TABLE OF CONTENT
Page
Cover page i
Title page ii
Approval iii
Certification iv
Dedication v
Acknowledgement vi
Table of content vii
List of tables viii
List of figures ix
List of appendix x
Abstract xi
Chapter One: Introduction
Background to the study 1
Statement of problem 3
Purpose of the study 4
Objectives of the study 4
Research Questions 5
Significance of the study 5
Scope of the study 5
Operational definition of terms 6
Chapter Two: Literature Review
Conceptual review 8
Recruitment and retention of health workers 8
Predictors to recruitment and retention in rural areas 11
Barriers to retention in rural areas 12
Attractors to rural posting 14
Community factors contributing to non-stay 15
Incentives to motivate health workers 16
Theoretical Review 19
Hertzberg’s two factor theory 19
Contingency theory 22
Conceptual framework 24
Empirical Review 26
Summary of Literature review 30
Chapter Three: Research Method
Research design 31
Area of study 31
Population of the study 31
Sample 31
Sampling technique 32
Instrument for data collection 32
Validity of instrument 33
Reliability of instrument 33
Ethical consideration 33
Procedure for data collection 33
Method of data analysis 34
Chapter four: Presentation of Result 35
Summary of Findings 47
Chapter five: Discussion of Findings 48
Conclusion 53
Limitation of the study 53
Summary 54
Recommendation 54
Suggestion for further studies 55
References
Appendices
List of Tables
Page
Table 1: Demographic data of the respondents 35
Table 2: Personal factors affecting non-stay of health workers in rural areas 36
Table 3: Institutional factors affecting non-stay of health workers in rural areas 38
Table 4: Community factors contributing to non-stay of health workers in rural areas 40
Table
5: Strategies to retain health
workers in rural areas 42
List of figures
Page
Figure
1: Hertzbergs two factor theory of
job satisfaction
20
List of Appendix
Appendix 1 Number of
professional health workers in Enugu State
Appendix 11 Sample size
calculation
Appendix 111 Sample of questionnaire
Appendix 1V Measure of reliability
test
Appendix V Ethical approval letter
Appendix VI Sample of the
informed consent form
ABSTRACT
A major challenge to the achievement of Millennium
Development Goals is the shortage of health workers in the remote areas,
especially in the developing countries where preventable disease burden is
high. The aim of the study was to determine perceived factors contributing to
non-stay of professional health workers in rural areas of Enugu state and
strategies to retain them. The study was a descriptive, cross-sectional,
questionnaire-based study carried out in randomly selected health districts of
Enugu state. A total of 236 consenting professional health staff with at least
two years working experience were randomly selected. A validated researcher
developed questionnaire was used to obtain information from the respondents. Data
were analysed using descriptive statistics and facilitated by the Statistical
Package for the Social Sciences (SPSS version 17.0). Findings revealed that there
were 70.8% females and 29.2% males in the study. Age distribution showed a mean
age of 33.8 with a standard deviation of 8.23. Family tie was the most
significant personal factor identified as contributing to non-stay of health
workers (P<0.0005). Among the institutional factors affecting non-stay of
health workers in rural areas, poor organizational policy and inadequate
reward/ recognition were considered very strong reasons for non-stay
(P<0.005). None of the community factors had a significant relationship with
the staff decision to stay or not stay in the rural areas. Suggested strategies
identified by respondents to retain health workers in rural areas included
paying more to professionals working in rural areas (92.79%), provision of
adequate security in the health centres (88.56%) and provision of rural
allowance (92.79%). It is therefore recommended that the observed factors
should assist stakeholders and government of Enugu State in formulating
effective strategies that would improve retention of health workers in the
rural areas.
Postings to the rural areas should be rotational and preferably staff family
locations should be considered. In addition, adequate remuneration and
motivation for staff working in the rural areas should be considered as ways of
improving shortage of professional health workers in the remote areas.
CHAPTER ONE
INTRODUCTION
Background to the study.
The
shortage of healthcare professionals in rural communities remains an
intractable problem that poses a serious challenge to equitable healthcare
delivery. Both developed and developing countries report
geographically skewed distributions of healthcare professionals, favouring
urban and wealthier areas (Wilson, Couper & De Vries,
2009). Rural communities are on the average poorer, less educated and have
higher disease burden; they also have worse access to health care than people
in urban areas (Wilson, Reid, Fish, & Marais, 2009). This discrepancy
between health care needs and service provision has been captured by Hart’s
‘inverse care law’, which states that those with the greatest health needs
usually have the worst access to healthcare services
(Flament, 2012). Rapid urbanization is a global phenomenon but it also poses
particular health problems in developing countries with poor infrastructural
development (Wilson, Reid, Fish & Marais, 2009). Improved access to
healthcare should therefore be seen as an indicator of the level
of development of any nation.
International
attention has recently been drawn to the problems of attracting, retaining and
motivating health workers in developing countries particularly in remote areas,
which has created human resource for health (HRH)
crisis (Williams, 2007). Health workers form the foundation of health service
delivery and therefore the staff strength, skill and level of commitment are
critical for the delivery of good, quality and effective health care (Serneels,
Montalvo & Lievens, 2010). Renewed attention is being given to the role of
geographical imbalances in the health workforce, a feature of nearly all health
systems. This raises concerns about the equity in access to health care as well
as the efficiency of allocation of human resources bearing in mind the impact
on health outcomes (Petterson, Serneels, Aklilu & Butera, 2010). The issue
is particularly relevant for developing countries with limited resources and
poor health outcomes. Ultimately, the difficulties to attract and retain staff
in rural facilities may also stem from the preferences and choice made by the
health workers. Furthermore, a growing body of evidence shows that apart from
wages, other job attributes like training opportunities, career development
prospects, living and working conditions may also play a role (Hays, Veitch,
Cheers & Crossland, 2007).
The
challenges in maintaining an adequate workforce that meets the needs of a
population with social, demographic, epidemiological and political transitions
require a sustained effort in addressing workforce planning, development and
financing. Skilled health workers are increasingly taking up job opportunities
in the global labour market as the demand for their expertise rises in high
income areas. It has been suggested that the rural to urban and international
migration of health workers in African countries inevitably leaves poor, rural
and remote areas underserviced and disadvantaged (Bach, 2003). Developing
countries often experience ‘urban-bias’ where the political and economic forces
support the provision of services and investment in urban areas to the
detriment of rural areas. This increases the disparities in health worker
distribution, access to services and health outcome (Zurn, Dal Poz,
Barbara
& Orvill, 2004).
A
regression of data for 117 countries found a significant relationship between
health worker density and maternal mortality rates (Gerein, 2006). Nigeria
has high numbers of healthcare providers, who together make up the largest
human resource for health in Africa. There are 52,408
doctors, 219,399 nurses and midwives, and 19,268 community health workers practicing
in the public sector (Professional Regulatory Agencies, 2008). However, these values translate to only 23
doctors, 112 nurses, and 64 community health workers per 100,000 people. To put these figures into context, European
health worker density values are 332 doctors and 780 nurses per 100,000 people
(World Health Organisation [WHO], 2008). Poor, rural communities experience the
lowest health worker densities, with three times as many doctors and two times
as many nurses practicing in urban areas as opposed to rural. These figures imply that the number of women
in rural areas giving birth unaccompanied by skilled birth attendants is
directly impacted by the understaffed rural health facilities.
Maternal
mortality continues to be the leading cause of death of women of reproductive
age in developing countries. Maternal death is primarily a result of the health
care system’s inability to deal effectively with complications during and
shortly after childbirth (World Health Report, 2005). Recruitment and retention of skilled workers,
particularly midwives, nurses, doctors, and obstetricians, are essential to the
provision of quality antenatal, delivery, emergency obstetric and postnatal
services. It is necessary to realize both the United Nations millennium
development goals (MDG) 4 (Reduce under 5 mortality) and MDG 5 (reduction of
maternal mortality) (MDG Report, 2006). Nigerian policy-makers are looking for
solutions. Researchers and development
agencies agree that the disproportionate rates in the developing world,
particularly Sub-Saharan Africa, are as a result of high rate of births
unaccompanied by a skilled birth attendant (WHO, 2005).
To
achieve the MDGs for health by 2015, improving access to key interventions such
as anti-retroviral therapy, immunizations, tuberculosis and malaria treatments
are top priorities for most health system (Adano & Vicks, 2008). However,
in addition to financial resources for commodities, improving access requires a
well-functioning health system and adequate workforce capable of delivering
interventions at a large scale (Drager, Gedik & DolPoz, 2006). The 2004
joint learning initiative report on human resource for health and others have concluded
that shortage and skewed distribution of health personnel especially in the
rural areas undermine the scaling up efforts, particularly in low income
countries (Bloom & Barnighausen, 2009). It is against this background that this study
sought to determine perceived factors that affect non stay of health workers in
rural areas of Enugu State.
Statement of problem
PERCEIVED FACTORS AFFECTING NON STAY OF HEALTH WORKERS IN RURAL AREAS OF ENUGU STATE
