of the Congo (DRC); a systemic approach; based on the PRECEDE PROCEED model of analysis; led to a better understanding of the educational determinants and of the factors favourable to a better match between training in health sciences and the expected competences of the health professionals. This article must be read on two complementary levels: one reading; focused on the methodological process; should allow our findings to be transferred to other problems (adaptation of a health promotion model to the educational sphere). The other reading; revolving around the specific theme and results; should provide a frame of reference and specific avenues for action to improve human resources in the health field (using the results of its application in health science teaching in the DRC). Results: The results show that it is important to start this training with a global and integrated approach shared by all the actors. The strategies of action entail the need for an approach taking into account all the aspects; i.e. sociological; educational; medical and public health. Conclusions: The analysis of the results shows that one cannot bring any change without integrated strategies of action and a multidisciplinary approach that includes all the complex determinants of health behaviour; and to do it within the organization of local structures and institutions in the ministry of health in the DRC

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

Human resources for emergency obstetric care in northern Tanzania: distribution of quantity or quality?

Background: Health care agencies report that the major limiting factor for implementing effective health policies and reforms worldwide is a lack of qualified human resources. Although many agencies have adopted policy development and clinical practice guidelines; the human resources necessary to carry out these policies towards actual reform are not yet in place. Objectives: The goal of this article is to evaluate the current status of human resources quality; availability and distribution in Northern Tanzania in order to provide emergency obstetric care services to specific districts in this area. The article also discusses the usefulness of distribution indicators for describing equity in the decision-making process.Methods: We conducted a quantitative facility survey in six districts of Northern Tanzania. We collected data from all 129 facilities that provide delivery services in the study area. The data includes information on the emergency obstetric care indicators; as described by the WHO/UNICEF/UFPA guidelines for monitoring the provision of obstetric care. The inventory also includes information on the numbers of qualified health personnel at the basic and comprehensive emergency obstetric care level. We analysed the distribution and workload of the available human resources in a wider policy context with a particular focus on equity; use and quality; by means of descriptive statistics and the Spearman's correlation test. Results: We determined that there are adequate human resources allocated for health care provision in Tanzania; according to national standards. Compared to similar countries however; Tanzania has a very low availability of health care staff. Most qualified staff are concentrated in a few centralized locations; while those remaining are inequitably and inefficiently distributed in rural areas and lower-level services. Rural districts have restricted access to government-run health care; because these facilities are understaffed. In fact; voluntary agency facilities in these districts have more staff than the government facilities. There is a statistical correlation between availability of qualified human resources and use of services; but the availability of qualified human resources does not automatically translate into higher availability of qualified emergency obstetric care services. Conclusion: National guidelines for human resources for health care in Tanzania require focused revisions in order to reflect the quality indicators more adequately when monitoring and setting criteria for HR distribution. Availability of qualified personnel as well as institutional management and capacity determine the quality of emergency obstetric care services and personnel. The current wide distribution of staff of inadequate quality should be reconsidered. The use of distribution indicators alone is not useful to properly monitor equity. This article suggests increasing access to high-quality health care instead of distributing low-quality services widely

Wastage in the health workforce: some perspectives from African countries

"Background: Sub-Saharan Africa faces a human resources crisis in the health sector. Over the past two decades its population has increased substantially; with a significant rise in the disease burden due to HIV/AIDS and recurrent communicable diseases and an increased incidence of noncommunicable diseases. This increased demand for health services is met with a rather low supply of health workers; but this notwithstanding; sub-Saharan African countries also experience significant wastage of their human resources stock. Methods: This paper is a desk review to illustrate suggestions that the way human resources for health (HRH) are trained and deployed in Africa does not enhance productivity and that countries are unable to realize the full potential expected from the working life of their health workers. The paper suggests data types for use in measuring various forms of ""wastage"". Results: ""Direct"" wastage - or avoidable increases in loss of staff through factors such as emigration and death - is on the rise; perhaps as a result of the HIV/AIDS epidemic. ""Indirect"" wastage - which is the result of losses in output and productivity from health professionals' misapplied skills; absenteeism; poor support and lack of supervision - is also common. HIV/AIDS represents a special cause of wastage in Africa. Deaths of health workers; fear of infection; burnout; absenteeism; heavy workloads and stress affect productivity. Conclusion: The paper reviews strategies that have been proposed and/or implemented. It suggests areas needing further attention; including: developing and using indicators for monitoring and managing wastage; enhancing motivation and morale of health workers; protecting and valuing the health worker with enhanced occupational safety and welfare systems; and establishing the moral leadership to effectively tackle HIV/AIDS and the brain drain."

Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review

Background: Substitute health workers are cadres who take on some of the functions and roles normally reserved for internationally recognized health professionals such as doctors; pharmacists and nurses but who usually receive shorter pre-service training and possess lower qualifications. Methods: A desk review is conducted on the education; regulation; scopes of practice; specialization; nomenclature; retention and cost-effectiveness of substitute health workers in terms of their utilization in countries such as Tanzania; Malawi; Mozambique; Zambia; Ghana etc.; using curricula; evaluations and key-informant questionnaires. Results: The cost-effectiveness of using substitutes and their relative retention within countries and in rural communities underlies their advantages to African health systems. Some studies comparing clinical officers and doctors show minimal differences in outcomes to patients. Specialized substitutes provide services in disciplines such as surgery; ophthalmology; orthopedics; radiology; dermatology; anesthesiology and dentistry; demonstrating a general bias of use for clinical services. Conclusions: The findings raise interest in expanding the use of substitute cadres; as the demands of expanding access to services such as antiretroviral treatment requires substantial human resources capacity. Understanding the roles and conditions under which such cadres best function; and managing the skepticism and professional turf protection that restricts their potential; will assist in effective utilization of substitutes

Public sector nurses in Swaziland: can the downturn be reversed?

Background: The lack of human resources for health (HRH) is increasingly being recognized as a major bottleneck to scaling up antiretroviral treatment (ART); particularly in sub-Saharan Africa; whose societies and health systems are hardest hit by HIV/AIDS. In this case study of Swaziland; we describe the current HRH situation in the public sector. We identify major factors that contribute to the crisis; describe policy initiatives to tackle it and base on these a number of projections for the future. Finally; we suggest some areas for further research that may contribute to tackling the HRH crisis inSwaziland. Methods: We visited Swaziland twice within 18 months in order to capture the HRH situation as well as the responses to it in 2004 and in 2005. Using semi-structured interviews with key informants and group interviews; we obtained qualitative and quantitative data on the HRH situation in the public and mission health sectors. We complemented this with an analysis of primary documents and a review of the available relevant reports and studies. Results: The public health sector in Swaziland faces a serious shortage of health workers: 44of posts for physicians; 19of posts for nurses and 17of nursing assistant posts were unfilled in 2004. We identified emigration and attrition due to HIV/AIDS as major factors depleting the health workforce. The annual training output of only 80 new nurses is not sufficient to compensate for these losses; and based on the situation in 2004 we estimated that the nursing workforce in the public sector would have been reduced by more than 40by 2010. In 2005 we found that new initiatives by the Swazi government; such as the scale-up of ART; the introduction of retention measures to decrease emigration and the influx of foreign nurses could have the potential to improve the situation. A combination of such measures; together with the planned increase in the training capacity of the country's nursing schools; could even reverse the trend of a diminishing health workforce. Conclusion: Emigration and attrition due to HIV/AIDS are undermining the health workforce in the public sector of Swaziland. Short-term and long-term measures for overcoming this HRH crisis have been initiated by the Swazi government and must be further supported and increased. Scaling up antiretroviral treatment (ART) and making it accessible and acceptable for the health workforce is of paramount importance for halting the attrition due to HIV/AIDS. To this end; we also recommend exploring ways to make ART delivery less labour-intensive. The production of nurses and nursing assistants must be urgently increased. Although the migration of HRH is a global issue requiring solutions at various levels; innovative in-country strategies for retaining staff must be further explored in order to stem as much as possible the emigration from Swaziland

The match between motivation and performance management of health sector workers in Mali

Human resources for health (HRH) play a central role in improving accessibility to services and quality of care. Their motivation influences this. In Mali; operational research was conducted to identify the match between motivation and the range and use of performance management activities. Objectives: To describe the factors motivating and demotivating health workers in Mali and match the motivators with the implementation of performance management. Methods: First an exploratory qualitative study was conducted: 28 interviews and eight group discussions were held. This was followed by a cross-sectional survey; during which 370 health workers were interviewed. The study population consisted of health workers of eight professional groups. The following issues were investigated:motivating and demotivating factors; experiences with performance management; including: job descriptions; continuous education; supervision; performance appraisal and career development.Findings: The study showed that the main motivators of health workers were related to responsibility; training and recognition; next to salary. These can be influenced by performance management (job descriptions; supervisions; continuous education and performance appraisal). Performance management is not optimally implemented in Mali; as job descriptions were not present or were inappropriate; only 13of interviewees received 4x per year supervision; and training needs were not analysed. Some 48of the interviewees knew their performance had been appraised in the last two years; the appraisals were perceived as subjective. No other methods were in place to show recognition. The results enabled the research team to propose adaptations or improvements upon existing performance management. Conclusion: The results showed the importance of adapting or improving upon performance management strategies to influence staff motivation. This can be done by matching performance management activities to motivators identified by operational research