BackgroundResearch on practical and effective governance of the health workforce is limited. This paper examines health system strengthening as it occurs in the intersection between the health workforce and governance by presenting a framework to examine health workforce issues related to eight governance principles: strategic vision, accountability, transparency, information, efficiency, equity/fairness, responsiveness and citizen voice and participation.MethodsThis study builds off of a literature review that informed the development of a framework that describes linkages and assigns indicators between governance and the health workforce. A qualitative analysis of Health System Assessment (HSA) data, a rapid indicator-based methodology that determines the key strengths and weaknesses of a health system using a set of internationally recognized indicators, was completed to determine how 20 low- and middle-income countries are operationalizing health governance to improve health workforce performance.Results/discussionThe 20 countries assessed showed mixed progress in implementing the eight governance principles. Strengths highlighted include increasing the transparency of financial flows from sources to providers by implementing and institutionalizing the National Health Accounts methodology; increasing responsiveness to population health needs by training new cadres of health workers to address shortages and deliver care to remote and rural populations; having structures in place to register and provide licensure to medical professionals upon entry into the public sector; and implementing pilot programs that apply financial and non-financial incentives as a means to increase efficiency. Common weaknesses emerging in the HSAs include difficulties with developing, implementing and evaluating health workforce policies that outline a strategic vision for the health workforce; implementing continuous licensure and regulation systems to hold health workers accountable after they enter the workforce; and making use of health information systems to acquire data from providers and deliver it to policymakers.ConclusionsThe breadth of challenges facing the health workforce requires strengthening health governance as well as human resource systems in order to effect change in the health system. Further research into the effectiveness of specific interventions that enhance the link between the health workforce and governance are warranted to determine approaches to strengthening the health system.

Formalized task shifting structures have been used to rapidly scale up antiretroviral service delivery to underserved populations in several countries, and may be a promising mechanism for accomplishing universal health coverage. However, studies evaluating the quality of service delivery through task shifting have largely ignored the patient perspective, focusing on health outcomes and acceptability to health care providers and regulatory bodies, despite studies worldwide that have shown the significance of patient satisfaction as an indicator of quality. This study aimed to measure patient satisfaction with task shifting of antiretroviral services in hospitals and health centres in four regions of Ethiopia. This cross-sectional study used data collected from a time–motion study of patient services paired with 665 patient exit interviews in a stratified random sample of antiretroviral therapy clinics in 21 hospitals and 40 health centres in 2012. Data were analyzed using f-tests across provider types, and multivariate logistic regression to identify determinants of patient satisfaction. Most (528 of 665) patients were satisfied or somewhat satisfied with the services received, but patients who received services from nurses and health officers were significantly more likely to report satisfaction than those who received services from doctors [odds ratio (OR) 0.26, P < 0.01]. Investments in the health facility were associated with higher satisfaction (OR 1.07, P < 0.01), while costs to patients of over 120 birr were associated with lower satisfaction (OR 0.14, P < 0.05). This study showed high levels of patient satisfaction with task shifting in Ethiopia. The evidence generated by this study complements previous biomedical and health care provider/regulatory acceptability studies to support the inclusion of task shifting as a mechanism for scaling-up health services to achieve universal health coverage, particularly for underserved areas facing severe health worker shortages.

Due to their shared history under the Soviet Union and similar health systems, countries in the Central Asia Region offer an important opportunity for the analysis of health system reforms. Building on extensive documentation of health reforms in the region, this article draws on information from a key informant virtual focus group and uses a systematic health systems framework to compare the national health reforms that Kazakhstan, the Kyrgyz Republic, Tajikistan, Turkmenistan, and Uzbekistan implemented. This comparison across the five countries captures variations in their approaches to health system reform. In alignment with health needs shared by the five nations, most country reforms and external investments focused on strengthening primary care, benefit packages, and institutional capacity. The comparison shows that of the five countries, the Kyrgyz Republic underwent the broadest, most sustained, and most successful health sector reform in the region. Though the Kyrgyz Republic enacted many reforms that were similar to those in the other countries, it was unique in implementing a comprehensive set of health financing reforms. This article also provides lessons based on external investment made by the donor community in this region's health reforms. Three implementation factors are identified as critical to making the external investment in the Central Asia region effective: sustained and coordinated external support; early and frequent investment in national ownership; and utilization of a sequenced, pragmatic approach. Based on analysis of the shared experiences of these countries and their supporters, the article offers lessons for other countries undertaking health reform.

The present study attempts to estimate cost differences associated with anti-retroviral therapy (ART) task shifting in a limited resource setting in Ethiopia, and to analyze the determinant factors for length and cost of a visit. A stratified random sample of health facilities was surveyed. An ordinary least square (OLS) regression model was employed. The average time spent by patients in ART services was estimated to be 8.5 minutes (Range: 1 to 60 minutes). The OLS model estimated that the median cost per visit for doctors was 15% higher than for the nurses, when controlling for type of facility and type of visit. We found that ART services were less costly when delivered by nurses and health officers, compared with doctors. Since task-shifting to less specialized health-care workers yields additional economic benefits, the expansion of ART task-shifting should be considered by healthcare policy makers and stakeholders in a limited resource settings.