Ackers Louise, Ioannou Elena, Ackers-Johnson James
Allerton Building, School of Nursing, Midwifery, Social Work and Social Sciences, University of Salford, Salford, M6 6PU, UK
Department of Obstetrics & Gynaecology, Homerton Hospital, Homerton Row, London E9 6SR.
Health Policy Plan. 2016 Nov;31(9):1152-61. doi: 10.1093/heapol/czw046. Epub 2016 May 3.
Maternal mortality in low- and middle-income countries continues to remain high. The Ugandan Ministry of Health's Strategic Plan suggests that little, if any, progress has been made in Uganda in terms of improvements in Maternal Health [Millennium Development Goal (MDG) 5] and, more specifically, in reducing maternal mortality. Furthermore, the UNDP report on the MDGs describes Uganda's progress as 'stagnant'. The importance of understanding the impact of delays on maternal and neonatal outcomes in low resource settings has been established for some time. Indeed, the '3-delays' model has exposed the need for holistic multi-disciplinary approaches focused on systems change as much as clinical input. The model exposes the contribution of social factors shaping individual agency and care-seeking behaviour. It also identifies complex access issues which, when combined with the lack of timely and adequate care at referral facilities, contributes to extensive and damaging delays. It would be hard to find a piece of research on this topic that does not reference human resource factors or 'staff shortages' as a key component of this 'puzzle'. Having said that, it is rare indeed to see these human resource factors explored in any detail. In the absence of detailed critique (implicit) 'common sense' presumptions prevail: namely that the economic conditions at national level lead to inadequacies in the supply of suitably qualified health professionals exacerbated by losses to international emigration. Eight years' experience of action-research interventions in Uganda combining a range of methods has lead us to a rather stark conclusion: the single most important factor contributing to delays and associated adverse outcomes for mothers and babies in Uganda is the failure of doctors to be present at work during contracted hours. Failure to acknowledge and respond to this sensitive problem will ultimately undermine all other interventions including professional voluntarism which relies on local 'co-presence' to be effective. Important steps forward could be achieved within the current resource framework, if the political will existed. International NGOs have exacerbated this problem encouraging forms of internal 'brain drain' particularly among doctors. Arguably the system as it is rewards doctors for non-compliance resulting in massive resource inefficiencies.
低收入和中等收入国家的孕产妇死亡率仍然居高不下。乌干达卫生部的战略计划表明，在乌干达，孕产妇健康（千年发展目标5）方面几乎没有取得任何进展，更具体地说，在降低孕产妇死亡率方面也没有进展。此外，联合国开发计划署关于千年发展目标的报告将乌干达的进展描述为“停滞不前”。一段时间以来，人们已经认识到了解资源匮乏地区延误对孕产妇和新生儿结局影响的重要性。事实上，“三个延误”模型揭示了需要采取整体多学科方法，既要关注临床投入，也要注重系统变革。该模型揭示了塑造个人能动性和就医行为的社会因素的作用。它还指出了复杂的就医问题，这些问题与转诊机构缺乏及时、充分的护理相结合，导致了广泛且具有破坏性的延误。很难找到关于这个主题的研究不将人力资源因素或“人员短缺”作为这个“难题”的关键组成部分。话虽如此，但很少看到对这些人力资源因素进行详细探讨。在缺乏详细批评的情况下（隐含地），“常识”假设盛行：即国家层面的经济状况导致合格卫生专业人员供应不足，而国际移民又加剧了这种情况。在乌干达进行了八年结合多种方法的行动研究干预后，我们得出了一个相当严峻的结论：导致乌干达母亲和婴儿出现延误及相关不良结局的最重要单一因素是医生在规定工作时间内未出勤。不承认并应对这个敏感问题最终将破坏所有其他干预措施，包括依赖当地“共同在场”才能有效的专业志愿服务。如果有政治意愿，在当前资源框架内可以取得重要进展。国际非政府组织加剧了这个问题，助长了内部“人才外流”，尤其是在医生中。可以说，现行制度奖励不遵守规定的医生，导致了大量资源效率低下。
