Factors explaining the shortage and poor retention of qualified health workers in rural and remote areas of the Kayes, region of Mali: a qualitative study.

INTRODUCTION: Shortage of health workers is a worldwide problem but is particularly critical in sub-Saharan Africa. In Mali, the number of health workers is insufficient and their retention is low, particularly in rural and remote areas. Rural postings are unattractive to health workers. Very few studies have examined the factors contributing to the shortage and poor retention of health workers in Mali. The objective of this study is to identify and understand these factors with regards to skilled health workers in two rural health districts (Yélimané and Bafoulabé) in the region of Kayes, Mali. METHODS: This qualitative study is based on the conceptual framework of Lehman, Dieleman and Martineau. Data were collected through 46 in-depth interviews with health workers and decision-makers. A thematic content analysis was conducted with the support of QDA Miner software. RESULTS: The study identified factors contributing to the insufficient allocation and poor retention of rural health workers in these districts. They are individual-level factors (gender, family situation, age), unattractive living and working conditions, community recognition and participation, quality of leadership, an unfavourable recruitment/assignment process and insufficient financial incentives. It shows that female staff have specific constraints that prevent them from deploying to or staying in rural areas for long periods. In addition, the number of staff recruited at the national level is unpredictable and insufficient, while their recruitment and assignment process is perceived to be inequitable and not very transparent, disadvantaging rural health structures. Some strategies were identified to improve the availability and retention of health workers in these areas. They take into account certain social norms, notably gender roles, and include the improvement of living and working conditions, as well as the strengthening of health workforce management. CONCLUSION: This study's findings highlight the multifaceted nature of factors contributing to the availability and retention of health workers in rural and remote areas of sub-Saharan Africa and the challenges associated with them. This study identifies some strategies that can be combined to facilitate the retention and availability of health workers in these areas. Some strategies involve actors outside the health sector, requiring joint efforts for their implementation. This research provides decision-makers with evidence to support informed decision making with regards to the retention of health workers in rural areas.

Addressing social and gender norms to improve uptake of maternal health services in Mali: a descriptive study of CARE's Project Hope for Mothers and Newborns (PEMN).

This study examines the design and implementation of a maternal mortality prevention intervention in central Mali. It uses Project Hope for Mothers and Newborns (PEMN) as a case study to examine the context around implementation, with special emphasis on the role of social, gender and power norms in meeting programme objectives. Interventions to strengthen the health system and workforce were coupled with a social norms change approach to catalyse the personal transformation of staff, community-level health workers and communities via critical reflection and dialogue on gender and social power norms related to maternal health. Processes of reflection among staff, health workers and the community, coupled with activities that challenged restrictive norms, provided a platform for critical thinking, communication and motivation for change. Rigorous and comprehensive monitoring and evaluation is needed to identify and understand unique pathways to transformative change.

The influence of intrafamilial power on maternal health care in Mali: perspectives of women, men and mothers-in-law.

CONTEXT: Evidence from diverse settings suggests that women often have limited control over their own reproductive health decisions. To increase uptake of preventive services and behaviors, it is important to understand how intrafamilial power dynamics and the attitudes of women, their husband and their mother-in-law are associated with maternal health practices. METHODS: In 317 households in two rural districts of central Mali, women who had given birth in the previous year, their husband and their mother-in-law each completed a survey gauging their attitudes toward constructs of gender, power and health. Bivariate and multivariable logistic regression analyses were conducted to identify associations with four maternal health outcomes: antenatal care frequency, antenatal care timing, institutional delivery and postnatal care. RESULTS: In multivariable analyses, the preferences and opinions of mothers-in-law were associated with the maternal health behaviors of their daughters-in-law. Women's own perceptions of their self-efficacy, the value of women in society and the quality of services at the local health facility were also independently associated with their preventive and health-seeking practices. Husbands' preferences and opinions were not associated with any outcome. CONCLUSION: Interventions focusing on women or couples may be insufficient to advance women's reproductive health in patriarchal societies such as Mali. Future research and programmatic efforts need to address gender norms and consider the influence of other family members, such as mothers-in-law.

Emergency obstetric care in Mali: catastrophic spending and its impoverishing effects on households.

OBJECTIVE: To investigate the frequency of catastrophic expenditures for emergency obstetric care, explore its risk factors, and assess the effect of these expenditures on households in the Kayes region, Mali. METHODS: Data on 484 obstetric emergencies (242 deaths and 242 near-misses) were collected in 2008-2011. Catastrophic expenditure for emergency obstetric care was assessed at different thresholds and its associated factors were explored through logistic regression. A survey was subsequently administered in a nested sample of 56 households to determine how the catastrophic expenditure had affected them. FINDINGS: Despite the fee exemption policy for Caesareans and the maternity referral-system, designed to reduce the financial burden of emergency obstetric care, average expenses were 152 United States dollars (equivalent to 71 535 Communauté Financière Africaine francs) and 20.7 to 53.5% of households incurred catastrophic expenditures. High expenditure for emergency obstetric care forced 44.6% of the households to reduce their food consumption and 23.2% were still indebted 10 months to two and a half years later. Living in remote rural areas was associated with the risk of catastrophic spending, which shows the referral system's inability to eliminate financial obstacles for remote households. Women who underwent Caesareans continued to incur catastrophic expenses, especially when prescribed drugs not included in the government-provided Caesarean kits. CONCLUSION: The poor accessibility and affordability of emergency obstetric care has consequences beyond maternal deaths. Providing drugs free of charge and moving to a more sustainable, nationally-funded referral system would reduce catastrophic expenses for households during obstetric emergencies.