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Human Resources for Primary Health Care in Africa

Final Report Summary - HURAPRIM (Human Resources for Primary Health Care in Africa)

Executive Summary:
Scientific evidence shows that the number and the quality of health care workers are positively associated with, for example, the reduction of infant, child and maternal mortality. Primary health care especially plays an important role in addressing key public health care problems.
HURAPRIM is a research project that aimed at developing and evaluating policies and key interventions to address the crisis in human resources in health, especially in sub-Sahara Africa. Five African countries are involved (Mali, Sudan, Uganda, Botswana and South Africa), as to represent Africa’s broad diversity.
Four main research tasks underpin the HURAPRIM project:
1. a literature review on existing human resources for primary health care in each participating country;
2. participatory research with stakeholders to collect information on the reasons for the deficit in human resources, interventions already tried, and ideas for new interventions;
3. a confidential enquiry into maternal and child deaths in Mali and Uganda, with the aim of prioritizing how human resources for health could best be used in order to reduce maternal and child mortality;
4. qualitative interviews with African migrant health workers in Europe, South Africa and Botswana, in order to get their perspective on reasons for the health workers’ crisis in Africa, and possible solutions.
Based on the results of this preliminary research, the following interventions were developed, implemented, monitored and evaluated in the different African countries:
1. Primary Health Care (PHC) re-engineering, including PHC Outreach Teams, as a Human Resources Strategy in South Africa
2. The Confidential Enquiry in Uganda and Mali
3. Supportive Supervision in Botswana
4. Role of nurses in Sudan
5. Traditional Birth Attendants in Mali
The project results were presented to stakeholders, policymakers and the wider audience. Key recommendations were made and captured in a policy brief.
A reflection paper on the ethical aspects of the brain drain and the socio-cultural, economic, political and historical influences on allocation of resources in order to address the ethical consequences of the Human Resources Crisis in primary health care was developed.

Project Context and Objectives:
In short, health workers save lives. Scientific evidence shows that the number and the quality of health care workers are positively associated with, for example, the reduction of infant, child and maternal mortality. Primary health care especially plays an important role in addressing key public health care problems.
Today, immense advances in human well-being for some coexist with extreme deprivation for others. In global health, it is no different. The World Health Report of 2006 “Working together for Health” shows a worldwide shortfall of 4.3 million health care workers, of which 1.8 million in Africa. The African continent has 24% of the global disease burden but only 3% of the world’s health workers and less than 1% of the world’s health expenditure.
The causes for this deficit in African countries are multiple and relate to a combination of factors such as insufficient professionals, internal misdistribution, inappropriate task allocation, deficient working conditions and brain drain. The final aim of the HURAPRIM project is to arrive at a better understanding of the scope and causes of the deficit in human resources for primary health care in Africa, and to develop interventions and policy recommendations to address this problem.
The project focus on primary health care (not only doctors and nurses but also community health workers and traditional health practitioners) as this is the most accessible and holistic level of health care with the potential to make the greatest impact on achieving the Millennium Development Goals by improving access to (primary) health care, especially for people living in underserved areas.
The complexity of the problem does not allow a “one size fits all” approach, therefore the project brings together five African partners which are purposively selected representing a wide range of geographic, socio-economic and political realities: Mali in West Africa, Sudan in northern Africa, Uganda in East Africa and Botswana and South Africa in Southern Africa.
In the first stage of the project the deficit and its causes were examined. This was done through four broad tasks:
1. A literature review, including grey literature, on the availability of health workers and the scope of the shortage in each participating African country;
2. A participatory research with stakeholders to collect information on the reasons for the deficit in human resources, interventions already tried, and ideas for new interventions;
3. A confidential enquiry into maternal and child deaths in Mali and Uganda, with the aim of prioritizing how human resources for health could best be used in order to reduce maternal and child mortality;
4. Interviews with migrant health workers from sub-Sahara Africa who moved to the UK, Belgium and Austria in Europe or South Africa and Botswana in Africa, in order to find out their reasons for migration and what might motivate them to return to their country to work in the health sector and to get their perspective on reasons for the lack of health workers in Africa, and possible solutions.
Based on the results of this preliminary research, several interventions were developed, implemented, monitored and evaluated in the different African countries. The project results were presented to stakeholders, policymakers and the wider audience.
The evaluation of the implemented interventions enabled the project team, together with different key-stakeholders, to formulate conclusions regarding their feasibility, acceptability, sustainability and cost effectiveness and to translate these conclusions into policy recommendations. This resulted into a policy brief, titled “Building comprehensive primary health care teams for Africa: the way forward” that describes concrete measures to address the human resource crisis in primary health care in Africa.
The HURAPRIM project ultimately aims to increase awareness and political attention on the issue of health workers in order to contribute to the realization of the Millennium Development Goals by improving access to (primary) health care, especially for people living in underserved areas.

Project Results:
The Scope and Causes of the Deficit in Human Resources for Primary Health Care in Africa
In the first stage of the project, the deficit and its causes were examined.
The information obtained from diverse angles provides a consistent picture of the extent, causes and consequences of the shortage of health workers in primary health care in sub-Saharan Africa. It is clear in Uganda that both absolute numbers and percentages of vacancies are greater in primary than in secondary or tertiary health care settings. In other countries such as Mali and Sudan, the vacancies do not even exist because very few clinical posts have been created in primary health care, and there has been very little recruitment. Lack of public funds for employing health workers is the main bottleneck. Many health workers are not even offered the possibility of being employed in public primary health care facilities.
Interviews and focus groups with health workers both in and from Africa confirm that living and working conditions are tougher in rural primary health care than in other settings, and yet this is not recognised in increased levels of pay. These factors deter health workers from working in these settings. Unlike other workers who may be forced to endure difficult conditions, health workers are skilled, in high demand, and able to find jobs in other areas. The shortage is not only caused by international migration, but also by migration to other sectors in the same country, and “moonlighting” in other jobs when theoretically the health workers should be present in the primary health care centre. The fewer health workers are there, the larger the workload for those remaining, which in turn encourages them to leave.
The confidential enquiry completes the loop by showing that those areas with the highest child and maternal death rates have the fewest primary health care workers. Therefore the “inverse care law”, a phenomenon first reported in the UK in 1971, is very much a reality in Africa today. But the enquiry also shows that accessibility and quality of health workers is as important as quantity. Proximity to a health centre with a qualified health worker is not sufficient to save lives – the service must be financially accessible and the health worker must also provide good quality of care. The confidential enquiry itself may be a tool to improve this quality of care by helping health workers at every level to analyse events surrounding a death and change practices to improve quality of care.
South Africa has the highest ratios of health workers per population but the data shows a similar situation in primary health care compared to the four other countries studied, with fragmented health systems and specialist hospital care prioritised. In particular, the role of doctors in primary health care was not well defined. A difference appears to be political and racial tensions in the workplace and general insecurity related to crime in living areas. This emphasises the point that addressing health system factors is necessary but not sufficient for retention of health workers. Although it is important to improve the health system, this alone is not enough to recruit and retain health workers in primary health care. It is equally important to address broader factors such as racial tensions in the workplace and living conditions, in particular security.
Limitations of this group of studies include the fact that only five African countries were included. Researchers in each country adapted the participatory and migrant health worker interview protocols to their own local situations so the sampling strategies were not uniform across the different areas. In South Africa the participatory research took a quite different approach to the other countries, as it consisted mainly of focus groups and meetings in the capital city and did not include any interviews of health workers in rural primary health care settings. This may explain at least part of the differences observed.
This work has important implications for policy-makers in Africa. The “inverse care law” can only be reversed by a multi-pronged approach addressing working and living conditions, recruitment and remuneration. Firstly, posts should be created and adequately funded so that the pay is at least sufficient to compensate health workers in difficult settings for the increased workload and increased living expenses which they incur. This will attract more health workers to take up posts in such areas, which in turn will reduce the workload per health worker. Secondly, interventions to improve quality of care, such as the confidential enquiry, may help health service managers to target scarce resources (staff, medicines and equipment) to the areas with the greatest need, and may also help to improve quality of care, and so motivation of health workers. Thirdly, broader development initiatives are needed beyond the health service, such as security, schools, water, electricity, transport and communications – all of which impact on health workers’ decisions of where they wish to work. The priorities vary from area to area, but the principle remains the same: improved health and health care requires “joined-up” government across several sectors. Achieving these objectives will probably require an increase in funding, or at least a reshuffle of spending to target areas of greatest need.
Such interventions are so obviously necessary that they should be implemented without waiting for any further research. However research may help to improve the targeting of resources, and to refine the methods for achieving these objectives. For example, what are the most effective ways of motivating good performance by health workers? Can a confidential enquiry into maternal and child deaths be scaled up, and help to target resources, at a national level?
In the UK, the crucial policy response to the initial “inverse care law” paper was a detailed national plan to provide the staff and working conditions which allowed the delivery of high quality primary care, and targeting of resources according to need. In Brazil, in infant mortality has fallen by 4.5% for every 10% step increase in population coverage with effective primary care delivery. Similar improvements are most probably achievable in Africa by implementing locally appropriate policies according to the same broad principles of improving the availability and quality of primary health care in the areas of greatest need. This will require political will, and prioritisation of health within national budgets.

Interventions to address the Human Resources Crisis in African Primary Health Care
Based on the above results and conclusions, the following interventions were developed, implemented, monitored and evaluated in the different African countries:

1. Primary Health Care (PHC) re-engineering, including PHC Outreach Teams, as a Human Resources Strategy in South Africa
An integrated model of PHC practice (including COPC) was developed in 20 sites in the poorest wards in Johannesburg. It was based on four elements: a community care worker program working in defined communities; stakeholder engagement; active communication with residents and a strongly integrated clinic team – based on doctor, nurse and community care worker – with the patient as organizing principle. There were 300+ community health workers, 7 nurses and 15 doctors in 20 sites and potentially covering more than 300 000 people. There were 35 000 people registered in the program between January and June 2012, supported by the HURAPRIM Project. However, the National and Provincial Departments of Health insisted on strict adherence to the national guidelines for Municipal Ward-based PHC Outreach Teams (MWPHCOT) from August 2012 and the HURAPRIM Project was excluded from the Johannesburg Task Team.
The HURAPRIM Project moved its focus from facilitating the optimal implementation of PHC Re-engineering and MWPHCOT (as a form of COPC) to just evaluating its current implementation. It strives to use this enormously useful window into understanding the larger implementation of MWPHCOT and the related human resource challenges.
In addition the HURAPRIM team has re-organized itself considerably to develop the Chiawelo Community Practice (CCP) as a functioning example of a well-integrated MWPHCOT in the Chiawelo Community Health Centre in Soweto since September 2014. This site is currently covering Ward 11 in Soweto with Community Health Workers (CHW) employed by the project since February 2014. The project team re-engineered the processes from current practice to an integrated COPC/ MWPHCOT model and explored the HR difficulties.
CCP functions as part of the public service in the Chiawelo Community Health Centre (CHC). WITS research funds have been used to create the system with basic infrastructure and add an enrolled nurse (as CHW Team Leader), and 21 CHWs. CHWs have been deployed in screening, educating and supporting health and inter-sectorial action. A Family Medicine registrar and a clinical associate (as employees of Gauteng Health) are seeing all patients from this community in strong teamwork with CHWs. Local stakeholders are also engaged strongly, supporting a growing health promotion program.
In order to be able to translate the research into action, the Participatory Action Research (PAR) method was used. This method includes qualitative and quantitative approaches, but is above all participative. It has as its twin goals “the achievement of both action and research in the same evaluation method”. The key advantage of employing an action research methodology is that it draws attention to how an intervention unfolds and how the actions of an intervention can mutually benefit a community of practitioners.
Results and conclusion
CCP as a model based on community-oriented primary care and led by a family physician offers a model that can support comprehensive PHC service under the new National Health Insurance system, including general practitioners fully contracted and regulated as providers in the overall public health system. The human resources available do not limit this and the efficiencies, as evident from CCP, make it preferred.
Our key recommendations are to enforce policy requirements, as laid out in the Guidelines for PHC Re-engineering, and strengthen it with a more integrated PHC team that includes CHWs nurses, clinical associates and family physicians. Contracting for re-engineered PHC in an NHI system can work. It must integrate comprehensive care around patient, person and people and truly re-engineer primary health care.

2. The Confidential Enquiry in Uganda and Mali
The literature review reveals a considerable understaffing in the health care systems of Uganda and Mali. The shortages are the highest at the base of the system, in the ‘health centres II and III' in Uganda and in the Centres de Santé Communautaires (CSCOMs) in Mali.
The confidential enquiry approach
The confidential enquiry approach is an no-blame independent expert audit of a series of cases which seeks to identify and potentially remedy modifiable system failure.
In the UK this methodology was used for conducting enquiries into maternal and child health and was perceived as having a positive impact on reducing maternal and perinatal deaths.
For the HURAPRIM project, the method was adapted to the Malian and Ugandan reality. A system of community-based confidential enquiry was set up in selected sub-counties (Uganda) /aires de santé (Mali) with a view to identify gaps in service accessibility or provision, in human resources, and possible interventions which could have prevented deaths.
The confidential enquiry revealed that quality of human resources for health may be even more important than quantity. It also transpired that the process of the confidential enquiry itself is a useful way of effecting improvement in quality of health care. The fact that the confidential enquiry is going on is an incentive for health workers to take greater care in their management of patients.
The aim was to refine and evaluate the confidential enquiry process into a tool which can be scaled up and used both to improve quality of human resources and to prioritize and advocate for more human resources in areas which are in greatest need. The process included a strong element of dissemination of results at all levels from the community to health workers to politicians and policy makers.
The specific objectives were:
1. To refine the confidential enquiry process into a tool which can be scaled up to district and national levels
2. To develop a mechanism for dissemination of results and recommendations at all levels, within a regular CPD meeting.
3. To develop and implement a way of improving the functioning of health unit management committees.
4. To evaluate the impact of these interventions on perinatal and child mortality.
The primary outcome measure was the rate of perinatal and child mortality in the selected subcounties (Uganda)/ aires de santé (Mali), collected through the reporting system.
The sample size was not sufficient to show a statistically significant difference between “pre” and “post” intervention areas. However this sample enabled us to estimate the size of the effect of the confidential enquiry mechanism on perinatal and child mortality.
Results and conclusion
The confidential enquiry has shown that quality of human resources is as important as quantity, if not more. It has transpired that this process is in itself a promising intervention to improve quality of care and to inform public health policy on allocation of human resources. The confidential enquiry is adaptable to the developing world. The process potentially reduces under-five child mortality.
Confidential enquiry mechanism and its derived tools have an impact on the perinatal and child mortality but the danger exists that its effects will diminish over time. It is envisaged that the Ministry of Health will put in more effort to make sure that maternal and child death audits are carried out. The findings will inform the Ministry to emphasis on what is already on their plan of implementation to do audits. This was a presidential directive. This can be done within existing health systems with Village health teams reporting regularly.

3. Supportive Supervision in Botswana
How can the supportive supervisory capacity of primary care teams by the District Health Management Team and mid-level health managers be strengthened in Botswana?
Qualitative research done through HURAPRIM confirms the shortage of health care workers in Botswana and its causes.
Amongst others, inadequate supportive supervision both from central government and the District Health Management Teams (DHMTs) has been cited as a significant cause for job dissatisfaction in primary care. The relocation in 2010 of primary health from the Ministry of Local Government to Ministry of Health is blamed for some of the health workers unhappiness leading to early retirement and resignation of some.
Due to this restructuring, district health teams, which previously managed primary care at district level, were disbanded and a new governance entity, the DHMT, was created.
The DHMTs’ primary role is to manage all of healthcare at district level. Health care workers and policy makers recognise the importance of a strong empowered DHMT for a properly functioning primary health system, motivated health care workers and good patient care. However, stakeholders claim that the DHMT’s are ineffective since the organisational structure and roles of the team have not been clearly defined.
The overall aim was to improve the retention of health workers in the primary health care. The specific objectives were:
• Facilitate the DHMT members and mid-level supervisors to identify a problem in their supervision of primary care workers;
• Facilitate the team to develop and implement action to address the identified problem;
• Improve health worker satisfaction;
• Train the DHMT in participatory action research;
• Train DHMT in writing and reflection on their practice.
The intervention was work-based or ‘professionalizing’ participatory action research with the participants being the DHMT who developed action to strengthen their capacity and ability to provide supportive supervision to the primary health workers. This involved 4 interrelated phases, which can be repeated several times in a cyclic manner as new knowledge emerges and there is better understanding of the problem. The fases are problem identification, planning, action, evaluation.
Interpretative ethnographic and qualitative data collection methods were used for the evaluation of the intervention. Evaluation was made of both the experiences of the participants as well as the results and outcome of the intervention.
The success of the intervention was judged by the level of engagement of the participants with the process as well as their perceived empowerment to be better managers and supervisors. The developed new knowledge and outcome of the intervention was also used to assess success. Retention before and during the intervention period was compared.
Results and conclusion
The DHMT and cluster heads are expected to provide supportive supervision to the primary healthcare workers but it is apparent that this is not prioritized enough to have adequate resources allocated for it and the managers have not been trained to be effective supervisors. One of the major challenges encountered by these leaders was lack of autonomy even over their time. Their schedules were repeatedly interrupted by unplanned meetings, workshops and visits from the ministry of health headquarters. The supervisors also faced formidable challenges to carry out the supervision visits and even communicate with the primary care workers because of lack of transport and telecommunication facilities.
Even with these challenges the consensus is that supportive supervision can help attract and retain healthcare workers in primary healthcare . However, supportive supervision is only possible with adequate resources, leadership development and a cultural transformation.

4. Role of nurses in Sudan
A recent review, Primary Health Care (PHC) Research and Information Service ( 2013) concluded that nurses play a critical role in dealing with problems of access within the PHC system. The multidisciplinary role of nurses as health care provider, educator and advocate enhances the provision of good practice at PHC settings.
Like other countries in sub-Sahara Africa, Sudan is below the critical level of 2.5 health care professionals per 1.000 inhabitants. Sudan suffers from a huge deficiency especially in nursing and registered midwives.
The Sudanese government has taken policy measures to improve the training and recruitment of nursing. In November 2005 The Academy of Health Sciences (AHS) was established with branches in all 15 states to train allied health care workers (HCW), to aim at graduating cadre locally and ready to assume role in the health care settings, basic health units, health centers and rural hospitals.
The overall objective was to collect quantitative and qualitative data to evaluate the recent policy measure, promoting primary health care.
The specific objectives were:
- To identify choices of AHS final year nurse and medical assistant students (FYS);
- To measure satisfaction of nurse and medical assistant graduates with their functions and responsibilities;
- To measure the satisfaction of users of HCW at the different health units.
The study was a descriptive comparative study between Academies of Health Sciences in three states in Sudan. Both quantitative and qualitative methods were used.
Results and conclusion
This limited study covered three AHS out of the existing 15 AHS and they were representative of the different AHS. There were 389 FYS in the three AHS i.e an average 130 FYS in each AHS, which if the same number is found in the 15 AHS, there will be a total of 1950 FYS in the 15 states every year, which will be a good addition to the HRH pool.
Overall 81% of FYS preferred to work in PHC settings in their states after graduation which is a very positive indicator if they will be incited to remain. This means if extrapolated that 1580 new PHC cadre will be added to PHC facilities every year. This will also encourage authorities to reevaluate the curricula and training to achieve the appropriate skill mix. The study determined that the overall majority of nurses and medical assistants were highly satisfied with their functions and responsibilities. They stated that they will continue to work in their current jobs. The study also found an overall high rate of users-satisfaction with the performance of HCW. This was also confirmed by the focus groups discussions with users.
To conclude, the policy initiative of the Sudanese government was successful on the basis of this evaluation of three AHS. The estimated numbers of FYS and their preference to work in PHC settings after graduation, fulfills one of the objectives of the initiative to graduate HCW who can contribute effectively to health care services and delivery.

5. Traditional Birth Attendants (TBA’s) in Mali
Despite the efforts of the Malian Ministry of Health and its financial partners to establish a system for managing obstetric emergencies in the health districts, available data shows that maternal and infant mortality rates remain very high in Mali.
International literature reviews show that traditional birth attendants (TBAs) could play an important role in reducing maternal and neonatal mortality.
The TBA is a person who is known in the village to help new mothers during childbirth and whose competence comes from a family heirloom. TBAs represent the first link in the chain to save the lives of mothers and newborns.
Results of previous activities shows that the involvement of TBAs in the detection and quick referral of high-risk obstetric cases improves women's access not only to the system for managing obstetric emergencies, but also to all the services in the field of maternal and neonatal health.
The aim was to improve and evaluate a model for collaboration between traditional and modern medical systems, by involving TBAs in the management of obstetric emergencies and in the promotion of low risk motherhood in 3 health areas in the Kolokani District.
The intervention was carried out with a participatory action-research methodology. Such an approach not only aims to generate statistically significant results, but also wants to build a behavioral model of articulation between traditional and modern systems of pregnancy monitoring and delivery assistance and a framework for evaluating it in future larger studies.
Results and conclusion
The results shows that TBAs can be considered as human resources for Maternal and Neonatal Health, under a collaboration organized, monitored and evaluated with the staff of the Community Health Centers. High-risk obstetric cases are referred in time, while simple cases are cared for properly in the villages.
TBAs, as members of local communities to whom people turn for first contact concerning maternal and infant care or advice, should be trained and supported in recognizing and referring high risk deliveries.

Ethical issues regarding brain drain and the human resource crisis in health
During WP10 a reflection paper on the ethical aspects of brain drain and the socio-cultural, economic, political and historical influences on allocation of resources in order to address the ethical consequences of the Human Resources Crisis in primary health care was developed.
The most important observations from this research were:
1. Exclusion of human resources for health care that would be available
Traditional health practitioners (THPs) outnumber government health workers by far in many rural and remote areas in African countries. In many countries, however, THPs are formally excluded from the public health system and do not have the opportunity to attend continuous training activities. Therefore, the resources that actually would be there are not taken into consideration and are sometimes even criminalized (like in Uganda where traditional birth attendants are illegal). The participatory intervention in Mali from the NGO Aidemet showed that it is possible to include traditional health practitioners in continuous training activities and to improve mutual cooperation between THP and government health workers.
2. Neglecting personal needs of primary care workers
The available human resources for primary health that work in government service are often subjected to severe coercive rules regarding their job placement. Often the family situation or other aspects (i.e. gender and security) are no taken into account. In Botswana stakeholder interviews showed that health workers were often placed in rural areas for many years with unclear transfer regulations and separated from their families.
3. Blaming the health care workforce that stay in the countries with severe shortages
The Uganda media analysis showed that there is a culture of blaming individual health workers for problems in health service delivery in countries with severe human resource shortages. The results suggest that in some countries unethical attitude of health workers towards patients is a real problem. However, unless there is an improvement of the support system that goes along with a control system for health workers there will be no improvement of the situation. The confidential enquiries are an example for both a sort of control system for health workers and for provision of continuous professional development without blaming them.
4. Restrictive measures on migration of health workers are applied on an international level before the improvement of working and living conditions
In their literature review Jirovsky and colleagues reported that all the answers to the resource crisis so far target the international distribution of health workers. The only global political strategy until today seems to be the restriction of the migration of individual health workers from countries with shortages (MoU between SA and UK, for example); little is done on the level of improving the living and working conditions for those health workers that live and work in rural and remote primary health care (PHC) settings. The 89 interviews with migrant health workers as well as other stakeholder interviews showed that push factors had majorly impacted the decision to leave the job in PHC.
5. Neglecting community participation and the right for health care
Although community empowerment and participation has shown good results in many studies, communities are often taken out of the equation in researching public health strategies. The HURAPRIM research with stakeholders (focus groups and face-to-face interviews) in five African countries showed that it was possible to include community members and health care users when researching the scope and causes of the HRH crisis and that a more in-depth view could be obtained by including them.

The following recommendations were made:
1.1. Include all available human resources for health in services, research and policy
• Improve cooperation between government health workers and THP in communities
• Increase ethics training and accountability of health workers and traditional healers
(E.g. formulate a code of ethics adapted to the development of traditional medicine in a changing society (urbanization, increasing individualism, etc.)
• Recognize THP as stakeholders: Involve traditional healers in public health structures in African countries (e.g. include them in continuous training activities) as a form of monitoring. They are an important part of health seeking structures in local communities, so they have to be part of the solution of the human resource crises in PHC
• Allocate more funding for training and involving traditional health services

2.1. Improve services and incentives for health workers in rural/remote areas
• Improve availability of basic needs (accommodation, allowance)
• Develop family reunification schemes (dual career)
• Develop clear transfer regulations for remote areas
• Implement training schemes locally for PHC

3.1. Install a support, mentoring and control system for health workers
• Give professional and psychosocial support to health workers in rural and remote areas
• Develop and implement non-monetary incentives like strengthening work autonomy, encouraging career development, providing opportunities for training, adapting working time and shift work (for nurses), reducing violence in the workplace, and open leadership
• Create monetary incentives for community health workers (CHW)
• Include confidential enquiries (as a form of continuous professional development (CPD)) in the work agendas of government health workers
• Increase post-natal visits by CHW
• Promote solidarity between health workers
• Install mentoring systems between senior and junior health workers
• Teach micro ethics (applied ethics) in curricula in health care: what ethical challenges can graduates expect in PHC in their countries and how can they deal with them? (Shortage of resources, misallocation of resources, corruption, community expectations, isolation, etc.)

4.1. Target the push factors more and put resources into the improvement of working and living conditions of health workers
• Local needs assessment is necessary. What are the professional and private needs of health workers on the ground?
• Strengthening communication/cohesion between health workers and the community

5.1. Take the right to health of the community seriously and include them in the process of finding solutions to the human resource crises in health
• Local needs assessment is necessary. What are the needs of patients and communities on the ground?
• Educate community members about their rights to health (what can they expect, what can they not expect from the health system?)
• Build health consumer associations
• Increase monitoring and decision power of the community regarding PHC

Potential Impact:
• The project gained substantial knowledge on the effectiveness of interventions to address internal and external brain drain and increased knowledge on acceptability and cost-effectiveness of the interventions. On the basis of these new insights, evidence-based policies to address brain drain can be developed and implemented. The HURAPRIM project contributed and will contribute to discussions and policy actions on an international level. All of the scheduled interventions were directly anchored on actual health policy commitments and plans.
• Apart from the scientific and research objectives of this project, the African partners were taking part in this project in order to improve the human resources for health situation in their particular countries. Special emphasis was given in the project to dissemination and exploitation activities tailored to maximize the anticipated effect of influencing key stakeholders in stewardship and regulation in study countries and included workshops, regular meetings, national and regional conferences, such as the PRIMAFAMED workshop and the 4th Wonca Africa Regional Conference, both in Accra, Ghana. This means that all HURAPRIM “interventions” or action research was directly anchored on actual health policy commitments and plans, as to guarantee the practical relevance of the research done. A clear example of this can be given in the case of Uganda, where an intensive political debate was held between the executive and the members of parliament on the intended plans of the government to reduce health expenditures. The HURAPRIM project provided the members of parliament with a brief “why Uganda needs to increase its health budget”, also focusing on the actual shortages and needs of (primary care) health workers. Finally, the national health budget passed with a far smaller reduction than originally foreseen in the overall health budget and an increase in resources for recruiting more health workers and increasing the salary of doctors.
• The action research interventions of the HURAPRIM project in the African partner countries aimed precisely at the bringing together of academic stakeholders with governmental leadership and civil society actors in the providing concrete & agreed upon solutions for a collectively accepted diagnosis
• This project established close and productive working relationships between participating institutions. Maintaining the sound linkages between partners is seen by the participating institutions as a very important contribution to building capacity and scientific networks. Networking and scientific exchange occured in different combinations.
• The development of research capacity in the partner countries formed an important project component that will enable partner research institutions to identify priority issues, carry out research in key areas, and develop their abilities, in order to build a basis for enhanced knowledge development in their countries. This included strengthened capacity to incorporate gender and ethical issues into research.

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