Strikes of physicians and other health care workers in sub-Saharan African countries: a systematic review.

Introduction: Strikes in the health sector have been of growing concern, given their disruptive nature, negatively impacting the provision of health care and jeopardizing the well-being of patients. This study aims to identify the main actors, the reasons behind industrial actions protests, strikes and lockouts (IAPSL) in sub-Saharan African countries and their impact on health care workers (specifically doctors) and health services, as well as to identify the main strategies adopted to reduce their impact on healthcare services. Methods: Studies published between January 2000 and December 2021 and archived in MEDLINE, Google Scholar, Scopus, ProQuest, and Science Direct were included. Quantitative, observational (i.e., cohort, case-control, cross-sectional, and ecological) and experimental studies, as well as mixed methods, quasi-experimental, and qualitative studies were eligible. Results: A total of 5521 studies were identified and after eliminating duplicates, applying the inclusion criteria, and assessing the risk of bias, a total of 11 studies were included in the review. Nurses and doctors are the actors most commonly involved in strikes. The main causes of strikes were salary claims and poor working conditions. The main strategies adopted to mitigate the strike consequences were to restrict services and prioritize emergency and chronic care, greater cooperation with the private sector and rearrange tasks of the available staff. The strikes led to a reduction in hospitalizations and in the number of women giving birth in health units, an increase in maternal and child morbidities and delays in the immunization process. Increased mortality was only reported in faith-based hospitals. Discussion: This evidence can assist decision-makers in developing strategies and interventions to address IAPSL by health care workers, contributing to strengthen the health system. Strikes in the health sector disrupt healthcare services provision and compromise the well-being of patients, especially the most disadvantaged, with consequences that may be difficult to overcome ever. The potential health impacts of strikes highlights the importance of their prevention or timely resolution through regulation and negotiations to balance the rights of health care workers and the rights of patients. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=334173, identifier CRD42022334173.

Ethical challenges in health care during collective hunger strikes in public or occupied spaces.

Public collective hunger strikes take place in complex social and political contexts, require medical attention and present ethical challenges to physicians. Empirical research, the ethical debate to date and existing guidelines by the World Medical Association focus almost exclusively on hunger strikes in detention. However, the public space differs substantially with regard to the conditions for the provision of health care and the diverse groups of healthcare providers or stakeholders involved. By reviewing empirical research on the experience of health professionals with public collective hunger strikes, we identified the following ethical challenges: (1) establishment of a trustful physician-striker relationship, (2) balancing of medico-ethical principles in medical decision-making, (3) handling of loyalty conflicts and (4) preservation of professional independence and the risk of political instrumentalization. Some of these challenges have already been described and discussed, yet not contextualized for public collective strikes, while others are novel. The presence of voluntary physicians may offer opportunities for a trustful relationship and, hence, for ethical treatment decisions. According to our findings, it requires more attention to how to realise autonomous medical decisions in the complex context of a dynamic, often unstructured and politically charged setting, which ethical norms should shape the professional role of voluntary physicians, and what is the influence of the hunger strikers' collective on individual healthcare decisions. Our article can serve as a starting point for further ethical discussion. It can also provide the basis for the development of potential guidelines to support health professionals involved in public collective hunger strikes.

Public-Private engagement and health systems resilience in times of health worker strikes: a Ghanaian case study.

In low and middle-income countries like Ghana, private providers, particularly the grouping of faith-based non-profit health providers networked by the Christian Health Association of Ghana (CHAG), play a crucial role in maintaining service continuity during health worker strikes. Poor engagement with the private sector during such strikes could compromise care quality and impose financial hardships on populations, especially the impoverished. This study delves into the engagement between CHAG and the Government of Ghana (GoG) during health worker strikes from 2010 to 2016, employing a qualitative descriptive and exploratory case study approach. By analysing evidence from peer-reviewed literature, media archives, grey literature and interview transcripts from a related study using a qualitative thematic analysis approach, this study identifies health worker strikes as a persistent chronic stressor in Ghana. Findings highlight some system-level interactions between CHAG and GoG, fostering adaptive and absorptive resilience strategies, influenced by CHAG's non-striking ethos, unique secondment policy between the two actors and the presence of a National Health Insurance System. However, limited support from the government to CHAG member facilities during strikes and systemic challenges with the National Health Insurance System pose threats to CHAG's ability to provide quality, affordable care. This study underscores private providers' pivotal role in enhancing health system resilience during strikes in Ghana, advocating for proactive governmental partnerships with private providers and joint efforts to address human-resource-related challenges ahead of strikes. It also recommends further research to devise and evaluate effective strategies for nations to respond to strikes, ensuring preparedness and sustained quality healthcare delivery during such crises.