Frontline health worker motivation in the provision of maternal and neonatal health care in Ghana

The health of mothers and neonates is a concern for many countries, because they form the future of every society. In Ghana efforts have been made to address quality health care in order to accelerate progress in maternal and child health and reduce maternal and neonatal mortality through the implementation of a number of polices including a fee exemption for pregnant women for antenatal, delivery and postnatal care and a national health insurance scheme among others. However these interventions have not led to an improvement in the quality of health care and concerns have been raised whether health workers are sufficiently motivated to provide health care that is responsive to the needs of mothers and children. This study set out to study motivation as an individual quality of the worker, however it became obvious in the analytical phase that motivation is an outcome of interactions between the worker and the work environment. So the research resorted to analyse and understand the various ways in which interpersonal interactions and organisational processes contribute to the motivation of health workers and quality of care in a Ghanaian hospital setting. The research tried to answer the following questions: what are the interpersonal processes that influence health worker motivation; what are the organisational and managerial processes that influence health worker motivation; how does the setup of the Ghana health sector and its associated policies influence health worker motivation and how does health worker motivation influence health worker response to client health needs? The research focused on the quality of interpersonal interaction, such as attitudes, motivation, trust and conflict, on a number of organizational characteristics such as power relations, power being defined as the ability to affect organizational outcomes, uncertainty in decision-making and the provision of resources to deliver quality health care and on wider policy-making that affects the ability of health care institutions to take care of the staff (remuneration, human resource management) and the decision-making space of health facility managers. In order to investigate health worker motivation in a real life setting ethnographic research was conducted for twenty months in two hospitals; a specialist referral hospital and a district hospital that offer basic maternal and child health services in the greater Accra region in Ghana. Between 2011 and 2013, data was collected in mostly the maternity and new-born units of both hospitals. The researcher interacted with hospital staff including nurses, doctors, anaesthetists, orderlies, laboratory technicians, accounts officers and managers and collected data on daily activities and interactions in the hospital environment. The hospitals, which had different characteristics, were not selected for comparative purposes, but to enable a better understanding of how the organizational context influences worker motivation. Conversations were useful in helping the researcher to understand social phenomena. Interviews were conducted to explore social phenomena in depth. Participant observation was also a very important tool in helping the researcher to observe at first- hand how health care is provided in a natural hospital environment. An important source of information consisted of the reactions of hospital staff on the research and the researcher and the researcher’s emotional reactions to this, as it helped her to experience motivation, which was very useful in understanding and analysing motivational processes in the hospital environment. Ethical clearance was obtained from the Ghana Health Service Ethics Review board (approval number GHS-ERC:06/01/12) and the proposal was reviewed by the Wageningen School of Social Sciences board. Written informed consent was obtained from all interview participants. Verbal consent was obtained for conversations and pseudonyms are used for the names of the study hospitals and frontline workers throughout the thesis. Interpersonal processes including limited interaction and communication between collaborating frontline workers and perceived disrespect from colleagues and managers contributed to poor relations between frontline workers. A high number of frontline workers engaged in locum (private practice) in private hospitals. Such workers came to work late, or left early and some even skipped their official work to engage in locum practice. Workers also believed that some of their colleagues sneaked in their clients from their locum site to the hospital and charged them illegal fees, which they did not share with colleagues. Such practices and perceptions contributed to distrust relations among workers and to a poor organisational climate, which resulted in demotivation of staff, poor collaboration in the provision of health care, and eventually to conflicts. Conflicts contributed to delays in the provision of care and those who were willing to work felt disempowered, as they were unable to marshal their resources with collaborating professionals to respond to clients’ needs. They also contributed to angry and bitter workers and negative perceptions of other professional groups. Sometimes cases were postponed and on some occasions clients had to be referred to other facilities. Organisational and managerial processes equally influenced health worker motivation in various ways. Health workers perceived distributive, procedural and interactional injustice in organisational and managerial processes as they perceived that managers were not responding to their personal and organisational needs, which compromised their ability to offer quality health care. Health workers perceived distributive injustice in the fact that they worked hard and deserved to be given incentives to offset the stoppage of bonuses that the government initially paid to workers when the fee exemption for maternal health was introduced. Workers felt their managers were not meeting the hospitals’ needs for essential medical supplies, equipment and were incapable of putting up appropriate infrastructure to accommodate workers and an overwhelming number of clients. They perceived interactional injustice because of the fact that managers did not communicate with them on decisions that affected them and that managers were out of touch with the needs of workers. They complained that they were not respected by their superiors, who shouted at them when they made mistakes, and suggested that managers and superiors did not treat them with dignity in matters of discipline. Workers further argued that managers did not care whether they had adequate workforce to support them to provide quality health care. Some felt overworked and some felt burn out. However, managers felt disempowered at their level as well. The setup of the Ghana health sector and its associated policies remains largely centralised, so managers who are expected to meet the needs of frontline health workers and their hospitals, do not have the power to do so. They could not beef up staff numbers, since recruitment and allocation of staff to health facilities is centralised. In addition, managers received little financial support to run their hospitals. Their main source of funding was from reimbursement of funds from the National Health Insurance Authority, but reimbursement usually delayed for up to six months and they did not receive subvention from the Ghana Health Service or the Ministry of Health (MOH) to run their hospitals, so they were always cash strapped. Also the MOH, which is the body responsible for putting up infrastructure, could not meet the infrastructure needs of the hospitals. Additionally managers had to deal with conflicting policies including procurement policies that made decisions on purchasing essential supplies and drugs bureaucratic and slowed managers’ response to frontline worker and organisational needs. As a result, managers faced uncertainty in securing human and physical resources. To cope with uncertainties managers had to distribute their funds thinly among competing priorities of worker and organisational needs. At times managers had to sacrifice certain needs of workers and their hospitals in order to meet others. Consequently, workers lost trust in managers, which demotivated them in the provision of health care. Also the fee exemption policy made health care accessible to the general populace, but it did not lead to a commensurate increase in salaries, infrastructure development and increase in staff numbers. For that matter managers and frontline workers were overwhelmed with client numbers and had to turn some away. Both hospital managers and frontline workers perceived that policy makers and their superiors were not interested in how they provided care to clients or even their own safety, which demotivated them. It is important to note that some workers were observed to be intrinsically motivated and responded to the health needs of clients, despite the fact that they faced similar challenges as those who were demotivated. Such workers explained that their sources of motivation included a belief in a supreme being, the desire to maintain work standards and others perceived that clients had a right to quality health care. Also some indicated that they derived inner satisfaction when they were able to provide quality care to clients. Demotivation contributed to absenteeism, workers reporting to work late and some closing early as strategies to avoid collaborating with colleagues that they did not feel comfortable working with, which further worsened the conflict situation. Some workers also picked and chose to work with particular professionals. Workers exercised power negatively in two ways: 1. Some workers exhibited negative attitudes towards their colleagues, which contributed to poor interaction and poor communication. It further created gaps in clinical decision making. 2. Workers transferred their frustrations and disappointments to clients by shouting at clients and insulting them, which compromised with the quality of care that clients received. Another important consequence of demotivation was that workers got angry, some felt frustrated, and some reported experiencing high blood pressure. Consequently it affected the wellbeing of health workers who were supposed to cater for clients. Also demotivation became so deeply seated in some workers that they appeared to be beyond redemption. Some even hated the hospital environment that they worked in and others chose to leave the hospital. For health workers to be able to respond to the health needs of clients who visit the hospital there is the need that their personal needs including demand for better terms and conditions of service, incentives and training needs are catered for. Also their organisational needs including demand for essential supplies, equipment, appropriate infrastructure among others need to be addressed. Additionally managers have to be transparent, communicate and interact more frequently with frontline workers to enable them appreciate managers’ efforts in meeting workers’ personal and organisational needs. Also for managers to be able to meet the needs of frontline workers and their organisations managers must be given the power to make decisions on human and other resources. Also managers should be supported with the necessary funds, so that they can meet the multiple needs of their workers and hospitals. Health worker motivation in the hospital context is determined by an interaction of interpersonal and organisational processes that are shaped by external and internal influencers, who exercise power in their bid to influence organisational outcomes. Thus this study contributes to theory by propounding that motivation is not an individual quality of the worker, but it is an outcome of interactions between the worker and the work environment. Also power and trust relations within and outside the hospital influence worker motivation and for that matter theories on organisational power and trust relations are central to understanding and analysing worker motivation.