A descriptive study on health workforce performance after decentralisation of health services in Uganda

Table 2 shows that all respondents (100.0%) know what is expected of them. Most health workers (89.9%) agreed that their clients are always satisfied with their services. The majority of the respondents (79.7%) indicated that they get professional support to improve their performance. A total of 70.3% health workers indicated that they clearly know who they serve and many of them (69.9%) are always willing to address the clinical and emotional demands of their clients. As many as 59.4% health workers agreed that the stakeholders are satisfied with the health workers’ cooperation and the quality of service they provide. However, as many as 40.6% health workers indicated that clients were not satisfied with the quality of service they receive and 30.4% of respondents indicated that the clients were not satisfied with the level of cooperation they get from the health workers. Half of the respondents (50%) indicated that rarely do the stakeholders complain about individual health workers, 30.1% were undecided and 19.9% disagreed. It is, however, noted that 60.1% of the respondents disagreed that the patients were satisfied with the timeliness of the services, while 10.1% were uncertain.

Generally, from their own point of view, the health workers demonstrated satisfactory levels of service and responsiveness towards their clients. However, from their own point of view, the services that health workers provide are not timely. Health workers must demonstrate the ability and willingness to understand and address both the clinical and emotional needs of their clients [15, 16]. This study revealed that health workers were not providing timely services. This can be attributed to organisational constraints such as the low staffing levels, heavy workload, poor work flow structures and probably lack of some essential drugs and equipment necessary for performance [17]. It is essential that health workers are responsive to the demands of the communities they serve. This allows for a more holistic approach to health service provision, taking into consideration both the technical aspects and client satisfaction, thereby guaranteeing quality [18].

Most of the health workers (90.2%) indicated that their health facilities have attendance registers that are completed by all staff. Similarly, 90.2% of health workers agreed that they put in much effort when they are on duty. Approximately ninety percent (89.9%) of the health workers indicated that they are always available when needed. A total of 60.1% indicated that they are always present at work during the official working hours and also agreed that their organisations have clear retention policies. As many as 59.8% agreed that the staff attendance in their organisations was good, however, 40.2% disagreed. There were mixed views in the responses from the health workers concerning patients’ waiting-times. A total of 40.6% of health workers agreed that waiting-times were short, while 39.5% disagreed and 19.9% were uncertain (see Table 3).

A large proportion of health workers (80.1%) disagreed that the rural facilities are as well staffed as the urban ones. Fifty percent of the health workers disagreed that their health facilities have adequate numbers of staff to deliver the services, 39.9% agreed and 10.1% were undecided. There were also mixed views among health workers concerning the workload. As many as 40.2% health workers indicated that the workload at their health facilities is not manageable while 39.5% stated that the workload was manageable and 20.3% were undecided (see Table 3).

The results of this study demonstrate that health workers try their best to be present at work. The reported high rate of disagreement among health workers regarding adequacy of staffing (Table 3) may probably explain high workload and long patients’ waiting-times [17]. It is however, important to note that availability of health workers on its own cannot directly improve the health outcomes unless there is effective drug supply, functioning facilities and good clinical practice [19]. A well performing health workforce is a significant component of a strong health system that together with other social determinants can improve the health status of the population. As the numbers of health workers drop, the ability of systems to deliver health services also reduces [1, 20]. Hence, the maldistribution of health workers between rural and urban health facilities as reported by the health workers in this study (Table 3), could affect the quality of health care and waiting-times may be longer [21].

Of the health workers, 80.1% agreed that their skills are suited for the type of work they do. The majority of health workers (79.7%) indicated that availability of drugs and equipment improves their productivity. Most health workers (70.3%) indicated that their health facility management encourages them to perform. As many as 60.5% of workers agreed that they spend most of their time at work attending to the patients and that their productivity is measured according to the number of clients they attend (see Table 4).

A total of 39.5% of the health workers disagreed that their productivity is measured according to the number of clients they manage and 29.3% disagreed that they spend most to their time attending to clients, while 10.1% were undecided. With regard to indicators for measuring performance, 50.4% of respondents indicated that their organisations do not have indicators for measuring productivity of health workers, 39.9% agreed, and 9.8 % were uncertain (see Table 4).

Generally, the health workers’ self-reporting indicates that they possess adequate skills necessary to perform their jobs. The workers stressed the importance of having adequate supplies of drugs and equipment to support their productivity. The results, however, show that the measurement of productivity of health workers is generally lacking in most health facilities. Much as the health workers have adequate skills, their productivity can be limited by a host of factors like lack of equipment, supplies or drugs, poor management structures and low salaries [22, 23]. This study revealed that some health workers (39.5%) did not seem to understand how their productivity was measured and slightly over half did not know that there were indicators for measuring productivity. There is, therefore, a need to develop and communicate clear indicators for measuring productivity.

All the health workers (100.0%) indicated that they have mastered the skills necessary to do their work and are confident about their prescribing practices, and all said that they improve their knowledge and skills through continuous professional education, and use their knowledge and skills to improve the safety of their clients. All health workers (100.0%) agreed that their attitude towards patient care is good and always make timely referrals of patients in need of further treatment and care (see Table 5).

All the health workers (100.0%) indicated that they have good communication skills and are able to use the available technology to support patient care. The majority of health workers (89.9%) agreed that they are confident about their ability to perform their jobs.

Generally, the results show that the health workers are competent and this is highly likely to enhance their performance. High level of knowledge, skills and abilities among health workers are necessary for effective performance [24]. Health workers also reported that they have good communication skills. This is very important because listening, guidance, clear expectations and feedback are prerequisites for better performance [25]. The health workers in this study reported that they make timely referral when required. This is consistent with findings from a study done in India, where maternal health outcomes improved as a result of good skills in identifying complicated obstetric cases, good counselling and communication skills [26]. The findings of this study however, are contrary to what is reported in Niger, where rural health workers lack the competence to communicate, counsel and convince patients with complications requiring referral to higher level facilities [27].

All the health workers (100.0%) agreed that they communicate openly with each other, coordinate their work amongst themselves and support their co-workers when requested. Most health workers (80.1%) indicated that they use standard procedures to ensure that their core tasks are properly done while 19.9% disagreed. Furthermore, 79.9% of the health workers indicated that they portray a positive image of their organisations and 10.1% were either in disagreement or uncertain (see Table 6).

Overall, health workers display satisfactory proficiency behaviours that are likely to support good performance. This finding contradicts what was found by a Kenyan study [17], which established that health workers working in hospital paediatric departments were not cooperating and communicating openly with each other and this was affecting their performance and the quality of care given to patients. Some researchers have established that behaviours that involve cooperation, creativity and self-development contribute to job performance [28]. Additionally, role clarity is known to be one of the strongest predictors of individual, team, and task organisational proficiency behaviours for performance [29].

All health workers (100.0%) agreed that they adjust well to changes in their core tasks and have learned new skills to help them adjust to change. Most health workers (89.9%) indicated that they are flexible with regard to the overall changes within their organisations and 10.1% disagreed. Similarly, 80.1% of the health workers agreed that they respond constructively to changes in the way their teams work (see Table 7).

These results indicate that the health workers display positive individual adaptive behaviours, which can contribute to good performance. This is contrary to what was found in Kenya where health workers were reported to have inadequacies in adapting or responding to new clinical practices or guidelines due to lack of perceived benefits linked to their uptake [17]. In that study, senior and older health workers were often reported to be stuck in the patterns of previous clinical practice although there were some exceptions [17]. This problem was attributed to the lack of experience in being compelled to change by emerging knowledge. Openness to change is known to be a strong predictor for adaptive behaviour. This can enhance task performance for an individual, teams and the organisation as a whole [29].

From Table 8, it is clear that all health workers (100.0%) indicated that that they have initiated better ways of performing their core tasks. A large proportion of health workers (90.2%) agreed that they have developed new and improved methods to help their work units or teams perform better and 9.8% disagreed. Of the health workers, 80.1% indicated that they have made suggestions to improve the overall performance of their organisations, 10.1% were undecided and 9.8% disagreed.

The results clearly indicate that the health workers are proactive and this is likely to enhance their performance. Some studies report that workers who score highly on creative performance or are proactive achieve high outcomes in innovative effectiveness [28]. This is good for individual, team, and organisational performance. Proactive behaviours ensure that the whole organisation develops rather than only individual departments [29].

Table 9 shows that all health workers (100.0%) are aware of their task of serving the clients, have the clients’ interest in mind and respect their clients’ opinions. All the health workers (100.0%) indicated that they always behave professionally, take a problem-solving approach to care for their clients and give their clients opportunity to express their needs. The majority of health workers (99.3%) agreed that they try to assess their clients’ needs and 90.2% have respect for their clients. Ninety percent of the health workers indicated that they always take time to perform their clinical duties and try to address their clients’ needs with the appropriate treatment available.

These results demonstrate that health workers are generally inclined to display client-oriented behaviours. Client-oriented behaviours include attributes such as empathy, assurance, responsiveness, authenticity, listening, dedication and civility which the health workers in this study seem to display [30]. The behaviours of health workers such as doctors, nurses and clinical officers are critical to both patient satisfaction and successful health outcomes.

The results show that individual performance behaviours are positively related to the dimensions of performance. There is a significant and high positive correlation between responsiveness and the individual proficiency behaviours of health workers (rs = 0.856; P < 0.01). There are also significant and moderate correlations between individual client-oriented behaviours (rs = 0.669; P < 0.01), individual adaptive behaviours (rs = 0.623; P < 0.01), individual proactive behaviours (rs = 0.598; P < 0.01) and the responsiveness of health workers. Indeed there is a high likelihood that health workers who are highly proficient, client-oriented and display adaptive and proactive behaviours, will demonstrate high responsiveness towards clients. The individual workers’ behaviours that involve teamwork, innovativeness and self-advancement contribute to performance [28] (see Table 10).

The results also indicate significant and high positive correlation between the individual proactive behaviours (rs = 0.759; P < 0.01), individual proficiency behaviours (rs = 0.724; P < 0.01) and the availability of health workers. There is significant and moderate correlation between the individual adaptive behaviours (rs = 0.659; P < 0.01), individual client oriented behaviours (rs = 0.537; P < 0.01) and the availability of health workers. This demonstrates that proactive and proficient individuals are likely to be available to perform their duties. There is significant but low positive correlation between individual client-oriented behaviours, (rs = 0.396; P < 0.01), individual adaptive behaviours (rs = 0.343; P < 0.01), individual proactive behaviours (rs = 0.262; P < 0.01), individual proficiency behaviours (rs = 0.235; P < 0.01) and the productivity of health workers. Indeed while adaptive, proactive and proficiency behaviours may facilitate individual productivity; it is not always certain that this will be the case (see Table 10).

The results in Table 10 further show that there are significant and moderate correlations between the individual adaptive behaviours (rs = 0.643; P < 0.01), individual proficiency behaviours (rs = 0.562; P < 0.01) and the competence of health workers. There are also significant but low correlations between the individual client-oriented behaviours (rs = 0.449; P < 0.01), individual proactive behaviours (rs = 0.359; P < 0.01) and competence of health workers. This can be interpreted as follows: adaptive and proficient health workers are highly likely to be competent but this may not always hold since competent health workers may not always be adaptive. The workers who score highly on creative performance are likely to achieve high outcomes in creative effectiveness [28].