Academic journal article Bulletin of the World Health Organization

Increasing Access to Health Workers in Underserved Areas: A Conceptual Framework for Measuring Results/ Ameliorer L'acces Au Personnel De Sante Dans Les Zones Mal Desservies : Cadre Conceptuel Pour la Mesure Des Resultats/ Ampliar El Acceso a Los Trabajadores Sanitarios En Las Zonas Subatendidas: Marco Conceptual Para Medir Los Resultados

Academic journal article Bulletin of the World Health Organization

Increasing Access to Health Workers in Underserved Areas: A Conceptual Framework for Measuring Results/ Ameliorer L'acces Au Personnel De Sante Dans Les Zones Mal Desservies : Cadre Conceptuel Pour la Mesure Des Resultats/ Ampliar El Acceso a Los Trabajadores Sanitarios En Las Zonas Subatendidas: Marco Conceptual Para Medir Los Resultados

Article excerpt

Introduction

Health workers' willingness to practise in underserved areas, "such as rural, remote or poor areas, is a recognized challenge in achieving equitable access to health services. Many countries have developed strategies to attract and retain qualified health workers in these areas. But the evidence on the successes or failures of such interventions is scarce and weak, and it is difficult to compare lessons and measure results from the few evaluations that are available. (1-3)

There has been significant progress in generating common understanding and debate on ways to evaluate the impact of development interventions, and on using consistent monitoring and evaluation terminology, such as "outputs", "outcomes" and "impact". (4-6) However, this has yet to be applied to the evaluation of human resources for health interventions and, specifically, to those seeking to increase access to health workers in underserved areas. There is an urgent need to achieve an agreement and strengthen the evidence that would underpin sound policy recommendations in this area.

Seeking to address this gap, this paper proposes a conceptual framework to guide managers, policy-makers and evaluators in the assessment of interventions to increase access to health workers in underserved areas. The framework aims to support all stages of policy development. It suggests a logical sequence that can be followed when deciding on any intervention that addresses attraction and retention issues and assists in formulating key questions to be answered when designing, monitoring and evaluating such interventions. It includes examples of indicators to inform the process, which can be adapted to a specific context. A comprehensive consideration of indicators to monitor the health workforce in general is offered elsewhere. (7)

Challenges in evaluation

Policy- and decision-makers need to know whether interventions work or not, why they work and in which context. Therefore it is important to have information about the effects of the interventions, but also about the factors that made the intervention succeed or fail (the questions dealing with "when, why, how, and in what circumstances such interventions work well or fail to work"). (8)

Evaluating interventions to improve human resources for health is complex for different reasons. First, relating these interventions to health status is very difficult due to broad socioeconomic, cultural, political and health systems factors that influence health. For instance, although improved health outcomes, such as reduction in maternal mortality, are directly correlated with increased availability of health workers, it is difficult to attribute the improvement directly to a certain health workforce intervention. (9,10) Illustrative country case studies showed that Afghanistan and Ethiopia have implemented comprehensive health sector strategies with multiple co-existing interventions, like the recruitment of community health workers, which may have promoted access to life-saving services, thus improving health status. (11)

Another problem is that many evaluations lack a baseline against which to assess the results, particularly in countries with a major health worker deficit, (3,10,12) as well as a specific intervention logic that clarifies the expectations of the intervention designers (S Kane, B Gerretsen, R Scherpbier, M Dal Poz, MA Dieleman, unpublished data, 2009). (13) Moreover, the social, political and economic context in which interventions are designed and implemented is rarely considered in monitoring and evaluation of human resource interventions. (14,15)

Thus, the main challenges which evaluators face are related to the multidimensional nature of interventions, and the difficulty of assessing the influence of contextual factors. To be able to assess such interventions in complex systems, there is a need for multimethod and multidisciplinary monitoring and evaluation approaches, inclusive of all relevant stakeholders. …

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