Recruitment and retention of human resource for health

Introduction

No country can develop without healthy people; this is because poor health is one of the sources of low labour productivity. A nation cannot have healthy people if there is no effective healthcare system. In this regard, the most critical factor that determines the quality of healthcare is the quality and quantity of human resources. Although every nation aspires to have the right number of people who are most knowledgeable, skilled, and with the right attitude and motivation, this has remained a challenge for most nations (CIPD 2008).

Various specific studies have unearthed the extent and causes of labour shortages in both developed and developing countries. For example, in the United Kingdom, job dissatisfaction was a major contributor for nurses quitting their jobs (Shields & Ward 2001). The same conclusions were reached in Taiwan (Tzeng 2002). In Japan, recruitment and staff retention is a serious problem particularly in rural areas where both monetary and non-monetary reward environments were not favourable (Matsumoto et al. 2009). In South Africa, studies showed a strong positive correlation between job dissatisfaction among nurses and turnover (Pillay 2009). Earlier, in 2000/2002, statistics show that Uganda had a shortage of 3,172 health workers (Bataingaya 2003). Therefore, as correctly observed by Martinez & Martinez (2002) and Wyss (2003), the major problem, and which is more serious in developing countries than in other countries, is limited government ability to train, attract, and reward staff.

In Tanzania, despite strong health reform initiatives and success in the improvement of healthcare infrastructure and supplies, human resource shortages are equally critical. For example, during the 2003/2004 financial year, the government supported community efforts to build 175 dispensaries. The increase in infrastructure led to the increase in the supply of drugs by twenty five percent and equipment by thirty percent (URT 2004; PO-RALG 2004). However, this achievement cannot by itself improve healthcare if it does not match with the improvement in human resource capacity in terms of numbers and competencies. A study conducted by the World Health Organisation estimated that Tanzania has 48,508 health workers, of whom 822 are physicians and 13,292 are nurses (WHO 2006), but the country was found to have the lowest physician/population ratio in the world. The same study shows that the country has 717 assistant medical officers with practical clinical skills comparable to those of physicians. In addition, there were 5,642 clinical officers, who undertake a substantial share of the clinical practice. Medical assistants, with little or no formal training, constitute a large share (40%) of the healthcare workforce (Munga & Maestad 2009).

Labour shortages in the health sector have contributed to the worsening of health in Tanzania particularly in women and children. The Ministry of Health (URT 2005) asserts that maternal healthcare services and child malnutrition do not seem to have made any improvements over the last two decades, partly due to among others, a lack of sufficiently skilled and motivated staff, although patchy successes are noted elsewhere particularly in more wealthy and urbanised areas (URT 2003). As a result of these multiple factors, it is estimated that eight out of ten children die at home and 6 of them without any contact with formal healthcare, while ninety percent could be cured (URT 2005). It is worse in rural areas where health workers are less attracted due to a difficult working environment and lack of government capacity to attract and retain such workforce (Itika 2007).

At the end of the chapter, the learner should be able to:

· Appreciate the challenges facing human resources in health.

· Establish the relationship between theoretical and practical issues that influence staff recruitment and retention.

· Develop initiatives for improving human resource management for health in a constrained environment.

Recruitment and retention of health staff as a global issue

A survey of 779 organisations in the United Kingdom (CIPD 2008) showed difficulties in recruitment by 86% of the cases. There are a number of reasons including lack of necessary skills (70%), higher level of employees’ expectations (44%) and lack of skills (42%). Seventy five of the organisations surveyed had adopted a strategy of appointing those with the potential to grow. There were also serious problems of staff retention by 80%, which was addressed through more pay by 53%, and learning and development by 46% while the improvement of selection process helped by 46% (CIPD 2008).

Healthcare personnel to population ratios in Africa have been high and have always lagged behind the rest of the world. For example in the 1980s, one doctor catered for 10,800 persons in Sub-Saharan Africa (SSA), compared to 1,400 in all developing countries and 300 in industrialised countries (USAID 2003). In the same period, one nurse served 2,100 persons in Africa, compared to 1,700 persons in all developing countries and 170 in industrialised countries (World Bank 1994). The provider-to-population ratios remained persistently high in the 1990s, with most countries having 1 doctor per 10,000 populations or more. In fact, ten countries have 1 doctor per 30,000 populations. Other countries like Bolivia, Honduras, and India have 1 per 2,000 or 1 per 3,000 ratios. Thirty one countries do not meet the WHO’s ‘Health for All’ standard of 1 doctor per 5,000 members of the population.

The HR crisis has been best documented in three southern African countries including Malawi, Zambia, and Zimbabwe (USAID 2003). According to USAID studies, poor economic growth and consistent fiscal difficulties appear to be the major cause of the crisis. First, budgetary frugality reduces African governments’ ability to attract, retain, and maintain the morale of professional healthcare workers, as treasuries are unable to raise salaries and improve working conditions, especially of skilled staff. Second, because medical and nursing training in Africa is mostly government provided or financed, fiscal crises have also severely limited governments’ capacity to train healthcare workers. This double pressure on the training and retention of health workers has created shortages in key areas such as doctors, clinical officers, medical assistants, nurses, midwives, and laboratory technicians.

Until recently, Zambian law forbade nurses and midwives from prescribing medicines and carrying out any invasive procedures (USAID 2003). These functions were restricted to doctors and clinical officers (although the latter have the same length of training as nurses). The critical shortage of clinical officers let alone doctors, in Zambia made it impossible to follow this law at rural healthcare centres, where there were long queues of patients. In early 2001, the Zambian law was amended to authorise nurses to prescribe and to insert drips.

Moonlighting and finally voluntary departure from the civil service for more lucrative local employment has also constrained the African health sector labour market in recent years (USAID 2003). A major factor has been the rather quick liberalisation of healthcare in countries such as Malawi, and Mozambique resulting in trained ministry of health, civil servants moving to private practice, either individually or with non-profit or for-profit healthcare providers. Service providers (especially doctors) may opt to initially maintain two jobs, keeping their civil service posts while moonlighting on the side. Countries may formally allow this double-practice, even in government healthcare facilities, as in Mozambique. While this looks like a reasonable arrangement, it has tended to result into the disappearance of civil servants who report to duty on shorter work-hours. It has also resulted into the displacement of poor patients by private-paying patients in government facilities. As medical practice is privatised, doctors may eventually opt to only practice privately. Pharmacists and, to a lesser extent, laboratory technicians are more likely to completely move to the private sector, as has been shown in Ghana (Ghana MoH 2000).

The proliferation of NGOs in the 1990s caused an exodus of health workers from the government service, either as direct health providers, programme managers, or consultants. NGO health projects attract a wide range of government health professionals since the pay is much better and the work is similar to that of the civil servants, hence very little retraining costs are needed. With hindsight, the lack of a pre-service training programme for the NGO’s demand for healthcare professionals meant that NGOs had little recourse but poach from the existing civil service pool. Therefore, the problem of recruitment and retention is global and it has largely been attributed to insufficient supply of workers and limited ability to attract and retain.