Innovation to improve health care provision and health systems in sub-Saharan Africa – Promoting agency in mid-level workers and district managers

Abstract

Initiatives to address the human resource crisis in African health systems have included expanded training of mid-level workers (MLWs). Currently, MLWs are the backbone of many health systems in Africa but they are often de-motivated and they often operate in circumstances in which providing high quality care is challenging. Therefore, assuming that introducing additional people will materially change health system performance is unrealistic. We briefly critique such unifocal interventions and review the literature to understand the factors that affect the motivation and performance of MLWs. Three themes emerge: the low status and inadequate recognition of MLWs, quality of care issues and working in poorly managed systems. In response we propose three interrelated interventions: a regional association of MLWs to enhance their status and recognition, a job enrichment and mentoring system to address quality and a district managers’ association to improve health systems management. The professionalisation of MLWs and district managers to address confidence, self-esteem and value is considered. The paper describes the thinking behind these interventions, which are currently being tested in Kenya, Nigeria, South Africa and Uganda for their acceptability and appropriateness. We offer the policy community a complementary repertoire to existing human resource strategies in order to effect real change in African health systems.

Keywords:

• mid-level workers
• Africa
• health systems
• district management
• health policy and services
• agency
• motivation
• human resources

Acknowledgements

We gratefully acknowledge the contributions of James Tumwine and Charles Ibingira, Makerere University, Uganda; Ian Couper, Jane Doherty and Daphney Conco, University of the Witwatersrand, South Africa; Eren Oyungu, Moi University and Lucy Muchiri University of Nairobi; and Alex Ezeh, Caroline Kabiru and Chimaraoke Izugbara, African Population Health Research Centre, Nairobi, Kenya. Funding for this research is provided by the Bill and Malinda Gates Foundation.

Notes

1. The outcome of the stakeholder analysis and acceptability review will be presented in a subsequent publication on completion of the research. The stakeholders from each country included mid-level health workers, district health managers, staff in hospitals employing MLWs, higher education trainers of doctors and MLWs, representatives of nursing, medical and pharmaceutical professional bodies, and representatives from the Ministries of Health and Finance.