You are here

Poor health worker attitude: Are the health workers solely to blame or do health policy decisions contribute as well to this poor attitude? By: Dr. Abdallah Ibrahim, CPH

Whether you are a patient at a health facility or someone visiting a loved-one receiving health service at a public health facility in Ghana, you may not escape the discussion regarding patient experiences of poor health worker attitudes. In previous blogs, Dr. Elizabeth Ekirapa-Kiracho and Rornald Muhumuza Kananura took us through the issue of poor health worker attitude and some reasons why some patients opt for services elsewhere, rather than at public health facilities. My attempt in this blog is to take the discussion that Dr. Ekirapa-Kiracho started on the health worker workload a step further and unpack some of the health policy decisions that may influence poor health worker attitude based on the healthcare workload in a place like Ghana.      

In order to understand the possible workload-influenced poor health worker attitude, we need to take a step back to unravel some health policy decisions that could play a role in increasing the workload at health facilities in Ghana. About a decade ago, there was a major health insurance policy measure in Ghana that led to a significant change in the number of people who sought health services in the country, particularly maternal and child health services. 

In August of 2003, the Parliament of Ghana passed the National Health Insurance Act (NHIA) that authorized the establishment of a National Health Insurance Scheme (NHIS).  This novel health insurance policy in a sub-Saharan African country arguably influenced the flow of patients to health facilities. This is because the new insurance policy provided the opportunity for increased access to health facility services for things such as free antenatal care and skilled service at delivery at health facilities in Ghana.  

In fact, the increased access to skilled health care by Ghanaian women for maternal and child health services would not otherwise be possible if affordability for such services continued to be a barrier as it was in the past (and before the NHIS was introduced).

Previously, Ghana had a health user fee system (also known as Cash & Carry) that was in place throughout the 1980s and 1990s.  The cash and carry system created financial barriers for access to healthcare for those who needed it the most.  During the health user fee system, there was a tremendous impact on the way people utilized health care.  Many studies have found that in Ghana and elsewhere, the number of attendance at government health facilities dropped immediately following the introduction of health user fees.

 Poor health outcomes for many indicators, including maternal mortality, infant, and child under-five mortalities were noticeably increasing. To reverse this trend, among other reasons, the government of Ghana passed the NHIA to authorize the establishment of the NHIS.  The NHIS initiative had some built-in exemptions for pregnant women to enable them to access antenatal services and skilled care at delivery at health facilities at no cost to them.  

The exemptions influenced increased attendance at outpatient health facilities dramatically for most of the women who needed maternal and child health services.  Increases in health facility utilization were observed in all levels of the health system, including the district, regional and at the tertiary health facilities.  Implementation of the exemption policy also affected the demand for at-home delivery and traditional birth attendant services, both of which declined while delivery services at health facilities increased. 

Some studies have shown that between 2008 and 2011, demand for antenatal care services increased from about 40 percent to more than 90 percent while postnatal care services almost doubled from about 34 percent to about 65 percent.  Such increases in demand for healthcare services do not happen in vacuum.  Instead, such increases in demand for services are basic indicators of additional workload that was suddenly added onto the workload of public health facility workers as a result of the major health insurance program implementation in the country. 

Health workers who used to have manageable workloads suddenly had to do more with the influx of new patients thanks to the NHIS in Ghana.  In some regions in Ghana, there were already severe health professional staff shortages prior to the nationwide implementation of the NHIS. For instance in a 2005 Northern Regional health report, it is noted that of the 595 nurses and other staff normally needed to manage health centers in all the region’s districts, only 380 were at posts, leaving the districts in the region with a shortfall of 215 nurses and other staff.  What compounds the problem is that some healthcare staff does not accept posting to some districts because they feel it is a rural area.  Such refusal of posting leaves the few and the willing to manage the health centers with an increasingly heavier workloads.    

Regardless of how good any health worker may be, the increased and constant workload will certainly become a recipe for declining health workers’ morale.  It may also ignite worker burn-out, and ultimately influence that worker to seek a transfer or at worse, inadvertently project the workload frustration onto the patients or health facility visitors.

In order to change the trajectory of the workload-influenced poor health worker attitude towards patients in Ghana, and for that matter in similar other African countries, there needs to be a parallel health sector workload management programs like training and bonding of health workers so that they will accept postings to the so-called rural health facilities with limited option to refuse.  The government or health policy makers could fully fund the health sector workforce development and training so that the newly trained staff or existing health workers who need skill upgrade could obtain such training fully paid for by the government and in return accept posting to any health facility or areas of specific healthcare skills shortage. 

Such workload management measures should be introduced alongside (or even prior to) health insurance policy measures such as the exemption for maternal and child health services under the health insurance or fee-for-service programs.  Such measures could have an effect on the increased workload and health worker burn-out, especially in areas where health workers refuse postings.  It could also positively change the workload-influenced poor health worker attitude towards patients.  This is because if the influx of new patients to a health facility is equally matched with inflow of additional health facility workers, then health workers may not feel the extra workload influenced by health policy decisions since there are other health workers to share the workload from the influx of new patients.  

 

The writer is a Lecturer at the University Of Ghana School Of Public Health and a Post-Doc fellow on the Accelerate Project in Ghana. He is also the contact fellow on the Knowledge Translation Network (KTNet) Africa project in Ghana. 

 

Contact: [email protected]

 

    

Share this Article..

To Post your Comments Securely, a quick, one-time sign-in/registration is needed below.

Follow us