The evolution of the national licensing system of health care professionals: a qualitative descriptive case study in Lao People's Democratic Republic.

BACKGROUND: The introduction of a systematic framework for the licensing of health care professions, which is a crucial step in ensuring the quality of human resources for health (HRH), is still evolving in Lao People's Democraic Republic. The aim of this study was to review and document the evolution of Lao HRH policies and the development of its national licensing system. CASE PRESENTATION: A qualitative descriptive case study methodology was applied to document and describe how Lao People's Democratic Republic laid the foundation for the development of a licensing system. The results demonstrate that Lao People's Democratic Republic is currently in the process of transitioning the focus of its HRH policies from the quantity and deployment of services to remote areas to improvements in the quality of services. The key events in the process of developing the licensing system are as follows: (1) the systematic development of relevant policies and legislation, (2) the establishment of responsible organizations and the assignment of responsible leaders, (3) the acceleration of development efforts in response to the Association of Southeast Asian Nations Mutual Recognition Arrangement for standard qualifications, (4) the strengthening of educational systems for fostering competent health care professionals, (5) the introduction of a 3-year compulsory service component in rural areas for newly recruited government servants, and (6) the introduction of a requirement to obtain a professional health care certificate to work in a private hospital. The Lao Ministry of Health (MOH) has endorsed a specific strategy for licensing to realize this system. CONCLUSION: The need for licensing systems has increased in recent years due to regional economic integration and a shift in policy toward achieving universal health coverage. A national licensing system would be a significant milestone in health system development, helping to ensure the competency of health care professionals by means of a national examination, continuing professional development, and the revoking of licenses when appropriate.

Strengthening the Engagement of Provinces in Health Workforce Planning and Management: A Case Study From Lao PDR.

The purpose of this health workforce plan is to provide guidance for the staffing of the Bolikhamxay. Province health services and the training of health service personnel to the year 2020. It must be stressed, however, that this plan is in its first iteration and does not provide all the solutions. Rather, it identifies issues that need to be further investigated and resolved at the local level. For example, the provincial health department (PHD) will need to further investigate the reasons for the significant variability in the utilization of services in different facilities and in the different ratios of staff in relation to the activities performed. The accuracy of the data must be validated and specific interventions must be determined. For Bolikhamxay, particular attention by PHD and district health authorities should be given to the following issues identified in the analysis:• Shortage of clinical staff, particularly in the age group 30 to 40 years old, to provide supervision, guidance, and support for junior staff in coming years;• The existence of health centers with less than minimum staffing level (<3), including a midwife and/or staff capable of properly addressing emergencies with particular reference to maternal and child health.• The median number of activities per staff per year is around 470 (Nakoun/Bolikhan), which means that, on average, a health worker will participate in fewer than two activities per day. The situation in some district hospitals and most health centers is even worse, with an annual average number of activities per staff of only 163, which means that, on average, one staff participates in one activity every 3 days, hardly enough to maintain skills and justify deployment.• This low level of staff activity raises questions about the need for further increase of staff supply to health centers and districts unless effective interventions are implemented to increase the demand and utilization of services in these facilities.• It is also necessary to document all relevant activities, including outreach activities and home visits, in order to give appropriate weight in the calculation of utilization and productivity.• Development of the provincial health workforce development plan requires validated human resources for health information and engagement of local health authorities, as well as strong collaboration with the national authorities and development partners, to ensure adequate support and resourcing.

Addressing the human resources crisis: a case study of Cambodia's efforts to reduce maternal mortality (1980-2012).

OBJECTIVE: To identify factors that have contributed to the systematic development of the Cambodian human resources for health (HRH) system with a focus on midwifery services in response to high maternal mortality in fragile resource-constrained countries. DESIGN: Qualitative case study. Review of the published and grey literature and in-depth interviews with key informants and stakeholders using an HRH system conceptual framework developed by the authors ('House Model'; Fujita et al, 2011). Interviews focused on the perceptions of respondents regarding their contributions to strengthening midwifery services and the other external influences which may have influenced the HRH system and reduction in the maternal mortality ratio (MMR). SETTING: Three rounds of interviews were conducted with senior and mid-level managers of the Ministries of Health (MoH) and Education, educational institutes and development partners. PARTICIPANTS: A total of 49 interviewees, who were identified through a snowball sampling technique. MAIN OUTCOME MEASURES: Scaling up the availability of 24 h maternal health services at all health centres contributing to MMR reduction. RESULTS: The incremental development of the Cambodian HRH system since 2005 focused on the production, deployment and retention of midwives in rural areas as part of a systematic strategy to reduce maternal mortality. The improved availability and access to midwifery services contributed to significant MMR reduction. Other contributing factors included improved mechanisms for decision-making and implementation; political commitment backed up with necessary resources; leadership from the top along with a growing capacity of mid-level managers; increased MoH capacity to plan and coordinate; and supportive development partners in the context of a conducive external environment. CONCLUSIONS: Lessons from this case study point to the importance of a systemic and comprehensive approach to health and HRH system strengthening and of ongoing capacity enhancement and leadership development to ensure effective planning, implementation and monitoring of HRH policies and strategies.

Measuring students' approaches to learning in different clinical rotations.

BACKGROUND: Many studies have explored approaches to learning in medical school, mostly in the classroom setting. In the clinical setting, students face different conditions that may affect their learning. Understanding students' approaches to learning is important to improve learning in the clinical setting. The aim of this study was to evaluate the Study Process Questionnaire (SPQ) as an instrument for measuring clinical learning in medical education and also to show whether learning approaches vary between rotations. METHODS: All students involved in this survey were undergraduates in their clinical phase. The SPQ was adapted to the clinical setting and was distributed in the last week of the clerkship rotation. A longitudinal study was also conducted to explore changes in learning approaches. RESULTS: Two hundred and nine students participated in this study (response rate 82.0%). The SPQ findings supported a two-factor solution involving deep and surface approaches. These two factors accounted for 45.1% and 22.5%, respectively, of the variance. The relationships between the two scales and their subscales showed the internal consistency and factorial validity of the SPQ to be comparable with previous studies. The clinical students in this study had higher scores for deep learning. The small longitudinal study showed small changes of approaches to learning with different rotation placement but not statistically significant. CONCLUSIONS: The SPQ was found to be a valid instrument for measuring approaches to learning among clinical students. More students used a deep approach than a surface approach. Changes of approach not clearly occurred with different clinical rotations.

Negotiating norms, navigating care: findings from a qualitative study to assist in decreasing health inequity in cardiac rehabilitation.

PURPOSE: People from culturally and linguistically diverse backgrounds (CaLDBs) have lower rates of participation in cardiac rehabilitation (CR). Systematically evaluating barriers and facilitators to service delivery may decrease health inequalities. This study investigated approaches for promoting cultural competence in CR. METHODS: A qualitative study of 25 health practitioners was undertaken across three CR programs using a purposive sampling strategy. Interviews and participant observation were undertaken to identify factors to promote culturally competent care. RESULTS: Three key foci were identified for implementing cultural competence approaches: (1) point of contact; (2) point of assessment; and (3) point of service. Based upon study findings and existing literature, a conceptual model of cultural competency in CR was developed. CONCLUSION: Culturally competent strategies for identifying and tailoring activities in the CR setting may be a useful approach to minimise health inequities. The findings from this study identified that, in parallel with mainstream health services, CR service delivery in Australia faces challenges related to cultural and ethnic diversity. Encouragingly, study findings revealed implementation and integration of culturally competent practices in rehabilitation settings, in spite of significant odds.

A review of the cultural competence view of cardiac rehabilitation.

AIMS AND OBJECTIVES: This paper describes cultural competence issues within the scientific and scholarly discourse surrounding cardiac rehabilitation (CR). BACKGROUND: CR is an important secondary prevention strategy, improving health-related outcomes and reducing the risks of subsequent cardiovascular events. Internationally, it is widely accepted as a discrete health service model and is endorsed by government and professional bodies. Over past decades, low participation rates in CR remain a concern, particularly among minority groups and culturally and linguistically diverse populations. DESIGN: Systematic review. METHODS: Search of electronic databases. CONCLUSIONS: Few studies to date have described cultural competence in CR service design and as a consequence, there are minimal data to assist CR professionals and policy makers in tailoring health service delivery models. The limited scholarly debate and discussion regarding cultural competence in the CR literature limits the development and evaluation of culturally appropriate interventions. RELEVANCE TO CLINICAL PRACTICE: There needs to be greater attention to the concept of cultural competence, both in practice and research settings, to ensure access to CR for people from culturally and linguistically diverse backgrounds.

A framework for evaluating the impact of the United Nations fellowship programmes.

The United Nations (UN) System's agencies have been criticized for not adequately assessing the impact of their training and fellowship programmes. Critics point out that beyond documentation of the number of fellows that underwent training, and their immediate reaction to the experience, it is necessary to ascertain that fellows are using what they have learned, and most importantly that their institution and country are benefiting from the significant investments made in the fellowship programmes.This paper presents an evaluation framework that was adopted by the 17th Meeting of the UN System Senior Fellowship Officers convened in London in 2008 in response to this challenge. It is arranged in three sections. First, the assumptions and constraints concerning impact evaluation of training are presented. Second, a framework for evaluating the impact of training in the context of UN System programmes is proposed. Third, necessary conditions and supportive measures to enable implementation of the impact evaluation framework are identified.The critical message emerging from this review is the importance of constructing a 'performance story' based on key milestones associated with the design and implementation of fellowship programmes as a way of assessing the contribution of different components of the fellowship programmes to institutional outcomes.

Alumni survey of Masters of Public Health (MPH) training at the Hanoi School of Public Health.

BACKGROUND: 1) To elicit the opinions of the Public Health alumni of the MPH program; 2) To assess the applicability of the knowledge and skills acquired; 3) To identify the frequency of the public health competencies that the alumni performed. METHODS: We requested 187 graduates to complete a self-administered questionnaire and conducted in-depth interviews with 8 alumni as well as a focus group discussion with 14 alumni. RESULTS: In total 79.1% (148) of the MPH graduates completed and returned the questionnaire. Most alumni (91%) agreed that the MPH curriculum corresponded with the working requirements of public health professionals; and nearly all were satisfied with what they have learnt (96%). Most respondents said that the MPH program enabled them to develop relevant professional skills (95%) and that they were satisfied with the curriculum (90%). Notably fewer respondents (73%) felt that the MPH program structure was balanced and well designed. Most alumni (64.3%) were satisfied with Hanoi School of Public Health (HSPH) full-time lecturers; but even more (83%) were satisfied with visiting lecturers. The most commonly selected of the 34 pre-identified public health competencies were: applying computer skills (66.4%), planning and managing health programs (47.9%), communicating with the community and/or mobilizing the community to participate in health care (43.2%). Overall, the MPH alumni felt that HSPH emphasized research methods at the expense of some management and operational competencies. The most important challenges at work identified by the alumni were insufficient skills in: data analysis, decision making, inter-sectoral cooperation development, English language and training. CONCLUSION: The training program should be reviewed and revised to meet the needs of its graduates who enter diverse situations and positions. English language skills were identified as top priority for further emphasis. The training program should comply with a more advanced accreditation system and standards.

The organisational response to patient complaints: a case study in Taiwan.

PURPOSE: To explore and evaluate how hospital staff respond to patient complaints. DESIGN/METHODOLOGY/APPROACH: A teaching hospital with 1,500 beds in Taiwan was purposefully chosen as a case study of hospital response to patients' complaints. Data was obtained through interviews with quality surveying managers (n = 53), government managers (n = 4), staff of non-government organizations (n = 3) and a senior social worker, as well as analysis of documents (September 2001-April 2002). FINDINGS: Using the managerial-operational-technical framework developed by the researchers, the study demonstrated problematic aspects of handling complaints at the case hospital. It was revealed that: complaint handlers were not sufficiently empowered, information sharing was limited within the organization, communication among professional staff and with management was inadequate, the physical safety of workers had been threatened, and improvements could not be sustained. Moreover, it became apparent that the case study hospital generally responded to patient complaints in a reactive and defensive manner. ORIGINALITY/VALUE: It is evident that the hospital did not use patient complaints as a source of learning that could have promoted higher standards of care. The case study reveals some of the constraints and identifies requirements for appropriate use of information and feedback from patients. The study raises some issues requiring further research to ensure more appropriate use of patient complaints to improve quality of care.

Public health job vacancies--who wants what, where?

This paper presents a snapshot of job vacancies in the public health workforce labour market. The analysis is based on 404 advertised public health jobs appearing in the press, and on-line job alerts over a 2-month period in mid 2003. The analysis reveals who was seeking employees, what formal qualifications and competencies were required, what salary and other conditions of employment were offered and where the vacant jobs were located. The study demonstrates the heterogeneity of the public health workforce, which limits definition of clear practice boundaries and complicates workforce planning. The findings further demonstrate the benefit of reviewing both the demand and the supply side of the labour market, and point to the value of repeated surveys of advertised jobs as part of an ongoing public health workforce monitoring and planning process.

Closing the gap: building the capacity of non-government organizations as advocates for health equity.

Seeking achievement of health equity has underpinned national government and global health policies for decades. However, major difficulties and challenges faced in the practice of achieving 'Health for All' has led to a recognition of the need to broaden the focus of efforts to improve health equity. Civil society groups have been identified as key stakeholders in attempts to achieve health equity, and the importance of strengthening their capacity to influence relevant government policy and practice has been highlighted. This paper presents the results of a qualitative study which examined the role of organizations outside government in advocating for health equity, and the capacities and conditions that were related to their success. In-depth, unstructured interviews were conducted with 26 non-government organizations (NGOs) who were active in three important health policy debates in Australia. The grounded theory method was used to direct data collection and analysis, and member checking was employed to ensure soundness and build ownership of the findings. Effective advocacy was found to be a dynamic process characterized by flexibility and opportunism within a framework of longer term goals. Two key ways of working were identified--in partnership and in conflict with government, with shifts in emphasis in response to organizational strengths and a changing environment. A number of domains of capacity, which together are termed 'capacity for advocacy', were also identified. It is clear that NGOs can learn a great deal from each other, but there needs to be investment by governments, international agencies and NGOs themselves if advocacy for health equity is to be strengthened.