Background to the study.
The shortage of healthcare professionals in rural communities remains an intractable problem that poses a serious challenge to equitable healthcare delivery. Both developed and developing countries report geographically skewed distributions of healthcare professionals, favouring urban and wealthier areas (Wilson, Couper & De Vries, 2009). Rural communities are on the average poorer, less educated and have higher disease burden; they also have worse access to health care than people in urban areas (Wilson, Reid, Fish, & Marais, 2009). This discrepancy between health care needs and service provision has been captured by Hart’s ‘inverse care law’, which states that those with the greatest health needs usually have the worst access to healthcare services (Flament, 2012). Rapid urbanization is a global phenomenon but it also poses particular health problems in developing countries with poor infrastructural development (Wilson, Reid, Fish & Marais, 2009). Improved access to healthcare should therefore be seen as an indicator of the level of development of any nation.
International attention has recently been drawn to the problems of attracting, retaining and motivating health workers in developing countries particularly in remote areas, which has created human resource for health (HRH) crisis (Williams, 2007). Health workers form the foundation of health service delivery and therefore the staff strength, skill and level of commitment are critical for the delivery of good, quality and effective health care (Serneels, Montalvo & Lievens, 2010). Renewed attention is being given to the role of geographical imbalances in the health workforce, a feature of nearly all health systems. This raises concerns about the equity in access to health care as well as the efficiency of allocation of human resources bearing in mind the impact on health outcomes (Petterson, Serneels, Aklilu & Butera, 2010). The issue is particularly relevant for developing countries with limited resources and poor health outcomes. Ultimately, the difficulties to attract and retain staff in rural facilities may also stem from the preferences and choice made by the health workers. Furthermore, a growing body of evidence shows that apart from wages, other job attributes like training opportunities, career development prospects, living and working conditions may also play a role (Hays, Veitch, Cheers & Crossland, 2007).
The challenges in maintaining an adequate workforce that meets the needs of a population with social, demographic, epidemiological and political transitions require a sustained effort in addressing workforce planning, development and financing. Skilled health workers are increasingly taking up job opportunities in the global labour market as the demand for their expertise rises in high income areas. It has been suggested that the rural to urban and international migration of health workers in African countries inevitably leaves poor, rural and remote areas underserviced and disadvantaged (Bach, 2003). Developing countries often experience ‘urban-bias’ where the political and economic forces support the provision of services and investment in urban areas to the detriment of rural areas. This increases the disparities in health worker distribution, access to services and health outcome (Zurn, Dal Poz, Barbara & Orvill, 2004).
A regression of data for 117 countries found a significant relationship between health worker density and maternal mortality rates (Gerein, 2006). Nigeria has high numbers of healthcare providers, who together make up the largest human resource for health in Africa. There are 52,408 doctors, 219,399 nurses and midwives, and 19,268 community health workers practicing in the public sector (Professional Regulatory Agencies, 2008). However, these values translate to only 23 doctors, 112 nurses, and 64 community health workers per 100,000 people. To put these figures into context, European health worker density values are 332 doctors and 780 nurses per 100,000 people (World Health Organisation [WHO], 2008). Poor, rural communities experience the lowest health worker densities, with three times as many doctors and two times as many nurses practicing in urban areas as opposed to rural. These figures imply that the number of women in rural areas giving birth unaccompanied by skilled birth attendants is directly impacted by the understaffed rural health facilities.
Maternal mortality continues to be the leading cause of death of women of reproductive age in developing countries. Maternal death is primarily a result of the health care system’s inability to deal effectively with complications during and shortly after childbirth (World Health Report, 2005). Recruitment and retention of skilled workers, particularly midwives, nurses, doctors, and obstetricians, are essential to the provision of quality antenatal, delivery, emergency obstetric and postnatal services. It is necessary to realize both the United Nations millennium development goals (MDG) 4 (Reduce under 5 mortality) and MDG 5 (reduction of maternal mortality) (MDG Report, 2006). Nigerian policy-makers are looking for solutions. Researchers and development agencies agree that the disproportionate rates in the developing world, particularly Sub-Saharan Africa, are as a result of high rate of births unaccompanied by a skilled birth attendant (WHO, 2005).
To achieve the MDGs for health by 2015, improving access to key interventions such as anti-retroviral therapy, immunizations, tuberculosis and malaria treatments are top priorities for most health system (Adano & Vicks, 2008). However, in addition to financial resources for commodities, improving access requires a well-functioning health system and adequate workforce capable of delivering interventions at a large scale (Drager, Gedik & DolPoz, 2006). The 2004 joint learning initiative report on human resource for health and others have concluded that shortage and skewed distribution of health personnel especially in the rural areas undermine the scaling up efforts, particularly in low income countries (Bloom & Barnighausen, 2009). It is against this background that this study sought to determine perceived factors that affect non stay of health workers in rural areas of Enugu State.
Statement of problem
Survey report has shown that more than 75% of Nigerian population live in rural areas and are left at the mercy of untrained personnel (Demographic and health survey, 2007). Studies have also shown that the five commonest causes of maternal and child mortality is preventable in most cases with the presence of qualified and skilled attending health personnel (WHO, 2006).
With a population of more than 140 million people (National Population Commission [NPC], 2007), Nigeria is the most populous country in Africa. The latest estimates also put life expectancy in Nigeria at 44 years (NPC 2007). Seventy two (72) % of the urban population and just forty nine (49) % of rural population have access to safe drinking water. The shortage of health workers in the areas where they are most needed is an important problem for health systems. Patients who have the greatest need for health care tend to live in remote and rural areas, but attracting skilled health workers to such areas and retaining them there has proved difficult. Such an uneven distribution of health workers contributes directly to the global burden of ill health and inequity in health outcomes. Improvements in key health indicators have been slow and today Nigeria ranks among the countries with the highest child and maternal mortality: the Under-five mortality rate is two hundred and one (201) per 1,000 live births, and the maternal mortality ratio is estimated at eight hundred and forty (840) per 100,000 live births (United Nations Children Emergency Fund [UNICEF], 2010). Many Nigerian doctors and nurses have emigrated to North America and Europe. In 2005, two thousand three hundred and ninety two (2,392) Nigeria doctors were practicing in the United States alone; in United Kingdom the number was one thousand five hundred and twenty nine (1529). Retaining these expensively-trained professionals in their countries of training has been identified as an urgent goal (United Nations Population Fund [UNPF], 2005). Most developing countries face shortages of health workers in rural areas. This has profound consequences for health service delivery and ultimately for health outcomes.
In 2003, Enugu State adopted the district health system and tried to meet the 5km distance approved by WHO for citing of health care facilities in order to improve access. However, the 2009 survey by State Ministry of health showed that these facilities are underutilized primarily due to the dearth of qualified health care workers in these rural health facilities (Partnership for transforming Health systems [PATHS2], 2009). The State has 482 nurses, 25 pharmacists, 80 medical doctors, and 24 medical laboratory scientists. Out of these only 127 nurses, 10 pharmacists, 22 doctors and 5 medical laboratory scientists are posted to the rural areas (State health board statistics office, 2010). In 2010 the Ministry of Health recruited 96 nurses to make up for this shortage, but their nominal roll in 2012 revealed that 27 nurses had absconded, while 11 resigned officially.
Personal visits to rural health facilities by the researcher showed that there is inadequate staff in these health facilities. This has raised some basic questions in the researcher’s mind: Are there personal factors responsible for non-stay of health workers in rural areas? Do institutional factors contribute to non-stay of health workers in rural areas? What are the community factors responsible for non-stay of health workers in rural areas? This study attempted to answer the above questions.
Purpose of the study.
The purpose of this study was to determine the perceived factors that contribute to non-stay of professional health workers in rural areas of Enugu State and strategies to retain them.
The specific objectives were to;
- Identify personal factors contributing to non-stay of health workers in rural areas.
- Determine institutional factors contributing to non-stay of health workers in rural areas.
- Assess community factors contributing to non-stay of health workers in rural areas.
- Identify strategies that will motivate workers to live and work in the rural areas of Enugu state.
- What are the personal factors that negatively affect the decision of health professionals to live and work in the rural areas?
- What are the institutional factors that negatively affect the decision of health professionals to live and work in the rural areas?
- What are the community factors that negatively affect the decision of health professionals to live and work in the rural areas?
- What are the incentives/resources/strategies available to motivate workers to stay in
the rural areas?
Significance of the study
The result from this study would help health administrators to understand the peculiar local factors that contribute to non-stay of health professionals in rural areas in Enugu State. This information would equip health administrators better on how to handle issues regarding rural postings of health care professionals in Enugu state. This is an important step in boosting rural health care delivery services since effective policy formulation and implementation based on the findings from this research will help to address the needs of health care providers in the rural areas and ensure that staff are committed to assigned jobs. This in turn may help to reduce the currently unacceptable high rate of preventable maternal and infant morbidity and mortality since staff will always be on ground to attend to preventable life threatening emergencies in the rural areas.
In addition, the result of this study will provide a basis for policy makers to know what to put in place in health care facilities to serve the elderly who stay in the rural areas to achieve optimum health care.
The result of this study will also assist policy makers to determine and design strategies to attract and retain health workers in rural areas in order to achieve the health related Millennium Development goals (MDG 4 and 5).
Scope of the study
This study is delimited to skilled health workers comprising of doctors, nurses, pharmacists and medical laboratory scientists posted and working in health centres in Enugu state. It is also confined to variables such as institutional, community and personal factors that contribute to non-stay of health workers in the rural areas of Enugu state.
Operational definition of terms.
Professional health workers refer to doctors, nurses, pharmacists and medical laboratory scientists who are currently working in Enugu State Ministry of Health who have been duly registered and licensed to practice by their respective professional bodies.
Perceived factors that contribute to non-stay of health workers refer to such factors like personal, institutional, community that health workers feel may affect their decision not to live and work in rural areas
Personal factors refer to certain individual constraints that may influence a decision to live and work in a rural area. This may include marriage status, family ties, low standard of rural schools and future academic ambitions.
Institutional/administrative factors are those hindrances in/from the institution or administrative issues that discourage trained staff from working in rural areas. This may include relationship with senior staff, lack of or unacceptable quality of accommodation provided for the staff, inadequate medical instruments, security concerns in the work place, quality of supervision and remuneration.
Community factors will include the community’s belief, language barrier and the attitude of the host community towards strangers.
Strategies to retain health workers refer to necessary resources and incentives that will motivate or enhance health workers stay in rural areas e.g. rural allowance, offering scholarships to children of staff, provision of working materials, accommodation and car allowances.