Overlooking workplace violence in health workforce planning in sub-Saharan Africa

• Authors: Paulo Ferrinho, Mohsin Sidat, António Pedro Delgado, Eva Pascoal
• Publication Year: 2021
• Journal: International Journal of Health Planning and Management, 37(1), pp 568 - 571
• Link: https://doi.org/10.1002/hpm.3366

LETTER TO THE EDITOR

Workplace violence is defined as ‘incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, wellbeing or health’.¹ Health care workers (HCW) are relatively more exposed and experience more commonly violence and aggressive behaviour within working settings. Workplace violence is a serious problem with diverse negative consequences for the workers as well as for the patients. In fact, workplace violence is associated directly with higher incidence of HCW burnout, lower patient safety, and with greater risk of adverse events.^1–3

In sub-Saharan Africa (SSA), studies on violence against HCW (VHCW) in the workplace have been reported from several countries: Congo,⁴ Ethiopia,^5–7 Gambia,⁸ Ghana,^9–11 Malawi,¹² Mozambique,^13–18 Nigeria,^19–24 Rwanda,²⁵ South Africa.^26–29 These reports demonstrate the endemic dimension of the phenomenon, the negative impact on HCW and services, the high level of tolerance to violence, a lack of mechanisms to report the problem and the absence of policies to deal or adequately respond to violence occurrences in health care settings.

Hence, in June 2021, we conducted a Google search (using country name associated with human resources for health OR health workforce OR health care worker AND planning) for health workforce strategic plans since 2012 in SSA (year when the Ministers of Health in the WHO’s African Region endorsed a ‘Regional Road Map for Scaling Up the Health Workforce’ from 2012 to 2025, then adopted by the sixty-second session of the African Regional Committee, 2013³⁰). Retrieved plans were subsequently subject to a content analysis for key words related to VHCW (violence, harassment, aggression and bullying).

Thirteen of the 14 SSA strategic workforce plans that we could identify, covering the years since 2012 (Angola, Cabo Verde, Chad, Guiné-Bissau, Kenya, Mali, Malawi, Mozambique [2 plans], Namibia, Rwanda, Sierra Leone, Sudan and Zambia) did not refer to VHCW. The exception was South Africa. The South African health workforce strategy 2020–2030 identifies the need to adopt measures such as national legal frameworks and collection of data on obstruction, threats and physical attacks on health workers and calls for the review, update or development of specific occupational health and safety programs for health workers, including on work-related violence and harassment.³¹

The literature supports the argument that VHCW is a significant public health problem, that affects mostly young professionals, mostly nurses. This problem is endemic, although subject to acute surge events of violence under situations of armed conflict and/or public health emergencies.^32–38

Despite this, VHCW remains invisible to the highest levels of policy-making in most SSA countries, as most SSA strategic workforce plans that we could identify, covering the years since 2012 did not refer to this issue, even in countries where the problem has been studied and identified as a major problem.^12, 18, 25 This neglect is not surprising if we consider that, until 2017, the guiding text for health workforce strategic development in Africa (‘Regional Road Map for Scaling Up the Health Workforce’ from 2012 to 2025), did not identify or address the problem.³⁰ According to Afriyie et al. (2019) the Road Map had a significant impact on the development of national strategic plans and all countries complied with the outlined guidelines. All plans prioritised improving utilisation, retention and performance of the available health workers and addressing the working conditions and remuneration of health workers was also included in the strategies. However, these plans were not explicit enough as to how the working conditions improvements would be achieved.³⁹

The exception is South Africa. The South African health workforce strategy 2020–2030 identifies the need to adopt measures such as national legal frameworks and collection of data on obstruction, threats and physical attacks on health workers and calls for the review, update and development of specific occupational health and safety programs for health workers, including on work-related violence and harassment.³¹ It is noticeable the influence of a rights-based approach to health workforce planning⁴⁰ and of a new framework, the ‘The African Regional Framework for the Implementation of the Global Strategy on Human Resources for Health: Workforce 2030’.⁴¹

Adopted in 2017, during the sixty-seventh session of WHO’s African Regional Committee, this Framework, calls on countries to ‘uphold the personal, employment and professional rights of all health workers, including safe and decent working environments’ and ‘freedom from all kinds of discrimination, coercion and violence’ and to ‘eliminate gender-based violence, discrimination and harassment’.⁴¹

The evidence-to policy feedback loop has not been effective in relation to VHCW in most of SSA. Effective evidence-to policy feedback loops are an essential feature of resilient health systems, with a potential for major improvements in the coming decade.⁴² Specific opportunities stem from the adoption and implementation of the National Health Workforce Accounts, a tool to improve the quality of data and exchange of information with regard to attacks and VHCW, in order to strengthen national health systems’ policy developments.⁴³ Further, academic institutions, professional associations and civil society must adopt an advocacy, communications and accountability role in bridging the evidence-to-policy gap with regard to VHCW.⁴²

The findings of the study are supportive for the development of appropriate policy and strategies on workplace VHCW. They also highlight the power of WHO’s recommended frameworks and reflect a greater sensitivity to a rights-based approach to health workforce planning.