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| Creating a High Retention Workforce in Eye Care | |
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Jeyachandran Sowmia
Retention of employees is a major challenge for health care. Success at retaining employees requires an organizational culture that inspires loyalty and commitment. Recruitment and Retention is one of the biggest challenges in healthcare. Wide spread labor shortages exist in many healthcare professions, including laboratory technicians, radiology technicians, certified nursing assistants, pharmacists, medical technicians and most alarming of all, registered nurses .On a broader scale all business and professions are competing for the same pool of talented people, especially those who are technically or scientifically adept .No matter what the state of the economy, the best and the brightest are always in demand. Shortages of workers throughout the industry are expected to continue into the foreseeable future. An attempt is made to study the human resource crisis in different parts of the world, encompassing both the developing and developed countries and present a solution to the crisis. The regions and the countries covered are: Retention in Developing Countries Africa Asia Retention in Developed countries
The important websites are Attrition in Developing countries There is a severe lack of human resources due to the recruitment by northern countries of medical professionals and staff attrition due to poor motivation or remuneration. It is estimated that developing countries invest about 500 million in training health professionals who are then recruited by developed countries, equivalent to roughly 25 per cent of the total overseas development aid to these countries .
The African continent is characterized by an extreme lack of health care personnel and facilities. The state of health care in Africa provides an alarming contrast to the rest of the world. Poor practitioner-to patient ratios, total absence of eye care personnel, inadequate facilities, poor state funding and a paucity of educational programs are the hallmarks of eyecare in Africa. The prevalence of blindness in Africa is 0.8 to 1.4% compared to 0.2% in America and Europe.1 The tragedy of the African statistics is that much of the blindness is preventable. A significant feature of the eyecare crisis is the lack of programs to adequately train optometrists in Africa. The entire continent has only nine optometric programs which are based in four countries: South Africa, Ghana, Nigeria and Tanzania. These programs vary in their scope and produce far too few optometrists to meet the needs of their own countries, let alone the needs of other countries. Penisten2 found that Ghana, for example, had 10 optometrists and 14 ophthalmologists who served the needs of 15 million people. (source : http://www.worldoptometry.org/PDF/may2000.pdf )
Ghana, a low income developing country, is undergoing health sector reforms aimed at achieving greater equity of access to services, improved efficiencies in resource utilization, development of wider linkages with communities and other partners, as well as improved quality of health services. Unpublished preliminary studies indicate a high level of migration of Ghanaian physicians and nurses soon after graduation. The rates are expected to be as high as 50% - 70% outside the country within 5 years of graduation. This is a serious issue that threatens the MOHs capacity to implement its health reform and decentralization programme. These reforms have strong influences on, and are influenced by, issues of human resources development, deployment and motivation. Some of the human resources issues debated under the reforms include issues of distribution of personnel, re profiling of staff types and skill mixes including delegation of some essential skills. Issues of gender influence on staff distribution, as well as social and geographical factors, affect human resources deployment to meet the health sector reform goals.
The prevalence of blindness in South Africa is 0.75%, which amounts to some 240,000 people who are blind. There are also nearly 350,000 people who have low vision. (source :http://www.sightsavers.org.uk/html/savingsight/southafrica/default.htm ) There are 275 ophthalmologists in the whole of South Africa: 250 of them work in the private sector catering for the needs of 8 million people, whilst only 25 work in the government practice that services 32 million people. The CSR for the indigent population is 850 per million of the general population per year. In order to eliminate blindness due to cataract, it should be 3000 for South Africa Another matter of concern is the high attrition rate of staff. It regularly happens that experienced members of staff leave and are replaced by inexperienced more youthful members without the same experience. It has been identified that the high attrition rate of staff as a major problem and developed the following strategies which are contained in their strategic plan:
Ministry of Health reports indicate that the prevalence of blindness in Malawi is 1%, in other words about 100,000 people. We estimate that there are around 20,000 incurably blind adults and nearly 4,000 children. Some 150,000 people suffer from low vision. In the not too distant past, discussions involving "health" and "migration" would likely have focused on the physical and mental condition of immigrants,. Today, however, the connection between health and migration can just as readily be illustrated by a hospital Malawi, which has only 30 nurses, 26 of whom have plans to leave the country. Controversy surrounds the proper role of policy interventions in the global labor market of health care professionals. Emigration of health care workers weakens already failing health systems in the developing world. Yet this movement may more accurately be described as a symptom or an aggravating factor, and not the root cause of health care system failures in the developing world. It is still unclear what the new rules of engagement will be to retain and train health care workers where they are most needed and to mitigate the grave imbalance between the rich and the poor with regard to health care. In light of these factors, experts are weighing a series of policy options that have important implications for the migration of the world's health care workers. Ethical considerations that pit the right of individuals to move against a greater public good are at stake as well. Policymakers find themselves struggling with two complex sets of issues: how can health care workers with needed skills maintain their freedom of movement and the opportunity to respond to more favorable employment offers outside their country or region of origin without damaging the fundamental right of others in a population to a basic standard of health care? (source : http://www.migrationinformation.org/Feature/display.cfm?id=271)
Zimbabwe has approximately 11,000 healthcare professionals, many of whom are infected with HIV/AIDS. While some health workers are able to pay for antiretroviral therapy, the majority cannot afford the cost which ultimately leads to a significant mortality rate. In addition, in their search for access to healthcare, many healthcare providers migrate from Zimbabwe, leaving an ever-larger gap in local healthcare services. As a result, healthcare services are becoming increasingly scarce in Zimbabwe. In an effort to reduce attrition, Healthcare Provider Antiretroviral Drug Access Initiative provides antiretroviral treatment to healthcare workers who are unable to pay for medication. The programs premise is that if treatment is provided locally, retention of healthcare workers will improve, which will be beneficial for the health of the entire community. The Initiative is an international collaboration between the University of Harare in Zimbabwe, Brown University Medical School, The Miriam Hospital of Rhode Island and ICEHA. (source :http://www.iceha.org/programs/programs5.shtml )
The demand for eye and vision care services and personnel in Asia will, most likely, continue to increase with the technological demand for visual skills and vision-related performance in the workplace.
Cambodia, with a largely rural population (80%) of over 10 million, is still emerging from a long period of civil conflict and instability. The health workforce still remains in transition from the period of destruction of physical and social infrastructure during the Khmer Rouge period between 1975 and 1979. "Massive numbers" of Cambodian health professionals were killed in this period, with only 50 doctors remaining by 1980. This contrasts with the figure of 431 medical doctors who graduated from the Faculty of Medicine in Phnom Penh's six-year program in 1975. The rural medical workforce in Cambodia faces challenging recruitment, retention and professional support issues. Currently in Cambodia there are over 17,000 health staff, of which 1,998 are doctors (11% of the workforce). Of these, 948 are centrally based in Phnom Penh. There are 1,050 at Provincial and District level, but no public doctors based in communes or villages. Numbers of women doctors remain low. Rural doctors in developed countries such as Australia have recruitment and retention deficits and high occupational risks (especially stress-related), professional isolation, high workloads, reduced access to professional development, and special practice needs. Substantial progress has been made by the College to gain formal recognition of the distinct professional standards for Rural and Remote Medicine. ACRRM(The Australian College of Rural and Remote Medicine) recognizes and accepts its responsibility to support and represent the rural and remote medical profession and improve the health services of rural communities. ACRRM is committed to providing sound training and continuing medical education models based on appropriate standards, innovative methods of service delivery, and partnerships that improve practice. The partnership concept arose at the 4th World Rural Health Conference in Calgary, Canada. ACRRM had discussions with a number of Asian Doctors' Associations and offered support for capacity strengthening activities. Agreement has now been made with the President of the Cambodia Medical Association. The project has been established as collaboration between ACRRM and CMA, as opposed to an imposed "aid" activity.
Data from developed countries tend to indicate that recruitment and retention are serious issues in health care An alternative indicator to vacancy is job turnover, which is often used to evaluate retention difficulties. In countries such as the United Kingdom (UK) and the United States of America (USA), turnover rates are quite significant, as they are estimated to be around 20%. Various consequences are associated with the inability to recruit and retain nursing staff. Closure of, or reduced access to, clinics and wards, as well as lower quality of care and productivity, are common examples of nursing shortages. In addition, high turnover is likely to lead to higher provider costs, such as in recruitment and training of new staff and increased overtime and use of temporary agency staff to fill gaps. Turnover costs also include the initial reduction in the efficiency of new staff and decreased staff morale and group productivity. The literature shows that the costs associated with recruitment and retention problems are substantial. The challenge for each health system is to identify and implement a package of different types of incentives that will meet its needs; it is unlikely that one package of incentives will be right for all organizations or contexts. Most of the research on increasing motivation and job satisfaction in health workers has been undertaken in developed countries, where the resources for such activities are available.
Alaska Community Health Aide Programme (CHAP) Directors association served as the advisory committee for the project. The purpose of this study was to identify the factors that contribute to Community Health/Practioner (CHA/P) retention and attrition, with an emphasis on the influence of CHA/P support structures within the community and from family, colleagues and employers. The data were initially collected and sorted by an number of factors to identify those most pertinent to CHA/P retention and attrition. The primary factors responsible for retention or attrition of CHA/P include the following. Co-worker support Good communication and team work with co- workers helps provide CHA/Ps with empathetic emotional support and improves their ability to share workload and support one another. Access to basic training Newly hired CHA/P s need to feel adequately prepared and trained for their duties. A fully trained clinic staff helps relieve the workload burden of other CHA/P in the clinic as well. Fully staffed clinic - A fully staffed fully trained clinic enables the sharing of the daily workload and on-call duties. Community support : Individual community members and tribal councils can do much to make CHA/p feel valued and appreciated for their efforts . Family support : CHA/Ps need family to help with child care and eldercare responsibilities , as well as basic household and subsistence activites. Analysis and findings: The analysis and findings is organized according to major findings based on specific questions from CHA/P interview guide.
The major theoretical model used to organize our research findings is Maslows Hirearchy of needs. Using this model less experienced CHA/P s cam be understood separately from their more experienced counterparts , facilitating a better understanding of each groups unique needs. Maslows Hierarchy of Needs: Maslows Hierarchy of Needs provides one way of classifying human needs, and also has been one of the most influential psychological models of the 20th century. It has also emerged as a fairly popular model for explaining job satisfaction factors ,partly because it provides a classification system for human needs, but also because it provides concrete implications for managing these needs within complex organizations.This model is shown in fig.1 
According to Maslow , people are motivated to fulfill their unsatisfied needs, and there are certain lower needs which must be satisfied before higher needs can be fulfilled . Maslow classified needs into general types , including physiological, safety, love , and esteem- arguing that these needs must be met before a person can meet higher needs and be self actualized . Maslow calls all these basic needs Deficiency needs because humans cannot move towards the higher level of self actualization, where they can maximize their potential . until these lower cravings have been assuaged. There are considerable implications with this theory for employer organizations . It can be argued that unless employers provide with a mean to placate their basic deficiency needs, employees will not be able to reach for the higher levels of job satisfaction and self-actualization in the workplace. Maslows Theory and CHA/P Profession: This research would indicate that CHA/P have a hierarchy of needs within their profession , as well , this model is shown in the figure.2 This model uses the Maslow concept that there are basic needs that must be met before CHA/Ps can move towards Self- actualization or complete satisfaction with their career. The research would support the notion that the items on the lowest level of the pyramid( the most basic CHA/P needs) are most likely to be associated with attrition. Items higher on the pyramid are probably not as likely to have a causal relationship with attrition , but the fulfillment of these needs can help improve job satisfaction for CHA/P .Based on the data, CHA/Ps from high attrition communities , or who have less experience , with more than ten years of experience , appear to function more toward the top of the triangle , while CHA/:Ps from high attrition communities , or who have less experience ,are more likely to be working to fulfill the five basic needs demonstrated at the bottom of the pyramid . These basic needs include positive co-worker support , timely access to basic training ,access to a fully staffed-clinic , support from the community served, and family support 
Fatigue and stress in the Attrition Cycle In summary, the following five major areas were found to form the basis of CHA/P retention needs: co-worker support , adequate and timely basic training , a fully staffed clinic , positive community support, and family support. Although the other factors (such as fair wages , good benefits , generous leave policies , adequate clinical support and access to additional training opportunities ) were also important to CHA/Ps , focusing on them alone without addressing the five basic CHA/P needs is unlikely to positively impact retention. Each of the five primary factors contributing to attrition affects CHA/P fatigue, stress , and burnout , thus fostering the cycle of attrition in many communities . this feeling of burnout was exemplified by one CHA/P interviewee who told the research team , They cant pay me enough to do this job . This cycle of attrition is summarized in the fig.3 
In this cycle , the decision by a CHA/P to quit leads to either a short-staffed clinic and /or a clinic that is staffed with new ,inexperienced and untrained staff members. Both of these situations lead to inadequate staffing to share job duties , especially complex cases and on call hours. Therefore remaining clinic staff members are saddled with an unreasonable burden of patient care, leading to long hours, fatigue, and strife both within their families and amongst the remaining clinic staff.. These in turn may lead to perceptions of poor quality of care ,both amongst community members and by CHA/P themselves , if they feel that they must provide services that are beyond their comfort level of training they have completed. Consequently, more CHA/P may quit, which then exacerbates and compounds this cycle. Breaking this cycle is not easy, but developing interventions that solve different aspects of this cycle are what will ultimately bring staffing to a community. Conclusion and Recommendations CHA/Ps practicing in remote locations are an integral part of Alaskas rural tribal health care infrastructure. However, some advances in patient access that CHA/Ps has made could be made threatened by high attrition rates within the profession. This research suggests that a number of improvements could be made to the program so that CHA/Ps feels more satisfied in their jobs and acknowledged as an important component. Recommendations: The research suggests a number of potential solutions for decreasing the CHA/P attrition. The recommendations include
The studys main focus is the global health workforce, which it identifies as being in crisis. In turn, this is contributing to crumbing health systems in many countries. Recent international attention to health systems is welcomed; however it is remarkable how little attention has been focused upon health workers, who are central to the functioning of any health system. Noting that neglect of human resources is an old problem, the study identifies new forces that are buffeting health workers.
Moreover, unlike other inputs, a health workforce cannot simply be bought on demand. It takes decades to build up a dedicated, professional and effective health workforce: it is an investment. Recommendations 1. The first of these is that initiatives to strengthen the health workforce must focus on the national and community levels, with global reinforcement.' This cannot be achieved with a one size fits all' approach: policies and programmes must be specifically tailored for each country. 2. A second key action is to bring together relevant national and regional stakeholders and actors into a global Action-Learning Network,' to provide a valuable hub for accelerating exchange and learning on human resources for health. 3. Addressing the issue of international labor migration of health workers, the emphasize is on the principle of essential national human resources' in the health sector. Thus, rich countries should no longer rely on importing health professionals from poor countries, but should seek domestic self-sufficiency. 4. Noting the critical shortage of human resources for health in Africa, the report calls for an urgent programme of training an additional one million health professionals for Africa. 5. In the case of the developed countries where there is a sizeable percentage of attrition of health care workers , focus should be on to make the health care workers feel important ,indispensable and integral part of the system. References:
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