Effectiveness of a chatbot in improving the mental wellbeing of health workers in Malawi during the COVID-19 pandemic: A randomized, controlled trial.

We conducted a randomized, controlled trial (RCT) to investigate our hypothesis that the interactive chatbot, Vitalk, is more effective in improving mental wellbeing and resilience outcomes of health workers in Malawi than the passive use of Internet resources. For our 2-arm, 8-week, parallel RCT (ISRCTN Registry: trial ID ISRCTN16378480), we recruited participants from 8 professional cadres from public and private healthcare facilities. The treatment arm used Vitalk; the control arm received links to Internet resources. The research team was blinded to the assignment. Of 1,584 participants randomly assigned to the treatment and control arms, 215 participants in the treatment and 296 in the control group completed baseline and endline anxiety assessments. Six assessments provided outcome measures for: anxiety (GAD-7); depression (PHQ-9); burnout (OLBI); loneliness (ULCA); resilience (RS-14); and resilience-building activities. We analyzed effectiveness using mixed-effects linear models, effect size estimates, and reliable change in risk levels. Results support our hypothesis. Difference-in-differences estimators showed that Vitalk reduced: depression (-0.68 [95% CI -1.15 to -0.21]); anxiety (-0.44 [95% CI -0.88 to 0.01]); and burnout (-0.58 [95% CI -1.32 to 0.15]). Changes in resilience (1.47 [95% CI 0.05 to 2.88]) and resilience-building activities (1.22 [95% CI 0.56 to 1.87]) were significantly greater in the treatment group. Our RCT produced a medium effect size for the treatment and a small effect size for the control group. This is the first RCT of a mental health app for healthcare workers during the COVID-19 pandemic in Southern Africa combining multiple mental wellbeing outcomes and measuring resilience and resilience-building activities. A substantial number of participants could have benefited from mental health support (1 in 8 reported anxiety and depression; 3 in 4 suffered burnout; and 1 in 4 had low resilience). Such help is not readily available in Malawi. Vitalk has the potential to fill this gap.

Putting health workers at the centre of health system investments in COVID-19 and beyond.

The COVID-19 pandemic highlights the implications of chronic underinvestment in health workforce development, particularly in resource-constrained health systems. Inadequate health workforce diversity, insufficient training and remuneration, and limited support and protection reduce health system capacity to equitably maintain health service delivery while meeting urgent health emergency demands. Applying the Health Worker Life Cycle Approach provides a useful conceptual framework that adapts a health labour market approach to outline key areas and recommendations for health workforce investment-building, managing and optimising-to systematically meet the needs of health workers and the systems they support. It also emphasises the importance of protecting the workforce as a cross-cutting investment, which is especially important in a health crisis like COVID-19. While the global pandemic has spurred intermittent health workforce investments required to immediately respond to COVID-19, applying this 'lifecycle approach' to guide policy implementation and financing interventions is critical to centering health workers as stewards of health systems, thus strengthening resilience to public health threats, sustainably responding to community needs and providing more equitable, patient-centred care.

Cost-Effectiveness of Rural Incentive Packages for Graduating Medical Students in Lao PDR.

BACKGROUND: The dearth of health workers in rural settings in Lao People's Democratic Republic (PDR) and other developing countries limits healthcare access and outcomes. In evaluating non-wage financial incentive packages as a potential policy option to attract health workers to rural settings, understanding the expected costs and effects of the various programs ex ante can assist policy-makers in selecting the optimal incentive package. METHODS: We use discrete choice experiments (DCEs), costing analyses and recent empirical results linking health worker density and health outcomes to estimate the future location decisions of physicians and determine the cost-effectiveness of 15 voluntary incentives packages for new physicians in Lao PDR. Our data sources include a DCE survey completed by medical students (n = 329) in May 2011 and secondary cost, economic and health data. Mixed logit regressions provide the basis for estimating how each incentive package influences rural versus urban location choice over time. We estimate the expected rural density of physicians and the cost-effectiveness of 15 separate incentive packages from a societal perspective. In order to generate the cost-effectiveness ratios we relied on the rural uptake probabilities inferred from the DCEs, the costing data and prior World Health Organization (WHO) estimates that relate health outcomes to health worker density. RESULTS: Relative to no program, the optimal voluntary incentive package would increase rural physician density by 15% by 2016 and 65% by 2041. After incorporating anticipated health effects, seven (three) of the 15 incentive packages have anticipated average cost-effectiveness ratio less than the WHO threshold (three times gross domestic product [GDP] per capita) over a 5-year (30 year) period. The optimal package's incremental cost-effectiveness ratio is $1454/QALY (quality-adjusted life year) over 5 years and $2380/QALY over 30 years. Capital intensive components, such as housing or facility improvement, are not efficient. CONCLUSION: Conditional on using voluntary incentives, Lao PDR should emphasize non-capital intensive options such as advanced career promotion, transport subsidies and housing allowances to improve physician distribution and rural health outcomes in a cost-effective manner. Other countries considering voluntary incentive programs can implement health worker/trainee DCEs and costing surveys to determine which incentive bundles improve rural uptake most efficiently but should be aware of methodological caveats.

Early implementation of WHO recommendations for the retention of health workers in remote and rural areas.

The maldistribution of health workers between urban and rural areas is a policy concern in virtually all countries. It prevents equitable access to health services, can contribute to increased health-care costs and underutilization of health professional skills in urban areas, and is a barrier to universal health coverage. To address this long-standing concern, the World Health Organization (WHO) has issued global recommendations to improve the rural recruitment and retention of the health workforce. This paper presents experiences with local and regional adaptation and adoption of WHO recommendations. It highlights challenges and lessons learnt in implementation in two countries - the Lao People's Democratic Republic and South Africa - and provides a broader perspective in two regions - Asia and Europe. At country level, the use of the recommendations facilitated a more structured and focused policy dialogue, which resulted in the development and adoption of more relevant and evidence-based policies. At regional level, the recommendations sparked a more sustained effort for cross-country policy assessment and joint learning. There is a need for impact assessment and evaluation that focus on the links between the rural availability of health workers and universal health coverage. The effects of any health-financing reforms on incentive structures for health workers will also have to be assessed if the central role of more equitably distributed health workers in achieving universal health coverage is to be supported.

La mauvaise répartition des travailleurs de la santé entre les zones urbaines et rurales demeure une préoccupation politique dans pratiquement tous les pays. Elle empêche l'accès équitable aux services de santé, elle peut contribuer à une augmentation du coût des soins de santé et de sous-utilisation des compétences des professionnels de la santé dans les zones urbaines, et elle représente un obstacle à la mise en place d'une couverture maladie universelle. Pour répondre à cette préoccupation qui existe depuis longtemps, l'Organisation mondiale de la Santé (OMS) a émis des recommandations visant à améliorer le recrutement et la rétention des travailleurs du secteur de la santé en milieu rural. Ce document présente différentes expériences locales et régionales concernant l'adaptation et l'adoption des recommandations de l'OMS. Il souligne les défis et les leçons tirées de mises en œuvre dans deux pays - en République démocratique populaire lao et en Afrique du Sud - et il offre une perspective plus vaste dans deux régions - en Asie et en Europe. Au niveau des pays, l'application des recommandations a permis un dialogue plus structuré et plus ciblé sur les règlementations, qui a abouti à l'élaboration et à l'adoption de politiques plus pertinentes basées sur les faits. Au niveau régional, les recommandations ont suscité un effort plus soutenu en ce qui concerne l'évaluation des politiques entre les pays et leur apprentissage commun. Il faut évaluer l'impact des liens qui existent entre la disponibilité des travailleurs de la santé dans les zones rurales et la couverture maladie universelle. Les effets de toutes les réformes financières sur les structures d'incitation des travailleurs de la santé devront également être évalués si le but principal est de répartir plus équitablement les travailleurs de la santé et d'atteindre une couverture maladie universelle.

La distribución ineficaz del personal sanitario entre las zonas urbanas y rurales constituye una preocupación política en casi todos los países, pues impide el acceso equitativo a los servicios sanitarios, puede contribuir al aumento de los costes de atención sanitaria y la infrautilización de las capacidades profesionales sanitarias en las zonas urbanas, y obstaculiza la cobertura sanitaria universal. Para solucionar este problema de larga data, la Organización Mundial de la Salud (OMS) ha publicado una serie de recomendaciones generales para mejorar la contratación a nivel rural y la conservación del personal sanitario. Este informe presenta las experiencias en relación con la adaptación local y regional, y la adopción de las recomendaciones de la OMS. Además, subraya los desafíos y las lecciones aprendidas de la aplicación en dos países, la República Democrática Popular Lao y Sudáfrica, y proporciona una perspectiva más amplia en dos regiones, en concreto, Asia y Europa. A nivel nacional, el uso de las recomendaciones facilitó un diálogo político más organizado y específico, lo que permitió el desarrollo y la adopción de políticas más relevantes con base empírica. A nivel regional, las recomendaciones motivaron un esfuerzo más firme para evaluar las políticas entre los países y el aprendizaje conjunto. Es necesario realizar una evaluación y una valoración del impacto que se centren en la relación entre la disponibilidad de personal sanitario en zonas rurales y la cobertura sanitaria universal. Asimismo, deben evaluarse los efectos de las reformas financieras en asistencia sanitaria sobre las estructuras de incentivos para el personal sanitario con miras a promover el papel central del mismo, distribuido de forma más equitativa, en la consecución de la cobertura sanitaria universal.

Net costs of health worker rural incentive packages: an example from the Lao People's Democratic Republic.

BACKGROUND: Many developing countries are examining whether to institute incentive packages that increase the share of health workers who opt to locate in rural settings; however, uncertainty exists with respect to the expected net cost (or benefit) from these packages. METHODS: We utilize the findings from the discrete choice experiment surveys applied to students training to be health professionals and costing analyses in Lao People's Democratic Republic to model the anticipated effect of incentive packages on new worker location decisions and direct costs. Incorporating evidence on health worker density and health outcomes, we then estimate the expected 5-year net cost (or benefit) of each incentive packages for 3 health worker cadres--physicians, nurses/midwives, and medical assistants. RESULTS: Under base case assumptions, the optimal incentive package for each cadre produced a 5-year net benefit (maximum net benefit for physicians: US$ 44,000; nurses/midwives: US$ 5.6 million; medical assistants: US$ 485,000). CONCLUSIONS: After accounting for health effects, the expected net cost of select incentive packages would be substantially less than the original estimate of direct costs. In the case of Lao People's Democratic Republic, incentive packages that do not invest in capital-intensive components generally should produce larger net benefits. Combining discrete choice experiment surveys, costing surveys and cost-benefit analysis methods may be replicated by other developing countries to calculate whether health worker incentive packages are viable policy options.

Differences in preferences for rural job postings between nursing students and practicing nurses: evidence from a discrete choice experiment in Lao People's Democratic Republic.

BACKGROUND: A discrete choice experiment was conducted to investigate preferences for job characteristics among nursing students and practicing nurses to determine how these groups vary in their respective preferences and to understand whether differing policies may be appropriate for each group. METHODS: Participating students and workers were administered a discrete choice experiment that elicited preferences for attributes of potential job postings. Job attributes included salary, duration of service until promotion to permanent staff, duration of service until qualified for further study and scholarship, housing provision, transportation provision, and performance-based financial rewards. Mixed logit models were fit to the data to estimate stated preferences and willingness to pay for attributes. Finally, an interaction model was fit to formally investigate differences in preferences between nursing students and practicing nurses. RESULTS: Data were collected from 256 nursing students and 249 practicing nurses. For both groups, choice of job posting was strongly influenced by salary and direct promotion to permanent staff. As compared to nursing students, practicing nurses had significantly lower preference for housing allowance and housing provision as well as lower preference for provision of transportation for work and personal use. CONCLUSIONS: In the Lao People's Democratic Republic, nursing students and practicing nurses demonstrated important differences in their respective preferences for rural job posting attributes. This finding suggests that it may be important to differentiate between recruitment and retention policies when addressing human resources for health challenges in developing countries, such as Laos.

Increasing community health worker productivity and effectiveness: a review of the influence of the work environment.

BACKGROUND: Community health workers (CHWs) are increasingly recognized as a critical link in improving access to services and achieving the health-related Millennium Development Goals. Given the financial and human resources constraints in developing countries, CHWs are expected to do more without necessarily receiving the needed support to do their jobs well. How much can be expected of CHWs before work overload and reduced organizational support negatively affect their productivity, the quality of services, and in turn the effectiveness of the community-based programmes that rely on them? This article presents policy-makers and programme managers with key considerations for a model to improve the work environment as an important approach to increase CHW productivity and, ultimately, the effectiveness of community-based strategies. METHODS: A desk review of selective published and unpublished articles and reports on CHW programs in developing countries was conducted to analyse and organize findings on the elements that influence CHW productivity. The search was not exhaustive but rather was meant to gather information on general themes that run through the various documents to generate perspectives on the issue and provide evidence on which to formulate ideas. After an initial search for key terminology related to CHW productivity, a snowball technique was used where a reference in one article led to the discovery of additional documents and reports. RESULTS: CHW productivity is determined in large part by the conditions under which they work. Attention to the provision of an enabling work environment for CHWs is essential for achieving high levels of productivity. We present a model in which the work environment encompasses four essential elements-workload, supportive supervision, supplies and equipment, and respect from the community and the health system-that affect the productivity of CHWs. We propose that when CHWs have a manageable workload in terms of a realistic number of tasks and clients, an organized manner of carrying out these tasks, a reasonable geographic distance to cover, the needed supplies and equipment, a supportive supervisor, and respect and acceptance from the community and the health system, they can function more productively and contribute to an effective community-based strategy. CONCLUSIONS: As more countries look to scale up CHW programmes or shift additional tasks to CHWs, it is critical to pay attention to the elements that affect CHW productivity during programme design as well as implementation. An enabling work environment is crucial to maximize CHW productivity. Policy-makers, programme managers, and other stakeholders need to carefully consider how the productivity elements related to the work environment are defined and incorporated in the overall CHW strategy. Establishing a balance among the four elements that constitute a CHW's work environment will help make great strides in improving the effectiveness and quality of the services provided by CHWs.

Preferences for working in rural clinics among trainee health professionals in Uganda: a discrete choice experiment.

BACKGROUND: Health facilities require teams of health workers with complementary skills and responsibilities to efficiently provide quality care. In low-income countries, failure to attract and retain health workers in rural areas reduces population access to health services and undermines facility performance, resulting in poor health outcomes. It is important that governments consider health worker preferences in crafting policies to address attraction and retention in underserved areas. METHODS: We investigated preferences for job characteristics among final year medical, nursing, pharmacy, and laboratory students at select universities in Uganda. Participants were administered a cadre-specific discrete choice experiment that elicited preferences for attributes of potential job postings they were likely to pursue after graduation. Job attributes included salary, facility quality, housing, length of commitment, manager support, training tuition, and dual practice opportunities. Mixed logit models were used to estimate stated preferences for these attributes. RESULTS: Data were collected from 246 medical students, 132 nursing students, 50 pharmacy students and 57 laboratory students. For all student-groups, choice of job posting was strongly influenced by salary, facility quality and manager support, relative to other attributes. For medical and laboratory students, tuition support for future training was also important, while pharmacy students valued opportunities for dual practice. CONCLUSIONS: In Uganda, financial and non-financial incentives may be effective in attracting health workers to underserved areas. Our findings contribute to mounting evidence that salary is not the only important factor health workers consider when deciding where to work. Better quality facilities and supportive managers were important to all students. Similarities in preferences for these factors suggest that team-based, facility-level strategies for attracting health workers may be appropriate. Improving facility quality and training managers to be more supportive of facility staff may be particularly cost-effective, as investments are borne once while benefits accrue to a range of health workers at the facility.

Retaining hospital workers: a rapid methodology to determine incentive packages.

As efforts are made to increase the production of new human resources for health, simultaneous attention must be placed on retaining existing health workers in hospitals and other health facilities for as long as possible to increase access to healthcare services. The US Agency for International Development (USAID)'s CapacityPlus project is designing a rapid retention survey tool using the discrete choice experiment, a powerful, quantitative method to determine the relative importance health workers place on different characteristics related to their choice of employment. The user-friendly tool will allow human resource managers to rapidly assess retention preferences to better pinpoint the bundle of incentives and interventions that would most cost-effectively motivate health workers to take up posts in underserved facilities. The results of the survey can be used locally to create evidence-based incentive packages or to advocate with policy-makers and other decision-makers regarding the most favorable national retention policies and strategies for implementation.