What motivates and retains health workers in Pakistan?

Author(s) Ali Mohammad Mir1, Gul Rashida2.
Affiliation(s) 1Program and Research, Population Council, Islamabad, Pakistan, 2Training Department, Population Council, Islamabad, Pakistan.
Country - ies of focus Pakistan
Relevant to the conference tracks Health Workforce
Summary Pakistan is a long way from achieving its Millennium Development Goals (MDGs) four and five. The national study on “Assessing Retention and Motivation of Public Healthcare Providers (Particularly Female Providers) in Rural Pakistan” was carried out by the Population Council to assess the core issue of availability of health providers, especially female providers and to ascertain the link between retention in the public sector and to identify factors that motivate providers to offer high quality services. This research tackled the confluence of job-related, institutional, demographic, social, and economic issues that health workers face in rural Pakistan.
Background One of the critical issues influencing reproductive health indicators in Pakistan has been access to services that impinge closely on the availability and quality of appropriate health care providers. This constraint applies in particular to women and their special needs, given limited autonomy and mobility especially in rural and distant areas. However, female providers in these remote areas are also confined by the same societal values as the women they serve. This is especially the case for women working in areas to which they themselves do not belong. The problem is self-reinforcing: areas that are backward in terms of female education and reflect the poor status of women are unlikely to have trained female providers. These areas lack indigenous healthcare providers and therefore have to depend on workers to come in from other districts. These workers require both residences and strong incentives to serve the villages and remote settlements they are relocating to. Therefore, it is important to address the core issue of availability of health providers, especially female providers and other issues such as work status and motivation, which affect the quality of care in Pakistan.
Objectives The main objectives of this project were to identify the core issue of availability of health providers, especially female providers that are required for provision of maternal and neonatal healthcare in Pakistan and determine the range of factors that either constrain or motivate providers to serve in key positions in public facilities in rural areas.
The following is a list of objectives that were identified for this study:
• To review and critically analyse past and existing intervention programmes on improving health worker retention in Pakistan and globally, and learn how the results were translated into specific policies;
• To analyse factors influencing the decisions and choices of health providers in rural and hard-to-reach areas by cadre (general, including MOs, WMOs, LHVs, nurses, dispensers and health technicians and specialists) and gender, on what motivates their retention or contributes to their leaving;
• To recommend strategies that can be employed in the provincial context to increase the retention of health providers in rural and remote areas in a sustainable manner, especially to improve maternal and newborn health outcomes.
Methodology A national study on ‘Assessing Retention and Motivation of Public Healthcare Providers (particularly female providers) in Rural Pakistan’ was conducted in 2012 in a representative sample of 28 randomly selected districts within eight regions in Pakistan. It consisted of a survey of health professionals interviewing 1365 providers and managers. A qualitative component comprised Focus Group Discussions with female providers and in-depth interviews with selected health providers and managers. Additionally, 533 primary, referral and tertiary care health facilities were assessed in the sampled districts to gauge the capacity of these facilities to provide MNCH services, as well as to explore the relationship between availability of equipment, medicines and supplies and health worker’s motivation and retention.We divided the country into seven strata. They comprised North and South Punjab, Sindh, KP, Balochistan, AJK (Azad Jammu Kashmir), Gilgit Baltistan (GB), and FATA. The reason for assigning two strata to Punjab was the vast differences between Northern and Southern Punjab. In the case of GB and FATA, we collapsed them into one stratum due to the paucity of health providers in these areas. However, due to the socio-demographic, cultural, political and geographical differences between GB and FATA, they were analysed as two separate strata.We randomly selected four districts on the basis of socio-economic index rankings and skilled birth attendance in each strata. One district per strata in the upper and middle socio-economic bands and two districts from the lower rung of district ranking were selected to over-represent the less or underserved areas of each strata. This was because we recognized that the problem of staff motivation and retention was greater in these areas. The oversampling of the lower-ranked districts was to ensure provider representation in precisely the areas where staff retention and motivation were problems.All facilities providing basic and comprehensive care, including teaching hospitals within the sampled districts were assessed as part of a situation analysis. Different levels of facilities that qualified as potential MNCH service outlets were randomly selected in each district, which included Districts Headquarter Hospitals, Tehsil Headquarter Hospitals, Rural Health Centres, Basic Health Units and Maternal and Child healthcare Centres.
Results The study findings reveal that a third of the providers are dissatisfied with their jobs to the extent that they would consider leaving for the private sector. The compelling factors include dissatisfaction with salary, political interference, lack of infrastructure and medicines. While the providers’ general level of satisfaction with their current jobs was high, more than half of them reported dissatisfaction with promotion opportunities, and more than a quarter of them were dissatisfied with the current method of annual appraisal. They reported that it lacked objectivity as it fails to capture staff performance and accomplishments. An important finding from this study is that 32% of all providers had never been promoted despite being in service for more than 16 years. These findings are a reason for concern as staff attrition can further compound the issue of staff non-availability in rural areas. Political interference was cited as a major issue impacting work by provinces in FATA and AJK.
The top three factors that motivated staff in their work included an opportunity to serve the community, professional growth and the respect accorded to them by the people because of the nature of their profession. Of the providers interviewed, nearly a fifth had not received any training at all since they joined the service signifying the need for having a Human Resource Development Policy. The research evidence raises serious concerns about safety and security issues confronting providers. Almost a quarter of providers reported not having a boundary wall around their facilities, which significantly impacts their perceived and actual safety levels. A fairly low proportion of providers are residing within the facilities due to non-availability of staff residences. This means long commutes from their residences to places of work. Compassion and altruism were identified as important reasons for joining as well as choosing to remain in government service.
This study also highlights some of the specific problems confronting female providers, such as issues of mobility, safety and security and community interference. These factors have been discussed in detail in the qualitative component of the report.
Conclusion This study identifies a number of problems faced by healthcare providers working in the public healthcare system in Pakistan. In order to increase the quality of and accessibility to healthcare, especially for women and children, policy makers must take steps to rectify the problems identified by the study. What is required:-
• Ensuring Implementation of a Human Resource for Health Management System: All provinces must ensure implementation of a “Human Resources for Health Management System” that includes the following components:-
• Training and development
A staff training and career development strategy must be established to include routine new and refresher trainings as part of a continuing education system.
• Filling of vacant posts
There should be a functioning MIS that can be used to dynamically identify areas of staff vacancies and these can then be filled either though redistribution of existing staff from urban to rural areas, or by hiring new staff.
• Strict adherence to organizational policies on recruitment, transfer, and promotion. All provincial health departments must adhere to the existing staff recruitment, promotion, and transfer policies.
• Improving the Physical Work Environment and Ensuring the Availability of Equipment, Medicine, and Supplies: All provinces must undertake a comprehensive facility infrastructure assessment; draw up a list of infrastructure repair, refurbishment and upgradation requirements and also carry out new construction such as of boundary walls and staff residences.
• Putting in Place a National Private Practice Regulation Policy: A national private practice regulation policy can contribute to improving providers’ performance as it will help in ensuring that they are able to rationally devote time to their official duties, both within and after office hours and to their private practice.
• Incentives for Attracting and Retaining Staff: A comprehensive rural services package needs to be developed that clearly incentivizes and makes working in the rural areas more attractive, especially for female providers. This should include monetary and non-monetary rewards, including a salary package that is competitive to the market.

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