Universal health coverage reforms: implications for the distribution of the health workforce in low- and middle-income countries.

To achieve universal health coverage (UHC), a range of health-financing reforms, including removal of user fees and the expansion of social health insurance, have been implemented in many countries. While the focus of much research and discussion on UHC has been on the impact of health-financing reforms on population coverage, health-service utilization and out-of-pocket payments, the implications of such reforms for the distribution and performance of the health workforce have often been overlooked. Shortages and geographical imbalances in the distribution of skilled health workers persist in many low- and middle-income countries, posing a threat to achieving UHC. This paper suggests that there are risks associated with health-financing reforms, for the geographical distribution and performance of the health workforce. These risks require greater attention if poor and rural populations are to benefit from expanded financial protection.

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.

Trabajadores de salud de nivel intermedio: un recurso prometedor / Mid-level health providers: a promising resource

Los trabajadores de salud de nivel intermedio (TSNI) son trabajadores capacitados en una institución de educación superior durante al menos dos a tres años, quienes son autorizados y regulados para trabajar de forma autónoma para el diagnóstico, control y tratamiento de dolencias, enfermedades y discapacidades, así como participar en la prevención y promoción de la salud. Su papel se ha ampliado progresivamente y ha recibido atención en particular en países de ingresos bajos y medios, como parte de una estrategia para superar los desafíos del personal sanitario, mejorar el acceso a servicios básicos de salud y lograr objetivos relacionados con los Objetivos del Desarrollo del Milenio. La evidencia, aunque limitada e imperfecta, muestra que donde los TSNI están debidamente capacitados, apoyados y coherentemente integrados en el sistema de salud, tienen el potencial para mejorar la distribución de los trabajadores de la salud y el acceso equitativo a los servicios de salud, manteniendo -si no sobrepasando- los estándares de calidad comparables a los servicios prestados por el personal médico. Sin embargo, existen desafíos importantes en términos de la marginación y el limitado apoyo a la gestión de los TSNI en los sistemas de salud. La expansión de los TSNI debe tener prioridad entre las opciones de política consideradas por países que enfrentan problemas de escasez y desigualdad en la distribución de recursos humanos. Una mejor educación, supervisión, administración y regulación de las prácticas y la integración en el sistema de salud tienen el potencial de maximizar los beneficios de la utilización de este personal.

Mid-level health providers (MLP) are health workers trained at a higher education institution for at least a total of 2-3 years, and authorized and regulated to work autonomously to diagnose, manage and treat illness, disease and impairments, as well as engage in preventive and promotive care. Their role has been progressively expanding and receiving attention, in particular in low- and middle-income countries, as a strategy to overcome health workforce challenges and improve access to essential health services and achieve the health related targets of the Millennium Development Goals. Evidence, although limited and imperfect, shows that, where MLP are adequately trained, supported and integrated coherently in the health system, they have the potential to improve distribution of health workers and enhance equitable access to health services, while retaining quality standards comparable to, if not exceeding, those of services provided by physicians. Significant challenges however exist in terms of the marginalization and more limited management support of MLP in health systems. The expansion of MLP should have priority among the policy options considered by countries facing shortage and maldistribution challenges. Improved education, supervision, management and regulation practices and integration in the health system have the potential to maximize the benefits from the use of these cadres.

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.