Reuben Nguyo Wachiuri

Abstract

The purpose of this paper is to look into the impact of teacher training programs on the attitude of teachers. The preservice and in service programs were considered. Various aspects were looked at such change of attitude towards inclusion, use of ICT, teaching profession, micro teaching and so forth. The results show that teacher training impacts positively on the attitude of the teachers. Notwithstanding individual teachers have particular temperaments and personality traits that influence how they approach new ideas and situations. Thus, learning outcomes in teacher education are a function of both what programs offer and what teacher trainees bring to the training course. It is also worth noting that at times experienced teachers did not have a change of attitude but they had an improvement in their efficiency. In some cases teachers change in attitude did not translate to a change in behavior due to lack of facilities in the schools.

Key Words: Attitude, pre service training, in service training, teacher trainee

Introduction

Education is undergoing transformations across different parts of the world including Africa. The reform impulse has seen the rise and construction of new learning standards and assessments which will only work if there is investment in the capacity of educators to work together effectively. It’s time to clear away non-essential demands and build capacity in our schools for smarter teaching and learning. Educators are ready for it, students deserve it, and our future prosperity and security require it (Valerie Strauss, 2013). Improving teachers by building their capacity in their professional and personal life is important in the process of reforming education.

Today, students need to learn how to transfer knowledge and skills to real-world problems by communicating and collaborating in groups locally, nationally, and globally to find creative solutions that are innovative, efficient, and sustainable (Valerie Strauss, 2013). Instead, we have 21st century learners being taught by 20^th century teachers in a 19th century educational system (Asia Society, 2012). Because of the globalized world’s new demands for careers and life in the 21st century, international educational leaders are transforming outdated educational systems to reflect a variety of instructional strategies and assessments that will engage multicultural and diverse student populations.

According to Trorey and Cullingford (2002), teachers are central to the capacity of schools to perform and no amount of policy reform will make education more effective unless teachers are

part of the change. One of the fundamental facts that educators and teachers have to bear in mind

is to know how important it is to have the ability to stay current and utilize the most up to date

information. Continuous provision of teachers needs through different forms of support such as

training and other forms of career development are a crucial component in nearly every modern

proposal for educational improvement. Regardless of how schools are formed or reformed, structured or restructured, the renewal of staff members’ professional skills is considered

fundamental to improvement.

Global trends show that majority of our teachers have had opportunities to attend well developed and thoughtful workshops on how to transform teaching and learning. However, the enthusiasm engendered by the workshops wane when they return to the classroom and the reality of the thousands of other things that have to be done in order to achieve effective teaching and learning (Joyce and Showers, 2002).

Attitude on Inclusion

            There is some evidence that an important predictor of successful integration of students with disabilities in regular classrooms is the positive attitude of teachers (Sharma, Florin, Lowerman & Earle, 2006; Al-Khatteb 2004; Avramidis, 2001; Mowes, 2000; Elloker, 1999; Gadium, 2002; Dover, 2002; & Mckeskey & Waldrom, 2002). Research evidence also sugggests that positive teachers’ attitudes towards inclusion often begins during pre-service teacher preparation (Jung, 2007; Avramisids, Bayliss, & Burden, 2001; Campbell, Gilmore, & Cuskelly, 2003; Shippen et al.,2005). Subban and Sharma (2007) pointed out that if teachers leave from the university with negative attitudes then those attitudes are difficult to change. Consequently, positive attitudes can and need to be fostered through both training and positive experiences with students with disabilities.

            The effect of teacher preparation for inclusion is known to have significantly affected pre-service teachers’ attitudes in both Jordan and UAE. Teacher efficacy in implementing inclusion directly affects their practices and attitudes toward including students with disabilities in general education (Sharam, et al., 2006; Pace, 2003). Both males and females had negative attitudes towards people with disabilities in both Jordan and the UAE. One reason for the negative attitudes of males and females could be that pre-service teachers in this study had not been informed that students with special needs would be included in their classrooms and that, as general educators, they do not prefer to be responsible for teaching students with disabilities in the regular classroom. Other reason could be attributed to the fact that the number of male students in this study was small (Al Zyoudi M., Al Sartwai A. & Dodin H.2011).

            Jordanian pre-service teachers had more positive attitudes than their counterparts in UAE. This result could be attributed to the fact that UAE as a nation is relatively new, having been established in 1971; hence, much of its effort has been devoted to creating new programs and services in all aspects, particularly in education. These efforts are still in early stages and need more time to prove their effectiveness. In contrast, Jordan has a long history of providing education for all students. Education in Jordan has received much attention and improvement including preparation of teachers, programs and curriculum. These developments play a major role in improving the quality of services and programs which reflects on improving pre-service teachers attitudes towards inclusive education. This interpretation seems supported by Sharam et al., (2006) who concluded that pre-service teachers from Western countries (i.e. Australia, and Canada) had more positive attitudes toward students with disabilities than their Eastern counterparts (i.e. Hong Kong and Singapore).

            Pre-service teachers in the UAE considered the absence of appropriate materials and equipment as barriers to successful inclusion. Pre-service teachers in this study were critical of the services provided for students in general education classrooms. On the other hand, in Jordan, pre-service teachers showed positive attitudes towards inclusion, because they found appropriate resources that facilitated successful inclusion. This result is supported by Alzyoudi (2006) who found a strong relationship between sufficient resources and successful inclusion. Pre-service teacher education must, therefore, be concerned with the promotion of teacher attitudes as well as instructional competences (Andrews, 2002; Reinke and Moseley, 2002).

            Pearson (2009) says that teacher education is a context in which changes in attitudes, beliefs and values do occur. Atkinson (2004) and Forlin et al. (2009) note that if the negative attitudes of pre-service teachers are not addressed during initial teacher education, they may continue to hamper the progress of inclusive education efforts in schools. Training in special/inclusive education has consistently been found to have influenced educators’ attitudes (Campbell et al., 2003; Cook, 2002). Lancaster and Bain (2007) agree that in general, there is a positive change in attitudes after undertaking an inclusive/special education unit of study and this is the case across a number of contexts and countries (Ching et al., 2007; Kyriakou et al., 2007).

            However, Molina (2006) found research evidence to demonstrate that theoretical classes and reading are not sufficient to modify teachers’ and students’ negative attitudes towards pupils with special educational needs. Loreman et al. (2007b) conclude that if pre-service teachers are going to develop positive attitudes towards inclusive education, they need opportunities for direct interaction with people with disabilities, instruction on policy and legislation relating to inclusive education, and opportunities to gain confidence in practical teaching situations with students with disabilities.

            Johnson and Howell (2009) also show that attitudes are amenable to change through a course and an assignment that involve the analysis of case studies in inclusive education. Elhoweris and Alsheikh (2006) suggest that attitudes can be improved by increasing students’ knowledge about learners with disabilities and ways to meet their learning needs and suggest that teacher education programmes may need to include more alternative learning styles and instructional strategy.

            Lambe (2007) found that successful teaching practice in the non-selective sector had the most positive influence on perceived competency and on general attitudes towards inclusion.  A study by Yellin et al. (2003) however, concluded that mere exposure to students with additional needs may not be enough to change attitudes in a positive way –it is the quality of experiences which produces real change. Campbell et al. (op. cit.) provided a one semester course on human development and education and field work with learners with Down syndrome. Following this, students felt significantly less discomfort, uncertainty, fear and vulnerability when interacting with people with disabilities. They also reported feeling less sympathy, an outcome also noted by Tait and Purdie (2000) which may indicate a more relaxed approach to disability as opposed to an overly sympathetic view.

            Studies overseas have found that many teachers have less than positive attitudes towards students with disabilities and their inclusion in general education classrooms (D’ Alonzo, Annemaree Carroll and Giordano, & Cross, 1996; Vaughn, Schumm, Jallad, Anne Jobling, Slusher, & Saumell, 1996). In a study of teachers in rural British Columbia, it was established that both their in service and preservice education had inadequately prepared them for the realities of inclusion (Bandy & Boyer, 1994). Teachers reported a high percentage of children with special needs in their classrooms who had a wide range of disabilities. They revealed a grave concern pertaining to the lack of support services available to the students and themselves, and disclosed a perceived inability to provide optimal educational programs to children with special needs because of inadequate teacher preparation and lack of adequate resources. Of 231 teacher trainees in Northern Ireland and Scotland, 96 percent indicated that they did not believe their professional training had prepared them to meet the challenge of inclusive education (Wishart & Manning, 1996). Another study conducted in 45 states in the U.S.A. concerning inclusion reported that respondents did not feel prepared to meet the needs of their students with disabilities (Lombard et al., 1998).

            Hickson, (1995) asserts a positive attitude change towards people with disabilities was noted on completion of a mandatory disability course component. In addition, attitude formation and change were also linked to contact with people with disabilities. In an Australian study, Forlin, Jobling, and Carroll (2001) identified several factors that were related to interactions with people with disabilities for a group of preservice teachers. It was found that preservice teachers had a high level of sympathy toward people with disabilities, were fearful of being disabled, and felt vulnerable in interactions with people with disabilities.

            A survey of teachers undertaken by the Queensland Government (Disability Services Queensland, 1999) further reported that 86 percent of the respondents considered that others would not feel relaxed and comfortable when interacting with people with a disability. Annemaree C., Chris F. & Anne J, (2003) observed that the most noticeable improvement regarding interactions with a person with a disability was that preservice teachers felt less ignorant, more able to act normally and surer of how to behave, once they had completed the course. They also demonstrated less pity and a greater focus on the person rather than the disability.

Attitudes on Computer Information Technology (ICT) Usage

            Teo, T., Lee, C. B., & Chai, C. S. (2007) study shows that perceived usefulness, perceived ease of use and subjective norm were significant determinants of pre-service computer attitudes. Facilitating conditions did not influence computer attitude directly but through perceived ease of use. These findings demonstrate that social norm and facilitating conditions are potential variables that may be used to extend the Technology Acceptance Model (TAM) for research on computer attitudes.

Wong et al (2005) examined the use of the Internet among 310 pre-service teachers using questionnaire survey method. They found that pre-service teachers’ use of the Internet was influenced by support from friends, confidence level, attitude towards the Internet and perceived usefulness (PU). Khine (2001) studied 184 pre-service teachers to examine their use of Information Communications Technology (ICT) through studying their attitudes towards computers and found a significant relationship between Computer Attitudes (CA) and its use in the institution. Yuen & Ma (2001) administered the Chinese Computer Attitude Scale for Teachers to 216 secondary teachers in Hong Kong to examine the factors that influence the instructional use of computers and their results revealed that affective attitudes, general usefulness, behavioral control and pedagogical use were significant in determining the use of ICT among teachers, accounting for 37% of the model specified. You can read more on the website.

            A key reason for studying teachers’ CA is the ability of attitudes to predict computer usage. Research has shown that a teacher’s attitude towards the computer is a major predictor for future computer use (Myers & Halpin, 2002) and their need for learning computing skills that in turn will lead to computer literacy (Zhang & Espinoza, 1997). For example, Yildirim (2000) found that teachers who used computers more would tend to develop positive attitudes that promote further use of the computer in their daily teaching tasks and conduct activities that require computers to play a major role in, for example, computer-mediated forums.

 Attitude on other Variables

            In a study in Iran, Shahmohammadi (2014) noted the short in service training course significantly affected the teachers’ attitude in the learning environment which includes: Relationship with Students, Presentation and Culture and Adjustment and not in Individuals and Activity. The reason being, they had already developed a positive attitude towards the same during their teaching practice and teaching experience. According to Senior (2006) it is nearly impossible for teacher to implement all the principles of teaching that they have been taught in training courses since these courses are overloading teachers with a plethora of methods, and teaching skills. This may account for the high number of mistakes in the two areas of presentation and execution/method.

            Shahmohammadi (2014) also asserts that in some cases there was a mismatch between the student teachers’ attitude and their teaching practice in class. That is to say they failed to put into practice what they valued .The researchers are of the opinion that the reason why the teachers did not follow some of the training guidelines might be due to their being overwhelmed with a surplus of principles on the one hand and being new to the atmosphere and inexperienced on the other. This might have made it difficult for them to make on the spot decisions in spite of their willingness to do so. This finding supports Ajzen’s (1988) claim that teachers’ attitudes may be something and their actual behaviors may be something else based on the opportunities and resources available to them. This point is consistent with the common observation that some teachers who agree with particular types of activities do not carry them out in their classrooms. For these teachers, attitude is not predictive of their behavior. The point to remember is that teachers’ inadequate performance should not be considered as an indication of their incompetence. If they are given enough time and practice they would probably gain the confidence to be more judicious in their decision making.

            Researchers have observed that some experienced teachers also did not follow the training course guidelines. The reason might be the incompatibility of what the teachers had gained through years of experience and what was introduced as sound practice in the training course. Their experience might have convinced them that what the training course introduced as effective practice was not feasible. This case is also in line with what Hollingsworth (1992) has theorized. He claims that prior knowledge and experience serve as a filter to pedagogical learning during the pre-service years, altering how pedagogical instruction is learned and enacted by teachers. This was actually observed in this study since some teachers who had a few years of experience in teaching did not follow exactly what was prescribed to them in the training course and preserved their previous beliefs and personal theories. As individuals, teachers have particular temperaments and personality traits that influence how they approach new ideas and situations. Thus, learning outcomes in teacher education are a function of both what programs offer and what teacher trainees bring to the training course.

            Srivastava (1989) attempted to study the impact of teacher education programme of Lucknow University on pupil- teachers’ attitude and teaching efficiency. The findings of study were: Most of the trainee groups changed their teacher attitude positively and significantly after training.  However the experienced male trainees did not show any change in their teacher attitude, there was no significant change in the teacher-aptitude of the male postgraduate student-teachers and the experienced female trainees as a result of the training. All the trainees showed significant and appreciable improvement in their classroom teaching performance, after the completion of the training, the females showed better teacher-attitude and aptitude than the male trainees. Male trainees showed better teaching efficiency than female trainees, and the trainees teaching social sciences showed better teaching efficiency than those teaching science and mathematics.

            Roy (1991) examined the impact of the elementary teacher education programme on attitudinal change of the elementary teacher-trainees of Orissa towards community involvement. The elementary teacher education programme with the elements of community involvement, both in theory and practice, positively affected the change in attitude of the student-teachers towards community involvement. Both the categories of student-teachers were almost equally prone to change in their attitude towards community involvement. Previous teaching experience had no role to play in the change in attitude of student-teachers towards community involvement.  The degree of interest in teaching was responsible for accelerating the development of attitude towards community involvement.

            Ramachandran (1991) attempted to conduct an enquiry into the attitude of student-teachers towards teaching. The findings of the study were: Regular college teacher-trainees had a more favorable attitude towards teaching than the correspondence course teacher-trainees, female teacher-trainees had a more favorable attitude towards teaching than male teacher-trainees, the sons and daughters of teachers had a highly favorable attitude towards teaching. Post Graduate (PG) teacher-trainees had a more favorable attitude towards teaching than undergraduate teacher-trainees; the nature of the course did not influence the attitude of teacher-trainees towards teaching.

            Yadav (1992) studied the impact of teacher training on certain personality characteristics of trainees. The findings of the study were:  All the dimensions of self-concept increased through teacher training except the feeling of inadequacy which decreased. Social maturity of the teacher-trainees increased in all the dimensions except for self-direction, personal adequacy and enlightened trust; the teachers’ training had a significant influence on their self-concept, social maturity and attitude towards the teaching profession.

            Fortune, et al. (1965) designed a questionnaire to assess attitudes of students towards micro teaching technique in Stanford summer micro technique clinic. The result was quite encouraging. It was found that 60 percent of the participating students reported their micro teaching experience either very or extremely valuable. Dhadwal (1981) in his study of attitude of B.Ed. trainees towards teaching profession found that trainees belonging to urban areas have more favourable attitude as compared to those belonging to rural areas. Men have less favourable attitude as compared to women towards teaching profession. Raina (1990) found that there was no significant difference in attitude towards teaching profession. Between the in-service education science, arts and commerce teachers differed significantly in their attitude to teaching.

Shukla (1997) conducted a study on the attitude of the college teachers towards their profession and found that majority of teachers show favourable attitude towards their profession. Female teachers show greater positive attitude than male teachers.

            Sali (2003) studied the attitude of teachers towards four aspects of in-service training programme i.e. content enrichment of school subject, teaching methods, new trends in education and innovation in education and interpreted favorable attitude towards different aspects. Depaul et al. (2003) studied the difference in the attitude of elementary school teachers towards in-service education in between non graduates, graduates and post-graduate, married, unmarried, urban and rural. The result showed that there is no significant differences between the mean attitude score towards the in-service education with regard to different variables.

Conclusion

 The review shows that the teacher training programmes have an impact on teachers’ attitudes towards various aspects in the teaching profession. Both preservice and in service programs were looked into. It is also notable that not only do the programs influence the attitude of the teachers but also their past experiences and personality traits. Moreover, the attitudes of the teachers do not always translate to behavior change due to lack of equipment and materials.

References

Ajzen, I. (1988), Attitudes, Personality, and Behavior. Milton Keynes: Open University

Al Zyoudi M., Al Sartwai A. & Dodin  H.(2011). Attitudes of Pre-service Teachers towards Inclusive Education in UAE and Jordan (a comparative study). International Journal of Disability, community and Rehabilitation. http://www.ijdcr.ca

Al Zyoudi, M. (2006). Teachers’ Attitudes towards inclusive education in Jordanian schools. International Journal of Special Education, 21 (2), 55-63.

Alkhateb, J. (2004). Teaching students in inclusive schools. Dar Wal, Amman, Jordan.

Andrews, L. (2002) Preparing general education pre-service teachers for inclusion: Web            enhanced case-based instruction, Journal of Special Education Technology, 17, 27-35

Annemaree C., Chris F. and Anne J. (2003).The Impact of Teacher Training in Special   Education on the Attitudes of Australian Preservice General Educators towards People      with Disabilities .Teacher Education Quarterly, 30, 3, 65-79: Caddo Gap Press         :http://www.jstor.org/stable/23478441

Asia Society. (2013). “Teacher Quality: The 2013 International Summit on the Teaching Profession.” New York: http://asiasociety.org/files/teachingsummit2013.pdf

Atkinson, D. (2004) Theorising how student teachers form their identities in perceptions about their initial education in relation to the special educational needs of  Press. British Educational Research Journal  30, 3, 379–394, DOI: 10.1080/01411920410001689698

Avramidis, E. (2001). Mainstream teacher’s attitudes towards the inclusion of children with special       educational needs in the ordinary school. Unpublished Doctoral Dissertation, University         of Exeter.

Avramidis, E.; Bayliss, P.; & Burden, J. (2001). A survey into mainstream teachers’ attitudes towards the inclusion of children with special educational needs in ordinary school in one local education authority. Educational Psychology, 20, 193-213.

Bandy, H. E. & Boyer, W. A. R. (1994). The impact of special needs students on teachers in the            rural areas of British Columbia. In D. McSwan & M. McShane (Eds.)

Campbell, J., Gilmore, L., & Cuskelly, M. (2003). Changing students teachers’ attitudes towards                              disability and inclusion. Journal of Intellectual and Developmental Disability, 28, 369-                              379.

Ching, S., Forlin, C. and Mei Lan, A. (2007) The influence of an inclusive education course on             attitude change of pre-service secondary teachers in Hong Kong. Asia-Pacific Journal of     Teacher Education, 35 (2), 161-179

Cook, B. G. (2002) Inclusive attitudes, strengths, and weaknesses of pre-service general           educators enrolled in a curriculum infusion teacher preparation program. Teacher            Education and             Special Education, 25, 262-277

D’Alonzo, B., Giordano, G., & Cross, T. (1996). Improving teachers’ attitudes through teacher             education toward the inclusion of students with disabilities into their class rooms.   Teacher           Educator, 31(4), 304-312.

Depaul, S. et al. (2003)..Attitude of School Teachers Towards in-Service Education. The Progress                      of Education.

Dhadwal,S. (1981).A study of the Attitude of B. Ed Trainees of D. A. V College of Education,     Hoshiarpur Towards Teaching (M. Ed Dissertation). Punjab University,            Chandigarh

Disability Services Queensland (1999). Community attitudes study: Community awareness         campaign testing. Brisbane: Queensland Government.

Dover, E. (2002). Instructional Management of Para-educator’s in inclusive classrooms: The     perspectives of teachers. Annual National Conference Proceedings of the American Council on    Rural Special education. (22nd), Reno, NV, March 7-9. U.S. South Carolina education. British            Educational Research Journal, 30 (3), 379-394

Elhoweris, H. and Alsheikh, N. (2006). Teachers’ attitudes toward inclusion. International Journal of   Special Education.21(1), 115-118.

Elloker, S. (1999). Inclusive education as a strategy to develop effective schools: A case study of a primary school in a socio-economic disadvantaged environment. Unpublished M.A Dissertation, University of the Western Cape

Forlin, C. Jobling, A., & Carroll, A. (2001). Preservice teachers’ discomfort levels toward people          with disabilities. The Journal of International Special Needs Education, 4, 32-38.

Forlin, C., Loreman, T., Sharma, U. and Earle, C. (2009). Demographic differences in changing            pre-service teachers’ attitudes, sentiments and concerns about inclusive education.       International Journal of Inclusive Education, 13 (2), 195-209

Fortune etal. (1965). Attitude of Student Teachers Towards Micro Teaching Technique. Journal           of the Institute of Educational Research

Gudium, D.M. (2002). A qualitative study of the perceptions of six pre-service teachers: Implementing oral and written retelling strategies in teaching reading to students with learning disabilities. Paper presented at the Annual Meeting of the Eastern Educational Research Association. (Sarasota), FL, 2 February-27 March 2002

Hickson, F. E. (1995). Attitude formation and change toward people with disabilities.     Unpublished Doctoral thesis. Sydney, NSW: University of Sydney.

Khine M.S. (2001) Attitudes toward computers among teacher education students in Brunei     Darussalam. International Journal of Instructional Media 28, 147–153.

Kyriakou, C., Avramidis, E., Høie, H., Stephens, P. and Hultgren, Ǻ. (2007). The development of student teachers’ views on pupil misbehaviour during an initial teacher training programme in England and Norway. Journal of Education for Teaching, 33,  3,  p. 293-307.

Lambe, J. 2007.Northern Ireland student teachers’ changing attitudes towards inclusive education during initial teacher training. International Journal of Special Education, 22, 1, 59-71.

Lancaster, J. and Bain, A. (2007) The Design of Inclusive Education Courses and The Self-      Efficacy of Preservice Teacher Education Students. International Journal of       Disability,        Development and Education, 54 (2), 245-256

Lombard, R. C., Miller, R. J., & Hazelkorn, M. N. (1998). School-to-work and technical           preparation: Teacher attitudes and practices regarding the inclusion of students with       disabilities. Career Development for Exceptional Individuals, 21, 161-172.

Loreman, T, Forlin, C. and Sharma, U. (2007b) An International Comparison of Preservice       Teacher Attitudes towards Inclusive Education. Disability Studies Quarterly, 27 (4)

Mcleskey, J. & Waldron, N.L. (2002). Inclusion and school change: Teacher perceptions regarding curriculum and instructional adaptations. Teacher education and special education. 25 (1), 41-54

Molina, S. (2006) Teacher education students’ and first year in-service teachers’

Mowes, D. (2000). The attitudes of educators in Namibia towards inclusive education.   Doctoral Dissertation, University of Stellenbosch.

Myers J.M. & Halpin R. (2002) Teachers’ attitudes and use of multimedia technology in the      classroom: constructivist-based professional development training for school districts.            Journal of Computing in Teacher Education 18, 133–140.

            needs; Hampshire England; Ashgate Publishing Ltd

Pace, D. (2003). Increasing awareness and understanding of students with disabilities. Academic Exchange, 205-214.

Pearson, S. (2009) Using activity theory to understand prospective teachers’ attitudes to and    construction of special educational needs and/or disabilities. Teaching and Teacher            Education, 25 (4), 559-568

Raina, V. K. (1990). A Factorial study of the personality, attitude to teaching and creativity of in-       service and student teachers belonging to subject areas Survey of Research in Education.          833.

Ramachandran, G. (1991). An Enquiry into the Attitude of Students Teachers Towards Teaching,           In Fifth Survey of Educational Research. New Delhi: NCERT

Reinke, K. and Moseley, C. (2002). The effects of teacher education on elementary and secondary        preservice teachers’ beliefs about integration: A longitudinal study. Action in reviewing         the potential for problem-based, e-learning pedagogy to support practice.

Roy, Sinha D. (1991): D. (1991) : D. (1991) : D. (1991) : “Impact of the elementary teacher       education programme on attitudinal change of the elementary teacher – trainees of Orissa       towards community involvement”. Fifth survey of Educational Research 1988-92. Vol. II. NCERT, Sri Aurobindo Marg, New Delhi, 110016

Shahmohammadi, N. (2013). The Effect of In-Service Training Courses on the Teacher’s Attitude and             Performance. International Letters of Social and Humanistic Sciences, 19, 183–191.             http://doi.org/10.18052/www.scipress.com/ILSHS.19.183

Sharma, U., Forlin, C., Lorman, T., & Earle, C. (2006). Pre-service teachers’ attitudes, concerns and sentiments about inclusive education: An international comparison of the novice pre- service teachers. International Journal of Special Education. 21 (2) 80-93.

Shippen, M., Crites, S., Houchins, D, Ramsey, M., Simon, M. (2005). Pre-service teachers’ perceptions of including students with disabilities. Teacher education and Special Education, 28 (2), 92-99.

Shukla. S. S. (1997). Attitude of the College Teachers Towards Their Profession. The     progress of Education.7(2), 69. Spanish pupils. In Gash, H. (ed.) Beginning teachers and diversity in school: A European Study. Instituto Politécnico de Bragança Report of research undertaken within Comenius    Project 94158-CP-1-2001-FR

Srivastava Madhu Bala (1989). “The Impact of teacher education programme of Lucknow         University on Pupil –Teachers attitude towards teaching efficiency”,Fifth Survey of         Research in Education (1988-92) NCERT New Delhi.

Subban, P., & Sharma, U. (2006). Teachers’ perceptions of inclusive education in Victoria, Australia.   International Journal of Special Education, 21 (1), 42-52.

Szabo, S. (2003). I’m not sure I can handle the kids, especially, the, uh, you know special         ed kids. Action in Teacher Education, 25 (1), 14-19

Tait, K. and Purdie, N. (2000). Attitudes toward disability: teacher education for inclusive

            Teacher Education, 24, 31-39 Teachers, Jaipur: M.Ed. Dissertation, University of Rasasthan.

Teo, T., Lee, C. B., & Chai, C. S. (2007). Understanding pre-service teachers’ computer    attitudes: applying and extending the technology acceptance model: Understanding pre-     service teachers’ computer attitudes. Journal of Computer Assisted Learning, 24(2), 128–      143. http://doi.org/10.1111/j.1365-2729.2007.00247.x

Trorey, G. and Cullingford, C. (2002). Professional development and institutional needs; Hampshire England; Ashgate Publishing Ltd.

Vaughn, S., Schumm, J., Jallad, B., Slusher, S., & Saumell, L. (1996). Teachers’ views of inclusion. Learning Disabilities Research and Practice, 11(2), 96-106.

Wishart, J. G., & Manning, G. (1996). Trainee teachers’ attitudes to inclusive education for           children with Down’s Syndrome. Journal of Intellectual Disability Research, 40, 56-65.

Wong S.L., Ng S.F., Nawawi M. & Tang S.H. (2005). Experienced and inexperienced Internet    users among pre-service teachers: their use and attitudes toward the Internet. Journal of       Educational Technology and Society 8, 90–103.

Valerie Strauss, (2013). Washington Post.      http://larryferlazzo.edublogs.org/2010/10/01/interview-of-the-month-washington-post-        journalist-valerie-strauss/

Yadav, H.R. (1971). Values of Most Accepted and Least Accepted Teachers, Jaipur:          M.Ed. Dissertation, University of Rasasthan

Yellen, P.G., Yellin, D., Claypool, P.L., Mokhtari, K., Carr, R., Latiker, T., Risley, L. and Szabo,             S. (2003). I’m not sure I can handle the kids, especially, the, uh, you know special ed             kids. Action in Teacher Education, 25(1), 14-19

Yildirim S. (2000). Effects of an educational computing course on pre-service and inservice          teachers: a discussion and analysis of attitudes and use. Journal of Research on           Computing in Education 32, 479–495.

Yuen H.K. & Ma W.K. (2001). Teachers’ computer attitudes: factors influencing the          instructional    use of computers. Proceedings of the International Conference on Computers in   Education (ICCE), Seoul Korea. 12–15 November 2001.

Zhang Y. & Espinoza S. (1997). Affiliations of computer self-efficacy and attitudes with need     for       learning computer skills. Journal of Educational Computing Research 17, 371–        383

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

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

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.

REFERENCES

Abreu, ECM & Vall, MML. (2000). Management Principles of Business Management. 10^th ed. Portugal: Mcgraw-Hill, de Portugal, Lda.

Addis Ababa City Government Urban Development Indicators: Finance & Economic Development Bureau August, 2011 Addis Ababa

AHWO, (2010).  Human Resources for Health Country Profile-Ethiopia: African Health work Force observatory.

Becker, G. (1993). Human Capital: A Theoretical and Empirical Analysis, with special reference to Education. Chicago and London, 3rd Edition: The University of Chicago Press.

Birn, A.-E., Zimmerman, S. and Garfield, R. (2000). To decentralize or not to decentralize, is that the question? Nicaraguan health policy under structural adjustment in the 1990s.   International Journal of Health Services, 30(1): 111-128.

Berhan, Y. (2008). “Medical Doctors’ profile in Ethiopia: production, attrition and retention”, Ethiopian Medical Journal, 46(01):1-7

Chiavenato I. (1997). Managing People, Sao Paulo: Makron Books do Brasil Editoria: Lda.

Creswell, JW. (2003). Research Design: Qualitative, Quantitative and Mixed Method Approaches. (2^nd ed). Sage. Thousand Oaks. CA.

Doug, P. (2006). “Modern timekeeping systems lead to better staffing”, Nursing Homes: Long Term Care Management, 55(7):22-23

Dovlo D. (2003).  Brain Drain and Retention of Health Professionals in Africa. A case study prepared for a regional training conference on improving tertiary education in Sub Saharan Africa. Available: http://www.medact.org/content/health/documents/brain_drain/Dovlo%20-%20brain%20drain%20and%20retention.pdf. [Accessed 12/12/2012]

EQUINET (2004). Equity in the Distribution of Health Personnel. Regional Research Review Meeting Report; 15-17 Apr 2004; Johannesburg, South Africa

Federal Ministry of Health (FMOH). (2008). Human Resources for Health and Aid Effectiveness Study in Ethiopia. Federal Ministry of Health, WHO Ethiopia, June 2008.

Federal Ministry of Health (FMOH). (2010). National Health Accounts (NHA) IV Part III. PLHIV Health Service Utilization and Expenditure Survey, Addis Ababa, Ethiopia.

Federal Ministry of Health (FMoH). (1998). Ethiopia Health Care Financing Strategy. Addis Ababa, Ethiopia.

Griffith, R.W. & Hom, P.W. (2001). Retaining Valued Employees. Thousand Oaks, CA: Sage Publications.

Harkins, P. J. (1998). Why Employees Stay or Go, Journal of Workforce, 77(10):36-42

Health Sector Financing Reform Project (2009). “Establishing Private Wings in Public Health Facilities: Operational Manual.” Addis Ababa

Kotzee, T. J and Couper, I. D. (2006). What interventions do South African qualified doctors think will retain them in rural hospitals of the Limpopo province of South Africa? Available

      http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=581 [10/12/2012]

Kirscherbaum A and Mano-Negrin R. (1999) Underlying Labor Market Dimensions of     “Opportunities”: The Case of Employee Turnover, Human Relations, 52 (23): 1233-1255

Luthans, F. (1995). Organizational Behavior, 7th Edition, New York, McGraw-Hill

Noe, R. A, Hollenbeck, J. R, Gerhart, B and Wright, P. M. (2010). Human Resources Management: Gaining a Competitive Advantage.5th Edition, New York, McGraw Hill

Mace, F.C. (1990). A Collateral Effect of Reward Predicted by Matching Theory. Journal of Applied Behavior Analysis 23:197-205.

Macleod H. (2003). An Introduction to Medical Schemes and Social Health Insurance in South Africa, Research report prepared for the Risk Equalisation Fund Task Group, National Department of Health, Pretoria.

McNabb (2009). The New Face of Government: How public Managers are forging a New Approach to Governance. Taylor and Francis Group, LLC. USA

Magner, N.& Welker, R. (1996). The Interactive Effects of Participation and Outcome Favorability on Turnover Intentions and Evaluations of Supervisors. Journal of Occupational & Organizational Psychology 69, 135-143.

Mara MT. (2010). An Investigation of Turnover And Retention Factors of Health Professional Staff Within the Eastern Cape Department of Health. Rhodes University, Eastern Cape. South Africa

Mateus G. (2007). Reasons for High Turnover of Nursing Professionals at Public Hospitals in Angola, University of South Africa. Available: http://hdl.handle.net/10500/532 [accessed 19/12/2013]

Miller HT. (2008). Theory, Marcia L. Whicker and Gerald J. Miller, Hand book of research methods in public administration, PP 13-23, New York: CRC press-Taylor & Francis Group.

Morrell K.M., Loan-Clarke J. & Wilkinson J. (2004). Organizational Change and Employee Turnover, Personnel Review, 33(2): 161-173.

Mylene Perez (2008). Human Resource management: Turnover Intent. Available: www.hrm.uzh.ch/static/fdb/uploads/da_mylene_perez.pdf. [accessed 14/12/13]

Nel. P.S; Gerber, P. D; Van Dyk, P. S; Haasbroek, G. D; Schultz, H. B; Sono, T and Werner, A. (2001). Human Resources Management, 5th Edition, Cape Town: Oxford University Press

Puah KH (2003). ‘Attacking Hospital Performance on Two Fronts): Innovations in Health Service Delivery: The Corporatization of Public Hospitals, World Bank, Washington D.C.

Price, J. (2001). Reflections on the Determinants of Voluntary Turnover, International Journal of Manpower 22, 600-624.

Ramlall, S. (2004). A review of employee motivation theories and their implications for employee retention within organizations. Journal of American Academy of Business, 5(1): 52-63

Runy, L. A. (2006). “Nurse Retention”, Journal of Hospitals & Health Networks, 80(1):53-57

Schrecker T. and Labonte R. (2004). Taming the Brain Drain: a Challenge for Public Health Systems in Southern Africa. International Journal of Occupational and Environmental Health,  10:409-415.

Serra, Daniela, Pieter Serneels, and Magnus Lindelow. (2010). “Discovering the Real World—How Health Workers’ Early Work Experience affects their Career Preferences in Ethiopia” (Draft Report). 2nd cohort study. World Bank, Washington, DC.

Spherion Staffing Services. (2010). Emerging Workforce 2009. Available: http://www.spherion.com/EW_Study/Spherion_EmergingWorkforce09.pdf    [accessed 17/11/2013]

Stephen Pilbeam and Marjorie Corbridge (2008). People Resourcing: Contemporary HRM in Practice (Third Edition). Harlow England: Person edition.

Suwandono A, Gani A, Purwani S, Blas E and Brugha R (2001). ‘Cost Recovery Beds in Public Hospitals in Indonesia’ in Health Policy and Planning, 16(2): 10-18.

Tang JH. (2003). Evidence-Based Protocol: Nurse Retention. Journal of Gerentogical Nursing, 29 (3): 7-14. Available: www.ncbi.nlm.nih.gov/pubmed/12683301.. [accessed 15/11/2013]

United Nations Development Program (UNDP). Statistical update, December 18, 2010. New York, United Nations Development Program, 2010.

USAID -HSFR Project, (2012). Health Care Financing Reform in Ethiopia: Improving Quality and Equity, Addis Ababa, Ethiopia

USAID (2011). Ethiopia Health Sector Financing Reform Project Mid-term Evaluation. Addis Ababa, Ethiopia.

Van Dormael, M; Dugas, S; Kone, y; Coulibaly, S; Sy, M and Despplats, D. (2008). “Appropriate training and retention of community doctors in rural areas: a study from Mali. Available: http://www.human-resources-health.com/content/6/1/25 [accessed 10/9/2012]

WB (2010). Fixing public hospital system in China Health. World Bank Nutrition and Population of East Asia and Pacific. Washington DC 20433 USA

WB (2012). Health Workforce in Ethiopia: Addressing the Remaining Challenges. Washington DC

World Health Organization (2004). Human Resources in Health: Report by the Secretariat for the Executive Board 114^th session. Geneva, Switzerland: World Health Organization.

World Health Organization (2005). Human Resource for Health: toolkit for planning training and management. Geneva, Switzerland: World Health Organization. Available: http://www.who.int/whr/2005/en/ [accessed 18/10/2013]

World Health Organization (2002). Technical Consultation on Imbalances in the Health Workforce; 10-12 Mar 2002; Ottawa, Canada. Available:

      www.labourmarketframeworkyukon.com/…/RR%20strategies.pdf  [accessed12/12/2013]