District nurses experiences in providing terminal care in rural and more urban districts. A qualitative study from the Faroe Islands.

OBJECTIVE: To explore district nurses' experiences in providing terminal care to patients and their families until death in a private home setting. DESIGN, SETTING AND SUBJECTS: Qualitative study. Data derived from focus group discussions with primary nurses in The Faroe Islands. RESULTS: Four themes were identified: 'Challenges in providing terminal care', 'The importance of supporting families', 'Collaborative challenges in terminal care' and 'Differences between rural districts and urban districts'. The nurses felt that terminal care could be exhausting, but they also felt the task rewarding. Involving the family was experienced as a prerequisite for making home death possible. Good collaboration with the local GPs was crucial, and support from a palliative care team was experienced as helpful. They pointed out that changes of GP and the limited services from the palliative care team were challenging. Structural and economic conditions differed between urban and rural districts, which meant that the rural districts needed to make private arrangements regarding care during night hours, while the urban districts had care services around the clock. CONCLUSION: Our findings underline the complexity of terminal care. The nurses felt exhausted yet rewarded from being able to fulfil a patient's wish to die at home. Experience and intuition guided their practice. They emphasised that good collaboration with the GPs, the palliative care team and the families was important. Establishing an outgoing function for the palliative care team to support the nurses and the families would increase the scope for home deaths. Working conditions differed between rural and urban districts.

District nurses are key providers of care for people dying in a home care setting.Collaboration with family is essential for making home death possible.Taking care of dying patients is experienced as exhausting but also meaningful.There is a need for an outgoing palliative care team to include all patients regardless of disease.

'Our Voices Aren't Being Heard': A qualitative descriptive study of nurses' perceptions of interprofessional collaboration in care supporting older people's functioning during a hospital stay.

INTRODUCTION: Older people admitted to hospital are highly susceptible to functional decline and related complications. Care supporting their functioning is complex and requires healthcare professionals working in concert, with nurses playing a central role. Yet, little is known about nurses' perceptions of interprofessional collaboration (IPC) in care supporting functioning in acutely admitted older people. To fill this knowledge gap, we elucidate the perspectives of nurses in Ontario, Canada, on IPC in care supporting older people's functioning during a hospital stay. METHODS: We employed a qualitative methodology in conjunction with a qualitative descriptive design. Thirteen focus groups were held with a purposeful, criterion-based sample of 57 acute care nurses practising in a range of acute care settings (e.g. Emergency, General Medicine, General Surgery, Intensive Care, Coronary Care). Data were thematically analysed. RESULTS: We identified two overarching themes: (1) IPC is improving, but nurses are excluded from decision-making and (2) nurse advocacy causes friction with other professionals. The first theme captures nurses' perception that IPC in older people's care is improving, but nurses are marginalised in interprofessional decision-making. As a result, nurses perceive that their knowledge is devalued, and their contributions to care supporting older people's functioning are undermined. The second theme underlines a tension between interprofessional team practices and patient- and family-centred care, while also demonstrating nurses' increasing willingness to act as patient and family advocates. CONCLUSIONS: Findings can be used to enhance IPC in care supporting the functioning of acutely hospitalised older people. To improve IPC, clinical and administrative leaders should cultivate more egalitarian team relationships that encourage nurses to contribute to decision-making and advocate on behalf of older patients and their families.

What matters in low-threshold collaboration? Perceptions of interprofessional collaboration between education and social and healthcare professionals in Finnish primary schools.

This study examined the factors linked to low-threshold interprofessional collaboration in the context of Finnish primary schools. The main purpose of the study was to analyze how education and health and social care professionals perceived their mutual collaboration. The PINCOM-Q scale was used to identify factors related to interprofessional collaboration in professionals' work settings. The results indicate that individual factors such as work motivation and personal power are prominent in low-threshold collaboration. At the group level, communication has an important role to play in interprofessional collaboration. Professionals (n = 204) perceived mutual exchange of information as an important aspect of working together. The aspects that matter in the low-threshold mode of interprofessional collaboration are a complex combination of individual, group and less obvious organizational factors, all of which both reflect and are reflected in an individual's motivation and commitment to cooperation. The establishment of long-term and systematic low-threshold, interprofessional collaboration presupposes that individual interests are realized in good interaction in equal encounters between different organizational domains.

Improving interprofessional teamwork in a community mental health team: a team building circle program based on the restorative justice paradigm.

Improving teamwork among mental health practitioners is crucial. However, there have been few intervention studies on teamwork enhancement among community mental health practitioners in South Korea. We aimed to determine the effectiveness of the Team Building Circle program (TBC) based on the restorative justice paradigm, which sought to promote integration and cohesion. The TBC was developed to improve conflict interpretation mind-set, interpersonal skills, and teamwork among practitioners in community mental health centers. We conducted a quasi-experimental study using a pre and posttest design with a non-equivalent control group. The participants were 44 practitioners from four community mental health centers. Data were collected before the implementation TBC (pretest), just after (posttest), and 3 months after TBC (follow-up test). A generalized estimating equation model was used for analysis. Our findings indicate that the intervention group had improved scores in the ability to cope with interpersonal stress in a constructive way, interpersonal relationship skills, and teamwork compared to the control group. To improve teamwork among community mental health practitioners, managers are encouraged to consider providing TBC intervention.

Interprofessional education and collaborative practice policies and law: an international review and reflective questions.

BACKGROUND: Healthcare is a complex sociolegal setting due to the number of policymakers, levels of governance and importance of policy interdependence. As a desirable care approach, collaborative practice (referred to as interprofessional education and collaborative practice (IPECP)) is influenced by this complex policy environment from the beginning of professionals' education to their initiation of practice in healthcare settings. MAIN BODY: Although data are available on the influence of policy and law on IPECP, published articles have tended to focus on a single aspect of policy or law, leading to the development of an interesting but incomplete picture. Through the use of two conceptual models and real-world examples, this review article allows IPECP promoters to identify policy issues that must be addressed to foster IPECP. Using a global approach, this article aims to foster reflection among promoters and stakeholders of IPECP on the global policy and law environment that influences IPECP implementation. CONCLUSION: IPECP champions and stakeholders should be aware of the global policy and legal environment influencing the behaviors of healthcare workers to ensure the success of IPECP implementation.

Interprofessional collaboration among health professionals in cleft lip and palate treatment and care in the public health sector of South Africa.

BACKGROUND: Collaboration among different categories of health professionals is essential for quality patient care, especially for individuals with cleft lip and palate (CLP). This study examined interprofessional collaboration (IPC) among health professionals in all CLP specialised centres in South Africa's public health sector. METHODS: During 2017, a survey was conducted among health professionals at all the specialised CLP centres in South Africa's public health sector. Following informed consent, each member of the CLP team completed a self-administered questionnaire on IPC, using the Interprofessional Competency Framework Self-Assessment Tool. The IPC questionnaire consists of seven domains with 51 items: care expertise (8 items); shared power (4 items); collaborative leadership (10 items); shared decision-making (2 items); optimising professional role and scope (10 items); effective group function (9 items); and competent communication (8 items). STATA®13 was used to analyse the data. Descriptive analysis of participants and overall mean scores were computed for each domain and analysed using ANOVA. All statistical tests were conducted at 5% significance level. RESULTS: We obtained an 87% response rate, and 52 participants completed the questionnaire. The majority of participants were female 52% (n = 27); with a mean age of 41.9 years (range 22-72). Plastic surgeons accounted for 38.5% of all study participants, followed by speech therapists (23.1%), and professional nurses (9.6%). The lowest mean score of 2.55 was obtained for effective group function (SD + -0.50), and the highest mean score of 2.92 for care expertise (SD + -0.37). Explanatory factor analysis showed that gender did not influence IPC, but category of health professional predicted scores on the five categories of shared power (p = 0.01), collaborative leadership (p = 0.04), optimising professional role and scope (p = 0.03), effective group function (p = 0.01) and effective communication (p = 0.04). CONCLUSION: The seven IPC categories could be used as a guide to develop specific strategies to enhance IPC among CLP teams. Institutional support and leadership combined with patient-centred, continuing professional development in multi-disciplinary meetings will also enrich IPC.

Coordinating health workforce management in a devolved context: lessons from Kenya.

INTRODUCTION: In 2013, Kenya fully and rapidly devolved health services to 47 county governments under its new constitution. It soon became evident that the coordination mechanism to manage the health workforce at a county level was inadequate. This case study describes how Kenya created an inter-county, multi-stakeholder human resources for health (HRH) coordination framework that promotes consensus, commitment, and cooperation in devolved HR management. CASE PRESENTATION: Through USAID funding, IntraHealth International built the health workforce management capacity of county governments by strengthening coordination mechanisms at the national and county levels. Informed by stakeholder mapping, Kenya's 47 counties were grouped into nine clusters with similar geographic contexts and HRH challenges. Inter-county cluster HRH stakeholder coordination forums are hosted by a rotating county-led secretariat and meet quarterly to address gaps, share successes and challenges, and track implementation of action plans. They link to the national level for capacity building, policy formulation, HRH regulation, and provision of standards. Counties have assumed ownership of the forums and contributed about US$85000 to date toward expenses. CONCLUSIONS: As a mechanism for transforming Kenya's national HRH agenda into action at the county level, the HRH coordination framework has been instrumental in (1) expediting development, customization, and dissemination of policies, (2) enabling national HRH officers to mentor their county counterparts, and (3) providing collaborative platforms for multiple stakeholders to resolve HRH challenges and harmonize HR practices nationwide. Successes catalyzed through the inter-county forums include hiring over 20 000 health workers to address shortages; expanding the national HR information system to all 47 counties; developing guidelines for sharing specialist providers; and establishing professionalized HRH units in all 47 counties. Kenya has made great strides in strengthening its health system through the HRH coordination framework, which supports standardization of county health operations with national goals while enabling national policy to address HRH gaps in the counties. Transitioning to fully local funding of inter-county forums is important for sustaining progress.

Cambodia's health professionals and the ASEAN Mutual Recognition Arrangements: registration, education and mobility.

BACKGROUND: From 2006, the Association of South East Asian Nations (ASEAN) has been developing Mutual Recognition Arrangements (MRAs) across key professions, including medicine, dentistry and nursing, that would facilitate the development of an ASEAN Economic Community, with shared regional standards and easier mobility of the workforce. This paper examines the interface between those agreements and the registration, professional education and mobility of health personnel in Cambodia. METHODS: This qualitative health policy analysis combined documentary and policy review with key informant interviews with 16 representatives of agencies relevant to the development and implementation of the MRAs in health. Thematic analysis identified three themes: registration, education and mobility. RESULTS: Cambodia is an active participant in the ASEAN MRA processes for doctors, dentists and nurses reporting progress annually. Education of health professionals has been increasingly formalised in the past 25 years, with nursing moving towards a 4-year bachelor degree. The private university sector has substantially increased, with English increasingly used as a language of instruction. Recent legislation provides for enforcement through fines and/or imprisonment to ensure all practising health professionals hold initial registration as a health professional and a renewable licence to practise as a health practitioner. Continuing Professional Development is a mandatory requirement for licence renewal. This is consistent with the MRA guidelines, though the capacity for enforcement appears limited. The Medical Council of Cambodia (MCC), and more recently, the Dental and Nursing Councils, have introduced continuing professional development initiatives, using them strategically as a positive reinforcer of registration. Midwifery education and registration in Cambodia does not conform with ASEAN guidelines. In education, course durations in medicine and dentistry are longer than regional counterparts, though anxiety around maintaining clinical standards has resulted in the introduction of a National Exit Examination and reluctance to abbreviate courses. The introduction of reforms appears to reference regional standards, though parity is still some way off. Mobility at present is infrequent and more likely to result from informal mechanisms than through the MRA mechanisms. CONCLUSION: The Royal Government of Cambodia is committed to the ASEAN MRA process. Developments in registration appear to use regional standards as benchmarks, as do reforms in the education of health professionals, though domestic factors appear to more directly impact on developments. Informal mechanisms facilitate the limited mobility currently occurring, with little formal application of the MRA provisions evident at this point.

Interprofessional team member's satisfaction: a mixed methods study of a Chilean hospital.

INTRODUCTION: The health organizations of today are highly complex and specialized. Given this scenario, there is a need for health professionals to work collaboratively within interprofessional work teams to ensure quality and safe care. To strengthen interprofessional teamwork, it is imperative that health organizations enhance strategic human resources management by promoting team member satisfaction. OBJECTIVE: To analyze the satisfaction of members in interprofessional teams and to explore interpersonal relationships, leadership, and team climate in a hospital context. METHODOLOGY: This study is an explanatory sequential mixed methods (quantitative/qualitative) study of 53 teams (409 professionals) at a university hospital in Santiago, Chile. The first phase involved quantitative surveys with team members examining team satisfaction, transformational leadership, and team climate. Social network analysis was used to identify interactions among team members (cohesion and centrality). The second phase involved interviews with 15 professionals belonging to teams with the highest and lowest team satisfaction scores. Findings of both phases were integrated. RESULTS: Significant associations were found among variables, and the linear regression model showed that team climate (ß = 0.26) was a better predictor of team satisfaction than team leadership (ß = 0.17). Registered nurse was perceived as the profession with the highest score on the transformational leadership measure (mean = 64), followed by the physician (mean = 33). Team networks with the highest and lowest score of team satisfaction showed differences in cohesion and centrality measures. Analysis of interviews identified five themes: attributes of interprofessional work; collaboration, communication, and social interaction; interprofessional team innovation; shared leadership; and interpersonal relationship interface work/social. Integration of findings revealed that team member satisfaction requires participation and communication, common goals and commitment for patient-centered care, clear roles and objectives to support collaborative work, and the presence of a transformational leader to strengthen well-being, dialog, and innovation. CONCLUSIONS: Results have the potential to contribute to the planning and decision-making in the field of human resources, providing elements to promote the management of health teams and support team member satisfaction. In turn, this could lead to job permanence especially where the local health needs are more urgent.

Workforce patterns in the prevention of mother to child transmission of HIV in Côte d'Ivoire: a qualitative model.

BACKGROUND: Côte d'Ivoire continues to struggle with one of the highest rates of mother-to-child HIV transmission in West Africa, previously thought to be in part due to suboptimal workforce patterns. This study aimed to understand the process through which workforce patterns impact prevention of mother-to child transmission of HIV (PMTCT) program success, from the perspective of healthcare workers in Côte d'Ivoire. METHODS: A total of 142 semi-structured interviews were conducted with physicians, midwives, nurses, community counselors, social workers, pharmacists, management personnel and health aides from a nationally representative sample of 48 PMTCT sites across Côte d'Ivoire. RESULTS: Healthcare workers described three categories of workforce patterns that they perceived to be affecting PMTCT success: workforce inputs, healthcare roles and responsibilities, and facilitators of task performance. According to their descriptions, PMTCT success depends on the presence of an adequate and trained PMTCT workforce, with an interdisciplinary team of healthcare workers with flexible roles and expanded task responsibilities, and whose tasks are translated into patient care through collaboration, ongoing trainings, and appropriate motivators. CONCLUSIONS: This study provides a model for understanding the impact of workforce patterns on PMTCT success in Côte d'Ivoire and provides insight into workforce-related facilitators and barriers of program performance that should be targeted in future research and interventions. It highlights the importance of workforce integration and collaboration between healthcare workers.

Performance of community health workers: situating their intermediary position within complex adaptive health systems.

Health systems are social institutions, in which health worker performance is shaped by transactional processes between different actors.This analytical assessment unravels the complex web of factors that influence the performance of community health workers (CHWs) in low- and middle-income countries. It examines their unique intermediary position between the communities they serve and actors in the health sector, and the complexity of the health systems in which they operate. The assessment combines evidence from the international literature on CHW programmes with research outcomes from the 5-year REACHOUT consortium, undertaking implementation research to improve CHW performance in six contexts (two in Asia and four in Africa). A conceptual framework on CHW performance, which explicitly conceptualizes the interface role of CHWs, is presented. Various categories of factors influencing CHW performance are distinguished in the framework: the context, the health system and intervention hardware and the health system and intervention software. Hardware elements of CHW interventions comprise the supervision systems, training, accountability and communication structures, incentives, supplies and logistics. Software elements relate to the ideas, interests, relationships, power, values and norms of the health system actors. They influence CHWs' feelings of connectedness, familiarity, self-fulfilment and serving the same goals and CHWs' perceptions of support received, respect, competence, honesty, fairness and recognition.The framework shines a spotlight on the need for programmes to pay more attention to ideas, interests, relationships, power, values and norms of CHWs, communities, health professionals and other actors in the health system, if CHW performance is to improve.

Analysis of an international collaboration for capacity building of human resources for eye care: case study of the college-college VISION 2020 LINK.

BACKGROUND: There is an extreme health workforce shortage in Eastern, Central, and Southern Africa. Shortage of eye care workers impedes effective implementation of prevention of blindness programs. The World Health Organization has identified education, partnership, leadership, financing, and policy as intertwined interventions that are critical to resolving this crisis on the long term. CASE PRESENTATION: The VISION 2020 LINK between the College of Ophthalmology of Eastern, Central, and Southern Africa and the Royal College of Ophthalmologists in the United Kingdom aims to increase the quantity and quality of eye care training in East, Central, and Southern Africa through a focus on five strategic areas: fellowship examination for ophthalmologists, training the trainers, curriculum development for residents in ophthalmology and ophthalmic clinical officers, continuous professional development (CPD), and mentoring program for young ophthalmologists. This study examined how education and partnership can be linked to improve eye care, through an evaluation of this north-south link based on its own targets and established frameworks to guide north-south links. METHODS: An exploratory qualitative case study design was used. Twenty-nine link representatives were recruited through purposive sampling and snowballing. Face-to-face interviews were conducted using a semi-structured interview schedule that incorporated the components of a successful link from an existing framework. Documents pertaining to the link were also examined. Thematic analysis was used for data analysis. RESULTS: The findings revealed that the perception to the contribution of the link to eye care in the region is generally positive. Process indicators showed that the targets in three strategic objectives of the link have been achieved. Framework-based evaluation also showed that the link is successful. Mutual learning and development of friendships were the most commonly identified success factors. Inadequate awareness of the link by college members is a key challenge. CONCLUSION: The study concludes that the link is active and evolving and has achieved most of its targets. Further developments should be directed to influence health system strengthening in Eastern, Central, and Southern Africa more strategically. The study recommends expansion of the scope of collaboration to involve multiple health system building blocks.

Transforming health professions' education through in-country collaboration: examining the consortia among African medical schools catalyzed by the Medical Education Partnership Initiative.

BACKGROUND: African medical schools have historically turned to northern partners for technical assistance and resources to strengthen their education and research programmes. In 2010, this paradigm shifted when the United States Government brought forward unprecedented resources to support African medical schools. The grant, entitled the Medical Education Partnership Initiative (MEPI) triggered a number of south-south collaborations between medical schools in Africa. This paper examines the goals of these partnerships and their impact on medical education and health workforce planning. METHODS: Semi-structured interviews were conducted with the Principal Investigators of the first four MEPI programmes that formed an in-country consortium. These interviews were recorded, transcribed and coded to identify common themes. RESULTS: All of the consortia have prioritized efforts to increase the quality of medical education, support new schools in-country and strengthen relations with government. These in-country partnerships have enabled schools to pool and mobilize limited resources creatively and generate locally-relevant curricula based on best-practices. The established schools are helping new schools by training faculty and using grant funds to purchase learning materials for their students. The consortia have strengthened the dialogue between academia and policy-makers enabling evidence-based health workforce planning. All of the partnerships are expected to last well beyond the MEPI grant as a result of local ownership and institutionalization of collaborative activities. CONCLUSIONS: The consortia described in this paper demonstrate a paradigm shift in the relationship between medical schools in four African countries. While schools in Africa have historically worked in silos, competing for limited resources, MEPI funding that was leveraged to form in-country partnerships has created a culture of collaboration, overriding the history of competition. The positive impact on the quality and efficiency of health workforce training suggests that future funding for global health education should prioritize such south-south collaborations.

The impact of professional and organizational identification on the relationship between hospital-physician exchange and customer-oriented behaviour of physicians.

BACKGROUND: Hospitals face increasingly competitive market conditions. In this challenging environment, hospitals have been struggling to build high-quality hospital-physician relationships. In the literature, two types of managerial strategies for optimizing relationships have been identified. The first focuses on optimizing the economic relationship; the second focuses on the noneconomic dimension and emphasizes the cooperative structure and collaborative nature of the hospital-physician relationship. We investigate potential spillover effects between the perceptions of physicians of organizational exchange and their customer-oriented behaviors. METHODS: A cross-sectional study was conducted on 130 self-employed physicians practicing at six Belgian hospitals. Economic exchange was measured using the concept of distributive justice (DJ); noneconomic exchange was measured by the concept of perceived organizational support (POS). Our outcomes consist of three types of customer-oriented behaviours: internal influence (II), external representation (ER), and service delivery (SD). RESULTS: Our results show a positive relationship between DJ and II (adjusted R(2) = 0.038, t = 2.35; p = 0.028) and ER (adjusted R(2) = 0.15, t = 4.59; p < 0.001) and a positive relationship between POS and II (adjusted R(2) = 0.032, t = 2.26; p = 0.026) and ER (adjusted R(2) = 0.22, t = 5.81; p < 0.001). No relationship was present between DJ (p = 0.54) or POS (p = 0.57) and SD. Organizational identification positively moderates the relationship between POS and ER (p = 0.045) and between DJ and ER (p = 0.056). The relationships between POS and II (p = 0.54) and between DJ and II (p = 0.99) were not moderated by OI. Professional identification did not moderate the studied relationships. CONCLUSION: Our results demonstrate that both perceptions of economic and noneconomic exchange are important to self-employed physicians' customer-oriented behaviours. Fostering organizational identification could enhance this reciprocity dynamic.

Exploring the influence of trust relationships on motivation in the health sector: a systematic review.

BACKGROUND: Dedicated and motivated health workers (HWs) play a major role in delivering efficient and effective health services that improve patients' experience of health care. Growing interest in HW motivation has led to a global focus on pay for performance strategies, but less attention has been paid to nurturing intrinsic motivation. Workplace trust relationships involve fair treatment and respectful interactions between individuals. Such relationships enable cooperation among HWs and their colleagues, supervisors, managers and patients and may act as a source of intrinsic motivation. This paper presents findings from a qualitative systematic review of empirical studies providing evidence on HW motivation, to consider what these studies suggest about the possible influence of workplace trust relationships over motivation. METHODS: Five electronic databases were searched for articles reporting research findings about HW motivation for various cadres published in the 10-year period 2003 to 2013 and with available full free text in the English language. Data extraction involved consideration of the links between trust relationships and motivation, by identifying how studies directly or indirectly mention and discuss relevant factors. RESULTS: Twenty-three articles from low- and middle-income countries and eight from high-income countries that met predetermined quality and inclusion criteria were appraised and subjected to thematic synthesis. Workplace trust relationships with colleagues, supervisors and managers, employing organisation and patients directly and indirectly influence HW motivation. Motivational factors identified as linked to trust include respect; recognition, appreciation and rewards; supervision; teamwork; management support; autonomy; communication, feedback and openness; and staff shortages and resource inadequacy. CONCLUSION: To the authors' knowledge, this is the first systematic review on trust and motivation in the health sector. Evidence indicates that workplace trust relationships encourage social interactions and cooperation among HWs, have impact on the intrinsic motivation of HWs and have consequences for retention, performance and quality of care. Human resource management and organisational practices are critical in sustaining workplace trust and HW motivation. Research and assessment of the levels of motivation and factors that encourage workplace trust relationships should include how trust and motivation interact and operate for retention, performance and quality of care.

Approaches to improving the contribution of the nursing and midwifery workforce to increasing universal access to primary health care for vulnerable populations: a systematic review.

BACKGROUND: Despite considerable evidence showing the importance of the nursing and midwifery workforce, there are no systematic reviews outlining how these cadres are best supported to provide universal access and reduce health care disparities at the primary health care (PHC) level. This review aims to identify nursing and midwifery policy, staffing, education and training interventions, collaborative efforts and strategies that have improved the quantity, quality and relevance of the nursing and midwifery workforce leading to health improvements for vulnerable populations. METHODS: We undertook a structured search of bibliographic databases for peer-reviewed research literature using a focused review question and inclusion/exclusion criteria. The quality of retrieved papers was appraised using standard tools. The characteristics of screened papers were described, and a deductive qualitative content analysis methodology was applied to analyse the interventions and findings of included studies using a conceptual framework. RESULTS: Thirty-six papers were included in the review, the majority (25) from high-income countries and nursing settings (32). Eleven papers defined leadership and governance approaches that had impacted upon the health outcomes of disadvantaged groups including policies at the national and state level that had led to an increased supply and coverage of nursing and midwifery staff and scope of practice. Twenty-seven papers outlined human resource management strategies to support the expansion of nurse's and midwives' roles that often involved task shifting and task sharing. These included approaches to managing staffing supply, distribution and skills mix; workloads; supervision; performance management; and remuneration, financial incentives and staffing costs. Education and training activities were described in 14 papers to assist nurses and midwives to perform new or expanded roles and prepare nurses for inclusive practice. This review identified collaboration between nurses and midwives and other health providers and organizations, across sectors, and with communities and individuals that resulted in improved health care and outcomes. CONCLUSIONS: The findings of this review confirm the importance of a conceptual framework for understanding and planning leadership and governance approaches, management strategies and collaboration and education and training efforts to scale up and support nurses and midwives in existing or expanded roles to improve access to PHC for vulnerable populations.

Strategic partnering to improve community health worker programming and performance: features of a community-health system integrated approach.

BACKGROUND: There is robust evidence that community health workers (CHWs) in low- and middle-income (LMIC) countries can improve their clients' health and well-being. The evidence on proven strategies to enhance and sustain CHW performance at scale, however, is limited. Nevertheless, CHW stakeholders need guidance and new ideas, which can emerge from the recognition that CHWs function at the intersection of two dynamic, overlapping systems - the formal health system and the community. Although each typically supports CHWs, their support is not necessarily strategic, collaborative or coordinated. METHODS: We explore a strategic community health system partnership as one approach to improving CHW programming and performance in countries with or intending to mount large-scale CHW programmes. To identify the components of the approach, we drew on a year-long evidence synthesis exercise on CHW performance, synthesis records, author consultations, documentation on large-scale CHW programmes published after the synthesis and other relevant literature. We also established inclusion and exclusion criteria for the components we considered. We examined as well the challenges and opportunities associated with implementing each component. RESULTS: We identified a minimum package of four strategies that provide opportunities for increased cooperation between communities and health systems and address traditional weaknesses in large-scale CHW programmes, and for which implementation is feasible at sub-national levels over large geographic areas and among vulnerable populations in the greatest need of care. We postulate that the CHW performance benefits resulting from the simultaneous implementation of all four strategies could outweigh those that either the health system or community could produce independently. The strategies are (1) joint ownership and design of CHW programmes, (2) collaborative supervision and constructive feedback, (3) a balanced package of incentives, and (4) a practical monitoring system incorporating data from communities and the health system. CONCLUSIONS: We believe that strategic partnership between communities and health systems on a minimum package of simultaneously implemented strategies offers the potential for accelerating progress in improving CHW performance at scale. Comparative, retrospective and prospective research can confirm the potential of these strategies. More experience and evidence on strategic partnership can contribute to our understanding of how to achieve sustainable progress in health with equity.

Global health leadership training in resource-limited settings: a collaborative approach by academic institutions and local health care programs in Uganda.

INTRODUCTION: Due to a limited health workforce, many health care providers in Africa must take on health leadership roles with minimal formal training in leadership. Hence, the need to equip health care providers with practical skills required to lead high-impact health care programs. In Uganda, the Afya Bora Global Health Leadership Fellowship is implemented through the Makerere University College of Health Sciences (MakCHS) and her partner institutions. Lessons learned from the program, presented in this paper, may guide development of in-service training opportunities to enhance leadership skills of health workers in resource-limited settings. METHODS: The Afya Bora Consortium, a consortium of four African and four U.S. academic institutions, offers 1-year global health leadership-training opportunities for nurses and doctors. Applications are received and vetted internationally by members of the consortium institutions in Botswana, Kenya, Tanzania, Uganda, and the USA. Fellows have 3 months of didactic modules and 9 months of mentored field attachment with 80% time dedicated to fellowship activities. Fellows' projects and experiences, documented during weekly mentor-fellow meetings and monthly mentoring team meetings, were compiled and analyzed manually using pre-determined themes to assess the effect of the program on fellows' daily leadership opportunities. RESULTS: Between January 2011 and January 2015, 15 Ugandan fellows (nine doctors and six nurses) participated in the program. Each fellow received 8 weeks of didactic modules held at one of the African partner institutions and three online modules to enhance fellows' foundation in leadership, communication, monitoring and evaluation, health informatics, research methodology, grant writing, implementation science, and responsible conduct of research. In addition, fellows embarked on innovative projects that covered a wide spectrum of global health challenges including critical analysis of policy formulation and review processes, bottlenecks in implementation of national HIV early infant diagnosis and prevention of mother-to-child HIV-transmission programs, and use of routine laboratory data about antibiotic resistance to guide updates of essential drug lists. CONCLUSION: In-service leadership training was feasible, with ensured protected time for fellows to generate evidence-based solutions to challenges within their work environment. With structured mentorship, collaborative activities at academic institutions and local health care programs equipped health care providers with leadership skills.

Building capacity to develop an African teaching platform on health workforce development: a collaborative initiative of universities from four sub Saharan countries.

INTRODUCTION: Health systems in many low-income countries remain fragile, and the record of human resource planning and management in Ministries of Health very uneven. Public health training institutions face the dual challenge of building human resources capacity in ministries and health services while alleviating and improving their own capacity constraints. This paper reports on an initiative aimed at addressing this dual challenge through the development and implementation of a joint Masters in Public Health (MPH) programme with a focus on health workforce development by four academic institutions from East and Southern Africa and the building of a joint teaching platform. METHODS: Data were obtained through interviews and group discussions with stakeholders, direct and participant observations, and reviews of publications and project documents. Data were analysed using thematic analysis. CASE DESCRIPTION: The institutions developed and collaboratively implemented a 'Masters Degree programme with a focus on health workforce development'. It was geared towards strengthening the leadership capacity of Health ministries to develop expertise in health human resources (HRH) planning and management, and simultaneously build capacity of faculty in curriculum development and innovative educational practices to teach health workforce development. The initiative was configured to facilitate sharing of experience and resources. DISCUSSION: The implementation of this initiative has been complex, straddling multiple and changing contexts, actors and agendas. Some of these are common to postgraduate programmes with working learners, while others are unique to this particular partnership, such as weak institutional capacity to champion and embed new programmes and approaches to teaching. CONCLUSIONS: The partnership, despite significant inherent challenges, has potential for providing real opportunities for building the field and community of practice, and strengthening the staff and organizational capacity of participant institutions. Key learning points of the paper are:• the need for long-term strategies and engagement;• the need for more investment and attention to developing the capacity of academic institutions;• the need to invest specifically in educational/teaching expertise for innovative approaches to teaching and capacity development more broadly; and• the importance of increasing access and support for students who are working adults in public health institutions throughout Africa.

Scaling up family medicine training in Gezira, Sudan - a 2-year in-service master programme using modern information and communication technology: a survey study.

BACKGROUND: In 2010 the Gezira Family Medicine Project (GFMP) was initiated in Gezira state, Sudan, designed as an in-service training model. The project is a collaboration project between the University of Gezira, which aims to provide a 2-year master's programme in family medicine for practicing doctors, and the Ministry of Health, which facilitates service provision and funds the training programme. This paper presents the programme, the teaching environment, and the first batch of candidates enrolled. METHODS: In this study a self-administered questionnaire was used to collect baseline data at the start of the project from doctors who joined the programme. A checklist was also used to assess the health centres where they work. A total of 188 out of 207 doctors responded (91%), while data were gathered from all 158 health centres (100%) staffed by the programme candidates. RESULTS: The Gezira model of in-service family medicine training has succeeded in recruiting 207 candidates in its first batch, providing health services in 158 centres, of which 84 had never been served by a doctor before. The curriculum is community oriented. The mean age of doctors was 32.5 years, 57% were males, and 32% were graduates from the University of Gezira. Respondents stated high confidence in practicing some skills such as asthma management and post-abortion uterine evacuation. They were least confident in other skills such as managing depression or inserting an intrauterine device. The majority of health centres was poorly equipped for management of noncommunicable diseases, as only 10% had an electrocardiography machine (ECG), 5% had spirometer, and 1% had a defibrillator. CONCLUSIONS: The Gezira model has responded to local health system needs. Use of modern information and communication technology is used to facilitate both health service provision and training. The GFMP represents an example of a large-volume scaling-up programme of family medicine in Africa.