Using modeling and scenario analysis to support evidence-based health workforce strategic planning in Malawi.

BACKGROUND: A well-trained and equitably distributed workforce is critical to a functioning health system. As workforce interventions are costly and time-intensive, investing appropriately in strengthening the health workforce requires an evidence-based approach to target efforts to increase the number of health workers, deploy health workers where they are most needed, and optimize the use of existing health workers. This paper describes the Malawi Ministry of Health (MoH) and collaborators' data-driven approach to designing strategies in the Human Resources for Health Strategic Plan (HRH SP) 2018-2022. METHODS: Three modelling exercises were completed using available data in Malawi. Staff data from districts, central hospitals, and headquarters, and enrollment data from all health training institutions were collected between October 2017 and February 2018. A vacancy analysis was conducted to compare current staffing levels against established posts (the targeted number of positions to be filled, by cadre and work location). A training pipeline model was developed to project the future available workforce, and a demand-based Workforce Optimization Model was used to estimate optimal staffing to meet current levels of service utilization. RESULTS: As of 2017, 55% of established posts were filled, with an average of 1.49 health professional staff per 1000 population, and with substantial variation in the number of staff per population by district. With current levels of health worker training, Malawi is projected to meet its establishment targets in 2030 but will not meet the WHO standard of 4.45 health workers per 1000 population by 2040. A combined intervention reducing attrition, increasing absorption, and doubling training enrollments would allow the establishment to be met by 2023 and the WHO target to be met by 2036. The Workforce Optimization Model shows a gap of 7374 health workers to optimally deliver services at current utilization rates, with the largest gaps among nursing and midwifery officers and pharmacists. CONCLUSIONS: Given the time and significant financial investment required to train and deploy health workers, evidence needs to be carefully considered in designing a national HRH SP. The results of these analyses directly informed Malawi's HRH SP 2018-2022 and have subsequently been used in numerous planning processes and investment cases in Malawi. This paper provides a practical methodology for evidence-based HRH strategic planning and highlights the importance of strengthening HRH data systems for improved workforce decision-making.

Analysis of policy interventions to attract and retain nurse midwives in rural areas of Malawi: A discrete choice experiment.

BACKGROUND: Inadequate and unequal distribution of health workers are significant barriers to provision of health services in Malawi, and challenges retaining health workers in rural areas have limited scale-up initiatives. This study therefore aims to estimate cost-effectiveness of monetary and non-monetary strategies in attracting and retaining nurse midwife technicians (NMTs) to rural areas of Malawi. METHODS: The study uses a discrete choice experiment (DCE) methodology to investigate importance of job characteristics, probability of uptake, and intervention costs. Interviews and focus groups were conducted with NMTs and students to identify recruitment and retention motivating factors. Through policymaker consultations, qualitative findings were used to identify job attributes for the DCE questionnaire, administered to 472 respondents. A conditional logit regression model was developed to produce probability of choosing a job with different attributes and an uptake rate was calculated to estimate the percentage of health workers that would prefer jobs with specific intervention packages. Attributes were costed per health worker year. RESULTS: Qualitative results highlighted housing, facility quality, management, and workload as important factors in job selection. Respondents were 2.04 times as likely to choose a rural job if superior housing was provided compared to no housing (CI 1.71-2.44, p<0.01), and 1.70 times as likely to choose a rural job with advanced facility quality (CI 1.47-1.96, p<0.01). At base level 43.9% of respondents would choose a rural job. This increased to 61.5% if superior housing was provided, and 72.5% if all facility-level improvements were provided, compared to an urban job without these improvements. Facility-level interventions had the lowest cost per health worker year. CONCLUSIONS: Our results indicate housing and facility-level improvements have the greatest impact on rural job choice, while also creating longer-term improvements to health workers' living and working environments. These results provide practical evidence for policymakers to support development of workforce recruitment and retention strategies.

Understanding job satisfaction and motivation among nurses in public health facilities of Ethiopia: a cross-sectional study.

BACKGROUND: Poor job conditions and limited resources are reducing job satisfaction and motivation among nurses in low-income countries, which may affect the quality of services and attrition rates. The objective of this study was to examine job satisfaction, motivation and associated factors among nurses working in the public health facilities of Ethiopia, with the aim of improving performance and productivity in the health care system. METHODS: The study employed a cross-sectional two-stage cluster sampling design. From a random sample of 125 health facilities, 424 nurses were randomly selected for face-to-face interviews in all regions of Ethiopia. Nurses responded to questions about their overall job satisfaction and job conditions, including items related to intrinsic and extrinsic motivation, using a 5-point Likert scale. Multilevel analysis was performed to adjust for different clustering effects. Satisfaction levels (percent of respondents who were satisfied) were calculated for individual items, and composite mean scores (range: 1-5) were calculated for motivational factors. Adjusted odds ratios were computed to examine the association of these factors with overall job satisfaction. RESULTS: Overall, 60.8% of nurses expressed satisfaction with their job. Composite mean scores for intrinsic and extrinsic motivational factors were 3.5 and 3.0, respectively. Job satisfaction levels were significantly higher for female nurses (65.6%, p = 0.04), those older than 29 years (67.8%, p = 0.048) and had over 10 years work experiences (68.8%, p = 0.007). Satisfaction with remuneration (AOR = 2.04, 95% CI = 1.36, 3.06), recognition (AOR = 2.21; 95% CI = 1.38, 3.53), professional advancement (AOR = 1.54; 95% CI = 1.06, 2.29), features of the work itself (AOR = 1.65; 95% CI = 1.20, 2.91) and nurses' work experiences from 5 to 10 years (AOR = 0.37, 95% CI = 0.17, 0.79) were significantly associated with overall job satisfaction after controlling for other predictors. CONCLUSIONS: The study findings are signals for the Ministry of Health to strengthen the human resource management system and practices to improve nurses' overall job satisfaction and motivation, especially among nurses with 5 to 10 years of experience on the job. Expanded recognition systems and opportunities for advancement are required to increase nurses' job satisfaction and motivation. Equitable salary and fringe benefits are also needed to reduce their dissatisfaction with the job.

Education, Practice, and Competency Gaps of Anesthetists in Ethiopia: Task Analysis.

PURPOSE: This study assessed the needs and gaps in the education, practice and competencies of anesthetists in Ethiopia. DESIGN: A cross-sectional study design was used. METHODS: A questionnaire consisting of 74 tasks was completed by 137 anesthetists who had been practicing for 6 months to 5 years. FINDINGS: Over half of the respondents rated 72.9% of the tasks as being highly critical to patient outcomes, and reported that they performed 70.2% of all tasks at a high frequency. More than a quarter of respondents reported that they performed 15 of the tasks at a low frequency. Nine of the tasks rated as being highly critical were not learned during pre-service education by more than one-quarter of study participants, and over 10% of respondents reported that they were unable to perform five of the highly critical tasks. CONCLUSIONS: Anesthetists rated themselves as being adequately prepared to perform a majority of the tasks in their scope of practice.

Factors Predicting Ethiopian Anesthetists' Intention to Leave Their Job.

BACKGROUND: Ethiopia has rapidly expanded training programs for associate clinician anesthetists in order to address shortages of anesthesia providers. However, retaining them in the public health sector has proven challenging. This study aimed to determine anesthetists' intentions to leave their jobs and identify factors that predict turnover intentions. METHODS: A nationally representative, cross-sectional survey of 251 anesthetists working in public-sector hospitals in Ethiopia was conducted in 2014. Respondents were asked whether they planned to leave the job in the next year and what factors they considered important when making decisions to quit. Bivariate and multivariable logistic regressions were conducted to investigate 16 potential predictors of turnover intentions, including personal and facility characteristics as well as decision-making factors. RESULTS: Almost half (n = 120; 47.8%) of anesthetists planned to leave their jobs in the next year, and turnover intentions peaked among those with 2-5 years of experience. Turnover intentions were not associated with the compulsory service obligation. Anesthetists rated salary and opportunities for professional development as the most important factors in decisions to quit. Five predictors of turnover intentions were significant in the multivariable model: younger age, working at a district rather than regional or referral hospital, the perceived importance of living conditions, opportunities for professional development, and conditions at the workplace. CONCLUSIONS: Human resources strategies focused on improving living conditions for anesthetists and expanding professional development opportunities may increase retention. Special attention should be focused on younger anesthetists and those posted at district hospitals.

Preparing the health workforce in Ethiopia: A Cross-sectional study of competence of anesthesia graduating students.

BACKGROUND: Efforts to address shortages of health workers in low-resource settings have focused on rapidly increasing the number of higher education programs for health workers. This study examines selected competencies achieved by graduating Bachelor of Science and nurse anesthetist students in Ethiopia, a country facing a critical shortage of anesthesia professionals. METHODS: The study, conducted in June and July 2013, assessed skills and knowledge of 122 students graduating from anesthetist training programs at six public universities and colleges in Ethiopia; these students comprise 80% of graduates from these institutions in the 2013 academic year. Data was collected from direct observations of student performance, using an objective structured clinical examination approach, and from structured interviews regarding the adequacy of the learning environment. RESULTS: Student performance varied, with mean percentage scores highest for spinal anesthesia (80%), neonatal resuscitation (74%), endotracheal intubation (73%), and laryngeal mask airway insertion check (71%). Average scores were lowest for routine anesthesia machine check (37%) and preoperative screening assessment (48%). Male graduates outscored female graduates (63.2% versus 56.9%, P = 0.014), and university graduates outscored regional health science college graduates (64.5% versus 55.5%, P = 0.023). Multivariate linear regression found that competence was associated with being male and attending a university training program. Less than 10% of the students believed that skills labs had adequate staff and resources, and only 57.4% had performed at least 200 endotracheal intubations at clinical practicum sites, as required by national standards. DISCUSSION: Ethiopia has successfully expanded higher education for anesthetists, but a focus on quality of training and assessment of learners is required to ensure that graduates have mastered basic skills and are able to offer safe services.