The performance of health workers in Ethiopia: Results from qualitative research

Abstract

Insufficient attention has been paid to understanding what determines the performance of health workers. This paper reports on findings from focus group discussions with both health workers and users of health services in Ethiopia, a country with some of the poorest health outcomes in the world. We describe performance problems identified by both health users and health workers participating in the focus group discussions, including absenteeism and shirking, pilfering drugs and materials, informal health care provision and illicit charging, and corruption. In the second part of the paper we present four structural reasons why these problems arise: (i) the ongoing transition from health sector dominated by the public sector, towards a more mixed model; (ii) the failure of government policies to keep pace with the transition towards a mixed model of service delivery; (iii) weak accountability mechanisms and the erosion of professional norms in the health sector; and (iv) the impact of HIV/AIDS. The discussions underline the need to base policies on a micro-analysis of how health workers make constrained choices, both in their career and in their day to day professional activities.

Introduction

It has long been recognized that human resources are an essential input into the delivery of health services. The human resource policy agenda has gradually shifted from a focus on workforce expansion and manpower planning, to concern with quality and financial sustainability (Martinez & Martineau, 1998). Yet, in many countries, human resource policy continues to be premised on the notion that health workers are passive actors that are both competent and motivated to serve the public. Recently, the limitations of this approach have become apparent. Health systems are today dealing with difficult reforms and transitions: expansion of the private sector, public sector and civil service reforms, growth in international migration, HIV/AIDS, etc. These challenges have had a dramatic impact on the opportunities and motivation of health professionals. Rather than being passive actors, they have responded purposively and strategically to these changing circumstances.

There is now broad agreement that the inadequate attention to human resource issues in the health sector has contributed to serious problems in many health systems, including internal and external brain drain, unequal geographical distribution of health workers, low morale, informal charging, etc. (Dussault & Dubois, 2003; ILO, 1998; Joint Learning Initiative, 2004; PAHO, 2001; USAID, 2003; Van Lerberghe, Adams, & Ferrinho, 2002; WHO, 2002). National governments, development agencies, and the academic community have come up with a range of proposals for addressing these challenges: increasing and decompressing salaries; improving recruitment; implementing performance monitoring and reward systems; upgrading training quality; developing and implementing practice standards. Although many of these proposals may have merit, their empirical foundations are often weak—i.e. the policy proposals are often not rooted in a solid understanding of the nature and source of performance problems or how health workers make choices in the labor market.

This paper comprises an effort to fill this gap. It focuses on health workers in Ethiopia, a country with some of the worst health indicators in the world.¹ Although both the network of facilities and the health workforce has been expanded dramatically in recent years, the number of health workers relative to population remains low, with a concentration in urban areas.² The situation of health workers in the country also has changed drastically in recent years. The delivery of health services in Ethiopia was long dominated by the public sector. However, after being banned for many years, the private sector was legalized in the mid-1990s, and the number of private for-profit facilities, pharmaceutical retail outlets, and NGO and faith-based providers has expanded steadily. The government has now made the expansion of private health care sector an explicit policy objective, but the institutional framework remains weak. Health workers are also on the frontlines in the ongoing battle against the HIV/AIDS crisis.

How do these changes affect the behavior of health workers—on the job and in the labor market? To address these questions we follow a bottom-up approach. The paper reports the findings from focus group discussions with both health workers and users of health services and seeks to make two contributions. First, the detailed and contextual information provided by the group discussions helps to better understand the nature of health worker performance and human resource problems in the health sector in Ethiopia. This understanding is an important building block for improved policy-making. Second, the qualitative research is useful for generating hypotheses that can be tested with further (quantitative) research. The paper is organized as follows. In the following section, we describe the data and research method, while in the next section we discuss the challenges as identified by users and health workers themselves. In the penultimate section, we discuss the reasons why these problems have arisen. Final section concludes.