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WORKING CONDITIONS AND RETENTION OF HEALTH WORKERS IN KABALE REGIONAL REFERRAL HOSPITAL
CHAPTER ONE: INTRODUCTION
1.0 Introduction
Africa currently faces a significant shortage of medical professionals, with an average of one doctor per 5,000 people. According to the World Health Organization (WHO, 2019), retaining healthcare workers in Africa remains a growing challenge, as many migrate to high-income countries like those in Europe and North America in search of better opportunities. For instance, while surgeons in New Jersey earn approximately $216,000 annually, their counterparts in Zambia earn around $24,000, and Kenyan doctors receive just about $6,000 per year (Van Damme et al., 2019). This disparity has contributed to the migration of medical professionals, with the number of Sub-Saharan African-trained doctors abroad rising from 2,014 in 2005 to 8,150 in 2015—a 304.6% increase.
This chapter outlines the background of the study, the problem statement, objectives, research questions, study scope, justification, significance, hypotheses, conceptual framework, and operational definitions of key terms.
1.1 Background of the Study
1.1.1 Historical Background
Historically, healthcare workers in developing regions, particularly Sub-Saharan Africa and parts of Asia, have faced poor working conditions characterized by inadequate equipment, substandard housing, low remuneration, and excessive workloads (Senkevich et al., 2019). Such conditions undermine the quality of care provided and contribute to low healthcare worker retention. For example, in Peru, similar challenges—fragmented systems, economic hardship, and limited infrastructure—have exacerbated staff grievances (Daniels, 2019).
Although health workforce shortages affect most countries, Sub-Saharan Africa and Asia are disproportionately affected due to their low worker density and high attrition rates (Kabbash et al., 2021). Migration of health professionals from Africa to developed nations has intensified, facilitated by modern communication technologies that expose potential migrants to global job opportunities (Daniels et al., 2019). Rural and remote areas are particularly disadvantaged, as health workers often prefer urban centers, worsening the urban-rural health service gap (Dal Poz, 2018).
Efforts by African countries since the 1990s have struggled to address health worker migration and retention challenges, despite having the world’s highest disease burden and the lowest number of specialists (WHO, 2016). Colonial-era healthcare systems reportedly offered better living conditions for medical personnel than current systems. The shortage of healthcare workers has continually impacted health outcomes such as maternal health, HIV/AIDS treatment, and child survival (Daniels et al., 2019).
Globally, healthcare worker shortages total approximately 4.3 million professionals, with Sub-Saharan Africa accounting for a significant share. While it carries 24% of the global disease burden, the region only has 3% of the workforce and 1% of global healthcare resources (Draiko et al., 2019). Around 28% of the region’s medical workforce currently works abroad, with push factors including low wages, poor infrastructure, and limited career growth, and pull factors such as better pay and working conditions in the global North.
1.1.2 Theoretical Background
This study draws upon three key theories:
Expectancy Theory (Victor Vroom): Suggests that individuals remain in a job when they believe their performance will lead to desired outcomes such as rewards or promotion (Salaman et al., 2005).
Goal Setting Theory (Edwin Locke): Emphasizes that employee motivation is enhanced when clear and attainable goals are established and supported with necessary resources and evaluations (Salaman et al., 2005; Abbas & Yaqoob, 2009).
Theory of Work Adjustment (TWA): Developed by Dawis, Lofquist, and England, this theory posits that job satisfaction and tenure are products of the alignment (correspondence) between individual expectations and environmental conditions (Helmreich & Merritt, 2017).
1.1.3 Conceptual Background
Retention refers to the duration healthcare workers remain in active service. Retention challenges in rural areas stem from heavy workloads, professional isolation, lack of development opportunities, and insufficient infrastructure (Dolea et al., 2019; WHO, 2017). Retention depends on both extrinsic rewards (e.g., salary, housing) and intrinsic motivators (e.g., autonomy, sense of purpose).
Working conditions encompass organizational climate, psychological and physical environments, job responsibilities, and access to equipment. Tools such as cannulas, catheters, and gas cylinders are essential for effective service delivery, and their absence can severely hinder performance (Helmreich & Merritt, 2017). Staff accommodation is also a key factor influencing retention, particularly in rural healthcare settings (Gough et al., 2019).
1.1.4 Contextual Background
Uganda has an extremely low doctor-to-population ratio—0.12 per 1,000—compared to countries like South Africa (4.3) and Egypt (2.8) (Fox et al., 2019). Kabale Regional Referral Hospital (KRRH), established in 1921, now serves over 2 million people in the Kigezi region. Despite renovations and its role as a teaching hospital for Kabale University, it suffers from critical staffing shortages. By December 2021, 137 of its positions were vacant.
This retention problem is echoed nationwide. Reports indicate that approximately 30% of new Ugandan physicians emigrate each year. From 2013–2019, over 240 specialist doctors left Uganda due to poor working conditions (MoH, 2019). KRRH specifically faces shortages in key specializations such as internal medicine, psychiatry, and radiology (KRRH Report, 2019). These conditions underscore the urgent need to investigate how working conditions influence staff retention at KRRH.
