Can health workforce management actions positively influence retention and attrition of health workers? : a study on human resources for health in the eastern region of Ghana

Background
As in many other countries in sub-Saharan Arica, a shortage of well-trained health workers is one of the biggest barriers to quality health-care services in Ghana. Human resources for health deficits must therefore be addressed by improving the effectiveness and performance of the existing and future health workers through improved retention, competence and productivity. This PhD project was carried out in the framework of PERFORM, a health human resource management intervention that aimed at improving the performance of health workers by strengthening District Health Management Teams (DHMTs). Attrition and retention, both important factors of performance, were the main focus of this thesis, which were analysed from the management as well as the health workforce perspective.
Methods
The studies for this thesis were carried out in three districts of the Eastern Region in Ghana by using a mixed-methods approach. Data were collected during three research visits between May 2012 and July 2014 covering 13 months in total. The first study was a qualitative study on DHMT efficiency, which aimed to identify factors resulting in inefficient district health management practices. The second study was an explorative study that investigated current DHMT time use practices by doing daily retrospective time use interviews with all 21 district health managers in the districts over a three-month study period. In order to explore health worker motivation and job satisfaction and their effects on turnover and to also identify how district health managers may improve health workforce retention, 256 clinical health workers from several staff categories (doctors, nursing professionals, allied health workers, and pharmacists) were interviewed for the third study by employing a cross-sectional study design. Given the design of this study with only one measurement in time, turnover intention was used as a proxy of turnover.
Results
Financial constraints, human resource shortages in the DHMTs, low control over financial and human resources, little authority over district activities, and inadequate managing skills regarding planning and time management were identified as key management problems. However, district health managers have higher authority to allocate resources in their districts and to influence certain human resource aspects relevant for staff retention, such as promotions and study leaves. Managers used most of their working time for data management (16.6%), attending workshops (12.3%), financial management (8.7%), training of staffs (7.1%), drug and supply management (5.0%), and travelling (9.6%), while at the same time neglecting other activities such as human resource management (1.3%) and the management of buildings and equipment (0.2%). Of the interviewed health workforce, 69% (95% CI: 63-75) reported to have turnover intentions. Motivation (OR=0.74, 95% CI: 0.60−0.92) and job satisfaction (OR=0.74, 95% CI: 0.57−0.96) were significantly associated with turnover intention and higher levels of both reduced the risk of health workers having this intention. The dimensions of motivation and job satisfaction significantly associated with turnover intention included career development (OR=0.56, 95% CI: 0.36−0.86), workload (OR=0.58, 95% CI: 0.34−0.99), management (OR=0.51. 95% CI: 0.30−0.84), organisational commitment (OR=0.36, 95% CI: 0.19−0.66), and burnout (OR=0.59, 95% CI: 0.39−0.91).
Conclusion
There is a shortage of essential DHMT staff, especially regarding drugs and supply management, administration, and human resources. Hence, most management activities in these areas are neglected, which are sources of health worker dissatisfaction. Financial shortages in the DHAs were identified as another major reason for several of the low job satisfaction outcomes, as they lead to the inability to provide financial incentives to health staff, do regular maintenance of buildings and equipment, and to equip health facilities with the necessary basic supplies. Although district health managers have low authority to solve district specific problems with regard to human resources, findings from PERFORM have shown that adequate human resource management practices have the potential to influence motivation and job satisfaction, which in turn will make health workers more likely to remain in their current positions, thereby improving retention.