Background. The performance of midlevel health workers is a critical lever for strengthening health systems and redressing inequalities in underserved areas. Auxiliary nurses form the largest cadre of health workers in Guatemala. In rural settings, they provide essential services to vulnerable communities, and thus have great potential to address priority health needs. This paper examines auxiliary nurses’ motivation and satisfaction, and the coping strategies they use to respond to challenges they confront in their practice. Methods. Semistructured interviews were conducted with 14 auxiliary nurses delivering health services in Alta Verapaz, Guatemala. Results. Community connectedness was central to motivation in this rural Guatemalan setting. Participants were from rural communities and conveyed a sense of connection to the people they were serving through shared culture and their own experiences of health needs. Satisfaction was derived through recognition from the community and a sense of valuing their work. Auxiliary nurses described challenges commonly faced in low-resource settings. Findings indicated they were actively confronting these challenges through their own initiative. Conclusions. Strategies to support the performance of midlevel health workers should focus on mechanisms to make training accessible to rural residents, support problem-solving in practice, and emphasize building relationships with communities served. 1. Background Midlevel health workers (MLHWs) are the mainstay of health service delivery in many low income countries. Given their prominent role, supporting the performance of MLHWs is a critical lever for strengthening health systems and redressing health inequalities in underserved areas. MLHWs are defined as health care providers with formal accreditation but shorter training and a more restricted scope of practice than professionals [1]. MLHW cadres share characteristics that make them particularly attractive for initiatives to improve access to care and mitigate health workforce deficits [2, 3]. Lower entry level education requirements make it easier to recruit locals who have potential to provide more culturally and linguistically appropriate care and may be easier to retain in rural placements [4]. Studies indicate that with adequate training and continued support, MLHWs can provide care comparable to professionals [5]. Increasing deployment of MLHWs can also be appealing as a lower cost alternative for improving coverage. Despite their centrality in the health workforce, MLHW cadres tend to have low status and
References
[1]
U. Lehmann, “Mid-level health workers. The state of the evidence on programmes, activities, costs and impact on health outcomes. A literature review,” World Health Organization, Geneva, Switzerland, 2008.
[2]
D. Y. Dovlo, “Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review,” Human Resources for Health, vol. 2, article 7, 2004.
[3]
N. Crisp, B. Gawanas, and I. Sharp, “Training the health workforce: scaling up, saving lives,” The Lancet, vol. 371, no. 9613, pp. 689–691, 2008.
[4]
C. Pereira, Task-shifting of major surgery to midlevel providers of health care in Mozambique and Tanzania a solution to the crisis in human resources to enhance maternal and neonatal survival [Ph.D. thesis], Department of Public Health Sciences, Karolinska Institutet, 2010.
[5]
S. I. Bangdiwala, S. Fonn, O. Okoye, and S. Tollman, “Workforce resources for health in developing countries,” Public Health Reviews, vol. 32, no. 1, pp. 296–318, 2010.
[6]
S. Fonn, S. Ray, and D. Blaauw, “Innovation to improve health care provision and health systems in sub-saharan africa-promoting agency in mid-level workers and district managers,” Global Public Health, vol. 6, no. 6, pp. 657–668, 2011.
[7]
N. Mwita, “The changing role of mid level and community health workers in the health system in Africa,” African Platform on Human Resources for Health, 2010.
[8]
N. G. Songstad, O. B. Rekdal, D. A. Massay, and A. Blystad, “Perceived unfairness in working conditions: the case of public health services in Tanzania,” BMC Health Services Research, vol. 11, article 34, 2011.
[9]
World Health Organization, “The World Health Report 2006: Working Together for Health,” World Health Organization, Geneva, Switzerland, 2006.
[10]
A. K. Rowe, D. de Savigny, C. F. Lanata, and C. G. Victora, “How can we achieve and maintain high-quality performance of health workers in low-resource settings?” The Lancet, vol. 366, no. 9490, pp. 1026–1035, 2005.
[11]
U. Lehmann, M. Dieleman, and T. Martineau, “Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention,” BMC Health Services Research, vol. 8, article 19, 2008.
[12]
I. Mathauer and I. Imhoff, “Health worker motivation in Africa: the role of non-financial incentives and human resource management tools,” Human Resources for Health, vol. 4, article 24, 2006.
[13]
M. Dieleman, P. V. Cuong, L. V. Anh, and T. Martineau, “Identifying factors for job motivation of rural health workers in North Viet Nam,” Human Resources for Health, vol. 1, article 10, 2003.
[14]
M. Dieleman, J. Toonen, H. Touré, and T. Martineau, “The match between motivation and performance management of health sector workers in Mali,” Human Resources for Health, vol. 4, article 2, 2006.
[15]
E. McAuliffe, C. Bowie, O. Manafa et al., “Measuring and managing the work environment of the mid-level provider—the neglected human resource,” Human Resources for Health, vol. 7, article 3, 2009.
[16]
S. Bradley and E. McAuliffe, “Mid-level providers in emergency obstetric and newborn health care: factors affecting their performance and retention within the Malawian health system,” Human Resources for Health, vol. 7, article 14, 2009.
[17]
M. Willis-Shattuck, P. Bidwell, S. Thomas, L. Wyness, D. Blaauw, and P. Ditlopo, “Motivation and retention of health workers in developing countries: a systematic review,” BMC Health Services Research, vol. 8, article 247, 2008.
[18]
M. Lindelow and P. Serneels, “The performance of health workers in Ethiopia: results from qualitative research,” Social Science and Medicine, vol. 62, no. 9, pp. 2225–2235, 2006.
[19]
M. Segall, “From cooperation to competition in national health systems- and back?: impact on professional ethics and quality of care,” The International Journal of Health Planning and Management, vol. 15, pp. 61–79, 2000.
[20]
W. Van Lerberghe, C. Concei？？o, W. Van Damme, and P. Ferrinho, “When staff is underpaid: dealing with the individual coping strategies of health personnel,” Bulletin of the World Health Organization, vol. 80, no. 7, pp. 581–584, 2002.
[21]
K. Gross, C. Pfeiffer, and B. Obrist, “‘Workhood’-a useful concept for the analysis of health workers' resources? an evaluation from Tanzania,” BMC Health Services Research, vol. 12, article 55, 2012.
[22]
A. García-Prado and M. Chawla, “The impact of hospital management reforms on absenteeism in Costa Rica,” Health Policy and Planning, vol. 21, no. 2, pp. 91–100, 2006.
[23]
J. Hermida and M. E. Robalino, “Increasing compliance with maternal and child care quality standards in Ecuador,” International Journal for Quality in Health Care, vol. 14, supplement 1, pp. 25–34, 2002.
[24]
E. C. Svitone, R. Garfield, M. I. Vasconcelos, and V. A. Craveiro, “Primary health care lessons from the Northeast of Brazil: The Agentes de Saude Program,” Revista Panamericana de Salud Pública, vol. 7, no. 5, pp. 293–302, 2000.
[25]
G. Estrada Galindo and K. Slowing Uma？a, “Síntesis?: Sistema de salud en Guatemala?: ？hacia dónde vamos?” UNDP, 2008.
[26]
？ Ministerio de Salud Pública y Asistencia Social, Segeplan, “Encuesta nacional de mortalidad materna,” Guatemala, 2011.
[27]
？ Instituto Nacional de Estadística, “ENCOVI: Encuesta nacional de condiciones de vida,” Guatemala, 2011.
[28]
Organización Panamericana de Salud and Universidad Rafael Landívar, “Estudio: Información sobre recursos humanos de salud en Guatemala,” Ministerio de Salud Pública y Asistencia Social, Guatemala, 2009.
[29]
J. Lewis, L. Spencer, and W. O’Connor, “Carrying out qualitative analysis,” in Qualitative Research Practice: A Guide for Social Science Students and Researchers, J. Ritchie and J. Lewis, Eds., pp. 219–262, Sage, London, UK, 2003.
[30]
R. N. Manongi, T. C. Marchant, and I. C. Bygbjerg, “Improving motivation among primary health care workers in Tanzania: a health worker perspective,” Human Resources for Health, vol. 4, article 6, 2006.
[31]
P. Serneels, J. G. Montalvo, G. Pettersson, T. Lievens, J. D. Buterae, and A. Kidanu, “Who wants to work in a rural health post? the role of intrinsic motivation, rural background and faith-based institutions in Ethiopia and Rwanda,” Bulletin of the World Health Organization, vol. 88, no. 5, pp. 342–349, 2010.
[32]
L. M. Franco, S. Bennett, and R. Kanfer, “Health sector reform and public sector health worker motivation: a conceptual framework,” Social Science and Medicine, vol. 54, no. 8, pp. 1255–1266, 2002.
[33]
S. A. Fritzen, “Strategic management of the health workforce in developing countries: what have we learned?” Human Resources for Health, vol. 5, article 4, 2007.
[34]
H. Razee, M. Whittaker, R. Jayasuriya, L. Yap, and L. Brentnall, “Listening to the rural health workers in Papua New Guinea—the social factors that influence their motivation to work,” Social Science & Medicine, vol. 75, no. 5, pp. 828–835, 2012.
[35]
M. K. Ranson, M. Chopra, S. Atkins, M. R. Dal Poz, and S. Bennett, “Priorities for research into human resources for health in low- and middle-income countries,” Bulletin of the World Health Organization, vol. 88, no. 6, pp. 435–443, 2010.
