WORKING CONDITIONS AND RETENTION OF HEALTH WORKERS IN

KABALE REGIONAL REFERRAL HOSPITAL

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. 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

The study will use two theories in order to clearly understand the influence of working conditions on the retention Health workers.

1.1.2.1 Herzberg’s two factor theory

The study will use Herzberg’s two factor theory. In 1959, Frederick Herzberg, a behavioral scientist proposed a two-factor theory or the motivator-hygiene theory. In which he states that there are certain factors in the workplace that cause job satisfaction while a separate set of factors cause dissatisfaction, all of which act independently of each other. Working conditions is a major determinant of job satisfaction and retention of employees, According to Herzberg’s motivational theory; factors that make people dissatisfied at work are dissimilar from those motivating them to do a good job. Dissatisfies relate to working environments rather than the task itself: low salary, poor career prospects and training opportunities, unsatisfactory access to equipment and support mechanisms, and disappointing human interactions with colleagues and managers all contribute to a sense of dissatisfaction. As opposed to these extrinsic motivational factors, intrinsic motivation relates to the real content of work, feelings of achievement, self-esteem and self-confidence; they add to job satisfaction and stimulate performance (Uta, 2018).

Basic assumptions of Herzberg’s theory are: Presence of Hygiene factor will not cause satisfaction but their absence will cause dissatisfaction. HERZBERG isolated two different sets of factors affecting motivation and satisfaction at work, Intrinsic or Motivators Factors: concerned with job content.

Herzberg considered the following hygiene factors from highest to lowest importance: company policy, supervision, employee’s relationship with their boss, work conditions, salary, and relationships with peers. Eliminating dissatisfaction is only one half of the task of the two factor theory.

In relation to this theory this study indicates that for Health workers to stay on the job there is need to ensure that they have proper working conditions such as presence of gloves, availability of medical equipment and all the other necessary tools and resources necessary to facilitate their work.

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.

Look at work conditions again

Change theory – googgle ‘work conditions theories’ u get better ones e.g person environment fit and theory of work adjustment

CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter examines the related literature to the study, the actual literature will be reviewed objective by objective, and the sources of literature reviewed include; secondary sources especially text books, journals, newspapers, research dissertations, Government reports and publications.

2.1 Retention of Health workers

There was an unequal distribution of skilled public health workers across selected institutions in Georgia, with lack of professionals in rural district centers and overstaffing in urban centers. Survey respondents disagreed or were unsure that skilled public health workers possess sufficient skills and knowledge necessary for delivery of public health programs. The survey shed additional light on the findings that there is no clear vision and plans on human resource development. Limited budget, poor planning, and lack of knowledge of the local government were mentioned as main reasons for inadequate staffing. The study participants were concerned with lack of good training institutions and training programs, lack of adequate legislation for Human Resource issues, and lack of necessary resources for Human Resource development from the government (Mamuka, 2018).

Aggressive external recruitment drives, particularly targeting nurses, were of great concern as they were a contributing factor for the increasing trends in nurse migration. The main factors in the migration of SHP were consistent with those found in other studies elsewhere in the world. These included low remuneration; poor working conditions, such as inflexible working hours, shortages of supplies and equipment and a poor working environment especially in rural and remote areas where health needs are least well served; limited continuing educational opportunities for professional development and career advancement; having trained and obtained a higher qualification abroad; the desire for better income and family well-being, including children’s education and remittances; the aggressive recruitment drives by external agencies; and the presence of relatives and friends abroad. While the decision to migrate or to leave the public health sector and seek employment elsewhere was primarily a personal decision, the study also revealed that structural and societal issues affected the migration of SHP. Some examples included the globalized labour markets in health care, small-scale economies, fiscal policies leading to downsizing of an already inadequate labor force, bureaucratic and governance weaknesses, limited capacity in labor force planning and management (the lack of comprehensive and reliable information and database of health personnel, particularly on the distribution of the health labor force, attritions and migration flows), and political and civil instability (WHO, 2016).

A study of health systems challenges in Nigeria showed that, with the many challenges facing the health system in Nigeria, is acute shortage of competent health care providers. As a result of poor infrastructure and inadequate compensation packages, a significant number of physicians, nurses and other medical professionals are lured away to developed countries in search of rewarding and lucrative positions. In fact, some of these countries have recognized recruiting agencies and examination protocols targeting the best and brightest medical brains in Nigeria, forcing the government to require that these agencies register with the Federal Ministry of Health and function within an established framework. Nigeria is a major health workforce exporting nation, accounting for 347 (recently revised upward to 432) out of a total of 2000 nurses that emigrated out of Africa between April 2000 and March 2001. This numbers appears to be underreported as it fails to take into account the vast number of nurses who move abroad under different pretexts. The efflux has resulted to severe shortages in local health facilities and drastically impacted access (Uneke, 2018).

The major challenge facing developed and developing countries is inequalities and imbalance of health care workers densities in urban compared with rural areas. For example, in Bangladesh, thirty per cent (30%) of nurses are located in four metropolitan districts where only 15% of the population lives. In South Africa rural areas are inhabited by forty six per cent (46%) of the total population, but only twelve per cent (12%) of doctors and nineteen per cent (19%) of nurses are working there. Rural and urban areas in South Africa face a critical shortage of health workers, as these health workers prefer to work in areas with better opportunities for income generation and professional development and better living and working conditions (WHO, 2019).

Shortages in the health labor force represent a major challenge for health policy-makers. There are various approaches to defining shortages. From an economic perspective, a shortage occurs when the quantity of a given skill supplied by the labor force and the quantity demanded by employers deviate at the existing market conditions. Non-economic definitions are generally normative, i.e. there is a shortage of labor relative to defined norms. In the case of skilled health personnel, these definitions are based either on a value judgment– for instance, how much care people should get – or on a professional determination – such as deciding what is the correct number of physicians for the general population. On the basis of those criteria, staff shortages are reported in most countries of the world, although the severity varies. The shortage seems most severe in Africa. For instance, serious staff shortages in all health professions categories are reported in Zimbabwe, including 2,000 vacancies for nurses. In Asia, Vietnam experienced a 57% decline in the number of nurses between 1986 and 1996. Shortages appear to have been accentuated by the migration of health personnel (Pascal, 2015).

2.2 Influence of accommodation on health worker retention

Retention of the health workforce is a recognized strategy for improving the availability and distribution of the health workforce at both global and country levels. It was a key strategy discussed during the first global conference on human resources for health held in Kampala in 2008 (WHO, 2008) and subsequently in other global platforms including the Workforce 2030 – the current global strategy on human resources for health (WHO, 2016).

Krause and associates (1998) found that temporary modifications or accommodations were better than no accommodations. They found employees with temporarily modified work were twice as likely to work harder as employees without access to any form of modified work. Moreover, it was estimated that on average, a fifty percent reduction in days lost from work could be expected for those employees with modified job activities (Krause et al., 1998). Overall, modified work programs facilitate return to work for temporarily and permanently disabled workers (Schultz, Crook & Winter, 2005) and reduce work absence duration (Crook, Milner, Schultz & Stringer, 2002; Franche, Frank & Krause, 2005; Krause et al., 1998; Turner, Sheppard & Gluck, 2008).

However, many jurisdictions within Canada have work programs external to workplaces. In current theories of RTW, timing is of particular importance. Interventions should be early but also appropriate (Franche et al., 2005). There has been some criticism of the indiscriminate use of early return to work, especially with workplace interventions. Some studies have found an increase in re-injuries (Pransky, Benjamin, HillFotouhi, Fletcher et al., 2002) further supporting this criticism. Key determinants of a safe and sustained RTW are appropriate timing, and properly structured accommodations to decrease ergonomic risks (Pransky et al., 2002). Providing adequate accommodations can be challenging. It is generally perceived to be more difficult in small workplaces where there may be fewer modified work options. Larger companies often have more established policies and procedures, and may have more flexibility in implementing accommodations (Schultz, Milner, Hanson & Winter, 2011).

Worldwide, the geographical distribution of health workers is skewed towards urban and wealthier areas. This pattern is found in nearly every country in the world, regardless of the level of economic development and health system organization, but the problem is especially acute in developing countries. There are multiple factors influencing a health worker’s decision to relocate, stay or leave a post in rural or remote areas. Such complex and interconnected factors are linked to a health professional’s characteristics and preferences relating to health systems organization and to the wider social, political and economic environment.

At the beginning of the 21^st century, the government of Uganda began implementing a series of health sector reforms that were aimed at improving the poor health indicators prevailing at the time. A Sector-Wide Approach (SWAp) was introduced in 2001 to consolidate health financing. Another demand side reform introduced in the same year was the abolition of user fees at public health facilities, which triggered a surge in outpatient attendances across the country. Decentralization of health services began in the mid-1990s alongside wider devolution of all public administration, and was sealed in 1998 with the definition of the health sub-district. Implementation of the health sub district concept extended into the early 2000s. The aim of decentralization was to improve the management and delivery of health services at the local level.

Because of the importance of health in societies, health workers have embarked on the delivery of various health services to their people in one-way or the other. Research has been carried out on the health service delivery and researchers have come up with mainly poor health services and lack of medical facilities as the major contributors of poor health service delivery. Therefore, the benefits of health service delivery have been witnessed and that there are other factors that have resulted into poor health service delivery and this has created an assumption that all health workers are not poor service providers and fail to maintain the standard medical services to the people of Uganda in particular Tororo. However besides the outcomes and benefits of health care services, people from rural families continue to experience increasing unsatisfactory health service delivery. It has also been noted that even the health workers who are willing to offer good services end up failing therefore this means that there are other latent factors within the environment of study which are contributing to poor health service delivery.

In the United Republic of Tanzania, in rural areas where the majority of the population continues to reside, problems of recruiting and retaining health staff are most pronounced. The recruitment and retention debate has tended to focus on absolute numbers of health workers, rather than exploring the dynamics, such as reason for of geographic differences, and health worker flows within (transition/intrasectoral mobility) in and out of (exit/intersectoral mobility/migration) the health workforce. Failure to retain existing staff incurs additional costs to the health system, including training new staff, recruiting replacements and overtime/locum costs to cover the ensuing staff shortages. It also has a detrimental impact on the health workforce team and its skill mix. In the Tanzanian context, distributional inequalities in health worker numbers are mirrored by large skill mix inequalities, where districts with fewer human resources have an even lower share of the highly skilled cadres.

Unsurprisingly then, the health workforce in the United Republic of Tanzania has been documented to be very unevenly distributed between rural and urban districts. A recent country survey (SARA), found that 69 % of all health professionals worked in urban facilities. This is despite the fact that roughly 70 % of the population lives in rural areas. It is noted that the health workforce challenges in the country’s public institutions are significantly related to poor working conditions, lack of resources and equipment. This situation drives some staff, especially highly trained ones, to seek private or third sector employment or to move outside the country. Those who remain working in the country can become greatly demoralized.

The current analysis draws on what is already well known and striven for in the Tanzanian context. In sum, quantitative studies demonstrate that problems persist and that the difficulties in the United Republic of Tanzania surpass those of many surrounding African nations. It appears that the situation has remained stagnant and slow to change. Qualitative studies have shown that infrastructure limitations and poor morale are persistent issues. It is hoped that fully elucidating qualitative questions, or the ‘whys’ and ‘hows’, of staff shortages will give a fuller picture of what is being experienced on the ground, to help better inform Human Resources for Health policy.

Health workforce retention is also mentioned in the national health policies of Malawi (Malawi HSSP 2011-16) and Tanzania (Tanzania HSSP 2016-25). However, there is a lack of clarity and standardization in the way retention and attrition are presented in these key documents. Adding to the problem is the lack of standardized indicators for health workforce retention and attrition. Similarly, there is a lack of standardized definition for the terms “rural” and “remote” (Dolea et al., 2010). This poses a challenge in describing, and assessing interventions for improving health workforce retention in rural and remote locations (Castro Lopes et al., 2017)

For example, Wilson (2009) defined retention as a stay of more than five years in total in a healthcare facility, or of more than two years beyond termination of a contractual agreement (Wilson et al., 2009), while Humphreys et al. (2009) defined health workforce retention as “the length of time between commencement and termination of employment” (Humphreys et al., 2009). This “length of time” referred to by Humphreys (2009) does not quantify retention but describes it in arbitrary terms. specify what length of time will amount to retention. Armstrong (2017) defines attrition, broadly, as the rate at which people leave the organisation (Armstrong, 2017).

Castro Lopes et al. (2017) delineates voluntary from involuntary causes of attrition and defines voluntary attrition as, “exits from the workforce for reasons other than death or retirement” (Castro Lopes et al., 2017). Castro Lopes et al. (2017) further noted that words and terms such as “brain–drain”, “turnover”, “drop-outs”, “losses”, “separation” and “premature departure” were used instead of the word “attrition”. Some authorities include health workforce migration, retirement, death, resignation or dismissal as part of attrition while others do not. Some authorities regard attrition to mean migration of the healthcare workers outside borders and consider internal movements as health workforce mobility (Castro Lopes et al., 2017). Thus, there is no international consensus on how to define health workforce retention, attrition or mobility.

Russell (2012) describes five parameters of measuring health workforce retention; the turnover rate, stability rate, survival probability, median survival years and Cox proportional hazard ratio (Russell et al., 2012). The ‘stability rate’ which measures the proportion of employees present at the start and end of a set interval is a preferred measure applied in most studies. However, different studies choose numerators and denominators of this indicator differently (Russell et al., 2013). The WHO proposes seven parameters of measuring health workforce market flows; graduates starting practice within a year, replenishment rate from domestic sources, entry rate of foreign health workforce, voluntary exits, involuntary exits, vacancy rate and health care worker’s unemployment rate. It proposes the numerator and denominator in each parameter and suggests the potential sources of data and the reporting frequency (WHO, 2017).

The data on the health workforce, routinely collected from LMIC is inconsistent, inadequate and usually of poor quality, making it challenging to calculate health workforce parameters – suggested by Russell et al. (2012) and the WHO (2017) a challenge. This limits the application of those indicators in research work and programmatic activities (; WHO, 2016). Also, there is often an overlap in reporting between “motivation”, “job satisfaction”, “intention to stay” and “retention” in studies. This has sometimes caused confusion (Mbemba, et al., 2016). For example, Taderera et al. (2016) reports that an intervention to improve retention in one location in Zimbabwe resulted in improved retention while what improved was job satisfaction (Taderera et al., 2016).

2.3 Management support and health worker retention

Health worker retention is a component of personnel management and planning activities, thus the capacity to keep workers in an organization is related to the measures by which companies seek to keep workers in their workplace. Organizations must investigate why workers leave or why they continue to stay. The International Labor Organization (of the year 2003 has been involved in supporting protections for workers since employees are an asset. The Occupational Safety and Health Act (2007), it is extremely important to ensure the health, safety, and wellbeing of workers and all individuals legally present at workplace, and to provide learning and developmental initiatives in their organisations (Mukherjee et al., 2020).

Increases in cultural differences within the workforce raise critical issues for employers. Employee retention efforts have proved very difficult to implement in some parts of the world due to differing expectations for pay, work assignments, benefits and the like. If a company is global in scope or simply has a highly diverse employee population, both cultural and national differences must be taken into account at the outset of the development of any new HR-related program, including employee retention strategies.

Managing for employee retention involves strategic actions to keep employees motivated and focused so they elect to remain employed and fully productive for the benefit of the organization.

A comprehensive employee retention program can play a vital role in both attracting and retaining key employees, as well as in reducing turnover and its related costs. All of these contribute to an organization’s productivity and overall business performance. It is more efficient to retain a quality employee than to recruit, train and orient a replacement employee of the same quality.

As per the World Health Organization (WHO,2013) the worldwide personnel capital problem, along with the poor practice of health by professionals in lower- and medium nations, is gaining worldwide attention. Workers are the most valuable resource in any business (Kundu & Lata, 2017). An effective and highly fluid company may be created by involving workers in the cultivation of their performance. As a result, to maintain a competitive edge, personnel must be able to demonstrate entire dedication to the needed overall performance ethics. Organizations are increasingly being required to significantly enhance their performance to meet high demands, volatile business conditions, and strong competition. Because of the international rivalry for talented individuals, the service sector needs to focus more on retaining competent personnel

Agyepong et al. (2018) describe retention as an ongoing effort to engage in business with a particular organization. Retention is’ customer love, reputation, loyalty, confidence, readiness to suggest and buyback intents, the first four of which are emotional-cognitive retention systems in place and the final two of which are determinants of intended outcome. According to Ellapen et al. (2018), retention is motivated by several key factors that should be treated cohesively: organizational culture theory, policy, rewards, and benefits. The economic implications will be detrimental to a company if businesses cannot keep their workers.

Movement within an organization is typically classified as advancement in a position where responsibilities and prestige are increased. Promotional incentives impact individual acts within the organization and encourage individuals to move forward with expanded potential. Promotion is used as a reward and incentive for successful work outcomes and other behavioral styles that are embraced organizationally. If they feel that will lead to promotion, people will work harder. They have little motivation if they feel reserved for outsiders to get better jobs. The promotion method helps companies to balance their need for skilled workers with the willingness of employees to apply their expertise. There is a strong link between the prospects for promotion and high rates of work satisfaction. An effective system of promotion will result in more organizational efficiency and high morale for employees (Akinwale & George, 2020).

2.4 Health safety and wellbeing of Employees on health worker retention

Employees undertake attempts to improve unsatisfactory work circumstances that might otherwise play a key role in their choice to leave their companies. Employees who are successful in improving dissatisfying work circumstances will experience less discontent, and their desire to quit will shift to intent to stay, increasing the probability that they will stay with their company. It is the management’s major job to discover bright and high performing employees in the first place, and they need be rewarded for their accomplishments in every way possible, including monetary awards. Employees who quit their jobs willingly are more likely to be paid less and have inadequate benefits. Many of the factors that lead employees to quit also make it difficult to find new candidates to fill their shoes. Employee turnover is expensive for businesses, with the average firm losing $100,000 for each professional or management employee that departs (Bäckström et al., 2016). The workplace environment encompasses not just the physical features of an employee’s work space, but also everything that pertains to the employee’s connection with the job. The working environment is defined by the Total Reward Association as “the complete collection of psychological, physical and behavioral elements present at work” (Kjellström et al., 2017). Workers are said to feel better about heading to work in a safe atmosphere, which provides the drive they need to get through each day. Bäckström et al. (2016) reaffirm this point, stating that firms that provide adequate degrees of privacy and solid workplace regulations are better able to recruit and retain employees, as well as increase motivation and engagement. Crawford et al. (2017) also state that maintaining a good work environment is one of the most important components of any company’s total compensation strategy. Because learning and development opportunities seem vital to the preservation of talented employees, an organization needs to create caring learning and work environment. The term ‘learning and working environment’ usually refers to the atmosphere in which all employees create the organization (Kjellström et al., 2017). More specifically, the definition can be expressed by referring to direction and respect at work; work stress; amount of pride and obligation faced by employees; choice of work and employment obligations; stipulation of demanding and essential jobs; and opportunities for development and growth and facilities. Previous studies, results suggest that the indebted strategy, operationalized by appreciative learning and working climate, has a positive impact on staff retention (Dipboye, 2018b).

Dipboye (2018a) found that the workplace environment is frequently described from an industrial standpoint, with an emphasis on physical factors such as hard lifts, noise, and hazardous chemical exposure. The intriguing element is that the work environment in the services sector differs from that in the manufacturing sector since it involves interacting with clients or consumers. Relations will vary in frequency and intensity based on the type of business and the type of employment. The connection between workers and customers or clients necessitates a shift in emphasis from the physical to the psychosocial aspects of the workplace. Support, volume of work, expectations, role ambiguity, and stressors all play a role in the psycho-social work setting. The work atmosphere may send negative signals regarding how much the company appreciates its people and the expectations it has for them (Dipboye, 2018b).

According to Behera et al. (2019), the physical office environment influences workers functions and determines the well-being of businesses. The physical work environment also comprises the indoor and outdoor workplace layout, temperature, comfort zone, and work setup or arrangement, according to the authors. Lighting (both natural and artificial), furniture, noise, and office spatial patterns are all elements in the physical working environment. Comfort, airflow, and warmth, as well as light, all contribute to the physical office environment. These elements help with the décor and design of the working environment on both a practical and aesthetic level, which helps to better the workers experience and necessitates higher performance. Employees’ health is also influenced by their degree of comfort and temperature. Busari et al. (2017) discovered that when temperatures are high, job performance suffers, and that colder temperatures affect manual task performance.

In Brazil, in a Dominican Republic hospital study comparing patient prescriptions and records of prescribed medications, 32 percent of patients reported prior knowledge of abuse in government pharmacies Cohen, (2002) and a significant proportion of medications were absent. In Ethiopia, an Addis Abeba health officer It was observed that “many health personnel are participating in such activities,” linking this to “external influences” and poor government employee salaries (Vandawaker et al., 2017)

The Kenya Medical Supplies Authority (KEMSA) has resolved these issues by turning it into a more autonomous and efficient medical logistics authority from a bureaucratic agency which it has been for many years. KEMSA is a state agency whose mission is to purchase, store and distribute medical supplies to public health facilities in 47 counties across the country. This is an important milestone that has helped improve the provision of service (Koech et al., 2020). Medicines and medical devices constitute 20-30 percent of global health spending, mainly in low- and middle-income countries, and therefore make up a large part of the budget anywhere health services are paid for. In certain situations, the burden will be higher, since a reasonable amount is charged by governments and businesses. Drug shortages have been shown to dissuade the use of public resources, with key procurement failures, largely in the utter lack of productivity improvement, process control, inspections, and unchecked political interference, and in dispersion, wherein stock management and analytics systems are especially vulnerable. Alleged pharmaceutical misuse both by healthcare workers and hospital patients are blamed on a lack of prescription prescribed and medicine supply restrictions (Bang et al., 2020).

Summary of literature review

CHAPTER THREE

METHODOLOGY

3.1 Introduction

This chapter presents the research methods that will be used to carry out the study. It covers the research design, Area of study, target population, sample design, sample size, research instrument, and measurement of variables, data collection procedure, data analysis and ethical considerations of the study.

3.2 Research Design

The study will adopt a cross-sectional survey research design because of the nature of the variables that will be at hand; to produce data required for quantitative and qualitative analysis and to allow simultaneous description of views, perceptions and opinions at any single point in time. The study will also use qualitative and quantitative methodologies for data analysis. Quantitative and qualitative methodologies will be used in examining the influence of working conditions on retention and productivity of Health workers. Quantitative research will consist of those studies in which the data concerned could be analyzed in terms of numbers while qualitative described events, persons and so forth scientifically without the use of numerical data. Quantitative research is based more directly on its original plans and its results are more readily analyzed and interpreted. Qualitative research is more open and responsive to its subject. (Hennink et al., 2020).

3.3 Study Population

Study population is defined as the entire group of people that a researcher wishes to investigate. Kabale Regional Referral Hospital is comprised of 150 employees comprising of a Hospitall Director, Senior Consultants, Consultants, Medical Officers Special Grade, Pharmacists, medical doctors, Clinical Officers, Allied Health Proffessionals nurses, and  midwives.

3.4 Determination of the sample size

It is impossible to study the whole targeted population of the study and therefore the researcher will take a sample of the population this is also further supported by Mugenda and Mugenda (2003) who notes that a research should choose a sample out of the whole targeted population. A sample is a subset of the population that comprises members selected from the population. Using Krejcie and Morgan’s (1970) table for sample size determination approach, a sample size of 60 respondents will be selected from the total population of 150 employees.

Table 1: Showing Population and Sample size of respondents

Source: Kabbale Regional Referral Hospital

3.5 Sampling techniques and procedure

Purposive sampling, also known as judgmental, selective or subjective sampling, is a type of non-probability sampling technique where the researcher chooses a sample based on what they think in other words they use their personal judgement (Palys, 2008). The study will use Purposive sampling technique because it saves time and also enables the researcher to get information from the right people who have knowledge and skills regarding the subject topic. This technique will use in selecting, Managers, Unit heads, the researcher will use this technique because these respondents hold enough knowledge and skills regarding the study topic.

The researcher will use simple random sampling technique, According to Amin, (2010) a simple random sample is a subset of individuals chosen from a larger set (a population). Each individual will be chosen randomly and entirely by chance, such that each individual has the same probability of being chosen at any stage during the sampling process, and each subset of individuals has the same probability of being chosen for the sample. The technique will be used to select from the other staff members.

3.6 Data collection methods

The section presents data collection methods which will include questionnaire survey, interview and documentary review.

3.6.1Questionnaire Survey

Questionnaire Survey method will be used to obtain the opinion of the respondents regarding the topic under study, according to (Johnson, Adkins, & Chauvin,(2020) states that questionnaires are important in research because the respondents are given time to think and they don’t feel intimidated. Questionnaire gives the respondents ample time to respond to the questions when ready and they can be kept for future references. This method will be deployed to capture information from Staff Members, unit heads and managers.

3.6.2    Interview

Face-to-face interview is a data collection method where the interviewer directly communicates with the respondent in accordance with the prepared questionnaire (Polak  & Green, 2015).

This method enables him to acquire factual information, consumer evaluations, attitudes, preferences and other information coming out during the conversation with the respondent. Thus, face-to-face interview method ensures the quality of the obtained data and increases the response rate.

Interviews will be used because they fetch a variety of ideas needed for the study and give a deeper understanding of the topic. The method will be used to generate information from Executive Director.

3.6.3    Documentary review

This will be used to supplement the data that is acquired from the interviews and questionnaires. The researcher will analyze the documents and publications related to the study topic. Documents that are expected to be reviewed include; Kabale regional referral Hospital reports, Journals, and Newspapers.

3.7 Data collection instruments

For each deployed data collection method, there is a corresponding data collection instrument that will be used. The study will use Questionnaire Guides, Interview Guide and Document review checklist as described in the sub-sections below.

3.7.1    Self-administered Questionnaire

The questionnaire shall be designed in a manner that motivates respondents with simple structured questions with the option of providing any addition information to the structured questionnaire as an option to obtain relevant data from them. The questionnaire is structured with both close-ended and open-ended questions. It has aLikert scale 1-5 indicating the level of a respondents’ agreement or disagreement, where 1 represents Strongly Disagree and 5 stronglyAgree.

3.7.2    Interview Guide

The researcher will use an interview guide to collect data in order to find out the vivid picture of the participants’ perspective of the topic. Interviews are an effective qualitative method for getting people to talk about their feelings, opinions and experiences. They are also an opportunity for us to gain insight into how people interpret the study topic. The views of the respondents is a personal reflection of their personal experience relating to the study topic. Open ended questions will be allowed to ease of expression and capture of vast information from study participants.

3.8 Data quality control of instruments

The data collection tools will be pre-tested on a smaller number of respondents from each category of the population to ensure that the questions are accurate.

3.8.1 Validity

Validity is defined as the extent to which results can be accurately interpreted and generalized to other populations (Oso & Onen, 2008). While Borg & Gall, 1989 as cited in Onyinkwa, (2013) validity is defined as the degree to which results obtained by the research instrument correctly represented to the phenomenon understudy and Mugenda & Mugenda, (1999) as the accuracy and meaningfulness of inferences which are based on the research results.

Amin, (2005) recommended minimum CVI of 0.7 to be used. Validity will be tested using content validity index which involves judges scoring the relevancy of the questions in the instruments in relation to the study variables.

The formula for Content Validity Index will be;

CVI =

Where CVI = content validity

n= number of items indicated relevant.

N = total no. of items in the instrument

In this study, validity will be achieved by establishing content validity. The researcher will  achieve content validity by using the experts to assess the validity of the research instrument.

The experts especially research supervisors and consultants from UMI will be given data collection tools to assess whether the items in the instruments are valid in relation to research topic, objectives, and questions. From the instruments they will declare some items valid and others invalid. Those declared invalid will be dropped, others adjusted, while the valid ones will be maintained.  Then content validity index (CVI) will be computed by dividing the number of items declared valid by total number of items/questions in the data collection instrument.

3.8.2 Reliability

According to Mugenda and Mugenda, (2003) reliability is the measure of the extent to which research instruments are able to provide the same results upon being tested repeatedly. Crobach’s coefficient alpha (a) as recommended by Amin, (2005, P.302) will be used to test the reliability of the research instrument. The instrument is deemed reliable if chronbach’s alpha of 0.7 and above is obtained and therefore, it will be adopted for use in the data collection.

Formula for reliability is

=       ( )

Where  = alpha reliability co efficiency.

K=Number of items included 4 in the questionnaire

= sum of variance of individual items

= variance of all items in the instrument.

To ensure credibility and trust worthiness of qualitative data the researcher will ensure that only the officials who are employees of Kabale regional referral Hospital will be interviewed.

How about validity for the interview guides

3.9 Procedure of data collection

The researcher will obtain an introductory letter from Uganda management institute to seek permission and enable easy access of information by the researcher from Kabale Regional Referral Hospital, after the permission is granted from the Hospital, the researcher will go ahead and administer questionnaires and interview selected respondents. The consent of the respondents will be sought before being given questionnaire and the respondents will be informed that the study is strictly for academic purposes.

3.10 Data analysis

Mugenda and Mugenda (1999) and Mbaaga (2000) both defined data analysis as a process of bringing order, structure and meaning to the data gathered to create information out of it. Data analysis will therefore be done with quantitative and qualitative methods. The quantitative (Questionnaires) and qualitative (interviews) will be analyzed separately and then combined during discussion of the findings.

3.10.1  Quantitative Data Analysis

Data processing will be done by entering the data into a statistics package for social sciences (SPSS) version 24.0 in line with the research questions. Data analysis will be done by also using this statistics package for social sciences (SPSS) to formulate frequency tables will the percentages, frequency, mean, variance and standard deviation will be obtained.

Under quantitative analysis, process includes; editing, classification, coding and presentation. Data will be summarized in frequency tables, percentage; data will be analyzed with the use of statistical package for social scientist (SPSS). Quantitative data will be collected through structured questionnaires and it will be cantered into a computer, tabulated and analyzed.

Spearman’s correlation coefficient and regression analysis is recommended by Amin (2005, P.378) will be used during data analysis in order to test the strength, degree and direction of the study topic. The formula will be used for this study because it is compatible with SPSS program in addition to being appreciated in analyzing data under which the data is arranged.

3.10.2 Qualitative Analysis

Qualitative data will be analyzed using content analysis.it involved gathering and analyzing data based on the content, where by the raw data collected from the field will be read through to enable the researcher to get familiar with the data. At this process the study will use noted cards to organize the available data to accelerate further analysis. Data will then be evaluated and analyzed to determine its accuracy, credibility, usefulness and consistency which will aide acceptance or rejection of the research hypothesis.

3.11Measurements of variables

A five point Likert ordinal scales ranging from; strongly agree which will be assigned 5, strongly Agree, 4 agree, Not Sure assigned 3, Disagree allocated 2 and strongly disagree allotted 1 to obtain responses on the variables. The Likert ordinal scale has been used by numerous scholars who have conducted similar studies such as Bowling, (1997).

3.12Ethical considerations

The researcher will ensure that before giving questionnaires to the respondents their consent is sought and when they accepted to participate in the study, they will be given questionnaires.

Confidentiality of the respondents ‘information will be assured and the researcher also informed that the study is strictly for academic purposes and therefore, they should not fear giving information.

Only respondents who are selected will be given questionnaires and only those meant to be interviewed will actually be interviewed.

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Daniels, K., Odendaal, W. A., Nkonki, L., Hongoro, C., Colvin, C. J., & Lewin, S. (2019). Incentives for lay health workers to improve recruitment, retention in service and performance. The Cochrane Database of Systematic Reviews, 2019(12).

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