From the three districts 64 participants overall attended the six FGDs. In each district the whole range of cadres was represented (from nurse auxiliary to Clinical Officer). Both male and female professionals were included, with an age range of 25 to 59 years.
Division of labour
Respondents in all the FGDs raised the issue that understaffing of key personnel within the PHC facilities resulted in various negative consequences for service provision – some shared across cadres and some unique to different positions.
Understaffing
The understaffing issue was summarized succinctly by a female nurse auxiliary who described it this way: "...Say at every centre you have got one nurse and one doctor. If it happens that the doctor faces a problem the nurse will be alone. Now she will do the cleaning and dispense drugs and deal with patients.... You often find that work to be done by two or three different people is performed by a single person".
Acting upwards
Many health workers felt they were forced to handle cases for which they were not trained. A nurse auxiliary was doing the work of a pharmacist and a clinician: dispensing drugs, giving injections, dressing wounds and assisting in the labour ward.
One female nurse auxiliary had this to say "....myself I'm handling these patients more compared to those of higher cadres...we should be given the opportunity to go for training so as to handle our patients properly..."
Acting downwards
When lower cadres were acting upwards in service provision, the result was often that non-medical work also had to be shared. Here there was evidence of an urban/rural divide, with rural clinical staff, but not urban, accepting the necessity of sharing all responsibilities – including cleaning – when lower cadres were acting upwards. An urban (female) clinical officer complained: "I am not happy to do cleanliness when I am already overworked without getting anything. No, I can't do cleaning."
In contrast, a rural (male) assistant clinical officer reported: "Though we have much work to do, cleanliness is important. Without cleanliness your medical profession will be meaningless. So we (the clinicians) clean up around us to care for the patient's health and also our own health."
Gambling with the health of patients
Across all FGDs health workers were aware that some community members looked for quality they simply could not produce. The lack of laboratory facilities alone forced them to treat patients by trial and error, which was compared with gambling.
One female assistant clinical officer said: "We don't have a microscope or even a laboratory. So we are only doing diagnosis and using our experience to decide. This is like playing a game of chance (Kamari) for the money as you are not sure if you are treating malaria or typhoid or both. I do feel hurt more than the patient himself. This is really discouraging for us working in these dispensaries."
The same woman went on to say: "People in the community nowadays know what quality of services they want. They usually ask 'Why don't I go to the hospital where there are medical officers and working facilities instead of going to the dispensaries where there is no laboratory and facilities?' I think the community should be allowed to go where there are good services."
Training, supervision and feedback
Given the environment already described – of a shortage of clinical staff in situ and more junior cadres acting upwards on a regular basis, this section highlights a number of issues related to training, the use of skills of health workers at all levels and the frustrations experienced in career development.
Referrals and feedback
Across all three districts the clinical officers felt they often saw cases (especially obstetric/gynaecological conditions, sexually transmitted illnesses, skin disease) that they could have handled better given some specific training. For the patient, there was a considerable cost attached to being referred to a district hospital and often relatives were unwilling or unable to pay for the transfer and subsequent care implied.
This was felt to be particularly true of obstetric cases when women without adequate financial resources commonly wait until the last possible moment to seek care and then may not be able to travel and gain access to emergency services. Understandably these cases deeply affected the health workers' morale. One male assistant clinical officer said: "One day in a health centre where I was working, a mother came around with labour pains. I was called from home to try to help. She managed to deliver normally but she had a postpartum haemorrhage. I did vaginal packing and elevated the bed while looking for any means of transport possible to a district hospital. We didn't get the transport until 6 a.m. [and] by that time it was too late. Everything was finished."
Further, if a patient was referred, considerable frustration was expressed regarding the lack of subsequent feedback. A female assistant medical officer said: "There are cases we refer just because we don't know how to go about them and we don't get feedback; next time when we get a similar case our job is just to refer. We don't learn anything."
Experienced but not trained
For less-qualified cadres the situation was seen quite simply. Due to the circumstances of their colleagues it was necessary from time to time to deal with things that they had no training to handle. A commonly heard quote from the FGDs was "We are not trained; it is just the working experience we use to manage".
This was raised in the in-depth interviews with the DMOs, who recognized the problem but said that as managers they were financially constrained. All three DMOs explained that under the former system the government examined all applicants for further training and sponsored successful applicants. However this has changed: "Nowadays the government has pulled out from sponsoring these health workers. Every district is supposed to upgrade the health workers according to their needs. The problem is money. We don't have an allocation for that. In my district I have told the health workers to apply for schools they want. Once they get admission, we pay half of the fees and they have to pay the rest".
Health workers in all the FGDs proposed a number of coping strategies. More sharing of information with other medical professionals was requested. They felt that it was time for them to be visited by specialists for training purposes "...These doctors who are specialists or those who are above our level should visit us once in awhile to discuss with us the management of those cases which we normally refer to them" (female clinical officer).
Improving systems for feedback to clinics from referral hospitals on case management was highlighted as another practical way of learning without creating a financial burden to the health service.
Many participants wanted to see a rotation system implemented within Regions and between staff of the same qualification as a means of keeping up and learning new skills: "...It will be a good idea if we do rotations. After two years we go back to work in a district /regional hospital and another group from there comes to take our places....after all we all have the same qualifications" (male clinical officer). Another clinical officer added "It will be good and motivating if we meet and share experience among ourselves. ...We don't want to be paid for this; we want the DMO to organize this and to give us permission."
Supervision and feedback
Across the FGDs it was agreed that during supervision more negative comments were received than positive. The health workers reported that there was little or no on-site supervision from their immediate superiors and the external supervision from DHMT was irregular and not supportive. One male assistant clinical officer said: "....The supervision is not friendly and lovingly done. There should have been a plan that every three months there will be supervision but instead, after six months you can see two people having papers and pen in their hands coming asking questions like a policeman; it is not a friendly one but faults-finding supervision."
Many complained that they never received any written or oral feedback from supervisory visits. One female assistant clinical officer said:"When the re-supervision is done for the second time, there should be feedback from the first supervision so that we can recognize where we went wrong and correct our mistakes. There should also be feedback of the problems identified from the previous supervision. It is not easy to think the supervisors are useful when reported problems remain and no feedback is given."
As part of the in-depth interviews with DMOs the fulfilment of MoH recommendations for monthly supervision was raised. One DMO said: "The problem of poor supervision is not human resource or transport or allowances but poor planning centrally (MoH). Most of the time we get unplanned visitors from MoH with emergency issues to tackle with short deadlines. They say we are decentralized but in fact we are still getting orders from above, "top down". As if this is not enough, we have to organize or attend several seminars and different workshops. Almost always we are called for ad hoc meetings. These activities also require the only vehicle we have. This of course is also a problem to the rest of team members. They are facing same problems. We have to use one vehicle for the team with different activities so, sometimes other activities have to suffer."
All health workers across all the FGDs knew of their right to be promoted every three years and, according to MoH regulations, that every promotion was to be accompanied by a salary increment. However, the majority of participants said they had worked for more than 10 years without being promoted, and this was mentioned as an important factor for dissatisfaction:
One female nurse auxiliary explained her situation: "You may work for seven to eight years without been given any promotion, at the same time you earn less compared to those auxiliary nurses who were employed later. Their salary scales are twice ours and we have been in work for 30 years. They tease us saying, "What are you proud of? After all we have more salary than yours."
Many respondents found promotion issues discouraging but clearly the coping strategy explained by many of the respondents was, "We are working for God". This was elaborated on by one male assistant clinical officer, who said: "You may work for 10 years and be promoted once. If your salary scale is not corrected it will continue going that way. It's really discouraging to work, but due to it being a community service, you keep on working as God will pay you in heaven one day."
A clear recommendation for alleviating the problem of distrust and dissatisfaction regarding promotion was to improve communication at two levels: first, for supervisors to clearly communicate performance appraisal to staff, and second, for improved transparency over the process of applications for promotion.
The DMOs could all clearly explain the correct procedure for promotion – that their role was to recommend to the local government the names of health workers who were due for promotion (for those with two years of training or less) and the rest to the MoH. "Normally we send confidential forms with our recommendations to the local government or to the MoH for our staff's promotion annually. We send our personnel officer to follow up, with no success. I think the issue is money here. Imagine all the workers employed by the government once they get promotion it comes with money as an incentive. So what (the MoH) do, they give these promotion in a piecemeal."