Research consultancy

WORKING CONDITIONS AND RETENTION OF HEALTH WORKERS IN

KABALE REGIONAL REFERRAL HOSPITAL

CHAPTER ONE

INTRODUCTION

1.0 Introduction

Currently Africa has about one doctor for every 5000 people, World Health Organization (2019) indicates that it has been increasingly difficult for the African continent to retain medical professionals on the continent. Most African Health workers leave Africa to go to Europe or United states in search of greener pastures since high income countries pay more than lower income countries. For example on average, surgeons in New Jersey earn $216,000 annually, while their counterparts in Zambia make $24,000. Kenyan doctors earn on average $6,000 per annum (Van Damme et al., 2019). The number of African-educated physicians who graduated from medical schools in Sub-Saharan countries was 2014 in 2005 and 8150 in 2015 (304.6% increase)

This chapter presents background of the study, the problem statement, purpose, objectives of the study, research questions, study scope, justification of the study, significance, Hypotheses, conceptual framework, as well as operational definition of key terms and concepts.

1.1  Background

The section presents, historical background, theoretical, contextual and conceptual background.

1.1.1 Historical Background

Throughout history the Health care workers in most parts of the developing world specifically Sub-Saharan Africa and most parts of Asia have been working under very poor working conditions with poor tools, lack of proper accommodation, poor salaries and overwhelming number of patients (Senkevich et l., 2019), These poor working conditions have made it difficult for many Health workers in these countries to deliver quality health care services needed by the population.  The poor working conditions have negative consequences on health care workforce and delivery of quality health care services. as such, developing countries have the lowest number of Health workers. In Peru for example, a fragmented health system, economical problems, geographic, and social problems due accessibility; deficiencies in infrastructure, lack of equipment and working conditions, has fuelled the level of grievances among Health workers in the country (Daniels, 2019).

Although the health workforce crisis affects virtually all countries worldwide including the high-income countries, sub-Saharan Africa and parts of Asia are most affected, as these regions have the lowest health worker densities when compared globally and are also strongly affected by poor attraction and retention as well as high attrition of health professionals (Kabbash et al., 2021).

African countries are confronted with the growing problem of the mass exodus of health professionals to the more developed countries, It occurs within and across national boundaries. The expression ‘brain drain’ refers to a situation where skilled persons move across national boundaries. Even though the phenomenon is not new to the continent, there is concern over the acceleration of the problem, Owing to a wide range of economic and political factors, health professionals have been leaving for destinations within the region and abroad. The advent of more efficient electronic communication networks since the 1990s has made the movement of health professionals much easier than before, as potential migrants are better informed of opportunities in other countries (Daniels et al., 2019).These problems are exacerbated in rural and remote areas, as health workers tend to stay in or migrate to the urban centres, leaving the countryside in short supply and consequently with insufficient health service coverage (Dal Poz, 2018).

In most parts of sub-Saharan African from the early 1990s policies, strategies and plans, acknowledge that African countries are facing a challenge in retaining Health professional in the continent as most professionals prefer to migrate to high income countries as a result, this has brought about imbalance in the global health workers creating inadequacy in African continent as indicated by WHO, 2019). Since the 1900s Africa, has been having the lowest heath specialists despite having the highest global disease burden. This indicated poor retention capabilities of the Health workers on the continent with many complaint of poor remuneration and lack of proper housing for the Health workers (WHO, 2016).

Ever since the colonial time the poor quality of healthcare in sub-Saharan Africa is related, in large part, to its poor retention of the health workers, and most scholars believe that in the colonial era, medical professional in sub-Saharan had more privileges in terms of accommodation than in the successive times. This region lacks an adequate number of Doctors, Nurses, Midwives, Allied Health Professionals and community healthcare workers. This deficit of human resources for healthcare has characterized sub-Saharan Africa throughout history. It persists in the present day because of factors such as a lack of medical graduates, outbreaks of diseases and infections, and the emigration of healthcare workers. The shortage of healthcare workers affects ‘almost every facet of public health in sub-Saharan Africa, including child and adult mortality, the quality of maternal healthcare and the treatment of human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) (Daniels et al., 2019).

Historically many parts of the world who struggle in retention of health professionals are known to also lack proper facilities for the Health workforce, some of these areas with poor facilities for health workforce is mainly  Africa , latin America and some parts of Asia, there has been  deficit of approximately 4.3 million workers, including doctors, nurses and midwives, in the global healthcare workforce, the large gap is mainly in sub-Saharan Africa and ever since the colonial times sub-Saharan African region carries nearly 24% of the world’s disease burden while containing only 3% of its healthcare workforce and only 1% of its financial resources for healthcare (Draiko et al., , 2019).

Throughout history and in the modern day, healthcare workers have been emigrating from lower-income countries in sub-Saharan African to higher-income countries within North America and Europe. This pattern of emigration has decimated the medical workforce in several areas. For instance, 70% and 75% of the physicians originally from Angola and Mozambique, respectively, are currently practicing abroad. In total, approximately 65,000 doctors and 70,000 nurses from sub-Saharan Africa, which is equal to approximately 28% of the region’s medical workforce, are working internationally. The outward flow of healthcare workers from sub-Saharan Africa is related to several push and pull factors. The push factors identified by emigrant healthcare workers include low salaries, poor working environments, underfunded healthcare facilities and the lack of opportunities for career advancement. Furthermore, there is a strong correlation between political instability in a country and its loss of medical personnel. The pull factors for emigration include higher salaries, better healthcare facilities and more opportunities for career advancement. To limit the emigration of healthcare workers from sub-Saharan Africa, it is necessary to minimize the influence of both the push and pull factors.

1.1.2 Theoretical Background

This study used expectancy theory, goal setting theory and work adjustment theory.

1.1.2.1 Expectancy Theory

The most widely accepted explanations of motivation have been propounded by Victor Vroom. His theory is commonly known as expectancy theory. The theory argues that the strength of a tendency to act in a specific way depends on the strength of an expectation that the act will be followed by a given outcome and on the attractiveness of that outcome to the individual to make this simple. Expectancy theory says that an employee can be motivated to stay in a specific job and place when there is a belief that the better performance will lead to good performance appraisal and shall result into realization of personal goal in form of some reward future events. The theory focuses on three things efforts and performance relationship, performance and reward relationship, rewards and personal goal relationship (Salaman et al, 2005).

This theory is based on the hypothesis that individuals adjust their behavior in the organization on the basis of anticipated satisfaction of valued goals set by them.

In this theory working conditions that employees face  can either be edued by employees depending on the future expectation. Employees expectation has big effect on their retention in a specific job , if employees expecte to earn better salaries in future they are willing to edure current difiicult conditions to get future benefits like promotion, better pay and improving standard of living.

In order for employees to perform in this theory is by making sure each employee’s workplace goals and values are aligned with the organization’s mission and vision is important for creating and maintaining a high level of motivation. That can lead to higher productivity, improve employee performance, reduce the chances of low employee morale which leads to low levels of employee retention and instill a positive attitude during challenging times (Salaman et al, 2005).

1.1.2.2 Goal Setting Theory

Edwin Locke first put forth the goal-setting idea in 1968. According to this view, an employee’s personal objectives are a big part of what keeps him motivated to stick with a given profession. It is necessary to have the ability to communicate role objectives clearly to employees, include them in developing common goals, and give regular performance evaluation. Additionally, it will be necessary to devote time and effort to managing processes, providing sufficient resources, and workplace training. It also suggests that managers and supervisors present their company’s human side in order to inspire the organization to work at its highest level. peak performance managers and supervisors must put out front the human face of their organization. Principle here is the human-to-human interaction through providing individualized support and encouragement to each and every employee, this is order to improve the coditions of the work place to motivate employees to stay in a specific job (Salaman et al, 2005).

Employee retention is a significant, multifaceted construct that aims to provide results and is closely related to an organization’s planned goals (Abbas and Yaqoob, 2009). Retention is the primary multi-character component meant to achieve results that have a significant connection to the organization’s planned objectives (Sabir et al. 2012).

According to this notion, achieving an attractive, pleasant, satisfying, and stimulating work environment can help employees feel more proud of and committed to their work. People’s feelings are influenced by how the workplace is set up and occupied, but it also has an impact on their job output, loyalty to their employer, and the generation of new knowledge within the business (Taiwo, 2009).

1.1.2.3 Theory of Work Adjustment

The Theory of Work Adjustment (TWA) describes the relationship of the individual to his or her work environment.

The theory of work adjustment is a theory in psychology that attempts to explain the adjustment of workers to their work environment. The theory of work adjustment owes its existence to Rene Dawis, George England, and Lloyd Lofquist, who were at the University of Minnesota in 1964. In the theory of work adjustment, workers interact with their work environment. The interaction of workers with their environment is what comprises adjustment. In the basics of the theory of work adjustment, persons can be simplified as P, while the work environment can be simplified as E. The interaction between P and E is necessary because both of them are in possession of requirements that can potentially be satisfied by the other.

An important concept in the theory of work adjustment pertains to satisfaction. According to the theory of work adjustment, as long as P is satisfied with the outcomes of E and E is satisfied with the outcomes of P, the interaction between P and E will be maintained. In the case of workers in the work environment, satisfaction is important to continued interaction with their work environments. In cases where the worker does not achieve job satisfaction, they may opt to leave, even after a short period in their work environments.

Work equilibrium is desirable at the workplace because it benefits both the organization and the worker. In the theory of work adjustment, work equilibrium is achieved when the employees match their set of skills to the tasks provided by management and successfully tackle these tasks.

Work is conceptualized as an interaction between an individual and a work environment;

• The work environment requires that certain tasks be performed, and the individual brings skills to perform the tasks.
• In exchange, the individual requires compensation for work performance and certain preferred conditions, such as a safe and comfortable place to work.
• The environment and the individual must continue to meet each other’s requirements for the interaction to be maintained. The degree to which the requirements of both are met may be called correspondence.
• Work adjustment is the process of achieving and maintaining correspondence. Work adjustment is indicated by the satisfaction of the individual with the work environment, and by the satisfaction of the work environment with the individual–by the individual’s satisfactoriness.
• Satisfaction and satisfactoriness result in tenure, the principal indicator of work adjustment. Tenure can be predicted from the correspondence of an individual’s work personality with the work environment.
• Work personalities and work environments can be described in terms of structure and style variables that are measured on the same dimensions.

The principles of the theory of work adjustment are comprised of four variables. These variables include flexibility, activeness, reactiveness, and perseverance. In the achievement of workplace equilibrium, flexibility is defined as the extent to which a worker is willing to reconfigure their expectations regarding the workplace. An example of flexibility can be seen in the case of a first-time construction worker reconfiguring their expectations of the construction site environment.

Activeness can be described as the extent of the alteration of the worker’s environment by the worker in an attempt to achieve work equilibrium. An example of activeness is the case of a new office secretary making changes to the immediate office environment.

Within the context of work equilibrium, reactiveness may be defined as the extent to which workers will change themselves to match their work environment. An example of reactiveness can be seen in an outgoing person who changes their lifestyle at work and becomes a quiet critical thinker to fit in with their work environment, which encourages introverted traits.

In the attainment of work equilibrium, perseverance can be defined as the extent to the duration of time that a worker is willing to wait so that they can attain work satisfaction.

The theory of work adjustment (TWA) is essentially about the interaction of the worker with the work environment. Work adjustment is successful if the interaction between the worker and their work environment is sustained. The interaction is sustained when the worker and the work environment meet each other’s requirements. The extent to which these requirements are met is referred to as correspondence.

The environment, , can be represented by E, while P can represent the person. In the TWA, there are P variables and E variables. Satisfactoriness and satisfaction are E and P variables, respectively. Satisfaction can be described as the contentment evident in the worker because of their job. In contrast, satisfactoriness can be described as the achievement of an acceptable level of performance by the worker.

Satisfactoriness is an E variable because it deals with the requirements of the work environment upon the individual. In contrast, satisfaction is a P variable because it deals with the requirements of the person upon their environment. In the theory of work adjustment, satisfaction and satisfactoriness can be gauged using tenure. Tenure refers to the length of stay of the worker on their job.

1.1.3 Conceptual Background of the study

Retention is defined as the length of time a health worker actively performs appropriate health care tasks in a health facility and is usually measured by length of service, proportion of health workers in rural areas, turnover rates or survival rates (Dolea et al., 2019). It was suggested that the uneven distribution of health workers has more to do with retention than with attraction, because health practitioners in rural and underserved areas face higher workloads, unsustainable work environments and professional isolation causing them to leave the workplace in search of more satisfactory working conditions in urban areas or abroad (World Health Organization, 2017). However, retention must not be regarded in isolation from attraction, as factors that attract health workers to rural areas are often similar to those that retain them there (Dussault and Franceschini, 2019).

Retention has also been found to be contingent on the extrinsic rewards provided by the employer and the intrinsic rewards that come from within the individual, which are derived from the role and the work being performed (e.g., degree of autonomy and/or challenge) . For rural and remote allied health professionals, the most cited extrinsic factors with a negative influence on retention are lack of professional development opportunities, professional isolation and insufficient supervision, while the most cited intrinsic factors with a positive influence on retention are autonomy and community connectedness, However, recent analyses posit that health professionals’ decisions to stay or leave a rural health position (retention/turnover) are complex and influenced by ‘a myriad of highly interactive dimensions within personal, organizational, social and spatial domains (Draiko  et al., 2019).

A healthcare worker is anyone who works in a healthcare or social care setting, including healthcare students on clinical placement, frontline healthcare workers and other healthcare workers not in direct patient contact. Working conditions are created by the interaction of employee with their organizational climate, and it includes psychological as well as physical working conditions.

According to business dictionary, the term working condition refers to working environment and all existing circumstance affecting labor in the work place, including job hours, physical aspects, legal rights and responsibility organizational climate and workload.

A salary is a fixed amount that is paid to an employee at regular intervals, irrespective of the hours or amount of work performed. The amount of a salary is usually stated as the full annual amount to be paid, such as $80,000 per year. Salaries are usually paid at bi-weekly, semi-monthly, or monthly intervals. A salaried employee is typically paid through the date of each paycheck, since the amount paid never varies. The annual salary amount to be paid is frequently stated in an offer letter or employment contract (Efendi, 2020).

Working conditions refers to the working environment and aspects of an employee’s terms and conditions of employment. This covers such matters as: the organization of work and work activities; training, skills and employability; health, safety and well-being; and working time and work-life balance (Zhu et al., 2019).

A work tool is any instrument or simple piece of equipment that is used by specific employee in this case medical professionals in the health facility use to perform specific task, some of them include; Bedpan, cannula, catheter,          Endoscope, Gas cylinder, among others these equipment are used by medical practitioners in order to perform tasks that enables them to achieve their work responsibility, when there is no equipment for a specific task the ability by the medical workers to achieve that task becomes difficult and this makes the patient’s life vulnerable (Helmreich, & Merritt, 2017).

Staff accommodation is the place where the employees reside, it is usually called staff quarters; buildings that house employees of the company (Gough et al., 2019). These settings include, but are not limited to, state-funded and private organizations providing services in the following areas: disability, older persons, nursing homes, acute and non-acute hospitals, community hospitals, mental health, social inclusion, palliative care, chronic illness, primary care (GP, dental, pharmacies, physiotherapy clinics), health and well-being, hospice, rehabilitation, home care, paramedics, and community services (e.g. youth, substance abuse, suicide prevention, community development (Carmen, 2014).

1.1.4 Contextual Background

According to 2015 WHO data, the doctor-to-population ratio in Liberia and Sierra Leone (two countries recently hit by the Ebola epidemic) is even worse: 51 doctors for Liberia’s population of 4.5 million (0.1 per 1,000 people) and 136 doctors for Sierra Leone’s 6 million people (0.2 per 1,000). Ethiopia has 0.2 doctors per 1,000 and Uganda has 0.12 doctors per 1,000 inhabitants, while South Africa and Egypt, at 4.3 and 2.8 per 1,000 respectively, have better ratios (Fox et al., 2019).

The outflow of African-educated physicians to the US has increased over the past 10 years, from 10 684 in 2005 to 13 584 in 2015 (27.1% increase). This represents 5.9% of all international medical graduates in the US workforce in 2015, while trends in new registration of overseas doctors from Africa by the UK General Medical Council shows an increase of 38% in 2017 over the 2007 figure (Van Essen et al., 2019).

Kabale Regional Referral Hospital (KRRH) is located in the central business district of the town of Kabale, approximately 139 kilometers (86 mi), by road, south-west of Mbarara City and Mbarara Regional Referral Hospital. This is about 406 kilometers (252 mi) south-west of Mulago National Referral Hospital. KRRH was founded as a mission hospital of the church Missionary Society in 1921 by Leonard Sharp and Algernon Smith and their spouses as an expansion from the Mengo Hospital. The original mission hospital included a school and a leprosy hospital on Bwana Island on Lake Bunyonyi, the hospital also served as a base for Sharp and Smith to found a hospital in Rwanda as well, the Ruanda Mission. The bed capacity of the hospital is quoted at 280 although many more admissions are made, with the excess sleeping on the floor. In 2014, work to expand and renovate the hospital got underway, in anticipation of turning the hospital into the teaching hospital for Kabale University.

According to Kabale district strategic plan , (2019), there has been an increase in the number of medical professionals leaving the Hospital and moving to other cities like Kampala , this is indicated by the fact that Kabale Regional Referral Hospital currently has vacant positions which are critical in the hospital’s ability to deliver effective service to the population of Kabale.

Some of the vacant position include senior consultant, consultants, and             Nutritionist among many others. In total the hospital has a total of 137 positions still vacant, despite the fact that most of the vacant positions were previously filled.

The existence of many vacant positions in Kabale Regional Referral Hospital, by December 2021, totaling to over 137 is an indication that, that hospital is having poor retention of employees since most of these positions were filled up 5 years ago, however the problem is not only unique to Kabale Hospital Regional Referral Hospital, this is despite of the fact that there is a crippling disease burden. nearly 30% of graduating physicians in Uganda choose to emigrate each year (Soucat 2016)., the author further indicates that, newly graduated physicians choose to leave the country when they are assigned to hospital in the Uganda, around 30% 0f Ugandan physicians work for a year to get work experience then they leave the hospitals that they have been assigned. According to MoH, (2018) around 263 health workers in Ugandan hospital left to go to Trinidad and Tobago alone, though at least 400 health workers, including senior specialists from government hospitals, applied to leave from 2013 to 2019, while 240 specialist doctors have left Uganda over the last five years due to poor pay and bad working environment (MoH, 2019). This poor retention of medical workers in Uganda’s Health centers is a matter of concern to the policy makers and therefore it is against this Background that this study intends to investigate into working conditions and retention of health workers in Kabale Regional Referral Hospital.

1.2 Statement of the problem

The structure of Kabale Regional Referral Hospital provides for 450 staff, however currently only 270 are filled leaving the hospital in need of 180. Accordingly, by December 2021 the Hospital had  67.5% , of the total staff and was unable to retain 32.5% of the staffs who had left  earlier (MoH, 2019).

Kabale Regional Referral Hospital   is in critical shortage of Health workers due to failure to retain health workers especially Specialists in Internal Medicine, Radiology, Anaesthesia, Psychiatry and Obstetrics and Gynaecology. The government of Uganda has tried to intervene into the matter by increasing the salary of the employees in the medical field (KRRH Report, 2019).

Currently according to Kabale Regional Referral Hospital   records of 2021 there are 23 vacancies for Medical staff, 6 vacancies for Clinical Officers, 4 vacancies for Radiography, Occupational and Physiotherapy 2, Laboratory 3, Dental staffs 4 and Psychiatric Clinicians 4, all of which are signs of poor attraction and retention.

Noble (2003,) states that more attention should be paid to identifying and dealing with working condition because when employee have negative perception to their environment they sometimes suffer from chronic stress. Kabale district records, (2020) indicate that most of the health workers in KRRH never serve for more than 10 years, something that has continued to be a challenge for the Ministry of Health. It’s against this background that this study intends to investigate the influence of working conditions on retention of Health workers, with specific reference to Kabale Regional Referral Hospital (KRRH.).

1.3 General objectives of the study

The general objective of the study is to examine the influence of working conditions on retention of Health workers.

1.4 Specific objectives of the study

1. To establish the influenc of accommodation and health worker retention at KRRH.
2. To establish the infuence of management support and health worker retention at KRRH.

• To examine the extent of health safety and wellbeing of employees on health worker retention at KRRH.

1.5 Research questions

1. What is the influence of accommodation on health worker retention at KRRH?
2. What is the infleunce of management support on health worker retention at KRRH?

• To what extent does health safety and wellbeing of employees affect health worker retention at KRRH?

1.6 Scope of the study

This section includes the content scope, geographical scope and Time scope.

1.6.1 Geographical scope

The study will be carried out in Kabale Regional Referral Hospital, a 280-bed hospital located in Kabale Municipality in Southwestern Uganda, approximately 426 Kilometers from Kampala. The hospital serves a population of about 2 million people in the districts of Kabale, Rubanda, Kisoro, Rukungiri, Kanungu, and some parts of Ntungamo as well as people from neighboring countries of Rwanda and the Democratic Republic of Congo. The mission of the hospital is “to provide quality and sustainable, general and specialized, health services to all people in Kigezi region”.

1.6.2 Content scope

This will specifically include; the relationship between Accommodation and health worker retention, the relationship between Management Support and health worker retention and the relationship between Health safety and wellbeing of Employees on health worker retention.

1.6.3 Time scope

This study will use information for literature of the last 10 years while only the data which is 5 years old will be considered from the organization.

1.7 significance of the study

The study will provide data to future academicians in relation to influence of employee motivation on retention.

The study will also provide the policy makers with the information regarding the influence of payment terms on retention of employees.

The government will use information on the influence of working conditions on employee retention in rural settings

1.8 Justification of the study

Sub-Saharan Africa currently bears 24% of the global disease burden, yet is home to just 3% of the global health workforce (Anyangwe 2007). Despite this crippling disease burden, nearly 30% of graduating physicians in Uganda choose to emigrate each year, this has been difficult for the Ugandan hospitals to retain health workers as going to developed countries is something that most medical practitioners dream of due to better pay and remuneration (Soucat 2013). Poor retention of Health workers is a human resource crisis that has plagued the healthcare systems of many developing countries, where newly graduated physicians choose to leave the country after receiving their formal medical education. For over a decade, public health leaders have attempted to meet this critical human resource shortage through an increase in the availability and efficacy of medical education (Akuffo 2014)

According to Sefa, it is not clear why most of the locally produced professionals go out to seek “greener pastures” from the South to the North and South to South (Sefa & Asgharzadeh, 2019). However, some causes are known although the major ones need to be pointed out. Although brain drain is an old problem and hindrance to development and organizational sustainability in the developing world, little has been done to assess the local factors responsible for the escalation of this problem. Most of the studies have been conducted abroad and little is known locally yet the issue of brain drain has its own impact on the remaining professionals within a country.

1.8 Conceptual frame work

Working Conditions                                                               Retention

According to the conceptual frame work, the independent variable working conditions is measured by the following dimensions; health safety and wellbeing of employees: provision of gloves, provision of  medical equipment, social amenities for health worker family members; management support which includes: listening to employee grievances, and provision of the required key needs, while accommodation is measured by provision of staff houses.