Qualitative Health Worker Study in Ghana Preliminary descriptive findings

1. Qualitative Health Worker Study in GhanaPreliminary descriptive findings Tomas Lievens (Oxford Policy Management, UK) & Peter Quartey (ISSER, Univ. of Ghana) Health Summit, Ministry of Health, Accra, November 2007 This study has been funded by the World Bank

2. Presentation Outline • Micro-economics of health worker behaviour • Study methodology • Selected preliminary descriptive findings

3. Micro-economics of health worker behaviour • Health workers are key in service delivery • external migration, rural-urban & sector distribution, performance & motivation issues • Approach • longstanding issues = ∑ [individual decisions] • individuals decisions [where and how to work] = f(x1, x2, …, xn) • policy can impact on some xi

4. Micro-economics of health worker behaviour • Factors shaping decision making • intrinsic motivation • high => high performance on some dimensions + self-selection • low => need for extrinsic motivators to elicit high observable performance + need for monitoring • extrinsic incentives • remuneration, training, workload, opportunities for additional income generation • monitoring system • health workers have heterogeneous preferences => health workers assess every job opportunity against individual preferences and choose

5. Study methodologyChoice • Qualitative method • variables difficult to measure • relationships between variables • understand observed behaviour • health workers’ perception of HRH policies

6. Study methodologyChoice • Focus Group Discussions • group interviews • elicit and contrast views • quality filter & consensus view • Challenges • magnitudes are approximate • relative weight of variables often unknown • weak objectivity • leading a FGD

7. Study methodologyPreparation • Participant selection • within-group homogeneity • doctors, professional nurses, auxiliary nurses • within-group heterogeneity • age, gender, having children • sector and facility variation • group dynamics • 8 FDG with [7,9] participants • 4 FGD on external migration

8. Study methodology Preparation

9. Study methodology Preparation

10. Study methodology Preparation • Challenges in participant selection • female doctors • male nurses • private sector in rural areas • confusion about sector of employment • doctors tend to know each other

11. Study methodology Preparation • Interview scripts for semi-structured discussions • expert interviews, literature review, similar research in Ethiopia and Rwanda • different scripts for health workers and health users • “prompt” questions and “probe” questions

12. Study methodology Implementation • Framing - discussion took place in health facilities • Soft drink to relax atmosphere • Introduction to participants • ‘academic character’ • interventions based on personal experience • invitation to react upon others’ interventions • confidential and anonymous • digital recording • Average duration: 1h57 minutes

13. Study methodologyData processing • Digital sound files transcribed in English • QSR NVivo 7.0 • 54 codes, not pre-identified • 1,812 participants’ quotations • retention of quotes  recurrent or important theme in discussions • coding report • health warning: how to read the findings • what health workers reported in FGD • no analysis, no conclusions

14. Preliminary descriptive findings • Reporting of selected preliminary findings • intrinsic motivation • extrinsic incentives • monitoring • performance outcomes • career choices

15. Preliminary descriptive findings • Intrinsic motivation • health warning • description by health workers • help and serve people; empathy, care, love; compassion • high levels of intrinsic motivation leads to… • `availability, improvise, not strike, not migrate • interaction with extrinsic incentives • extrinsic incentives too low => erosion • extrinsic incentives too high => attract undedicated health workers + erosion?

16. Preliminary descriptive findings • Extrinsic incentives – remuneration • high variability, but decreased since salary enhancement • uncertainty • strike paid off well – but concern about reputational effects • flows • higher salaries attracts undedicated health workers

17. Preliminary descriptive findings • Extrinsic incentives – workload • high / too high / relation to remuneration • rural versus urban • increased through NHIS • workload and quality of care • health workers: high workload => reduction of time per patient • patients: don’t receive sufficient quality time from health workers

18. Preliminary descriptive findings • Extrinsic incentives – specific incentive schemes • ADHA • sensible idea, poor implementation • Deprived Area Allowance • sensible idea, poor implementation • high uncertainty • Access to post-graduate training • before and after the Ghana College • high uncertainty • Access to cars • high uncertainty • Other incentives • faith-based sector

19. Preliminary descriptive findings • Extrinsic incentives – training • dedication can be learned • further training associated with the public sector • on the job training associated with the rural sector • post-graduate and specialisation • frustration with access due to conditions • Extrinsic incentives – HIV/AIDS • many feel sufficiently informed • how to treat patients; how to protect themselves • protection is key • differential treatment of HIV+ patients

20. Preliminary descriptive findings • Monitoring • performance evaluation linked to promotion • system for promotion not necessarily highly rated • seniority primes over performance; not always objective; not transparent to all • strong implicit monitoring systems • users relatively vocal but feel powerless

21. Preliminary descriptive findings • Performance - absenteeism • far from infrequent • ill-defined and difficult to monitor • implicit monitoring • locum work

22. Preliminary descriptive findings • Performance - malingering (shirking) • rather exception than rule • users complain • related to the type of health worker attracted

23. Preliminary descriptive findings • Performance - moonlighting • very common, for financial reasons • dual practice associated with higher level workers and the urban sector • public => private sector duty roster • rota • moonlighting and quality of care • exhausting, loss of efficiency

24. Preliminary descriptive findings • Performance - health worker attitude • users complain, health workers admit • better attitudes in faith-based sector • better attitudes in rural versus urban sector • largely unsanctioned

25. Preliminary descriptive findings • Career choices – the public sector • bonding • guaranteed employment; uncertainty • competitive financial benefit package => flows • workload and attitude • health workers as well as users • bureaucracy in referrals • sector assets: remuneration, access to further training, stability/security

26. Preliminary descriptive findings • Career choices – the faith-based sector • rural facilities • workload and health worker attitude • many restrictions • close monitoring and supervision • numerous incentives • outputs: highly dedicated health workers (self-selection), high quality of care, positive attitudes to patients

27. Preliminary descriptive findings • Career choices – the private sector • entry barriers for self-employment • client-base, capital, equipment, knowledge of equipment • mostly locum staff / few permanently employed • locum staff: pay for time worked, only • outputs: good attitude to patients, shorter waiting times, less bureaucracy in referrals, well furbished practices

28. Preliminary descriptive findings • Career choices – rural and urban service • many positive aspects of rural service • in-depth clinical experience, management experience, social recognition, saving opportunities • negative aspects also depends on health worker profile • female workers, singles, children, individual tastes • some health worker profile greater inclination to rural service • self-selection into rural areas • benefit-package for rural service • actual transfer policy = cumbersome, high-risk, inconsistent

29. Preliminary descriptive findings • Career choices – external migration • pull-factors • financial, ability to offer quality care • push factors • frustration with entering post-graduate training, promotion • external migration has become more difficult over time and slowed down with salary increases • negatively perceived in Ghana (norms) • tax money for education, money-loving health workers • those that want to migrate self-select into the health sector • families play an important role • pressure to enter health sector, migrate / help to leave / to settle in foreign country

30. Next steps • Refine and finalise descriptive findings • Similar exercise for the 4 ‘migration’ FGD • Develop hypotheses for policy formulation • Indicate areas for further research