Belayneh Bogale zewdie 

Abstract

The objective of this article is to assess the role of private wings in public hospitals to tackle medical professionals’ turnover in selected public hospitals. Retention of qualified health staff has become a major problem in Ethiopia. Medical professionals left the public sector mainly due to attractive remuneration elsewhere. To solve this problem the Ethiopian government launched private wings within public hospitals in 2008. In this study a descriptive design with mixed approach was applied. Data was collected through questionnaire, key informant interviews, and document review. Purposive sampling was also utilized to target respondents. Data was collected from 5 hospitals and 192 health professionals. The finding revealed that Medical professionals’ level of awareness on different aspects of private wing was not satisfactory; however most of them became happy to know about the chances of earning extra income at home. On average, 50% of the doctors’ and 40% of other health professionals’ total monthly income were earned from private wings. Accordingly, professionals expressed their intention to continue working in their facilities at least for the next 3 years. Hospitals’ human resource documents also reveal a slight but a steady decline in turnover. The study found out that the initiation of private wings in public hospitals contributed to motivation and retention of health professionals. Major benefits to private wing staff include rise in sense of hospitals ownership, skill use and better income.

 

Key Words: Private Wing set up, Turnover, Medical Professional, Health care reform and Public hospitals

INTRODUCTION

The African continent is facing a health crisis occasioned by very low funding of health services and deterioration of health service infrastructure (Dovlo, 2003). The loss of health workers has significant economic as well as replacement consequences which include high cost and time taken to recruit, select and train new staff. Ethiopia is among many other countries that have been affected by a turnover and brain drain of health workers. Many studies show that the shortage of health workers in Ethiopia has been at a crisis point. According to FMoH (2008), health professionals migrate either from rural to urban areas, from government to private institutions, or to foreign countries in a very alarming rate for various reasons.

 

After 1991 the Ethiopian government undertook a robust reform in deferent sectors. One of the reforms was health sector reform. After thorough study and assessment of the health situation, the FMoH of Ethiopia developed a health care financing strategy in 1998 that was endorsed by the Council of Ministers and became a very important policy document for introduction of health financing reforms. The government recognized that health cannot be financed only by government and underscored the importance of promoting cost sharing in provision of health services (FMoH, 1998).

In line with the health care financing strategy and based on the approved legal frameworks, a wide range of health care financing reforms have been implemented since 2006.
The initial phase of the implementation was very narrow in few selected regions and health institutions. However, later the health care financing reforms have been expanded to nearly all parts of the country. The reform consists of eight components; revising user fees charged at government health facilities, retaining the collected fees at the facility and using that revenue to improve quality, rationalizing and systematizing rules for fee waivers, increasing hospital managerial autonomy, opening private wings in public hospitals, and outsourcing nonclinical health services. These reforms are being implemented in all regions of Ethiopia (USAID, 2012:3).

Establishment of private wings in public hospitals is one aspect of the Ethiopian government’s health sector financial reform program which was launched in 2008. In the last four years or so, certain Ethiopian public hospitals have created private wards that function within their physical and organizational boundaries. According to FMoH (2010) the establishment of public hospital private wings has the potential to generate additional income and can increase the ownership of the hospital services by health professionals. The establishments provide services to those who can afford to pay more for those services. The set up is meant to improve the quality and timeliness of services. It also helps reduce the turnover of skilled manpower through additional compensation, and to motivate staff members to provide more and better service.

Hence the article will focus on the assessment and analysis of the role of private wings in reducing medical professionals’ turnover with particular reference to government owned hospitals under Addis Ababa Regional Health Bureau.

STATEMENT OF THE PROBLEM

Although Ethiopia has one of the highest numbers of health workers in sub-Saharan Africa, its large population leaves it with a very low health worker to population ratio. The Ministry of Health reported a total of 66,314 health workers are in service, including 30,950 health extension workers. The national health worker ratio per 1000 population is 0.84. This result is far less than the standard set by the World Health Organization of 2.3 per 1000 population (FMoH, 2010 cited in AHWO, 2010). Even out of the total health work force (in terms of skill mix), Doctors and Midwives form a significantly smaller share. Despite the government’s effort to tackle this problem, the shortage and high turnover of health workers has become a severe setback. The county is one of 57 countries considered to have a health workforce crisis (UNDP, 2010).

Retention of highly qualified health staff has become a major problem in Ethiopia. Between 1987 and 2006, 73.2% of Ethiopian medical doctors left the public sector mainly due to attractive remuneration in overseas countries, local NGO’s and private sectors. Unless the proper remedial measure is taken, the problem will even get worse in the coming years (Birhan, 2008). The 2005 bulletin of the WHO reports that there are more Ethiopia doctors working outside Ethiopia than in the country itself.

In developing countries where medical professionals’ turnover is rampant different intervention mechanisms to tackle the problem are emerging. Similarly, the Ethiopian government introduced Health Care Finance Reform including private wing establishment in public hospitals as one component. Setting up of private wings in government health institutions where the professionals could work at during their leisure time and earn additional income is mainly aimed at cutting back turnover due to low payments.

Despite all its benefits, prior researches and international experience suggests that this type of ward has much potential for promoting inequity within hospitals. The three key problems are the failure to generate sufficient revenue to sustain hospital-wide quality improvements, the likelihood of resource allocations within the hospital becoming biased towards the private wards and failure to meet their predetermined objective of reducing turnover (Birn et al., 2000; Suwandono et. al, 2001).

In Ethiopia as these private wing establishments were created and started delivering services, it became clear that not much was being done to evaluate them and to understand their governance arrangements and the impact on medical professional’s turnover. Even the limited available data is not rich enough to provide reliable information on the issue.  Therefore, whether public hospitals has gained benefit of retaining medical professionals as a result of setting up private wings and the role the establishments practically play is a critical knowledge gap that needs to be addressed. Thus, this study therefore sought to investigate the role of private wings in public hospitals in reducing medical professionals’ turnover.

OBJECTIVES OF THE STUDY  

The overall objective of this study is to assess and scrutinize the role played by private wings in public hospitals to tackle the problem of medical professionals’ turnover in five selected public hospitals in Addis Ababa. More specifically:

       

• To assess the extent of private wings’ contribution to motivate medical staff, and to improve their income;
• To describe the contribution and achievements of the private wings in retaining medical professionals;
• To find out the attitude and awareness of medical professionals on private wings;
• To describe the challenges/constraints of private wings in reducing medical professionals’ turnover.

METHODOLOGY

Research Design

 It is generally accepted that the selection and application of a research design is dictated by the problem at hand. Accordingly, to carry out this research and achieve the objectives, a mixed research approach (both qualitative and quantitative) is used. The mixed research approach is very efficient in answering research questions compared to the quantitative and qualitative approach when used in isolation (Creswell, 2003). Therefore, by using a mixed approach it is able to capitalize the strength of quantitative and qualitative approach and remove any biases that exist in any single research approach.

Besides, the research applied descriptive type of research design using the survey method. Descriptive research includes surveys and fact-finding enquiries of different kinds. The major purpose of descriptive research is description of the state of affairs as it exists at present (Creswell, 2003). Since little is known and researched about the roles and contributions of private wings in medical professionals’ turnover, the researcher has no control or effect on the variables of the study. The study was rather intended only to describe the roles and contributions of the wards.

Data Sources and Instruments

In this study, both primary and secondary data sources were utilized to address the research objectives. The techniques used to elicit primary data were questioners, key informant in-depth interviews and review of organizational documents. The design of the questionnaire and interview questions was guided by the objectives of the study and the literature research. The secondary data was more or less collected from published documents, books, and journal articles. Other magazines, internet sources including access to electronic scientific articles such as Google’s scholar search facilities, as well as hard copies or reports and other studies were also utilized in the process of data gathering.

Sampling and Sampling Procedures

The study was conducted on those government owned hospitals under Addis Ababa health bureau that have private wings. These hospitals are five in number namely Yekatit 12, Dagmawi Minilik, Gandhi Memorial, Ras Desta Damtew, and Zewuditu Memorial.

The population of this study was all health professionals in the five hospitals with diploma and above academic qualification in their field of work. According to AAHB (2014), there are 1,281 health professionals in the five hospitals that have diploma and above qualification. Since the study population of this study was homogeneous (all were government employed medical professionals) 15% (192) medical professionals were purposively selected as a sample to fill the questionnaires.

Proportional techniques of study subject allocation to the five hospitals were also applied. Accordingly, selection of intended study subjects from the five governmental hospitals under Addis Ababa health bureau was made using the following formula:

                                                 Where nx – sample size in x hospital

                                                             n – Estimated final sample size

                                                             Nx – Total number of medical professionals in x hospital

                                                             N – Total medical professionals in all hospitals

Table 1: Proportional sampling procedure of the study subjects

Hospitals	No of medical Professionals	Proportional allocation samples
Gandhi Memorial	207	32
Ras desta Damtew	177	27
Dagmawi Minilik	298	45
Yekatit 12	306	46
Zewditu	276	42
Total	1281	192

Source: calculated by the researcher based on the HR summary from the health bureau: 2014

The questionnaire was distributed to cover different categories of health professionals as it was given to doctors (all types), nurses and midwife, pharmacists, health officers, laboratory technologists, and radiologists. On the other hand key informant in-depth interview was also conducted with medical services directorate director of AAHB, hospital directors and personnel department heads of each hospitals.

 Method of Data Analysis

In this thesis both qualitative and quantitative data analysis techniques were employed. Data collected by using questionnaires was organized, coded and then analyzed. Specifically, simple statistical analysis like percentage, frequency, tabulation and graph were used in order to analyze the data easily. Microsoft excel was also applied for producing charts and to simplify the calculation. On the other hand, information gained through key informant interviews was described qualitatively.

 MAJOR FINDINGS AND RECOMMENDATIONS

Assessment on Motivation and Income Improvement

The data revealed that the establishment of private wings has contribution to motivate and improve the income of medical professionals; however there is still a considerable level of intent to quit among medical professionals. Close to 40 percent of the study participants showed their interest to continue working in their hospitals at list for the coming three years. This may justify the rise in commitment after the introduction of private wings. However there is still high intent to quit, close to 30 percent of the study subjects were actively searching for alternative jobs. Seeking better job oversea, narrow opportunity for further education, poor leadership and communication, poor pay and benefit, inadequate facility and supplies, and seeking better job in private sector and NGOs are reasons for the intent to quit.

The level of private wings’ contribution to make employees stay in the public sector was rated “to some extent” by most respondents. Besides, after the establishment of private wings medical professionals’ commitment and moral show some extent of improvement. The above statements infer that the extent of private wings contribution to make employees stay in the public sector is small and is not at the expected level. In addition regardless of the rise in income still considerable number of respondents claims no change in level of motivation and morale. Therefore, the hospitals must utilize non financial motivators at the same time so as to boost up the level of motivation and moral to the expected level.

Further, the study found that reliance on private wings as sustainable source of income has not yet deepened and professionals’ livelihood improvement after the introduction of the scheme is insignificant. Respondents expect little rise in income followed by those who expect no income rise from the future expansion and development of private wards. The level of livelihood improvement after the launching of private service was also rated insignificant/little; therefore it is difficult to say the establishment of private wings in public hospitals brought momentous improvement in the livelihood of health professionals.

Medical professionals are delighted with their chance of earning extra income from private wings. However, they criticize private wing set ups for not providing the entire necessary benefit package for the staff (see the table below).

Table 2: Level of medical professionals’ satisfaction with pay/benefits

No	Variables	(5)	(4)	(3)	(2)	(1)	Total
1	I am frustrated by the payment in the private wing	16 (8.7%)	64 (35%)	85 (46.5%)	18 (9.8%)	–	183 (100)
2	I feel satisfied with my chances for earning extra income	35 (19%)	66 (36%)	82 (45%)	–	–	183 (100)
3	There are benefits we do not have which we should have	24 (13.1%)	87 (47.6%)	48 (26.2%)	24 (13.1%)	–	183 (100)

Source: Owen Survey: 2014

Note: (5) = strongly agree, (4) = agree, (3) = neutral, (2) =disagree, (1) =strongly disagree

 In this regard the survey result indicated on an average 50% of the medical doctors (all types) and 40% of other professionals’ total monthly income is earned from private wings. This is a good rise in monthly income due to the establishment and operation of private wings.

Nonetheless, the finding illustrates the existence of equity related complain in the distribution of private wings profit which may contribute to resignation of professionals who feel that they are not sharing equally. (See the graph below). Moreover, the study also found that private wings payment is not as lucrative as other part time option.

Enhancement in Retention and Reduction in Turnover

In the study the contributions and achievement of private wings in retaining medical professionals was also assessed. One third of the health professionals had quit offsite dual practice because of the part time job created in private wings. Therefore, the success of private wings in avoiding off site dual practice (some call it public private overlap) is considerable. In addition all most all respondents who are still engaged in offsite dual practice would give up given private services strengthened and sustained. This implies if properly managed and strengthened public hospital private wings have a potential of reducing unregulated and illegal dual practice.

With regard to medical professionals’ public-private hospitals preference, the result shows “some extent” of preferences of private hospitals over the public ones. However in comparison with prior research (Tigist et.al, 2006) made in the same study area, medical professionals in the public sector had “great extent” of preference of the private sector over the public. Though other variables may contribute for the difference in the extent of preference (“great” and “some”), perhaps motivation resulted from private wings may also contribute which may in part be viewed as a success in this regard.

Moreover, despite the fact that the highest number of respondents (43%) responded that private wings did not significantly reduced turnover so far, decline in turnover after the initiation of private services was noted from the calculation of turnover rates over. Hospitals under the Addis Ababa Health Bureau experience a slow but steady decline in medical professionals’ turnover rate since the establishment of private wings in 2008. (See the graph below)

This decline in medical professionals’ turnover may also be due to other interior and exterior variables, but since private wings were lunched as intervention mechanism to reduce turnover its success in this regard is observable.

On the other hand, close to half of medical professionals who participated in this thesis were considering job oversea even after initiation of private services. Hence, the contribution of private wings to curb outmigration is very insignificant. A focus on monetary compensation as a tool to prevent medical professionals from migrating abroad would mean their total income would have to be raised impossibly high. Therefore, instead of considering private wings as sole instruments, some of the other push factors of outmigration may need to be focused on.

 Attitude and Awareness

With regard to the attitude and awareness of medical staff on different aspects of private wings, the general impression and experience of the medical professionals in private wings is rated positive/favorable and the time they spent in private wings is productive. The establishment of private

wings also created a chance to use maximum skill for medical professionals and sense of hospitals ownership also shows improvement.

The awareness survey reveals that most professionals (87 percent) are conscious of the objective of private wings, but the remaining 13 percent has little awareness of that. This shows some health workers are blindly involved in private service without clearly understanding the objectives. It also shows poor communication and awareness creation activates from the management side. Likewise, there is good level of awareness on the rights and responsibilities of medical professionals involved in private service and on types of services provided in private wards. However, the level of awareness regarding rights and responsibilities of patients and financial aspects (revenue and expenditure, and pricing policy of private wings) is limited. This ambiguity and knowledge gap on the rights and responsibilities of patients and financial aspects of the wards may create conflict and uncertainty which may generate intent to quit.

In the study, most health workers (more than 70 percent) are comfortable with the schedules of private wings (see the chart below). However, since all medical professionals (particularly nurses) are not involved in private wards at the same time, most of them feel underutilized and fail to get a permanent additional income.

 The study also reveals respondents are neither satisfied nor dissatisfied by their workload. Despite the fact that training or special orientation is critical before the implementation of a reform agenda, trainings or at least special orientation program designed particularly for private wing services are not given to the great majority of the professionals. Therefore, the hospitals should organize and provide special trainings for staff discharging private wing tasks.

  Constraints/Challenges of Private Wings in Reducing Turnover

The major constraints/challenges faced by private wings in an effort of reducing medical professionals’ turnover are as follows. First, the income tax issue has slowed down the success of the private wings. The incentive to provide services in the private wings is lessened since the staff member has to report the extra income and pay taxes. The tax issue needs to be resolved with the regional tax bureau, or there may need to be a national policy. A related issue rose by the study subject, particularly nurses, was the need for some system to reward staff based on performance and the equity on pay related complain. Secondly, little knowledge about the existence and operations of private wings among service seekers (patients) is another constraint. Medical service seekers low level of knowledge about private wings as alternative option may create a mismatch between service provider and clients. Thirdly, medical professionals also complain the irregularity of private wings pay due to poor management as a problem. Another constraint is related to the capacity of private wings which make the benefits neither consistent nor all inclusive. Fifthly and finally, hospital managers also expressed their fear of over stretching the already scarce resources in public hospitals due to the establishment of private wing. Therefore unless these problems are solved it may back slide the already attained promising achievements.

Overall, the establishment and operation of public hospital private wings has brought about considerable rise in motivation and in income of medical professionals. The scheme also improved the staffs’ sense of hospitals ownership; created chance of earning extra income, the actual turnover rate was also declined. Nonetheless, professionals’ level of awareness on some aspects of private wings is poor and various challenges/constraints are faced in the process of the wards operation.

 

RECOMMENDATIONS

On the basis of the findings and conclusions reached, the following recommendations are forwarded in order to improve the contribution of private wings in reducing health workers turnover.

 

• The medical professionals who discharge private wing tasks should have at least basic awareness on different aspects of private wings before taking the responsibilities. To this end relevant and continuous awareness creation and informative seminars has paramount importance to minimize the information gap of staff in private wards. Moreover, there has to be a mechanism to check out whether the provided training has improved the trainees’ attitude and knowledge as well as their performance. Hence, the hospitals should organize and provide informative trainings and seminars as soon as possible.

• The development of private wings in hospitals for health workers to earn additional income outside of regular hours may already be a step in the right direction. However, reliance on private wings and financial incentives as a sole motivator and retention mechanism is very erroneous. Therefore, hospital management bodies should create good working environment and encourage employees through the application of different incentive mechanisms both financially and non- financially with the support of the government and other stakeholders. Policies and interventions may also want to focus on nonmonetary compensation, which was found to affect health worker motivation worldwide. Policies that provide quality and needs-based compensation in the form of access to further training, career development opportunities, and professional guidance can help in motivating health workers to better perform and motivation.

• The health bureau and hospitals under it should promote and advertize private wing set ups in public hospitals and provide information for service seekers. Moreover, service seekers should be aware of a broad mix services provided in private wards, the pricing policy and the benefit they enjoy relative to other private options.

• • There are gray areas about private wings among medical professionals and service seekers. Some of these are due to information gap and different perceptions on the effect the private wing will have on the normal health facility services. Hence, the researcher recommends that an in-depth evaluative study on the various methods presently utilized in the various regions as well as in the AAHB facilities be conducted. And the best methods of operating private wings should be presented for all regions to consider. Some national guidelines may also need to be established to allow some consistency across the country.

Collaborations and partnerships form the backbone for most of the cost intensive projects. Public Private partnership projects if implemented and monitored carefully yields mutually beneficial results. Partnership can be monetary, skill based or resource based. Collaboration/ partnership can be within government departments, within private organisation or a mix of two. A case of taking land for using it as a financing tool is also possible as highlighted in thesis infrastructure financing through land which is a project undertaken by government agency.

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