New childbirth videos just released

We’d like to let you know that we’ve just released the first 3 videos in our new Childbirth Series: Giving Good Care in Labor, Examining the Placenta, and The Position of the Baby The primary audience for these teaching videos are birth attendants in developing countries. The videos showcase a midwifery approach to care with a birth attendant working solo, the norm in small facilities throughout much of the developing world. These films will soon be available in French and Spanish. They are downloadable free-of-charge for use in low-resource settings through our Creative Commons license. In an effort to improve our work we are grateful for any feedback, especially from those of you who are directly involved with training birth attendants.

Kind regards,


Deborah Van Dyke, Director

Global Health Media Project



Malaria Information – go directly to the source

The World Health Organization’s Global Malaria Program has many FREE downloadable documents on everything from malaria case management, to safe insecticides, to the latest diagnostic tools. These are important references for any health worker in a malaria endemic environment.  Check out the many malaria publications at: WHO | Malaria

Citation: Basic or enhanced clinician training to improve adherence to malaria treatment guidelines: a cluster-randomised trial in two areas of Cameroon

The Lancet Global Health, Volume 2, Issue 6, Pages e346 – e358, June 2014 <Previous Article|Next Article>


Wilfred F Mbacham, Lindsay Mangham-Jefferies, Bonnie Cundill, Olivia A Achonduh, Clare I R Chandler, Joel N Ambebila, et al.


Background: The scale-up of malaria rapid diagnostic tests (RDTs) is intended to improve case management of fever and targeting of artemisinin-based combination therapy. Habitual presumptive treatment has hampered these intentions, suggesting a need for strategies to support behaviour change. We aimed to assess the introduction of RDTs when packaged with basic or enhanced clinician training interventions in Cameroon.

Methods: We did a three-arm, stratified, cluster-randomised trial at 46 public and mission health facilities at two study sites in Cameroon to compare three approaches to malaria diagnosis. Facilities were randomly assigned by a computer program in a 9:19:19 ratio to current practice with microscopy (widely available, used as a control group); RDTs with a basic (1 day) clinician training intervention; or RDTs with an enhanced (3 days) clinician training intervention. Patients (or their carers) and fieldworkers who administered surveys to obtain outcome data were masked to study group assignment. The primary outcome was the proportion of patients treated in accordance with WHO malaria treatment guidelines, which is a composite indicator of whether patients were tested for malaria and given appropriate treatment consistent with the test result. All analyses were by intention to treat. This study is registered at, number NCT01350752.

Findings: The study took place between June 7 and Dec 14, 2011. The analysis included 681 patients from nine facilities in the control group, 1632 patients from 18 facilities in the basic-training group, and 1669 from 19 facilities in the enhanced-training group. The proportion of patients treated in accordance with malaria guidelines did not improve with either intervention; the adjusted risk ratio (RR) for basic training compared with control was 1·04 (95% CI 0·53—2·07; p=0·90), and for enhanced training compared with control was 1·17 (0·61—2·25; p=0·62). Inappropriate use of antimalarial drugs after a negative test was reduced from 84% (201/239) in the control group to 52% (413/796) in the basic-training group (unadjusted RR 0·63, 0·28—1·43; p=0·25) and to 31% (232/759) in the enhanced-training group (0·29, 0·11—0·77; p=0·02).

Interpretation: Enhanced clinician training, designed to translate knowledge into prescribing practice and improve quality of care, has the potential to halve overtreatment in public and mission health facilities in Cameroon. Basic training is unlikely to be sufficient to support the behaviour change required for the introduction of RDTs.

Hope and despair: community health assistants’ experiences of working in a rural district in Zambia

As part of our exploration of the information and learning needs of Community Health Workers, supported by mPowering Frontline Health Workers, please find below a new paper about Community Health Workers in Zambia, published in the open access journal Human Resources for Health.

Best wishes, Neil Pakenham-Walsh, HIFA moderator

Hope and despair: community health assistants’ experiences of working in a rural district in Zambia

Joseph Mumba Zulu, John Kinsman, Charles Michelo and Anna-Karin Hurtig

Human Resources for Health 2014, 12:30  doi:10.1186/1478-4491-12-30

Published: 25 May 2014

Abstract (provisional)

Background: In order to address the challenges facing the community-based health workforce in Zambia, the Ministry of Health implemented the national community health assistant strategy in 2010. The strategy aims to address the challenges by creating a new group of workers called community health assistants (CHAs) and integrating them into the health system. The first group started working in August 2012. The objective of this paper is to document their motivation to become a CHA, their experiences of working in a rural district, and how these experiences affected their motivation to work.

Methods: A phenomenological approach was used to examine CHAs’ experiences. Data collected through in-depth interviews with 12 CHAs in Kapiri Mposhi district and observations were analysed using a thematic analysis approach.

Results: Personal characteristics such as previous experience and knowledge, passion to serve the community and a desire to improve skills motivated people to become CHAs. Health systems characteristics such as an inclusive work culture in some health posts motivated CHAs to work. Conversely, a non-inclusive work culture created a social structure which constrained CHAs’ ability to learn, to be innovative and to effectively conduct their duties. Further, limited supervision, misconceptions about CHA roles, poor prioritisation of CHA tasks by some supervisors, as well as non- and irregular payment of incentives also adversely affected CHAs’ ability to work effectively. In addition, negative feedback from some colleagues at the health posts affected CHA’s self-confidence and professional outlook. In the community, respect and support provided to CHAs by community members instilled a sense of recognition, appreciation and belonging in CHAs which inspired them to work. On the other hand, limited drug supplies and support from other community-based health workers due to their exclusion from the government payroll inhibited CHAs’ ability to deliver services.

Conclusions: Programmes aimed at integrating community-based health workers into health systems should adequately consider multiple incentives, effective management, supervision and support from the district. These should be tailored towards enhancing the individual, health system and community characteristics that positively impact work motivation at the local level if such programmes are to effectively contribute towards improved primary healthcare.

SELECTED EXTRACTS (selected by Neil PW)

‘Delayed communication of important information to CHAs by a few supervisors also demoralised CHAs. For example, it was reported that some supervisors shelve important documents instead of giving them to CHAs upon receiving them from the MoH.

‘So it’s today that I have found a certain CHA implementation book. I asked her (supervisor) when it came and she said a long time ago. There are also other materials that came in October last year and we are only seeing them now in May.’ (CHA 6, male).

‘The way we are working with the neighbourhood health committee, we are not comfortable… they are not regarding us as trained staff. So they regard the cashier, watchman and cleaner as people who have better information. (CHA 3, male).’

Barriers to Skilled Birth Attendance in Gambia

A paper in the African Journal of Reproductive Health looks at barriers to Skilled Birth Attendance in Gambia. As would be expected the main barriers are lack of time to go to a health centre and/or lack of transport. Three in four are attended by traditional birth attendants. I was surprised to learn that only 3% of women thought that the TBAs knew what to do in the event of complications, despite the fact that TBAs in larger villages routinely receive government training.

CITATION: Barriers to Skilled Birth Attendance: A Survey among Mothers in Rural Gambia.

Priya Miriam Lerberg et al.  Afr J Reprod Health 2014; 18[1]: 35-43

Full text:


The objectives of this cross-sectional survey were to identify the most important barriers for use of skilled attendance during childbirth by women in rural Gambia. We also assessed information received during antenatal care, preparations made prior to childbirth, and experiences and perceptions that may influence the use of skilled birth attendance in rural Gambia. The most

frequently stated barriers for giving birth in a health facility were not having enough time to go (75%), and lack of transport (29%). The majority of the women (83%) stated that they preferred having a health worker attending their childbirth. More than seventy percent of the participants gave birth attended by a traditional birth attendant, but only 27% had intended to give birth at home. Sixty-four percent had made advance arrangements for the childbirth. Only 22% were informed about expected time of birth during antenatal care. Our findings suggest that the participants hold the knowledge and motivation that is necessary if practices are to be changed. Interventions aiming at ensuring timely transport of women to health facilities seem key to increased use of skilled birth attendants. (Afr J Reprod Health 2014; 18[1]: 35-43).


‘Villages with more than 400 inhabitants have resident TBAs that have received government-supported training’

‘Three out of four respondents reported that they were assisted by a TBA during childbirth. Eighty three percent said they would have preferred being assisted by someone else than the person who had assisted them, and most would have wanted a health professional. Four out of five mentioned skills and access to drugs as important reasons for wanting a health professional present during childbirth. Health personnel’s ability to handle complications was emphasised by two out of three respondents.’

‘Practically all (99%) agreed when asked if doctors and nurses are knowledgeable about the care a woman need, and 97% agreed that TBAs are.’

‘We asked the participants if they thought nurses/doctors/TBAs know what to do in case of complications: 99.5% agreed that doctors know what to do, 99% agreed that nurses know, and only three percent thought that the TBAs know what to do.’

Best wishes,


Let’s build a future where people are no longer dying for lack of healthcare knowledge:  Join HIFA:

Here, you fix it …

ANC leaders are anxious about the economy. The party’s national executive committee (NEC) lekgotla, which was held shortly after Standard & Poor’s downgraded SA’s rating and after a slew of other economic data confirmed the precarious position of the economy, raised concerns about government’s policy uncertainty and how this was undermining investment…..1 2 3

Cyril Ramaphosa sets goals for economic transformation

Economic transformation will take centre stage during this term, says Deputy President Cyril Ramaphosa. “Economic transformation must and will take centre stage during this new term of government,” Ramaphosa told a national Youth Day commemoration in Galeshewe, in the Northern Cape today. He said the youth must be at the centre of this economic transformation…..1 2 3 4

Human Resources for Health Migration: global policy responses, initiatives, and emerging issues

Overall messages

  • Skilled health worker migration has emerged as a major issue in global policy making over the last decade. Global dialogue on skilled health worker migration takes place through a range of multilateral organisations, with different missions and remits, inside and outside the UN system
  • Evolving global policy on migration for development, universal health coverage and HRH in the post‐2015 development agenda are shaping global dialogue on HRH migration in tangible ways.
  • Global governance on HRH migration has led to a range of global, regional and bilateral mechanisms resulting in varying levels of cooperation and policy development. They include normative frameworks for rights‐based approaches to migration, voluntary codes on ethical recruitment with a specific focus on HRH in source countries, diasporic initiatives aimed at ‘brain gain’ and development for source countries, data and forecasting on future HRH requirements, measures to ‘scale up’ HRH in source countries, and regional and bilateral agreements and partnerships on HRH migration, amongst others.
  • This report argues that integrated and coordinated global responses are needed to address a range of policy issues concerning workforce planning, retention of health workers and mechanisms to ensure that source countries benefit from migration in ways that are proportionate to the benefits gained by destination countries. These are complex, multifaceted issues to address, not least because of the different policy domains under which global health and global migration have evolved, differences in health policy and financing in high‐, medium‐ and low income countries, and unequal economic and social development.Articulating what the ‘right to health’ and the ‘right to migrate’ mean in this context is equally complex.
  • An overriding message from this report is that better are needed systems for: monitoring and capturing HRH requirements and HRH migration flows in source and destination countries; enforcing and monitoring ethical recruitment practices; ensuring that source countries benefit from global financial and technical assistance on HRH across a health system; facilitating reciprocal HRH arrangements and partnerships between source and destination countries; and promoting multistakeholder alliances and partnerships. It raises key questions about how to progress HRH migration policy in the context of global health, shared/global social responsibility, ethical recruitment and rights‐based approaches to migration.



Primafamed Conference Pretoria, South Africa

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Educationists from almost 20 countries, mostly from across Africa, came together in the Primafamed Conference in Pretoria, to deliberate on the development of research in primary care. There will be two days of deliberation to explore how family medicine departments from across Africa may collaborate in strengthening research in primary care in Africa. Poster presentations showed some interesting challenges and some amazing achievements.

Allied Healthcare Workers in the NHI

ImageMs Shehnaz Munshi, occupational therapist and researcher, presented thoughts on the allied healthcare workers in community-oriented primary care, as a model of service under national health insurance. This was at the 17th Family Physicians Congress in Pretoria. She spoke of interprofessional education and service development as a key path to improving the implementation of COPC. Her presentation is here: SANFP_AHP in IPC_Shehnaz Munshi_22-06-14_IPECP_Final. A colleague: Mr Stephen Pentz, also presented on Ethical challenges with CHWs in the PHC Outreach Team. See here:  SANFP_Ethics in PHC_Stephen Pentz_22-06-14

BARAGWANATH: Comfort zones even here

MOST CEOs have the first few months to settle in gradually. But not Sandile Mfenyana, CEO of Chris Hani Baragwanath Academic Hospital, Southern Africa’s largest hospital. The facility has regularly been in the headlines for all the wrong reasons. If it’s not the generators failing to kick in after a power cut, it is patients left unattended or linen and food going missing…..more

Future of Primary Care in South Africa in NHI era

Jannie Hugo

Professor Jannie Hugo spoke in plenary at the 17th National Family Practitioners Conference in Pretoria, South Africa. He used the analogy of a soccer game and emphasised that we move away from just defending ourselves from goals by the enemy of disease but to play an attacking game by empowering our centre-forwards, community health workers, to get out into community and scoring goals of prevention. He stressed community oriented primary care (COPC) as the ideal model for delivery of primary care in the era of national health insurance in South Africa.

Launch of Afriwon SA!


Young family doctors from across South Africa spent a day at the Pre-Conference of the SA Academy of Family Physicians and formed the South African chapter of Afriwon – the organisation of young family doctors in Africa linked to Wonca Africa. There was palpable excitement as representatives of each university were elected to serve in the interim committee to set up the new organisation. Professor Jannie Hugo, Conference Convenor, appealed to young doctors to advocate for better health for the people of South Africa, and not just focus on narrow interests.