Examining the extent, forms and factors influencing multiple job holding among medical doctors, professional nurses and rehabilitation therapists in two South African provinces: a cross-sectional study.

OBJECTIVE: Multiple job holding (MJH), or working in more than one paid job simultaneously, is a common characteristic of health labour markets. The study examined the extent (prevalence), forms and factors influencing MJH among public sector medical doctors, professional nurses and rehabilitation therapists in two South African provinces. DESIGN: A cross-sectional, analytical study. SETTING: 29 public sector hospitals in the Gauteng and Mpumalanga provinces of South Africa. PARTICIPANTS: Full-time public sector medical doctors, professional nurses and rehabilitation therapists. RESULTS: We obtained an overall response rate of 84.3%, with 486 medical doctors, 571 professional nurses and 340 rehabilitation therapists completing the survey. The mean age was 39.9±9.7 years for medical doctors, 43.7±10.4 years for professional nurses and 32.3±8.7 years for rehabilitation therapists. In the preceding 12 months, the prevalence of MJH was 33.7% (95% CI 25.8% to 42.6%) among medical doctors, 8.6% (95% CI 6.3% to 11.7%) among professional nurses and 38.7% (95% CI 31.5% to 46.5%) among rehabilitation therapists. Medical doctors worked a median of 20 (10-40) hours per month in their additional jobs, professional nurses worked 24 (12-34) hours per month and rehabilitation therapists worked 16 (8-28) hours per month. Private practice was the most prevalent form of MJH among medical doctors and rehabilitation therapists, compared with nursing agencies for professional nurses. MJH was significantly more likely among medical specialists (OR 4.3, p<0.001), married professional nurses (OR 2.4, p=0.022) and male rehabilitation therapists (OR 2.4, p=0.005). CONCLUSION: The high prevalence of MJH could adversely affect the care of public sector patients. The study findings should inform the review and revision of existing MJH policies.

Levels and determinants of overprescribing of antibiotics in the public and private primary care sectors in South Africa.

Although overprovision of antibiotics in primary care is a key driver of antibiotic resistance, little is known about its determinants in low-income and middle-income countries. Patient demand and financial incentives for providers are often held responsible for overprovision. Yet, inadequate provision exists in their absence and could be fuelled by quality of care issues and incorrect beliefs of providers regarding patients' expectations. We explored these issues in the private and public sector in South Africa, by conducting a cross-sectional study using standardised patients (SPs)-healthy individuals trained to portray a scripted clinical case to providers-presenting with symptoms of a viral respiratory infection in a sample of public and private sector clinics. We linked data from SP visits to rich survey data to compare the practices and their predictors in the two sectors. Unnecessary rates of antibiotics were similarly high in the public (78%) and private sector (67%), but private providers prescribed more antibiotics at higher risk of resistance development. In the private sector, overprescription of antibiotics diminished when consultations were more thorough, but increased for consultations scheduled later in the day, suggesting contrasting effects for provider effort and decision fatigue. We observed differences in beliefs that could be responsible for overprescription: in the public sector, a majority of providers (nurses) wrongly believed that antibiotics would help the patient recover more quickly. In the private sector, a majority of doctors thought patients would not come back if they did not receive antibiotics. Overall, this evidence suggests that different factors may be responsible for the high overprescribing rates of antibiotics in the public and private sectors. Tailored stewardship interventions are urgently needed that tackle providers' engrained habits and incorrect beliefs.

Perspectives of the cohort of health professionals in the WiSDOM study on the learning environment, transformation, and social accountability at a South African University.

BACKGROUND: The dearth of empirical research on transformative health professions education informed this study to examine the factors that influence the perspectives of the cohort of health professionals in the WiSDOM study on the learning environment, transformation, and social accountability at a South African university. METHODS: WiSDOM, a prospective longitudinal cohort study, consists of eight health professional groups: clinical associates, dentists, doctors, nurses, occupational therapists, oral hygienists, pharmacists, and physiotherapists. At study inception in 2017, participants completed a self-administered questionnaire that included four domains of selection criteria (6 items); the learning environment (5 items); redress and transformation (8 items); and social accountability (5 items). In the analysis, we, rescaled the original Likert scoring of 1 (strongly disagree) to 7 (strongly agree) to a new scale ranging from 0-10. We calculated the mean scores for each item and across items for the four domains, with low scores (0.00-1.99) classified as poor and high scores (8.00-10.00) as excellent. We used multiple linear regression analysis to compare the mean scores, while adjusting for different socio-demographiccharacteristics. RESULTS: The mean age of the 501 eligible participants was 24.1 years; the majority female (72.9%), 45.3% self-identified as Black African; and 12.2% were born in a rural area. The domains of selection criteria and redress and transformation obtained mean scores of 5.4 and 5.3 out of 10 respectively, while social accountability and the learning environment obtained mean scores of 6.1 and 7.4 out of 10 respectively. Self-identified race influenced the overall mean scores of selection criteria, redress and transformation, and social accountability (p < 0.001). Rural birth influenced the perceptions on selection criteria, redress and transformation (p < 0.01). CONCLUSION: The results suggest the need to create inclusive learning environments that foreground redress, transformation, and social accountability, while advancing the discourse on decolonised health sciences education.

Organisational and individual readiness for change to respectful maternity care practice and associated factors in Ibadan, Nigeria: a cross-sectional survey.

OBJECTIVES: This study assessed health providers' organisational and individual readiness for change to respectful maternity care (RMC) practice and their associated factors in Ibadan Metropolis, Nigeria. DESIGN: A cross-sectional survey using standardised structured instruments adapted from the literature. SETTING: Nine public health facilities in Ibadan Metropolis, Nigeria, 1 December 2019-31 May 2020. PARTICIPANTS: 212 health providers selected via a two-stage cluster sampling. OUTCOMES: Organisational readiness for change to RMC (ORCRMC) and individual readiness for change to RMC (IRCRMC) scales had a maximum score of 5. Multiple linear regression was used to identify factors influencing IRCRMC and ORCRMC. We evaluated previously identified predictors of readiness for change (change valence, informational assessments on resource adequacy, core self-evaluation and job satisfaction) and proposed others (workplace characteristics, awareness of mistreatment during childbirth, perceptions of women's rights and resource availability to implement RMC). Data were adjusted for clustering and analysed using Stata V.15. RESULTS: The providers' mean age was 44.0±9.9 years with 15.4±9.9 years of work experience. They scored high on awareness of women's mistreatment (3.9±0.5) and women's perceived rights during childbirth (3.9±0.5). They had high ORCRMC (4.1±0.9) and IRCRMC (4.2±0.6), both weakly but positively correlated (r=0.407, 95% CI: 0.288 to 0.514, p<0.001). Providers also had high change valence (4.5±0.8) but lower perceptions of resource availability (2.7±0.7) and adequacy for implementation (3.3±0.7). Higher provider change valence and informational assessments were associated with significantly increased IRCRMC (ß=0.40, 95% CI: 0.11 to 0.70, p=0.015 and ß=0.07, 95% CI: 0.01 to 0.13, p=0.032, respectively), and also with significantly increased ORCRMC (ß=0.47, 95% CI: 0.21 to 0.74, p=0.004 and ß=0.43, 95% CI: 0.22 to 0.63, p=0.002, respectively). Longer years of work experience (ß=0.08, 95% CI: 0.01 to 0.2, p=0.024), providers' monthly income (ß=0.08, 95% CI: 0.02 to 0.15, p=0.021) and the health facility of practice were associated with significantly increased ORCRMC. CONCLUSION: The health providers studied valued a change to RMC and believed that both they and their facilities were ready for the change to RMC practice.

Directly observed and reported respectful maternity care received during childbirth in public health facilities, Ibadan Metropolis, Nigeria.

Respectful maternity care (RMC) is believed to improve women's childbirth experience and increase health facility delivery. Unfortunately, few women in low- and middle-income countries experience RMC. Patient surveys and independent observations have been used to evaluate RMC, though seldom together. In this study, we assessed RMC received by women using two methodologies and evaluated the associated factors of RMC received. This was a cross-sectional study conducted in nine public health facilities in Ibadan, a large metropolis in Nigeria. We selected 269 pregnant women by cluster sampling. External clinical observers observed them during childbirth using the 29-item Maternal and Child Health Integrated Program RMC observational checklist. The same women were interviewed postpartum using the 15-item RMC scale for self-reported RMC. We analysed total RMC scores and RMC sub-category scores for each tool. All scores were converted to a percentage of the maximum possible to facilitate comparison. Correlation and agreement between the observed and reported RMC scores were determined using Pearson's correlation and Bland-Altman analysis respectively. Multiple linear regression was used to identify factors associated with observed RMC. No woman received 100% of the observed RMC items. Self-reported RMC scores were much higher than those observed. The two measures were weakly positively correlated (rho = 0.164, 95%CI: 0.045-0.278, p = 0.007), but had poor agreement. The lowest scoring sub-categories of observed RMC were information and consent (14.0%), then privacy (28.0%). Twenty-eight percent of women (95%CI: 23.0% -33.0%) were observed to be hit during labour and only 8.2% (95%CI: 4.0%-18.0%) received pain relief. Equitable care was the highest sub-category for both observed and reported RMC. Being employed and having completed post-secondary education were significantly associated with higher observed RMC scores. There were also significant facility differences in observed RMC. In conclusion, the women reported higher levels of RMC than were observed indicating that these two methodologies to evaluate RMC give very different results. More consensus and standardisation are required in determining the cut-offs to quantify the proportion of women receiving RMC. The low levels of RMC observed in the study require attention, and it is important to ensure that women are treated equitably, irrespective of personal characteristics or facility context.

A qualitative inquiry into pregnant women's perceptions of respectful maternity care during childbirth in Ibadan Metropolis, Nigeria.

Women's perceptions of respectful maternity care (RMC) are critical to its definition and measurement globally. We evaluated these in relation to globally defined RMC norms. We conducted a descriptive study involving eight focus group discussions with 50 pregnant women attending antenatal clinic at one primary and one secondary health facility each in the North-west and South-west local government areas of Ibadan Metropolis, Nigeria. One focus group each with primigravidae and multiparas were held per facility between 21 and 25 October 2019. Shakibazadeh et al's 12 domains of RMC served as the thematic framework for data analysis. The women's perceptions of RMC resonated well with seven of its domains, emphasising provider-client inter-personal relationships, preserving their dignity, effective communication, and non-abandonment of care, but with mixed perceptions for two domains. However, their perceptions deviated for four domains, namely maintaining privacy and confidentiality; ensuring continuous access to family support such as birth companions; obtaining informed consent; and respecting women's choices about mobility during labour, food and fluid intake, and birth position. The physical environment was not mentioned as contributing to an experience of RMC. Whilst the perceptions of the Nigerian women studied about RMC were similar to those accepted internationally, there were significant deviations which may be related to cultural differences and societal disparities. Different interpretations of RMC may influence women's demand for such care in different settings and challenge strategies for promoting a universal standard of care.

Acceptability and feasibility of inter-related activities to improve agency among African district health managers: A four-country study.

District health managers (DHMs) lead and manage Ministry of Health programmes and system performance. We report on the acceptability and feasibility of inter-related activities to increase the agency of DHMs in Kenya, Nigeria, South Africa and Uganda using a cross-sectional rapid appraisal with 372 DHMs employing structured questionnaires. We found differences and similarities between the countries, in particular, who becomes a DHM. The opportunity to provide leadership and effect change and being part of a team were reported as rewarding aspects of DHMs' work. Demotivating factors included limited resources, bureaucracy, staff shortages, lack of support from leadership and inadequate delegation of authority. District managers ranked the acceptability of the inter-related activities similarly despite differences between contexts. Activities highly ranked by DHMs were to employ someone to support primary care staff to compile and analyse district-level data; to undertake study tours to well-functioning districts; and joining an African Regional DHM Association. DHMs rated these activities as feasible to implement. This study confirms that DHMs are in support of a process to promote bottom-up, data-driven, context-specific actions that can promote self-actualisation, recognises the roles DHMs play, provides opportunities for peer learning and can potentially improve quality of care.

Methodological considerations in establishing and maintaining longitudinal health workforce studies: Lessons learned from the WiSDOM cohort in South Africa.

BACKGROUND: Health workforce cohort studies are uncommon in low-and middle-income countries (LMICs), especially those in sub-Saharan Africa. OBJECTIVE: Describe the methodology and lessons learned from establishing and maintaining the WiSDOM (Wits longitudinal Study to Determine the Operation of the labour Market among its health professional graduates) health professional cohort study in South Africa. METHODS: WiSDOM is a prospective longitudinal cohort study that commenced in 2017. The cohort focuses on the eight professional groups of clinical associates, dentists, doctors, nurses, occupational therapists, oral hygienists, pharmacists and physiotherapists. Annual, electronic follow-up surveys have been conducted in 2018, 2019 and 2020 with informed consent. Key steps in establishing the WiSDOM cohort include consultation, communication and marketing, stakeholder feedback, resources and infrastructure. Retention strategies consist of an electronic database, detailed cohort contact information, cohort engagement, communication and feedback, short survey tools, and appropriate incentives. RESULTS: We obtained an overall response rate of 89.5% at baseline in 2017, 79.6% in 2018, 68.3% in 2019 and 72.8% in 2020. The largest decline in response rates is for medical doctors: 66.0% response rate in 2018, 53.2% in 2019 and 58.2% in 2020. However, for each of the three follow-up surveys, we have obtained response rates in excess of 80% for clinical associates, dentists, nurses, oral hygienists, pharmacists and physiotherapists. Since baseline, the outright refusals have remained very low at 4.7%. The multiple logistic regression analysis showed that self-identified race was the only significant socio-demographic difference between medical doctor respondents and non-respondents. Black African doctors and Indian doctors were 2.0 and 2.6 times more likely respectively to respond than White doctors (p < 0.05). CONCLUSION: Other LMICs can learn from WiSDOM's lessons of establishing and maintaining a health professional cohort that aims to generate new knowledge for health system transformation.

Social exclusion and the perspectives of health care providers on migrants in Gauteng public health facilities, South Africa.

BACKGROUND: Universal health coverage (UHC) for all people, regardless of citizenship, is a global priority. Health care providers are central to the achievement of UHC, and their attitudes and behaviour could either advance or impede UHC for migrants. Using a social exclusion conceptual framework, this study examined the perspectives of health care providers on delivering health services to migrants in public health facilities in Gauteng Province, South Africa. METHODS: We used stratified, random sampling to select 13 public health facilities. All health care providers working in ambulatory care were invited to complete a self-administered questionnaire. In addition to socio-demographic information, the questionnaire asked health care providers if they had witnessed discrimination against migrants at work, and measured their perspectives on social exclusionary views and practices. Multiple regression analysis was used to identify predictors of more exclusionary perspectives for each item. RESULTS: 277 of 308 health care providers participated in the study-a response rate of 90%. The participants were predominantly female (77.6%) and nurses (51.9%), and had worked for an average of 6.8 years in their facilities. 19.2% of health care providers reported that they had witnessed discrimination against migrants, while 20.0% reported differential treatment of migrant patients. Exclusionary perspectives varied across the different items, and for different provider groups. Enrolled nurses and nursing assistants were significantly more exclusionary on a number of items, while the opposite was found for providers born outside South Africa. For some questions, female providers held more exclusionary perspectives and this was also the case for providers from higher levels of care. CONCLUSION: Health care providers are critical to inclusive UHC. Social exclusionary views or practices must be addressed through enabling health policies; training in culture-sensitivity, ethics and human rights; and advocacy to ensure that health care providers uphold their professional obligations to all patients.

Doctor retention and distribution in post-apartheid South Africa: tracking medical graduates (2007-2011) from one university.

BACKGROUND: Doctor emigration from low- and middle-income countries represents a financial loss and threatens the equitable delivery of healthcare. In response to government imperatives to produce more health professionals to meet the country's needs, South African medical schools increased their student intake and changed their selection criteria, but little is known about the impact of these changes. This paper reports on the retention and distribution of doctors who graduated from the University of the Witwatersrand, South Africa (SA), between 2007 and 2011. METHODS: Data on 988 graduates were accessed from university databases. A cross-sectional descriptive email survey was used to gather information about graduates' demographics, work histories, and current work settings. Frequency and proportion counts and multiple logistic regressions of predictors of working in a rural area were conducted. Open-ended data were analysed using content analysis. RESULTS: The survey response rate was 51.8%. Foreign nationals were excluded from the analysis because of restrictions on them working in SA. Of 497 South African respondents, 60% had completed their vocational training in underserved areas. At the time of the study, 89% (444) worked as doctors in SA, 6.8% (34) practised medicine outside the country, and 3.8% (19) no longer practised medicine. Eighty percent of the 444 doctors still in SA worked in the public sector. Only 33 respondents (6.6%) worked in rural areas, of which 20 (60.6%) were Black. Almost half (47.7%) of the 497 doctors still in SA were in specialist training appointments. CONCLUSIONS: Most of the graduates were still in the country, with an overwhelmingly urban and public sector bias to their distribution. Most doctors in the public sector were still in specialist training at the time of the study and may move to the private sector or leave the country. Black graduates, who were preferentially selected in this graduate cohort, constituted the majority of the doctors practising in rural areas. The study confirms the importance of selecting students with rural backgrounds to provide doctors for underserved areas. The study provides a baseline for future tracking studies to inform the training of doctors for underserved areas.

Socio-economic characteristics and career intentions of the WiSDOM health professional cohort in South Africa.

BACKGROUND: The human resources for health (HRH) crisis and dearth of research on the health labour market in South Africa informed the WiSDOM (Wits longitudinal Study to Determine the Operation of the labour Market among its health professional graduates) cohort study. The study aims to generate new knowledge on the career choices and job location decisions of health professionals in South Africa. METHODS: WiSDOM is a prospective longitudinal cohort study. During 2017, the first cohort for each of eight professional groups was established: clinical associates, dentists, doctors, nurses, occupational therapists, oral hygienists, pharmacists and physiotherapists. These cohorts will be followed up for 15 years. For the baseline data collection, each final year health professional student completed an electronic self-administered questionnaire (SAQ), after providing informed consent. The SAQ included information on: demographic characteristics; financing of training; reasons for choosing their profession; and their career intentions. We used STATA® 14 to analyse the data. RESULTS: We obtained an 89.5% response rate and 511 final year health professional students completed the baseline survey. The mean age of all participants was 24.1 years; 13.1% were born in a rural area; 11.9% and 8.0% completed their primary and secondary schooling in a rural area respectively. The health professional students came from relatively privileged backgrounds: 45.0% had attended a private school, the majority of their fathers (77.1%) had completed tertiary education, and 69.1% of their mothers had completed tertiary education. Students with higher socio-economic status (SES Quintiles 3-5) made up a larger proportion of the occupational therapists (77.8%), physiotherapists (71.7%), doctors (66.7%), and dentists (64.7%). In contrast, individuals from SES Quintiles 1 and 2 were over-represented among the clinical associates (75.0%), oral hygienists (71.4%), nurses (61.9%), and pharmacists (56.9%). Almost one quarter (24.9%) of cohort members indicated that they had partly financed their studies through loans. Although 86.3% of all cohort members indicated that they plan to stay in their chosen profession, this ranged from 43.2% for clinical associates to 100% for dentists. CONCLUSIONS: WiSDOM has generated new knowledge on health professional graduates of a leading South African University. The results have implications for university selection criteria and national health workforce planning.

'It needs a complete overhaul ' district manager perspectives on the capacity of the health system to support the delivery of emergency obstetric care in an urban South African district.

Background: A high maternal mortality ratio persists in South Africa despite developments in emergency obstetric care (EmOC), a known effective intervention against direct causes of maternal deaths. Strengthening the health systems is one of the focus areas identified by the National Committee for Confidential Enquiries into Maternal Deaths in South Africa. District managers as immediate overseers of the frontline health system are uniquely positioned to provide insight into the overall health system processes that influence the delivery of EmOC. Objective: We sought to identify health system enablers and barriers to the delivery EmOC from the perspective of district managers. This would potentially unearth aspects of the health system that require strengthening to better support EmOC and improve maternal outcomes. Methods: Face-to-face audio-recorded key informant interviews were conducted with 19 district managers in charge of the delivery of EmOC in one urban district. Interviews were transcribed and coded. Related codes were inductively grouped into emerging themes. Deductive thematic analysis was then applied to categorise emergent themes into the WHO health system building blocks. Results: Themes included a weaknesses in the organisation of health services; a high vacancy and turnover of senior management; poor clinical accountability from EmOC providers; inadequate resources (including infrastructure, staffing, and funding); and the need to improve district health information system indicators. Conclusion: The functioning of the district health system was weak, affecting the delivery of EmOC. Unless staffing is effectively addressed, the health system is unlikely to reduce maternal mortality to the desired level. Coordination of EmOC services by managers needs to be strengthened to limit fragmentation of care and improve the continuity EmOC. Furthermore, a high turnover of senior leadership affects implementation priorities and continuity in the overall strategic direction of EmOC.

Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda.

BACKGROUND: Africa's health systems rely on services provided by mid-level health workers (MLWs). Investment in their training is worthwhile since they are more likely to be retained in underserved areas, require shorter training courses and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need up-dating to be relevant to their practice and to reflect advances in health professional education. This study was conducted to review the training and curricula of MLWs in Kenya, Nigeria, South Africa and Uganda, to ascertain areas for improvement. METHODS: Key informants from professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. 421 District managers and 975 MLWs from urban and rural government district health facilities completed self-administered questionnaires regarding MLW training and performance. RESULTS: Qualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns regarding skills gaps and quality of training were raised. Nevertheless, quantitative data showed that most MLWs felt their basic training was adequate for the work they do. MLWs and district managers indicated that training methods needed updating with additional skills offered. MLWs wanted their training to include more problem-solving approaches and practical procedures that could be life-saving. CONCLUSIONS: MLWs are essential frontline workers in health services, not just a stop-gap. In Kenya, Nigeria and Uganda, their important role is appreciated by health service managers. At the same time, significant deficiencies in training program content and educational methodologies exist in these countries, whereas programs in South Africa appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable them to function with greater effectiveness and contribute to better quality care and outcomes.

Measuring the preparedness of health facilities to deliver emergency obstetric care in a South African district.

BACKGROUND: Improving the delivery of emergency obstetric care (EmNOC) remains critical in addressing direct causes of maternal mortality. United Nations (UN) agencies have promoted standard methods for evaluating the availability of EmNOC facilities although modifications have been proposed by others. This study presents an assessment of the preparedness of public health facilities to provide EmNOC using these methods in one South African district with a persistently high maternal mortality ratio. METHODS: Data collection took place in the final quarter of 2014. Cross-sectional surveys were conducted to classify the 7 hospitals and 8 community health centres (CHCs) in the district as either basic EmNOC (BEmNOC) or comprehensive EmNOC (CEmNOC) facilities using UN EmNOC signal functions. The required density of EmNOC facilities was calculated using UN norms. We also assessed the availability of EmNOC personnel, resuscitation equipment, drugs, fluids, and protocols at each facility. The workload of skilled EmNOC providers at hospitals and CHCs was compared. RESULTS: All 7 hospitals in the district were classified as CEmNOC facilities, but none of the 8 CHCs performed all required signal functions to be classified as BEmNOC facilities. UN norms indicated that 25 EmNOC facilities were required for the district population, 5 of which should be CEmNOCs. None of the facilities had 100% of items on the EmNOC checklists. Hospital midwives delivered an average of 36.4±14.3 deliveries each per month compared to only 7.9±3.2 for CHC midwives (p<0.001). CONCLUSIONS: The analysis indicated a shortfall of EmNOC facilities in the district. Full EmNOC services were centralised to hospitals to assure patient safety even though national policy guidelines sanction more decentralisation to CHCs. Studies measuring EmNOC availability need to consider facility opening hours, capacity and staffing in addition to the demonstrated performance of signal functions.

Physicians' responses to financial and social incentives: A medically framed real effort experiment.

Because compensation policies have critical implications for the provision of health care, and evidence of their effects is limited and difficult to study in the real world, laboratory experiments may be a valuable methodology to study the behavioural responses of health care providers. With this experiment undertaken in 2013, we add to this new literature by designing a new medically framed real effort task to test the effects of different remuneration schemes in a multi-tasking context. We assess the impact of different incentives on the quantity (productivity) and quality of outputs of 132 participants. We also test whether the existence of benefits to patients influences effort. The results show that salary yields the lowest quantity of output, and fee-for-service the highest. By contrast, we find that the highest quality is achieved when participants are paid by salary, followed by capitation. We also find a lot of heterogeneity in behaviour, with intrinsically motivated individuals hardly sensitive to financial incentives. Finally, we find that when work quality benefits patients directly, subjects improve the quality of their output, while maintaining the same levels of productivity. This paper adds to a nascent literature by providing a new approach to studying remuneration schemes and modelling the medical decision making environment in the lab.

Factors associated with the choice of public health service among nursing students in Thailand.

BACKGROUND: Despite the fact that public and private nursing schools have contributed significantly to the Thai health system, it is not clear whether and to what extent there was difference in job preferences between types of training institutions. This study aimed to examine attitudes towards rural practice, intention to work in public service after graduation, and factors affecting workplace selection among nursing students in both public and private institutions. METHODS: A descriptive comparative cross-sectional survey was conducted among 3349 students from 36 nursing schools (26 public and 10 private) during February-March 2012, using a questionnaire to assess the association between training institution characteristics and students' attitudes, job choices, and intention to work in the public sector upon graduation. Comparisons between school types were done using ANOVA, and Bonferroni-adjusted multiple comparisons tests. Principal component analysis (PCA) was used to construct a composite rural attitude index (14 questions). Cronbach's alpha was used to examine the internal consistency of the scales, and ANOVA was then used to determine the differences. These relationships were further investigated through multiple regression. RESULTS: A higher proportion of public nursing students (86.4% from the Ministry of Public Health and 74.1% from the Ministry of Education) preferred working in the public sector, compared to 32.4% of students from the private sector (p = <0.001). Rural upbringing and entering a nursing education program by local recruitment were positively associated with rural attitude. Students who were trained in public nursing schools were less motivated by financial incentive regarding workplace choices relative to students trained by private institutions. CONCLUSIONS: To increase nursing workforce in the public sector, the following policy options should be promoted: 1) recruiting more students with a rural upbringing, 2) nurturing good attitudes towards working in rural areas through appropriate training at schools, 3) providing government scholarships for private students in exchange for compulsory work in rural areas, and 4) providing a non-financial incentive package (e.g. increased social benefits) in addition to financial incentives for subsequent years of work.

Mapping of research on maternal health interventions in low- and middle-income countries: a review of 2292 publications between 2000 and 2012.

BACKGROUND: Progress in achieving maternal health goals and the rates of reductions in deaths from individual conditions have varied over time and across countries. Assessing whether research priorities in maternal health align with the main causes of mortality, and those factors responsible for inequitable health outcomes, such as health system performance, may help direct future research. The study thus investigated whether the research done in low- and middle-income countries (LMICs) matched the principal causes of maternal deaths in these settings. METHODS: Systematic mapping was done of maternal health interventional research in LMICs from 2000 to 2012. Articles were included on health systems strengthening, health promotion; and on five tracer conditions (haemorrhage, hypertension, malaria, HIV and other sexually transmitted infections (STIs)). Following review of 35,078 titles and abstracts in duplicate, data were extracted from 2292 full-text publications. RESULTS: Over time, the number of publications rose several-fold, especially in 2004-2007, and the range of methods used broadened considerably. More than half the studies were done in sub-Saharan Africa (55.4 %), mostly addressing HIV and malaria. This region had low numbers of publications per hypertension and haemorrhage deaths, though South Asia had even fewer. The proportion of studies set in East Asia Pacific dropped steadily over the period, and in Latin America from 2008 to 2012. By 2008-2012, 39.1 % of articles included health systems components and 30.2 % health promotion. Only 5.4 % of studies assessed maternal STI interventions, diminishing with time. More than a third of haemorrhage research included health systems or health promotion components, double that of HIV research. CONCLUSION: Several mismatches were noted between research publications, and the burden and causes of maternal deaths. This is especially true for South Asia; haemorrhage and hypertension in sub-Saharan Africa; and for STIs worldwide. The large rise in research outputs and range of methods employed indicates a major expansion in the number of researchers and their skills. This bodes well for maternal health if variations in research priorities across settings and topics are corrected.

Growing inequities in maternal health in South Africa: a comparison of serial national household surveys.

BACKGROUND: Rates of maternal mortality and morbidity vary markedly, both between and within countries. Documenting these variations, in a very unequal society like South Africa, provides useful information to direct initiatives to improve services. The study describes inequalities over time in access to maternal health services in South Africa, and identifies differences in maternal health outcomes between population groups and across geographical areas. METHODS: Data were analysed from serial population-level household surveys that applied multistage-stratified sampling. Access to maternal health services and health outcomes in 2008 (n = 1121) were compared with those in 2012 (n = 1648). Differences between socio-economic quartiles were quantified using the relative (RII) and slope (SII) index of inequality, based on survey weights. RESULTS: High levels of inequalities were noted in most measures of service access in both 2008 and 2012. Inequalities between socio-economic quartiles worsened over time in antenatal clinic attendance, with overall coverage falling from 97.0 to 90.2 %. Nationally, skilled birth attendance remained about 95 %, with persistent high inequalities (SII = 0.11, RII = 1.12 in 2012). In 2012, having a doctor present at childbirth was higher than in 2008 (34.4 % versus 27.8 %), but inequalities worsened. Countrywide, levels of planned pregnancy declined from 44.6 % in 2008 to 34.7 % in 2012. The RII and SII rose over this period and in 2012, only 22.4 % of the poorest quartile had a planned pregnancy. HIV testing increased substantially by 2012, though remains low in groups with a high HIV prevalence, such as women in rural formal areas, and from Gauteng and Mpumalanga provinces. Marked deficiencies in service access were noted in the Eastern Cape ad North West provinces. CONCLUSIONS: Though some population-level improvements occurred in access to services, inequalities generally worsened. Low levels of planned pregnancy, antenatal clinic access and having a doctor present at childbirth among poor women are of most concern. Policy makers should carefully balance efforts to increase service access nationally, against the need for programs targeting underserved populations.

Perspectives on the methods of a large systematic mapping of maternal health interventions.

BACKGROUND: Mapping studies describe a broad body of literature, and differ from classical systematic reviews, which assess more narrowly-defined questions and evaluate the quality of the studies included in the review. While the steps involved in mapping studies have been described previously, a detailed qualitative account of the methodology could inform the design of future mapping studies. OBJECTIVES: Describe the perspectives of a large research team on the methods used and collaborative experiences in a study that mapped the literature published on maternal health interventions in low- and middle-income countries (2292 full text articles included, after screening 35,048 titles and abstracts in duplicate). METHODS: Fifteen members of the mapping team, drawn from eight countries, provided their experiences and perspectives of the study in response to a list of questions and probes. The responses were collated and analysed thematically following a grounded theory approach. RESULTS: The objectives of the mapping evolved over time, posing difficulties in ensuring a uniform understanding of the purpose of the mapping among the team members. Ambiguity of some study variables and modifications in data extraction codes were the main threats to the quality of data extraction. The desire for obtaining detailed information on a few topics needed to be weighed against the benefits of collecting more superficial data on a wider range of topics. Team members acquired skills in systematic review methodology and software, and a broad knowledge of maternal health literature. Participation in analysis and dissemination was lower than during the screening of articles for eligibility and data coding. Though all respondents believed the workload involved was high, study outputs were viewed as novel and important contributions to evidence. Overall, most believed there was a favourable balance between the amount of work done and the project's outputs. CONCLUSIONS: A large mapping of literature is feasible with a committed team aiming to build their research capacity, and with a limited, simplified set of data extraction codes. In the team's view, the balance between the time spent on the review, and the outputs and skills acquired was favourable. Assessments of the value of a mapping need, however, to take into account the limitations inherent in such exercises, especially the exclusion of grey literature and of assessments of the quality of the studies identified.