<p>In 2007, at its 52nd Conference in Polokwane, the African National Congress (ANC) called for the implementation of a National Health Insurance (NHI) scheme. The announcement resulted in much debate, with critics voicing concerns about the state of the public health system, lack of consultation and the expense of a NHI scheme. However, little attention has been paid to the&nbsp / human resource (HR) needs, despite the fact that 57% of recurrent expenditure on health1 is on HR. This research aimed to identify the HR requirements to support the implementation of an effective and equitable health system funded by a NHI in South Africa. An overview of the current burden of disease and distribution of HR is provided. Through interviewing key stakeholders the study attempted to elicit information about factors which will hamper or assist in developing such a health system, specifically looking at the HR situation and needs. The research explores HR&nbsp / odels and proposes key HR requirements for implementation of a health system funded by a NHI in South Africa, including skills mix and projected numbers of health workers and&nbsp / proposes ways to improve the deficient HR situation. Exploratory qualitative research methods were used comprising in-depth individual interviews, with a purposive sample of key informants, including: public health professionals and health managers (working in rural and urban areas) / researchers / academics and NGO managers. The contents of the interviews were analysed to identify common responses about and suggestions for HR requirements within the framework of a NHI. 1 Personal communication Dr Mark Blecher, Director Social Services (Health), National Treasury, 17 July 2009 The literature review includes policy documents, position papers and articles from journals and bulletins. Key informants were asked to identify literature and research material to support recommendations. The research findings indicate that despite the South African Government&rsquo / s expressed commitment to Primary Health Care (PHC), the National Department of Health has continued to support and sustain a clinical model of health service delivery (Motsoaledi, 2010), primarily utilising doctors and nurses. The clinic based services are limited in their ability to reach community level, and, being focused on curative aspects, are often inadequate with regard to prevention, health promotion and rehabilitation services. While the curricula of health professionals have been through some changes, the training has continued to be curative in focus and the clinical training sites have not been significantly expanded to include peripheral sites. While there are many Community Health Workers in the country, they remain disorganised and peripheral to the public health system. The mid level worker category&nbsp / has not been fully explored. Finally there are no clear strategies for recruitment and retention of health workers in rural and under-resourced areas. In addition to the continued use of a clinical model, transformation of the health system hasbeen hampered by inadequate numbers of health workers, particularly in the rural and periurban townships and informal settlements. There is no clear strategy for addressing the critical&nbsp / health worker shortage in under-resourced areas, particularly rural areas. The last section makes recommendations, which will be submitted to the relevant task teams working on the NHI. It is intended that recommendations arising out of the research will influence the process and decisions about HRH within a NHI funded health system.</p>

Magister Public Health - MPH / In 2007, at its 52nd Conference in Polokwane, the African National Congress (ANC) called for the implementation of a National Health Insurance (NHI) scheme. The announcement resulted in much debate, with critics voicing concerns about the state of the public health system, lack of consultation and the expense of a NHI scheme. However, little attention has been paid to the human resource (HR) needs, despite the fact that 57% of recurrent expenditure on health1 is on HR. This research aimed to identify the HR requirements to support the implementation of an effective and equitable health system funded by a NHI in South Africa. An overview of the current burden of disease and distribution of HR is provided. Through interviewing key stakeholders the study attempted to elicit information about factors which will hamper or assist in developing such a health system, specifically looking at the HR situation and needs. The research explores HR odels and proposes key HR requirements for implementation of a health system funded by a NHI in South Africa, including skills mix and projected numbers of health workers and proposes ways to improve the deficient HR situation. Exploratory qualitative research methods were used comprising in-depth individual interviews, with a purposive sample of key informants, including: public health professionals and health managers (working in rural and urban areas); researchers; academics and NGO managers. The contents of the interviews were analysed to identify common responses about and suggestions for HR requirements within the framework of a NHI. 1 Personal communication Dr Mark Blecher, Director Social Services (Health), National Treasury, 17 July 2009 The literature review includes policy documents, position papers and articles from journals and bulletins. Key informants were asked to identify literature and research material to support recommendations. The research findings indicate that despite the South African Government’s expressed commitment to Primary Health Care (PHC), the National Department of Health has continued to support and sustain a clinical model of health service delivery (Motsoaledi, 2010), primarily utilising doctors and nurses. The clinic based services are limited in their ability to reach community level, and, being focused on curative aspects, are often inadequate with regard to prevention, health promotion and rehabilitation services. While the curricula of health professionals have been through some changes, the training has continued to be curative in focus and the clinical training sites have not been significantly expanded to include peripheral sites. While there are many Community Health Workers in the country, they remain disorganised and peripheral to the public health system. The mid level worker category has not been fully explored. Finally there are no clear strategies for recruitment and retention of health workers in rural and under-resourced areas. In addition to the continued use of a clinical model, transformation of the health system hasbeen hampered by inadequate numbers of health workers, particularly in the rural and periurban townships and informal settlements. There is no clear strategy for addressing the critical health worker shortage in under-resourced areas, particularly rural areas. The last section makes recommendations, which will be submitted to the relevant task teams working on the NHI. It is intended that recommendations arising out of the research will influence the process and decisions about HRH within a NHI funded health system. / South Africa

Bakgrund: Etiken inom vården går mot en personcentrering där varje patient ska ses som en unik person med resurser och behov. Samtidigt saknas det vårdpersonal. För att möta rekryteringsbehovet som finns har förändringar varit nödvändiga. Förändringar av kompetensmixen kan medföra att vården blir fragmenterad och helhetsbilden över patienten går förlorad. Det finns en kunskapslucka angående personcentrerad vård på vårdavdelningar som genomfört kompetens-mix.Syfte: Syftet var att belysa sjuksköterskors erfarenheter av personcentrerad vård på medicinska vårdavdelningar som genomfört kompetensmix.Metod: En kvalitativ metod med datainsamling genom tolv enskilda semistrukturerade intervjuer användes. Materialet analyserades med en induktiv ansats. En innehållsanalys av det manifesta innehållet genomfördes.Resultat: Analysen resulterade i tre huvudkategorier “Att etablera relationer”, “Att utforma vården i partnerskap” och “Att vårdkontexten påverkar” och tio underkategorier. Relationen mellan patient och sjuksköterska sågs som viktig för att kunna anpassa vården efter person. Flera utmaningar för personcentrerad vård lyftes där det framkom att såväl organisationen som vårdpersonal behöver skapa förutsättningar för att möjliggöra personcentrerad vård.Slutsats: Det upplevs positivt att bli avlastad av farmaceut och servicepersonal men sjuksköterskorna har helhetsansvaret över patienterna och har erfarenheter av att det främst är antalet patienter per sjuksköterska som behöver minska för att möjliggöra personcentrerad vård. / Background: Ethics in healthcare is moving towards a person-centred approach where each patient is to be seen as a unique person with resources and needs. At the same time, there is a lack of nursing staff. In order to meet the recruitment needs, changes have been necessary. Changes to the skill mix can mean that care becomes fragmented, and the overall picture of the patient is lost. There is a knowledge gap regarding person-centred care in medical wards that have imple-mented skill mix.Aim: The aim was to illustrate nurses' experiences of person-centred care in medical wards that have implemented skill mix.Methods: A qualitative method with data collection through twelve individual semistructured interviews was used. The material was analyzed with an inductive approach. A content analysis of the manifest content was carried out.Results: The analysis resulted in three main categories "To establish a relationship", "To design care in partnership" and "That the care context has influence" and ten subcategories. The relationship between patient and nurse was seen as important in being able to adapt care to the individual. Several challenges for person-centred care were raised, where it emerged that both the organization and health care professionals  need to create conditions to enable person-centred care.Conclusion: It is perceived positively to be relieved by the pharmacist and service staff, but the nurses have overall responsibility for the patients and have experience that it is mainly the number of patients per nurse that needs to be reduced to enable person-centred care.

Hållbar kompetensförsörjning är en av välfärdssamhällets största utmaningar, där offentlig sektor idag visar betydande problem. Två huvudprinciper ses kring hantering av dessa utmaningar. Den vanligaste utgångspunkten är att så långt som möjligt upprätthålla verksamheten genom att behålla samma organisation och arbetssätt, samt att söka behålla och helst öka antalet medarbetare i olika bristyrken. En annan utgångspunkt som får ökad uppmärksamhet är uppgiftsväxling (taskshifting, workshifting, kompetensmix), vilket innebär förändrad kompetens- och bemanningsstruktur. Samverkan mellan Vårdförbundet och sjukvårdens arbetsgivare kan vara en förutsättning för ständig förbättring och kompetensförsörjning i framtiden. Medan avståndet mellan behov och resurser ökar under Covid-19-pandemin, verkar samarbetsklimatet påverkas negativt i samma takt. Istället för akuta avlastande åtgärder som uppgiftsväxling så föreslår Vårdförbundet långsiktiga åtgärder som höjd yrkesstatus och lön. Som betydelsefull samverkanspartner till sjukvården är Vårdförbundets syn på uppgiftsväxling avgörande för framtida samarbete kring förbättringar och kompetensförsörjning. Studiens syfte är att undersöka hur fackliga ledare, här representerade av Vårdförbundets 21 lokala avdelningsordförande, ser på uppgiftsväxling kring specialistsjuksköterskor som en del i hållbar kompetensförsörjning inom intensivvården. Studien har en kvantitativ och en kvalitativ ansats med datainsamling via webbenkät. Studiens urval är samtliga avdelningsordförande (n=21) inom Vårdförbundets lokalorganisationer. Kvantitativa data analyserades med fördelning och frekvens och visas med deskriptiv statistik. Kvalitativa data analyserades med innehållsanalys. Svarsfrekvensen var 66 procent. Specialistsjuksköterskor inom intensivvård bör avlastas genom att anställa andra yrkesgrupper, anser majoriteten av deltagarna. Sjuksköterskor, farmaceuter, vårdnära administratörer och fysioterapeuter anges i störst utsträckning. Deltagare ser dock risker vid brister i implementeringen, där störst risk för patienten anses vara att arbetsgivare ålägger sjuksköterskor för stort ansvar. Implementering med noggrann konsekvensanalys och tillräckliga resurser ses som framgångsfaktorer. Negativa konsekvenser som anges är bristande helhetsbild för specialistsjuksköterskorna, liksom oklarheter kring sjuksköterskornas roll. Uppgiftsväxlingen ses som en karriärväg för sjuksköterskor, medan specialistsjuksköterskor kan använda sin specialistkompetens i ökad utsträckning. Ledningens roll nämns i liten grad. Vårdförbundet kan som samverkanspartner vara den externa kraft som krävs i sjukvården för att nå en hållbar lösning för kompetensförsörjning, arbetsmiljö och kvalitet. För god vård krävs sannolikt ökad samverkan i förbättringsarbete mellan arbetsgivare och Vårdförbundet. Studien visar att många lokala fackliga ledare förordar uppgiftsväxling, exempelvis att avlasta specialistsjuksköterskor genom att anställa andra yrkesgrupper inom intensivvården. En förutsättning för en framgångsrik förbättringsprocess är dock att samtliga aktörer är beredda att kompromissa med grundläggande principer och arbetssätt inom den egna organisationen. / Sustainable competence provision is a major challenge in the welfare state, with growing public sector demands to be met by limited resources. In handling this situation two main principles can be identified. Most organizations primarily chose to leave the organization and staffing structure unaltered, awaiting adequate workforce reinforcements. Task shifting (work shifting, task sharing) is getting increased attention in these parts. Cooperation between the nursing union (Vårdförbundet) and the healthcare employers is crucial for continuous improvement and competence provision in the future. However, as the gap between patient demands and available human resources is turning from bad to worse during the ongoing Covid-19 pandemic, the climate for cooperation seems to be affected in the same way. Vårdförbundet suggests long-term solutions such as increased salaries. As a pivotal health care partner Vårdförbundet and its view on task shifting is determining the success of forthcoming cooperation. The objective of this study is to investigate the view of nursing union leaders, represented by the 21 local section board presidents of Vårdförbundet, on task shifting concerning critical care nursing specialists, as a sustainable competence provision. The study has a quantitative and qualitative approach with data collection through a web survey. The study selection included the Vårdförbundet union board presidents at the local level. Quantitative data was analyzed using distribution and frequency displayed by descriptive statistics. Qualitative data was analyzed through content analysis. The response rate was 66 percent. Critical care nursing specialists (CCRN) should be relieved certain duties by staff with other professions, according to a most of the participants. Mentioned most frequently were non-specialized registered nurses (RN), pharmacists, administrators and physiotherapists. The participants anticipated hazards concerning inadequate implementation routines, particularly concerning RN getting too much responsibility to handle, being non-specialized nurses. Implementation including consequence analysis is seen as a crucial prerequisite along with sufficient resources. Negative consequences mentioned are difficulties getting the whole picture as the CCRN assume responsibility for extra critical care patients. Also mentioned are blurred responsibilities for the RN. The result reveals positive consequences of task shifting such as being an important career path for RN, whilst CCRN can use their specialist skills to an increased extent. The managerial role is faint in this study. Vårdförbundet is possibly the external power needed to reach a sustainable solution regarding competence provision, work environment and healthcare quality. Expanded improvement cooperation, between healthcare employers and unions, can be a tool to reach and maintain top quality healthcare. This study reveals that most of the local leaders in Vårdförbundet supports task shifting, as a tool using other professions to relieve the CCRN from non-specialist duties. A prerequisite is however that all actors are prepared to compromise organizational and professional principles to reach common ground and successful improvement.

Dans le cadre d’une stratégie nationale visant les objectifs du Millénaire pour le développement 4 et 5 au Maroc - réduire la mortalité maternelle et infantile -, un plan d’action a été développé au sein des trois systèmes (socioculturel, éducationnel, disciplinaire) dans lesquels évolue un rôle professionnel de la santé et ce, pour renforcer le rôle professionnel de la sage-femme. La présente thèse vise à évaluer le niveau d’implantation du plan d’action et à comprendre les facteurs contextuels ayant affecté son implantation et susceptibles d’empêcher l’atteinte de ses effets. Le cadre conceptuel adopté dérive du modèle de Hatem-Asmar (1997) concernant l’interaction entre les systèmes éducationnel, disciplinaire et socioculturel pour changer un rôle professionnel de la santé; et le cadre de Damschroder et al. (2009) pour l’analyse de l’implantation d’une intervention en santé. Le devis est une étude de cas unique à trois niveaux d’analyse. Les données sont recueillies à partir de multiples sources de données : 11 entrevues individuelles semi-structurées, 20 groupes de discussion, observations d’activités de formation, analyse de documents. Les résultats ont montré des déficits notables au niveau de l’implantation. Seize barrières et sept facilitateurs ont été catégorisés sous les construits du cadre de Damschroder et al. (2009) et sous les dimensions des trois systèmes. Un alignement inadéquat entre les dimensions (valeurs, méthodes, acteurs et finalités) du système socioculturel et celles (valeurs, méthodes, acteurs) des systèmes éducationnel et disciplinaire d’une part, avec le plan d’action d’autre part empêche son implantation globale. La structure bureaucratique et le manque de préparation du système socioculturel ont constitué les barrières les plus influentes sur: la diffusion de l’information; l’implication des acteurs du terrain dans le processus; et l’état de préparation du système éducationnel. Les principaux facilitateurs étaient : les valeurs promues à l’égard des droits humains et le mouvement politique pour renforcer le rôle professionnel de la sage-femme et réduire la mortalité maternelle. Quant au plan, il a été perçu comme étant bénéfique mais complexe et émanant d’une source externe. Les résultats mettent l’accent sur la nécessité de contourner les barrières identifiées dans les trois systèmes afin d’obtenir des contextes propices à la production des effets. Par ailleurs, les résultats ont soulevé aussi sept barrières qui risquent de compromettre l’atteinte des effets désirés. Elles concernent: le cadre légal, les représentations sociales et le support médiatique au niveau du système socioculturel; le réseautage et les mécanismes de communication, les caractéristiques liées au rôle, à l’environnement de pratique, et le niveau de préparation du système disciplinaire. Notre recherche confirme qu’un changement visant le système éducationnel isolément représente une vision réductrice pour le renforcement du rôle des sages-femmes. Une combinaison des conditions contextuelles favorables au niveau des dimensions des trois systèmes est requise pour atteindre le but de la stratégie gouvernementale, soit fournir des sages-femmes qualifiées selon les normes globales de la Confédération Internationale des sages-femmes, capables d’offrir des soins de qualité en santé de la reproduction qui permettront de contribuer à réduire la mortalité maternelle et néonatale. / As part of a national strategy for reaching the Millennium Development Goals 4 and 5 in Morocco – to reduce maternal and infant mortality - an action plan covering the three systems (socio-cultural, educational, disciplinary) in which evolves a health professional role was developed in order to strengthen the midwifery professional role. This thesis aims to assess the level of implementation of the action plan and to understand the contextual factors affecting its implementation and that may prevent reaching the targeted outcomes. We used a conceptual framework that builds on Hatem-Asmar’s model regarding the interaction between the socio-cultural, educational and disciplinary systems to change a health professional role; and on the Consolidated Framework for Implementation Research (CFIR) for the implementation analysis of a health intervention. A single case study design with three levels of analysis was chosen for this thesis. The data were collected through multiple data sources: 11 individual semi-structured interviews, 20 focus groups, observations of training activities, analysis of documents. The results showed a significant deficit in the implementation. Sixteen barriers and seven facilitators encountered during the implementation were categorized into the four system’s dimensions. Misalignment between the dimensions (values, methods, actors and targets) of the socio-cultural system and those (values, methods, actors) of the educational and disciplinary systems on the one hand, and with the action plan on the other hand, prevent its global implementation. The bureaucratic structure and lack of readiness of the socio-cultural system were among the most influential barriers on: diffusion of information; involvement of key actors in the process, readiness of the educational system. The main facilitators were the values promoted with respect to human rights, and the political movement to strengthen midwives’ professional role and to reduce maternal mortality. The plan was perceived as beneficial but complex and externally driven. The results emphasize the need to overcome the barriers identified in the three systems in order to obtain contextual conditions favorable to achieve outcomes. In addition, seven barriers were identified in the analysis that may compromise the achievement of the targeted outcomes. They relate to the: legal framework, social representations and media support at the socio-cultural system; and the practice environment, networks and communication mechanisms, characteristics related to the role and the readiness of the disciplinary system. Our research confirms that conducting a change in the educational system represents a partially focused view for strengthening the midwives’ role. A combination of favorable contextual conditions at the dimensions of the three systems is required to achieve the goal of the government's strategy which is to provide qualified midwives according to the International Confederation of Midwives global standards for midwifery, able to provide quality reproductive health care, and to contribute to reducing maternal and neonatal mortality.

Midwifery is the backbone of women and child healthcare. The shortage of staff in maternity units is a crisis faced by many countries worldwide, including South Africa. This study aims to investigate and explore the perceptions of midwives on the shortage and retention of staff in a public institution. An explorative, descriptive generic qualitative design method was followed. Non-probability, purposive sampling technique was used. The study was conducted at one tertiary hospital in the district of Tshwane, Gauteng Province. A total of 11 midwives were interviewed. Thematic coding analysis was followed in analysing data. Midwives are passionate about their job, despite the hurdles related to their day-to-day work environment. They are demoralised by a chronic shortage of staff, and feel overworked. Staff involvement in decision-making processes is a motivational factor for midwives to stay in the profession. / Health Studies / M.A. (Public Health)