Analysis of attraction and retention strategies of experienced health personnel by Gweru Municipality of Zimbabwe
OtI in a Ma kond a (M ara)
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060042436p North-West UniversityMafikeng Campus Library
Student Number: 23231408
Dissertation submitted in fulfilment of the requirements for the Master of Business Administration degree at the Mafikeng Campus of the North-West University
Supervisor: Dr G. N. Molefe
August 2013
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DECLARATION
I hereby declare that the mini thesis submitted for the degree (Master's Degree in Business Administration at North-West University), is my own original work and has not previously been submitted to any other institution of higher education. I further declare that all sources cited or quoted are indicated and acknowledged by means of a comprehensive list of references.
ACKNOWLEDGEMENTS
Firstly, I am indebted to God Almighty, the Creator, Provider and Sustainer who enabled me to complete this study. Secondly, I thank my very supportive husband, Livingstone, our sons Munyaradzi and Munashe and the only daughter, Mutsawashe for their endurance, patience and support during the study period. My extended family and brother Simbarashe are also thanked for their diverse support. I also thank my brethren, work mates, study mates and Batswana High principal and educators who supporting me in many ways. I also take this opportunity to thank the North-West University and the University of Venda for partially funding this study. I also recognize the astute role played by the statistician Mr Phemelo Seaketso in shaping this study. Lastly, this study materialized because of the insightful academic support rendered by Dr G.N. Molefe of the Faculty of Commerce and Administration at the North-West University, Mafikeng Campus. To all, may the soon returning Saviour Jesus Christ richly sustain and continue to bless them till His advent.
ABSTRACT
Purpose
This study examined the extent to which Gweru Municipality (GM) is managing to attract and retain properly qualified health professionals.
Design
This research is predominantly quantitative. Methodology
This research focused on eleven health centres in eleven randomly selected suburbs in GM. After permission was granted by the GM management, questionnaires were distributed to GM human resources staff responsible for the Health Department and health practitioners. A total of 194 questionnaires were returned. The findings of this study have been presented in tables and figures. Correlation coefficient analysis was also done to help establish variables that greatly influence the attraction and retention trends of health professionals at GM.
Result
It emerged that GM is failing to attract as well as to retain properly qualified health professionals hence the very low numbers of senior doctors, senior nurses and specialists of diverse areas. The factors that influence attraction and retention are of the correlation coefficients ranges of 0.5 to 0.959. This study established that five variables feature most in the linear relationship between random variables considered for this study. The results identify question 10 'how well paid are you for the work you do?' having been mentioned 14 times with questions 6 'how many opportunities do you have to get promoted where you work?, question 8 'are you proud of GM's attraction of qualified health professionals?' and question 9 'how meaningful is your work?' being mentioned 13 times each while question 7 'how easy is it to balance your work life and personal life while working at GM?' was mentioned 12 times.
Conclusion
This study concludes that attracting and retaining properly qualified and experienced health professionals is key for attainment of enhanced service delivery. Therefore, GM management need be proactive and improve on all identified militating variables.
TABLE OF CONTENTS PAGE
Declaration...ii
Acknowledgements...iii
Abstract...iv
Table of contents ... V Chapter 1 Background to the study...1
1.1 Introduction... 1
1.2 Background and context... 4
1.3 Problem statement... 6
1.4 Research objectives... 6
15 Research questions... 7
1.6 Importance of the study... 7
1.7 Research design and methodology... 8
1.8 Ethical requirements... 8
1.9 Representative sampling... 8
1.10 Data analysis... 9
1.11 Limitations of the study... 9
1.12 Chapter outline ... 9
1.13 Summary... 10
Chapter 2 Literature review...11
2.1 Introduction...11
2.3 Global retention strategies...14
2.4 Global retention challenges...18
2.5 African countries health staff attraction and retention trends...20
2.6 Zimbabwe health staff attraction and retention trends...26
2.7 Summary...30
Chapter 3 Research design and methodology...31
3.1 Introduction...31
3.2 Overview of research methods...31
3.2.1 Quantitative research...32
3.3 Description and justification of questionnaire as instrument...32
3.3.1 Why is a questionnaire important9 ... 32
3.3.2 Objectives in designing questionnaires... 33
3.3.3 Questionnaire design process... 33
3.3.4 Wording of individual questions...34
3.3.5 Length of questionnaire ... ... 35
3.3.6 Getting started... 35
3.3.6.1 How to administer questionnaires... 36
3.3.6.2 Piloting and evaluation of questionnaires... 36
3.4 Sampling... 37
3.5 Population of the study... 38
3.6 Explanations of components of the research instrument... 38
3.6.1 Section A: Biography...38
3.6.2 Section B: Questions ... .39
3.6.3 Section C: Consent...39
3.8 Ethics .40
3.9 Summary ... .40
Chapter 4 Results and discussions...41
4.1 Introduction...41
4.2 Presentation and analysis structure...41
4.2.1 Identify your age group7 ... 41
4.2.2 Gender...42
4.2.3 Race...43
4.2.4 For how many years have you worked in the health sector...44
4.2.5 What is your job title? ... 45
4.2.6 How many opportunities do you have to get promoted where you work? ... 47
4.2.7 How easy is it to balance your work life and personal life while workingat GM'? ... 49
4.2.8 Are you proud of GM's attraction of qualified health professionals'? ... 50
4.2.9 How meaningful is your work? ... 52
4.2.10 How well are you paid for the work you do'? ... 53
4.2.11 To what extent is your department adequately staffed'? ... 55
4.2.12 Are you satisfied with your job? ... 56
4.2.13 Is GM positive about retaining qualified health professionals'? ... 57
4.2.14 How likely are you to look for another job outside GM'? ... 60
4.2.15 Your workload is manageable'? ... 62
4.2.16 Are you supervised adequately'? ... 63
4.2.17 How comfortable is GM's work environment'? ... 65
4.2.18 Kindly comment on GM's health insurance plan... 66
4.2.20 How well did the members of your team work together to reach a
commongoaP ... 70
4.3 Correlations...72
4.4 Summary...77
Chapter 5 Conclusions and recommendations... 78
5.1 Introduction... 78
5.2 Research questions ... 78
5.3 Findings as per research question... 78
5.4 Limitations of the study... 82
5.5 Recommendations... 82
5.6 Suggestions for future research... 83
5.7 Final conclusion... 83
List of references...85
Annexures...96
5nnexure Confirmation of language editing...96
A Annexure Study questionnaire...97
B Table for determining sample size from a given Annexure
c
population...104Annexure Research Approval by Gweru Municipality...106
D List of Figures Figure1 Agegroup ... 42
Figure 2 Working years at GM... 44
Figure 3 Promotion opportunities ... .48
Figure 4 Proud of GM attraction... 51
Figure 5 Satisfied with GM job? ... 56
Figure 6 How likely are to look for another job outside GM... 61
Figure 7 Amount of supervision... 64
Figure 8 Comparison of health plans... 68
Figure 9 How well is team work... 71
Table 1 Gender
.43
Table
2
Race ...43
Table
3
Job title...46
Table
4
Work and personal life balance...49
Table
5
Meaningful work...52
Table
6
How
well paid are you at GM...54
Table
7
GM positive about retaining qualified health professionals...58
Table
8
Workload...62
Table
9
How
comfortable is GM's work environment...65
Table 10
How
consistently does your supervisor reward you for good work.69
Table 11 Correlations...73
CHAPTER ONE
BACKGROUND TO THE STUDY
1.1 INTRODUCTION
The lack of health workers in remote and rural areas is a worldwide concern. Many countries have proposed and implemented interventions to address this issue, but very little is known about the effectiveness of such interventions and their sustainability in the long run (Dolea, Stormont & Braichet, 2010). Dolea, Stormont and Braichet (2010) provide an analysis of the effectiveness of interventions to attract and retain health workers in remote and rural areas from an impact evaluation perspective. It reports on a literature review of studies that have conducted evaluations of such interventions. It presents a synthesis of the indicators and methods used to measure the effects of rural retention interventions against several policy dimensions such as: attractiveness of rural or remote areas, deployment/recruitment, retention, and health workforce and health systems performance.
Grabher (2011) study submits that looking at the working and living conditions and the salary levels many health workers endure, particularly in rural governmental facilities, one may wonder that any staff members remain at all, and that seeking bribes from patients is not even more common. The Public Expenditure and Tracking Survey (PETS) by the World Bank conducted in Zambia in 2008 showed that there was a 57% absenteeism rate in the rural areas - for various reasons such as attending trainings, moonlighting, malingering, attending funerals and taking extended sick leave.
Many health workers appear demotivated and frustrated because they are unable to offer effective care to patients due to inadequate resources in health facilities, especially in rural areas where the infrastructure is worse (Grabher, 2011). Inappropriately applied management and supervision tools add to their dissatisfaction. Workforce motivation not
only has a direct positive influence on their service delivery but also encourages long-term retention.
From Manafa, McAuliffe, Maseko, Bowie, MacLachlan and Normand (2009) this study learns that a range of factors, including worsening socioeconomic conditions in much of sub-Saharan Africa, increasing mobility and migration of health workers and the absence of strategies to train and retain adequate supplies of appropriate health workers, contributes to the resource drain. Their study is also important for noting that depletion of human resources is particularly acute at the district and community levels, as there are fewer incentives and supports available to attract and retain staff. There is also a lack of understanding of the factors that motivate and attract staff to work at district and community level. In the absence of this information, Manafa et at. (2009) conclude rightly that it is difficult to develop effective human resources strategies.
The study by Ebuehi and Campbell (2011) is important for showing that rural health workers were generally more likely to work in rural settings (62.5%) than their urban counterparts (16.5%). Major rural motivators for both groups included: assurances of better working conditions; effective and efficient support systems; opportunities for career development; financial incentives; better living conditions and family support systems. The main de-motivator was poor job satisfaction resulting from inadequate infrastructure. Rural health workers were particularly dissatisfied with career advancement opportunities. More urban than rural health workers expressed a wish to leave their current job due to poor job satisfaction resulting from poor working and living conditions and the lack of career advancement opportunities.
Previous reviews of retention strategies found that financial incentives can improve recruitment and retention in the short-term, but long-term impact on retention is less certain (Barnighausen & Bloom, 2009; Buykx, Humphreys, Wakerman & Pashen, 2010; Sempowski, 2004). These studies found unintended negative consequences from design and implementation shortcomings. Our findings contrast with those of Reid (2004) who found that between 28 and 35 per cent of his study population, mainly professional nurses, remained in rural hospitals as a result of the rural allowance. Reid
(2004) collected data soon after the implementation of the policy and near in time to the large back-dated payouts received by health professionals. Both could have influenced responses. In the absence of before and after studies, evidence on the effectiveness of financial incentives remains inconclusive (Buykx, Humphreys, Wakerman & Pashen, 2010).
Some studies found that financial incentives alone are insufficient to motivate and retain health professionals (Largade & Blaauw, 2009; Willis-Shattuck, Bidwell, Thomas, Wyness, Blaauw & Ditlopo, 2008). Some demonstrated that non-financial incentives related to working and housing conditions had greater potential to influence retention (Wilkinson, Symon, Newbury & Marley, 2001; Wilks, Oakley Browne & Jenner, 2008). Others recognized that health professionals will always move, often for reasons beyond the influence of any workforce retention programme, no matter how well designed (Buykx et at, 2010). Thus, no single measure is likely to improve motivation and retention if other factors are not taken into consideration.
The study by Grabher (2011) shows that the health sector is not only characterized by inadequate HR training and education systems which result in the insufficient production of various categories of health workers. The problems are aggravated by factors such as insufficient funding allocations to health ministries, a lack of strategic human resources planning, insufficient staff audits, comprehensive recruitment and retention strategies, weak management and a global competition for scarce human resources for health. Just increasing the stock of health workers and their skills will not change the fact that vacancies in rural health facilities remain unfilled while many of the best clinicians either end up in industrialized countries, private practice or in NGOs most likely in the urban areas. To this end, more of Malawi and Zimbabwean doctors, among others, are practicing in countries like Britain and Canada than in Malawi or Zimbabwe. Staff members serving at rural health facilities are often only nominally available full-time. The study by Grabher (2011) notes that the rest of the time health professionals moonlight other jobs or work in agriculture or in private practice. Studies from Tanzania
indicate that in some settings, health workers spend only 50 to 60 percent of their time on productive public health activities.
The study by Manafa et al. (2009) also points out that human resources is a major problem facing Malawi. This has seen most of the district health services being provided by clinical health officers specially trained to provide services that would normally be provided by fully qualified doctors or specialist, a situation similar to the developments at Gweru municipality health facilities in Zimbabwe. The study by Manafa et al. (2009) then proceeded to explore how these cadres are managed, motivated and the impact this has on their performance.
From Michal, Nissly and Levin (2001), it emerges that many studies use intention to leave instead of, or in addition to, actual turnover as the outcome variable because there is evidence that before actually leaving the job, workers typically make a conscius decision to do so. Also, in a study conducted by Pillay (2009), public sector nurses felt employment security, workplace organisation and the working environment were the most important factors, whereas the private sector nurses rated workplace organisation, employment security and professional practice as being the most important. Pertinent to this study are the findings by Pillay (2009) that younger nurses, nurses in the public sector and nurses from the more rural provinces were significantly less likely to be in their current positions within the next five years. Similarly, Mrara
(2010) study dealt with the intentions to stay or leave the organisation rather than the
actual reasons as to why the employees will leave or stay.
1.2 BACKGROUND AND CONTEXT
Since the attainment of independence in 1980, the Zimbabwean government constituted and conferred Municipalities governing powers of their localities. This move, among others meant that the Municipalities had to appoint Executive Mayors and Town Clerks who were to be the principal governing officials. Furthermore, the municipalities, on
behalf of the ruling party and the government of the day, had to ensure that residents get state of the art service delivery. To ensure that this is achieved, councillors would be appointed by the residents so that they represent their voices in the day to day municipal operations. The rational, among others was to ensure easy governance as well as the streamlining and standardization of efforts meant to ensure the provision of quality service to residents.
Municipalities are constituted to provide diverse service to their immediate localities within the specifications and expectations of the local communities and the government. To achieve this, municipalities must have the ability to attract and retain properly qualified and experienced Health personnel, among others, who can help in the achievement of the stated core municipal mandate. Yet, according to Chakeredza, Temu, Saka, Munthali, Muir-Leresche, Akinnifesi, Ajayi and Sileshi (2008) the current brain drain needs to be stemmed and the first step is to identify and solve the problems that lead to brain drain. This study reckons that there are professional, social and security reasons which require intensive studies which might be contributing to the challenge Gweru municipality (GM) is facing in the attraction and retention of properly qualified and experienced health staff.
This study draws heavily from the researcher's experience and insights as a Human Resource Manager and GM resident for 5 years.This experience exposed the researcher to Strategic Human Resource Planning (SHRP) issues GM management has to consider to ensure the availability of "the right number of qualified people into the right job at the right time" (Grobler, Warnich, Carrell, Elbert & Hatfield, 2006:131) within the 8 Human Resource Management (HRM) critical outcomes of ensuring that qualified and experienced health staff are available, competent, motivated, healthy, diverse, organised, focused and satisfied (Ehlers, 2011).
1.3 PROBLEM STATEMENT
This study's problem statement is:GM is failing to attract and retain properly qualified personnel in the Health department. This study choose Gweru firstly because the researcher was a resident and employee of the municipality hence had some experiences of the scope of this study. Also, Gweru, the third largest city in Zimbabwe was chosen because of its centrality in terms of it being located in the heart of Zimbabwe especially between Bulawayo and Harare, the second and first cities respectively. Gweru was also choen because it was assumed that its central location and efficient transport system makes it conducive for attracting investors and employees from all corners of Zimbabwe and beyond the borders.
Due to the effects of political polarization since the 1990s, the resultant economic downturn, economic hemorrhage and smart economic sanctions, many senior qualified personnel from diverse professions have left their employment for greener pastures within and outside the country. This turnover has seen Zimbabwean professionals looking and getting employment in countries like Zambia, Botswana, South Africa and United States of America among others. Conversely, employment opportunities opened up in Zimbabwean cities like Harare, Bulawayo and Mutare among others, developments which resulted in the city of Gweru failing to retain its qualified personnel in the health department.
1.4 RESEARCH OBJECTIVES
This study is driven by four objectives whose intend is to:
1.4.1 Mention the importance for GM to attract and retain qualified health personnel.
1 .4.2 Identify what GM could do to recruit qualified health personnel. 1 .4.3 Determine if GM is doing enough to retain qualified health personnel. 1.4.4 Highlight strategies that GM could implement to retain qualified health
1.5 RESEARCH QUESTIONS
These four research questions drive this study:
1.5.1 Discuss the importance for GM to attract and retain qualified health personnel? 1 .5.2 How could GM recruit qualified health personnel?
1 .5.3 What is GM doing to retain qualified health personnel?
1 .5.4 Identify which strategies GM could use to retain qualified health personnel?
1.6 IMPORTANCE OF THE STUDY
Firstly, this study would shed light to prospective and existent employees on the need to be properly qualified so that their prospective and existent employers can retain them. Employers will learn from insights shared in this study of the best practices of handling attraction and retention of properly qualified employees.
This study is crucial as it contributes to the body of knowledge on attraction and retention of qualified personnel in the Health department. Insights from this study will help the health and related sectors and employers caught in similar situations to consider innovative ways of attracting and retaining properly qualified personnel.
Policy makers will also benefit from clues from this study so that they can meaningfully contribute towards stabilizing the issue of high staff turnover in municipalities and towns like GM. Also, municipal residents will be encouraged to support the municipality when they reckon that it is involved in doing all within its powers to retain critical service delivery staff.
Non-governmental, the general populace and interested civic groups will come to know the challenges prevalent in the health sector due to failed attraction and retention efforts. To this end, they will have a fuller appreciation that this challenge can best be
handled if role players join hands in ensuring that employees are retained so that service delivery does not dwindle and collapse.
1.7 RESEARCH DESIGN AND METHODOLOGY
This study is predominantly a quantitative study. A questionnaire with 20 items was designed and approved. The researcher then went to Zimbabwe to self-administer questionnaires at GM health centres as well as to the human resource personnel at the GM head office.
1.8 ETHICAL REQUIREMENTS
The researcher got permission to carryout this study from the GM (refer to annexure D) management. The researcher made it clear that the respondents' confidentiality would be the given responses. Also, it was agreed that the respective institutions would not be named hence the umbrella GM reference was settled for.
1.9 REPRESENTATIVE SAMPLING
During 2006-2008, GM had 235=n qualified health personnel and 70n GM HRM manning the 11n health centres in the Mkoba 12,Mkoba 20, Mutapa, Sundowns, Athlorne, Mambo, Senga, Regimond, Gweru Central, Nehosho and Ascot areas under study. From Sekaran (2003:253) (see annexure C), it emerged that a total of 205 respondents are representative enough for a total population of 305. The 205s were got through random sampling from 59=s health staff at the GM Head Office Health department and from 146 health staff at clinics and hospitals in the 11=s residential areas under examination that comprise the GM.
1.10 DATA ANALYSIS
The researcher hired a statistician who coded data for this study and analysed it using Software Package for Social Sciences (SPSS) (IBM SPSS statistics2l) to determine the frequency and correlation among others relevant to the study's scope. Tables and figures were used to graphically present the data.
1.11 LIMITATIONS OF THE STUDY
The researcher could have relied on exit interview data but the supposed view that many leaving staff in the health department do not turn up for exit interviews led the researcher to resort to self-administering of questionnaires. This move was taken in-order not to compromise the findings of this study. Therefore, the design of this study is also a limitation.
1.12. CHAPTER OUTLINE
Chapter 1: Background of the study: This chapter dealt with the overview, scope and context of the study and the need for this research. It also sheds light on the objectives, research questions, significance of the study before concluding remarks are made. Chapter two: Literature review: This chapter handled relevant literature on the subject under study. It begun with a macro review of literature on attraction and retention of employees in diverse sectors before it delves into the health sector with particular reference to the GM.
Chapter three: Research design and Methodology: This chapter spelt out how data for this predominantly qualitative study was gathered through the use of questionnaires. It shed insights on the preferred data analysis approaches used by this study.
Chapter four: Research Results: Chapter four provides a discussion of the findings of the study. The findings are graphically presented in tables, graphs and figures alongside in-depth analysis of the emerging trends.
Chapter five: Conclusions and recommendations: This chapter contain conclusions and recommendations about attraction and retention of experienced Health personnel by Gweru municipality in Zimbabwe. It highlights, among others the core findings as well as recommendations for future related studies.
1.13. SUMMARY
This research proposal introduced the scope of the study on why GM is failing to retain senior qualified personnel in Health department and proceeded by presenting research background and context, problem statement, research objectives, literature review, research objectives, importance of the study, research design and methodology, ethical requirements, sampling, data analysis and closed by stating limitations of the study.
CHAPTER TWO
LITERATURE REVIEW
2.1 INTRODUCTION
This chapter reviewed literature relevant to the scope of attraction and retention of qualified health staff. To contextualize this study, the review begun by exploring global trends on the nature of competition for knowledge and motivated workers, global retention strategies, global health staff attraction and retention trends, African countries health staff attraction and retention trends and Zimbabwe health staff attraction and retention trends before concluding remarks.
The researcher consulted diverse secondary sources namely books, newspapers, journals, masters dissertations, doctoral theses, databases, periodicals, government publications, international and local papers. The researcher was interested with what literature says on this topic since the late 2000s. The literature search was guided by keywords like 'doctors', health workers', 'health professionals', 'knowledge workers', 'attracting', 'brain drain', 'skills shortage', 'health staff, 'skills shortage', 'Gweru health workers', 'retention', 'scarce skills', 'emigration', 'researchers', 'immigration' and 'nurses'. These sources of information were predominantly accessed through the EBSCOhost via the http://www.nwu.ac.za/library portal. The 'EBSCOhost' is a powerful academic and business resource providing online access to full text collections of thousands of e-journals and more than 100 abstracting and indexing databases.
The term 'turnover' is used as defined by Robbins (2003) to mean the voluntary and involuntary permanent withdrawal from an organisation, and a high turnover rate results in increased recruiting, selection, and training costs. In addition, Zhao and Zhou (2008) argue that in an organisational context, turnover refers to the termination of an employee's intra-organisational career trajectory, which is composed of a sequence of job changes from job entry to exit. On the other hand, employee retention is a
systematic effort by employers to create and foster environment that encourages current employees to remain employed by having policies and practices in place that address their diverse needs (Purcell, 2005).
2.2 GLOBAL COMPETITION FOR KNOWLEDGE AND MOTIVATED WORKERS
The review of the global nature of competition for knowledge and motivated workers contextualises this study by giving macro perspectives on the topic. It begins by pointing to the global nature of the topic, definition of knowledge and motivated workers and proceeds by looking at pertinent global examples that shed light on attraction and retention discourse.
Worldwide, there is a shortage of health professionals working in rural areas (Grobler, Marais,- Mabunda, Marindi, Reuter & Volmink, 2009; Hamilton & Yau, 2004) and this is a major obstacle to achieving the health Millennium Development Goals and improving health service access. South Africa has more health professionals than neighboring African countries, but it has a severe mal-distribution of personnel between the public and private sectors and between rural and urban areas (Department of Health, 2006). In 2004, 46 per cent of the South African population lived in rural areas, yet they were served by only 12 per cent of doctors and 19 per cent of nurses (George, Quinlan & Reardon, 2009).
This study makes reference to a study by Kerr-Phillips and Thomas (2009) that report of labour and skills shortages as internationally critical in virtually all industries. The study concludes that for organisations, the retention of skills is the only viable option. There is increasing demand for so-called 'knowledge workers' (Grove, 2010). Knowledge workers include medical and pharmaceutical professionals, manaQers, leaders. technicians, researchers, accountants, information specialists and consultants among others. Similarly, the study by Brannen (2008) is important for noting that knowledge workers often work together in teams that cross cultural and geographic borders. This
means that the need for highly motivated employees who are willing to be dedicated to working with focus and energy, and be highly productive (Timmons, 2010) is likely to remain strong as well.
The study by Rich (2010) notes that new jobs are still being created that requires higher levels of technical competencies. For existing jobs, there is a growing need for employees who are willing to do the job under new and changing conditions that require the development of additional competencies. For skilled jobs, this study benefits from the observation by Cummings, Manyika, Mendonca, Greenberg, Aronowitz and Chopra (2010) that there is a need for increased competencies to operate more sophisticated machinery, to interact with more demanding customers and to use more advanced technology to perform the functions of the traditional skilled jobs.
The study by Wooldridge (2007) also identifies another cause for talent shortage as worldwide demographic trends. In North America, Western Europe, Japan and Australia, the age of retirement is being ushered in by the Baby Boomer generation. While this may be a relatively short term phenomenon in North America (due to current birth and immigration rates), population shrinkage is a longer term event in Western Europe and Japan (Strack, Baier & Fahlander, 2008). On the other hand, Strack et al. (2008) note that while the populations of many developed economies are aging and shrinking in size, the populations of developing and emerging economies are expanding and getting younger.
The important role that appropriate recruitment plays in retaining good staff is highlighted by Collins (2007) with reference to hospitality industry. Improving the quality and quantity of hospitality staff appears to be dependent on improving the image of the industry, together with more strategic ways of managing work rosters and workloads. In addition, Carbery, Garavan, O'Brien and McDonnell (2003) found that a combination of demographic, human capital, psychological attributes and hotel characteristics, explain significant variance in turnover cognitions of hotel managers. On the other hand, the study by Robinson and Barron (2007) focus on the issues of deskilling and
standardisation that lead to lack of job satisfaction, organisational commitment and ultimately to the decision to leave the organisation. Research by Tutuncu and Kozak (2007) concur with these findings, noting that the work itself, the pay and supervision within the hotel industry can lead to job dissatisfaction and then employee turnover.
2.3 GLOBAL RETENTION STRATEGIES
This section discusses global retention strategies. Deery (2008) argues that maintaining a stable workforce is a key element in effective talent management strategy and yet over the years this has been something of a challenge for hospitality and tourism operators. Also, the role that constructs such as organisational commitment and job satisfaction play in contributing to employees' intentions to leave an organisation came to the fore.
On attracting and retaining talent in Australia, Holland, Sheehan and De Cieri (2007) argue that in an environment characterized by increasing levels of skilled labour shortages, organisations need to design employment systems that prioritize human resource development to enable competitive advantage. Their findings suggest that employers need to address issues related to attraction - recruitment and selection. However, in critical HR development areas associated with retention such as training, job design, skill development, careers management and team building, results indicate a lower level of resource allocation. They aptly conclude that this lack of resource allocation is of concern for Australian organisations that are struggling to compete both domestically and internationally for skilled workers.
From Newell, Robertson, Scarbrough and Swan (2002) this study notes that the term 'gold-collar worker' implies that these workers need to be managed carefully and be provided with excellent working opportunities. Newell et al. (2002) also argued that it is not possible to develop competitive advantage without consideration of these human resources that form the core of a firm's knowledge base. From an HR perspective the management of these human resources throws out particular challenges to
organisations that base their advantage on these managed resources and the knowledge they embody. Furthermore, the study by Storey and Quintas (2001) argue that organisations need to thoroughly reconsider their employment systems, practices and organisational structure to ensure they capture and retain this unique resource.
Literature points out that job satisfaction are significant to employee retention as it can make the employee feel comfortable physically and psychologically (Martin, Mactaggart & Bowden, 2006). From Qadrai (2009), it emerges that a good employer should know how to attract and retain his employees. Relatedly, the study by Parsley (2006) is important for pointing out that employee retention can be practiced better by motivating the employees. Some factors that motivate and retain employees are:
Open communication: Management should communicate philosophy and values of the company; open door policy (be a good listener); grievance procedures; have a genuine interest in people (and show it); explain why things have to be done in a certain way; meetings with employees; train supervisors in communication skills; personnel committee meetings among others.
The provision of human needs entails providing pay and benefits that truly meet employee needs. The list should include the following five items: Physical, Safety, Social, Esteem and Self-actualization.
Using the participative approach successfully (Durkin, 2007) requires the giving of opportunities for personal growth within the company and make employees feel a part of the company. Most importantly, from Macey and Schneider (2008) it emerges that management must be taught how to grow by: defining objectives clearly; provide system of rewards; make individuals, as well as groups, accountable and ensure a receptive attitude of top management.
The centrality of flexibility in attracting and retaining staff is highlighted by Wallace and Trinka (2009) who reckon that a good supervisor makes for happy employees. Organisations want employees who can be flexible with their working schedule. Management need to understand that employees also have personal lives, children and they need to know that we can be flexible for their needs also. In addition, this study
benefits from Memmott and Grnowers (2002) who submit that management needs view employees as equals, people with feelings, rather than just workers.
The study by Holland et al. (2007) is pertinent for reckoning that upgrading employees' knowledge, skills and ability ensures that these workers remain in demand in the wider employment market. Whilst the concept of job-hopping may become the norm, paradoxically it may be a factor in at least reducing the turnover (through on-going skill acquisition) and making the organisation an 'employer of choice' to return to or recommend to other highly skilled workers as organisations that provide on-going development opportunities for these increasingly discerning workers. In addition, these authors indicate that organisations that are prepared to focus on developing talent will be in a stronger position to retain key employees as the so-called 'war for talent' intensifies.
Furtherrfiore, human resource (HR) professionals spent a great deal of their time formulating and managing the HR policies and practices, such as recruiting, selecting, training, performance appraisal and compensation in a more traditional and administrative manner. Within this context, this study notes that Schuler, Jackson and Tarique (2011) recommend that the effectiveness of HR in managing global talent management initiatives results from being linked with the firm's strategies and directions and with the firm's talent strategy. This is key as, according to Rawlinson, McFarland and Post (2008:23) "HR underperforms in companies where its capabilities, competencies, and focus are not tightly aligned with the critical business priorities". Furthermore, according to Hieronimus, Schaefer and Schroder (2005), traditional recruiting focuses on functional employment benefits such as job security, opportunities for creativity and individual growth, and compensation. In addition, an employer's intangible, emotional associations—'it is fun to work at this company,' 'we have a passionate and intelligent culture,' 'there is a strong team feeling here'—are just as important to recruits.
This study notes that Gergen and Vanourek (2007) argue that there is no magic formula for maximizing retention. Much of what keeps people in jobs has to do with best practices in leadership, governance, organisational systems, including a healthy focus on developing people and creating a dynamic culture and workplace. Executives are increasingly realizing that training and leadership development programs must go beyond being an afterthought and become an integral part of a company's competitiveness initiatives (Vance, 2006). Benefits, according to Carraher (2006) are touted as having the ability to attract and retain employees, yet perceived benefits inequity could result in the converse, namely dissatisfaction, higher levels of absenteeism, lower levels of performance and higher turnover (Carraher & Buckley, 2008). Also, from Bradsher and Barboza (2010), this study learns that competition within and across nations has also resulted in increased compensation demands from local workers, as well as for workers who enjoy the benefits of being in a global labor market.
Similarly, literature shows that around the world, dissatisfaction with income is one of the major causes of doctors leaving public service, and improving salaries is often mentioned as an intervention to attract and retain rural doctors (Van Dormael, Dugas, Kone, Coulibaly, Sy & Desplats, 2008). Despite the importance of salaries, many doctors stated that other factors, such as job satisfaction and working conditions, were more important and the salary on its own would not retain them (Van Dormael, Dugas, Kone, Coulibaly, Sy & Desplats, 2008). To this end, DCamp (2007) mockingly calls money 'the penicillin of motivation' and Romley and Glennon (2007) conclude by calling organisations to consider all alternatives to compensating their workers for a job well done.
Many reasons for the turnover of employees have been advanced in the literature. Mallol, Holtom and Lee (2007) stress how, given alternatives, employees tend to remain with their organisations of employment if they experience job satisfaction and are committed to their organisations or leave if they are not. Luna-Arocas and Camps (2008) suggest a link between job enrichment strategies, employee commitment and
turnover intentions. Elangovan (2001) details the complex influence of causal events such as stress, job satisfaction and work commitment on the final decision to leave. Glen (2006) notes that retention of knowledge workers and their specialised skills are critical for the advancement of an organisations intellectual capital base. Therefore, the major pull factors are the positive factors that attract people to another country (Mattes & Richmond, 2000). They include attractive salary packages, early retirement in the education sector, opportunities to gain international work experience, improved lifestyles and various career choices (Du Plessis, 2009).
2.4 GLOBAL HEALTH STAFF ATTRACTION AND RETENTION TRENDS
The study by Marie (2008) highlights the free movement of people in search of opportunities and a better life has always been a part of the national and international scene. Dr Danzon quoted by Marie (2008) also points out that the last 50 years have seen a continued migration of health professionals from western Europe to North America, Australia and New Zealand for many of the same reasons that are now being seen in the movement of doctors and nurses from Africa to Europe (Marie, 2008). There is also a movement of health professionals between post-industrial countries, from eastern to western Europe, and with many of the same repercussions for source countries in Europe as those being experienced in Africa.
Furthermore, Marie (2008) notes that this challenge is compounded bya weak capacity to recruit and employ health personnel. This is making it increasingly difficult to meet current and expected needs and demands of health personnel. The late Dr Tshabalala-Msimang in Marie (2008) with reference to South Africa acknowledged that the push factor is not simply a question of poor salaries, but is rather a far more insidious combination of poor remuneration, poor infrastructure, poor referral capacities, very poor equipment back-up and increasingly run-down facilities that can no longer provide the type of incentive doctors and nurses look for.
Carraher and Buckley (2008) examined attitudes towards benefits; intentions to search for a new job, to quit, being absent, ratings of performance, and actual turnover - and absenteeism - were assessed using a sample of 386 nurses. The results indicate that behavioral intentions to search for a new job, to quit, and intention to be absent were related to actual turnover and performance but not to absenteeism.
In addition, Marie (2008) observes that the percentage of Jamaican doctors and nurses working in the Organisation for Economic Co-operation and Development (OECD) countries is far higher than that for countries such as Nigeria and India which are typically considered to be the main 'exporting' countries. The numbers leaving these countries may be significant, but they are from a much larger home-based 'stock'. This highlights that there are signs that migration of health personnel is no longer limited to a 'south' to north' movement as doctors and nurses are moving from developing countries to other developing countries and from industrial countries to other post-industrial ones.
Conversely, the Vientiane in the Lao People's Democratic Republic, WHO/HSS/HRH/HMR (2011:2) note the need to increase "access to health workers in remote and rural areas through improved retention". Misdistribution of staff, both geographically and by facility level, is reported to be a significant issue. There is 2992 high- and mid-level medical staff at health-facility level, equating to 0.53 workers per 1000 inhabitants, significantly below the WHO target of 2.5. The challenge is compounded by the relatively low wages by international standards - on average, equivalent to approximately US$ 405 per annum - may contribute to recruitment difficulties and to low health worker motivation and productivity. In 2007, the Asian Development Bank commented that, because of poor wages, Lao health workers can ill afford to work full time in a health facility, or be posted to remote health centres where they cannot earn an additional income.
With reference with the United Kingdom, the study by Marie (2008) notes that the demand for internationally recruited nurses rose dramatically in the late 1990s then
plateaued for about five years before falling relatively sharply as the United Kingdom began to invest aggressively in scaling up domestic training of nurses to meet its own needs. Related observation was made for Norway by Marie (2008) that projects a gap of 115 000 health workers by 2020 and another 25 000 ten years later. It sees no possibility of scaling up the training of nationals to meet this need, and will have to look abroad for staff.
In Ireland, where the source of incoming nurses has fluctuated over the years, the number of nurses arriving from European Union (EU) countries was consistently higher than the number from non- EU countries until the end of the 1990s. After the turn of the century, this trend has reversed and since 2001 the number of non-EU nursing staff has grown faster than for staff from within the EU.
Poor job satisfaction and low morale are endemic among health professionals in Africa (Bloom & Standing, 2001). Consequently, health professionals are leaving the continent in search of better opportunities elsewhere. On this note, Mutizwa-Mangiza (2002), in her study of the impact of health sector reform on the motivation of health professionals in Zimbabwe, states that because of staff leaving the public health sector, one hospital has a staff of 16, less than half of the 50 it should have.
2.5 AFRICAN COUNTRIES HEALTH STAFF ATTRACTION AND RETENTION TRENDS
It is widely acknowledged that Africa's health workforce is insufficient and will be a major constraint in attaining the Millennium Development Goals (MDGs) for reducing poverty and disease (Awases, Gbary, Nyoni & Chatora, 2003). Harrison, Bhana and Ntuli (2007) state that it is now widely accepted that the shortage of health workers in many places is among the most significant constraints to achieving the three health related Millennium Development Goals (MDGs): to reduce child mortality, improve maternal health, and combat HIV/Aids and other diseases. The World health report 2006 has shown that in general, countries with fewer than 2.3 doctors, nurses and midwives per
1000 people fail to achieve an 80% coverage rate of measles immunization, or the presence of skilled birth attendants during childbirth. Fifty-seven countries fall below this minimum threshold, mainly in sub-Saharan Africa and Asia. This has a major impact on infant and maternal mortality. Producing, recruiting and retaining health professionals remain key challenges facing but not confined to South Africa as these have been documented as challenges globally.
Stilwell, Diallo, Zurn, Adams and Poz (2004) studied migration of health-care workers from developing countries and suggested strategic approaches to its management. They note that of the 175 million people (2.9% of the world's population) living outside their country of birth in 2000, 65 million were economically active. They define highly skilled professionals as people who have completed tertiary education and have professional jobs and in terms of the health-care workforce this refers to physicians, nurses, dentists and pharmacists.
Studies conducted by Pillay (2009) found that nurses in the more urbanized provinces like Free State and Gauteng were significantly more satisfied than their colleagues from the more rural provinces and this may partly explain the gravitation of nurses from rural to urban areas. From Mrara (2010), the consistent theme to emerge from nurses in both sectors, irrespective of their future work plans, is the importance of workplace organisation, employment security, and the working environment and professional practice environment. The finding that nurses across sectors as well as those who intend to stay or leave, rate the importance of these factors equally, is compelling reason to prioritise these issues (Pillay, 2009). Hospitals that have successfully implemented retention programmes have focused on providing good working environments, professional development, and accommodating individual life styles (Runy, 2005).
Using a policy analysis framework, Ditlopo, Blaauw, Bidwell and Thomas (2011) analyzed the implementation and perceived effectiveness of a rural allowance policy and its influence on the motivation and retention of health professionals in rural
hospitals in the North West province of South Africa. In their study they conducted 40 in-depth interviews with policy-makers, hospital managers, nurses, and doctors at five rural hospitals and found weaknesses in policy design and implementation. These weaknesses included: lack of evidence to guide policy formulation; restricting eligibility for the allowance to doctors and professional nurses; lack of clarity on the definition of rural areas; weak communication; and the absence of a monitoring and evaluation framework. Although the rural allowance was partially effective in the recruitment of health professionals, it has had unintended negative consequences of perceived divisiveness and staff dissatisfaction (Ditlopoet a!, 2011). Government should take more account of contextual and process factors in policy formulation and implementation so that policies have the intended impact.
The research by Berhan (2008) conducted in Ethiopia suggested that the government discusses the possible solutions with health professional associations/societies and other health stakeholders, and applies concrete medical doctors retention mechanisms before the public medical schools and hospitals lose doctors. Strengthening relationships among doctors and between doctors and the communities that they serve also contributes toward their retention (Kotzee & Couper, 2006). Some of the most important factors in the retention of pharmacists and other health professionals in both urban and rural areas are;
the availability of the sufficient and suitably qualified staff; hospital management's support for pharmacy practice; professional development opportunities; and access to organized continuing education.
One of the major challenges facing health systems in sub-Saharan Africa is the international migration of health staff (Manafa et a!, 2009). In addition to international migration there is also considerable in-country migration between the public and private health sectors, between urban and rural areas and between tertiary and primary health care delivery. Increasing flows of health workers into private, urban, tertiary facilities is undermining attempts to provide appropriate public, rural, primary care. For instance, in 2002, Chad's capital, N'Djamena, had 71 doctors per 100 000 people, while in the
Charai-Baguirmi region the ratio was only two doctors per 100 000 (Wyss, Doumagoum & Callewaert, 2003). In 2002 in Ghana, 55% of pharmacists were in the Greater Accra region, which had 16% of the population and 2% in the Northern region, with 10% of the population (Ghana Ministry of health, 2002).
The shortage of health workers in Malawi is severe even by African standards, with fewer than 4000 doctors, nurses and midwives serving a population of approximately 12 million in 2003 (Manafa eta!, 2009). There are 156 physicians working in the Ministry of Health and the Christian Health Association of Malawi. There are 10 districts without an MOH doctor and four districts without any doctor at all (Palmer, 2006).
In Malawi in 2007, McAuliffe, Bowie, Manafa, Maseko, Maclachlan, Hevey, Normand and Chirwa (2009) and McAuliffe, Manafa, Maseko, Bowie and White (2009) undertook a study of three districts in Malawi to map the motivational environment of health workers. A quantitative survey measuring health workers' job satisfaction, perceptions of the work environment and sense of justice in the workplace, reported elsewhere found that health workers were particularly dissatisfied with what they perceived as unfair access to continuous education and career advancement opportunities, as well as inadequate supervision.
Munga and Mbilinyi (2009) explored the phenomenon of non-financial incentives and the retention of health workers in Tanzania. A shortage of health workers is a major problem for Nigeria, especially in rural areas where more than 70% of the population live (Ebuehi & Campbell, 2011). At the primary care level, trained community health officers provide services normally reserved for doctors or medical specialists. The community health officers must therefore be supported and motivated to provide effective quality healthcare services. This study aimed to determine factors that will attract and retain rural and urban health workers to rural Nigerian communities, and to examine differences between the two groups.
At the same time, countries in sub-Saharan Africa are equally in need of more than one million health workers. The question is how they will satisfy this need while at the same time being asked to share their graduates with other regions. For example, Marie (2008:5) cites Dovlo and Nyanator (2001) who examined the migration of medical graduates from the University of Ghana's Medical School. The effect of such losses has been largely negative on health care delivery in the country. They estimated that there was 1 doctor to 22 970 people in Ghana in 1990. The ratio was I to 420 and I to 810 in the US and UK, respectively, while it has been estimated that the minimum essential and public health interventions require about physician per 10 000 population.
For whatever the reason, at a global level, as Marie (2008) puts it, the WHO estimate of a shortfall of four million health personnel calls for urgent action, even though there is no 'quick fix'. She gave the example that between 1998 and 2002 Ghana, one of the major 'exporters' of medical personnel, lost £35 million of its investment in training of doctors and nurses while the United Kingdom saved £65 million through 'imported' staff. The migration of health professionals is a special dilemma for countries such as Ghana which, in 2004, trained 70 national doctors and then lost 67 of them to other countries (Marie, 2008). The reality, however, is that rich and poor countries alike are desperately short of qualified health personnel and the situation is getting worse rather than better.
In Cameroon, the migration of health professionals has been a cause for concern to health authorities over recent years (Awases, Gbary, Nyoni & Chatora, 2004). Whereas in 1990 there was one medical doctor per 11 407 inhabitants, the ratio had increased to one medical doctor per 14 730 inhabitants in 1997. Salient features of the diagnosis include low recruitment in the health sector for the past ten years, voluntary and/or compulsory departures, emigration, retirement and deaths. Similarly, in Senegal, most studies conducted on migration have focused mainly on internal migration. It has been demonstrated that most migrants end up in Dakar, the capital (Awases et al., 2004).
In addition, in Uganda, only a few studies have been undertaken on the migration of health professionals (Awases et al., 2004). However, relevant literature points out that
the country's brain drain started in the early 1970s during Idi Amin's regime when highly qualified staff mostly doctors fled Uganda. For instance, the number of doctors dropped from 978 to 574 during 1968-74 while the number of pharmacists fell from 116 to 15 over the same time period. Consequently, the doctor-to-patient ratio rose significantly from 1: 9200 to 1: 27600 over the same time period (Awases etal., 2004). By 1985 the state-run health services were seriously understaffed, underfinanced and poorly equipped. Rural health centres and dispensaries were the worst affected.
Research from other countries shows a correlation between quality of care, healthcare outcomes and the availability of health personnel (Mercer & Dal Poz, 2002). However, health systems in southern Africa face a variety of health personnel problems. These include an overall lack of personnel in key areas of the health sector; an inequitable distribution of those health personnel who are available; and a significant attrition of trained personnel from the health sector and from the region. The availability of health personnel in Africa is considerably worse than in other regions of the world and it is one of the stumbling blocks to the delivery of adequate healthcare. These issues were raised in Regional Network for Equity in Health in Southern Africa in 1998, profiled in an EQUINET discussion paper on the situation of health personnel in Zimbabwe (Munyuki & Jasi, 2009) and raised as a priority issue for concern in the Call for Action made at the 2000 EQUINET Southern African Meeting on Equity in Health. It is thus not surprising that two of the top 5 priorities for rural health care identified by an expert panel (Versteeg & Couper, 2011) are the need to focus on how to recruit, retain and support senior health care professionals in rural hospitals for the long term.
According to Bezuidenhout, Joubert, Hiemstra and Struwig (2009), the migration of doctors from their home countries is not a new phenomenon. Apart from voluntary migration for various reasons, developed countries actively recruit medical professionals, often from sub-Saharan Africa. In addition, Marie (2008) study is significant for identifying that there is a variety of push and pulls factors that impact on the movement of healthcare workers, arising both within and beyond the health system. Factors endogenous to the health care system are low remuneration levels, work
associated risks including of diseases like HIV/AIDS and TB, inadequate human resource planning with consequent unrealistic workloads, poor infrastructure and sub-optimal conditions of work. Marie (2008) further identifies exogenous push factors that include political insecurity, crime, taxation levels, repressive political environments and falling service standards. Movement is also influenced by pull factors, including aggressive recruitment by recipient countries, improved quality of life, study and specialisation opportunities and improved pay. These push and pull factors are mitigated by 'stick' factors in source countries, which lead to greater personnel retention, including family ties, psychological links with home, migration costs, language and other social and cultural factors.
2.6 ZIMBABWE HEALTH STAFF ATTRACTION AND RETENTION TRENDS
From Chikanda (2004) this study learns that brain drain has become topical in Zimbabwe where deteriorating economic, social and political conditions are aggravating the emigration tide. The country's health delivery sector is arguably the worst affected by the phenomenon as health workers are emigrating in search of greener pastures in southern Africa, western Europe, North America and Australia.
In Zimbabwe, research on migration issues has largely focused on internal migration (Munyuki & Jasi, 2009). However, more recent studies have been conducted on the migration of health professionals from the country. Other studies have focused on the impact of health sector reform on the motivation of health professionals (Ndlovu, Bakasa, Munodawafa, Mhlangu & Nduna, 2001). Awases et al. (2004) has recently explored the nature and extent of medical practitioners' autonomy and the dominance of government-employed doctors in Zimbabwe.
In addition, the study by Munyuki and Jasi (2009) is handy for submitting that most commonly cited reasons for departure from countries of origin by health professionals are: lack of continuing education opportunities and training institutions; salaries that are not realistic in terms of the risks and amount of work; lack of social and/or retirement
benefits; lack of proper equipment to carry out the procedures professionals have been trained to perform and deliver; and an unsatisfactory or unstable political environment. Often doctors go abroad to pursue postgraduate training that is not available in their own countries. Upon their return, many of these doctors find that their skills are needed, but nonetheless useless without the proper facilities and medical equipment necessary to carry out advanced procedures.
In addition, the study by Munyuki and Jasi (2009) is handy for submitting that most commonly cited reasons for departure from countries of origin by health professionals are: lack of continuing education opportunities and training institutions; salaries that are not realistic in terms of the risks and amount of work; lack of social and/or retirement benefits; lack of proper equipment to carry out the procedures professionals have been trained to perform and deliver; and an unsatisfactory or unstable political environment. Often doctors go abroad to pursue postgraduate training that is not available in their own countries. Upon their return, many of these doctors find that their skills are needed, but nonetheless useless without the proper, facilities and medical equipment necessary to carry out advanced procedures.
Also, Chikanda (2004) study has demonstrated that at the national level the number of health professionals employed is declining. Notwithstanding the fact that some health professionals are moving to the private sector, others have chosen to remain in the public sector for a number of reasons. In addition, the study by Chikanda (2004) reckons that the migration of health professionals has negatively impacted on health service delivery in GM. The community respondents complained of declining quality of care in health institutions as well as uncaring attitudes by the health professionals. The crisis in the public health system has benefited traditional healers, who have been able to offer an alternative form of medical care. While it was acknowledged that there are numerous 'bogus' traditional healers, the informal health sector compliments the formal health care system and provides medical care mostly to the poor who cannot afford the high fees charged by private clinics.
Chikanda (2004) is also important for noting that economic factors were cited as the major reasons for the migration of health workers from the public sector. Chikanda (2004) further submits that experienced nurses and doctors are leaving secure jobs in MOH&CW and going to work for nursing agencies in the United States and Britain. Cultural factors, such as the extended family, make it necessary for Zimbabweans to focus more on money than other issues. Taking into account the high inflation rate, it seems unlikely that the workers' need for higher remuneration will be fulfilled in the near future. This may mean that the MOH&CW will continue to experience high rates of turnover, strikes and other such behaviours. Factors such as job security, the work itself, training and advancement opportunities, supervision and recognition, even if met, will not improve worker motivation as long as the remuneration is perceived to be unsatisfactory.
Furthermore, Chikanda (2004) notes that during the past decade the economic situation in Zimbabwe has deteriorated significantly. Public sector health care workers have gone from being high status and relatively well paid members of the community to workers struggling to get a living wage from their jobs. The overall reform package is to include financial reforms (user fees and social insurance), strengthening of health management, liberalization and regulation of the private health sector, decentralization, and contracting out. Unfortunately, the process of reform implementation in Zimbabwe and the government's poor communication with workers, combined with a conflict between local cultures and the measures being implemented (Munyuki & Jasi, 2009), has undermined the potentially positive effect of reforms on health worker motivation. Workers perceived reforms as threatening their job security, salaries, and training/career advancement opportunities (Chikanda, 2004) and feared ethnic and political influence on new employment practices under a decentralized system. Worker demotivation has been expressed in terms of strikes, unethical behavior, neglecting public sector responsibilities to work in private practice and high turnover.
Although such movements are largely beneficial to the individuals concerned, they have negative socio-economic impacts on the sending country (Ndlovu et al., 2001). In
Zimbabwe, low salaries and poor working conditions stemming from the unsuccessful implementation of Structural Adjustment Programmes have fuelled the brain drain. Recent literature shows that Africa is losing its skilled health workers at an alarming rate (Munyuki & Jasi, 2009). Consequently, health service provision has been adversely affected, especially in remote locations.
The rural-to-urban migration of health professionals has led to a shortage of health professionals in disadvantaged areas (Awases et al., 2004). At the local level, the migration of health professionals has increased the workload of the remaining workers employed in disadvantaged health institutions. Evidence from the Ghanaian and Zimbabwean surveys show that health professionals employed in urban areas have lower workloads than those employed in rural settings. In addition, health institutions located in remote areas are poorly staffed, which means that those who opt to work in such locations have to endure the heavy workloads.
Substantial proportions of health workers, ranging from 26% in Uganda to 68% in Zimbabwe, are thinking of emigrating to other countries. While intention cannot be considered a firm indicator of future trends, it is nonetheless a cause for concern. The most popular destinations cited by the respondents are the United Kingdom and the United States of America. In the Francophone countries surveyed, France and Canada also ranked high among the prospective destinations.
According to Awases et al., (2004), the migration of skilled health professionals from Africa has adversely affected the quality of care offered in health institutions. Quality, effectiveness, and equity of care are closely linked to the impact of migration from the public sector. The movement of health professionals to the private sector has seriously disadvantaged the poor, most of whom cannot afford the huge fees charged at private health institutions (Munyuki & Jasi, 2009). The communities perceived the quality of care they receive from health institutions as being poor, as they have to wait for a long time before receiving medical attention, which is then hurried because of the patient load.
In countries such as Zimbabwe and Cameroon, the migration of health professionals has made it necessary for non-qualified personnel to perform duties that are normally beyond their scope of practice. This has resulted in skeleton staff servicing the overburdened public health service sector. A number of rural health centres have no trained staff and are run by nurses' aides whose competency is limited (Awases et al., 2004).
Nevertheless, some skilled health personnel choose to stay and continue to work in the public health sector despite the 'push and pull' factors that influence their colleagues to leave (Awases et al., 2004). Job security, career advancement, and opportunities for further training are all better in the public health sector, and particularly for older workers; these factors motivate them to stay. There may also be social and cultural factors which are influential, but no specific research has been conducted in this area (Munyuki & Jasi, 2009).
2.7 SUMMARY
This chapter did a review of literature relevant to attraction and retention discourse. The global nature of the present scope came to the fore. It became apparent that the bulk of health staff are knowledge workers that are relatively scarce due to global trends that sees them being employable almost in any country. This therefore calls for proper attraction and retention programmes for GM among others to emerge as employers of choice. In addition, the Zimbabwean country' plight with the attraction and retention of qualified health staff has been examined. Insights on retention strategies have been explored as well as the effects of lack of effective retention programmes.
In the next chapter three, this study now proceeds to discuss how data will be gathered from GM as well as alluding to how it shall be analysed in chapter four. The design of questionnaires shall be explored among others.
CHAPTER 3
RESEARCH DESIGN AND METHODOLOGY
3.1 INTRODUCTION
The preceding chapter focused on the review of relevant literature on the attraction and retention of employees. The review, however, did not answer these four research questions:
Discuss the importance for GM to attract and retain qualified health personnel? How could GM recruit qualified health personnel?
What is GM doing to retain qualified health personnel?
Identify which strategies GM could use to retain qualified health personnel?
Within the preceding context, this chapter proceeds by discussing primary and secondary data gathering methods. It will begin by sharing insights on research types thereby making a case for the predominantly quantitative approach this study is using. Comparisons between the quantitative and qualitative research paradigms shall be made. This would be followed by questionnaire development dynamics, a section that would be closed by making a summative presentation of the advantages and disadvantages of using questionnaires as a data gathering tool. The chapter shall make reference to the proposed nineteen questionnaire questions before concluding by making brief reference to data analysis approaches. Therefore, in essence, research design and methodology focuses on expounding on how data shall be gathered and analysed.
3.2 OVERVIEW OF RESEARCH METHODS
Anderson (2006) sheds a lot of light on quantitative and qualitative researches. To properly inform the ensuing study, this chapter discusses the quantitative research paradigm.
