A systematic review of participatory approaches to empower health workers in low- and middle-income countries, highlighting Health Workers for Change

Abstract

This systematic review assesses participatory approaches to motivating positive change among health workers in low- and middle-income countries (LMICs). The mistreatment of clients at health centres has been extensively documented, causing stress among clients, health complications and even avoidance of health centres altogether. Health workers, too, face challenges, including medicine shortages, task shifting, inadequate training and a lack of managerial support. Solutions are urgently needed to realise global commitments to quality primary healthcare, country ownership and universal health coverage. This review searched 1243 titles and abstracts, of which 32 were extracted for full text review using a published critical assessment tool. Eight papers were retained for final review, all using a single methodology, ‘Health Workers for Change’ (HWFC). The intervention was adapted to diverse geographical and health settings. Nine indicators from the included studies were assessed, eliciting many common findings and documenting an overall positive impact of the HWFC approach. Health workers acknowledged their negative behaviour towards clients, often as a way of coping with their own unmet needs. In most settings they developed action plans to address these issues. Recommendations are made on mainstreaming HWFC into health systems in LMICs and its potential application to alleviating stress and burnout from COVID-19.

“Not what we signed up for”: Nurse shortages, physician scarcity, and time for collective bargaining?

“…When the business of healthcare depends on exploiting doctors and nurses (Ofri, 2019b; Robbins et al, 2022), as well as indigent patients (Silver‐Greenberg & Thomas, 2022) and nursing home and hospice patients (Kofman, 2022; Rafiei, 2022), when big nonprofit hospitals expand in wealthier areas while retreating from poorer ones (Evans et al, 2022), when charity hospitals exploit safety‐net drug discount programs for major financial windfalls that do not benefit low‐income patients or the clinicians who serve them (Thomas & Schulman, 2020; Welles et al, 2022), when 7 of the 10 most profitable hospitals in the United States (each earning more than $163 million in total patient care) are categorized as “nonprofit” (Bai & Anderson, 2016), when hospitals and health systems facilitate “brain drain” by recruiting nurses from low and middle income countries to try to fill vacant positions and reduce labor costs (Nolen, 2022; Peters et al, 2020), when private equity firms purchase physician practices and pressure “them to maximize income with aggressive billing practices while including non‐disparagement agreements in their contracts that interfere with physicians’ obligations to report problems with the quality of care” (Derse, 2022), and when salary differentials continue to grow to record levels between nonprofit hospital executives and clinicians (Du et al, 2018; Saini et al, 2022), then arguably the time has come for physicians to become activists (Mangione & Tykocinski, 2021), and to at least consider both collective bargaining and joining forces with nurses in a professional alliance.…”