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MANAGING AND MOTIVATING A DIVERSE WORKFO... > MANAGING AND MOTIVATING A DIVERSE WO... - Pg. 81

Managing and Motivating better remuneration. However, there is growing evidence that other factors in the work environ- ment may also be acting as strong push factors. Workload and staff shortages are contributing to burnout, high absenteeism, stress, depression, low morale and de-motivation and are responsible for driving workers out of the public sector (Sanders & Lloyd, 2005). Poor working conditions are reported to seriously undermine health system performance by thwarting staff morale and mo- tivation, and directly contributing to problems in recruitment and retention (Troy, Wyness & McAuliffe, 2007; WHO, 1996). MANAGING AND MOTIVATING A DIVERSE WORKFORCE While there is clearly a need to scale up the health workforce in sub-Saharan Africa, the macroeconomic and fiscal reality that the region is facing present a significant challenge. Real Gross Domestic Product in SSA is expected to grow at an average rate of 5.8% per year and real per capita GDP is expected to grow at 3.3% for all Africa in the short term. As a result, in- creases in recurrent salary expenditures, that will accompany any large scale increase in the health sector workforce, may need to be gradual in order to be sustainable. Domestic resources in many countries may not be sufficient to support scaling up the health workforce to the levels re- quired to address population needs (JLI, 2004). It has therefore been suggested that countries need to move away from the expensive production of clinically oriented health professionals to focus instead on the more pragmatic production of health workers appropriate to their burden of disease, availability of resources, and minimum standards of care (Huddart & Picazo, 2003). Indeed this strategy has already been adopted by several countries who are increasingly relying on mid-level cadres, such as medical assistants, clinical officers, and enrolled nurses (who have shorter lengths of training than doctors or regis- tered nurses), to provide health care (Buchan & Dal Poz, 2003). Dovlo's study (2004) indicated that Mozambique, Kenya, Tanzania, Malawi, Uganda, and Zambia have various cadres called medical assistants, clinical officers, and nurse aides that are doing essential medical tasks, especially in rural areas. In Malawi, clinical of- ficers are a major resource of the health sector; they give anaesthetics, provide medical care and undertake some surgical procedures. In Tanzania and Mozambique approximately 90% of caesarean sections are performed by mid-level providers. Recent studies provide strong evidence for the clinical efficacy (Chilopora et al., 2007; Pereira et al., 2007) and economic value (Kruk, Pereira, Vaz, Bergstrom, & Galea, 2007) of mid-level cadres, particularly in the provision of emergency obstetric care. Given such positive indicators, it is important to recruit, retain and support these cadres to build the capacity of health systems in low-income countries. Educational qualifications that are less marketable internationally make it less likely that these staff will migrate, at least in the short term (as high-income countries re-evaluate their health systems' skill-mix this may change). The belief that these cadres are not internationally market- able has given rise to a certain complacency in the management and motivation of such workers. Many countries introduced them as a short-term measure with the anticipation that once the country built up its stock of health workers they would no longer be needed. Because of this there has been little investment in developing their career pathways, something which undoubtedly impacts on their motivation and relationships with other healthcare professionals. A number of studies have drawn attention to productivity problems arising from the de- motivating effects of the work environment. For example, Chaudhury and Hammer (2003) reported the results of unannounced visits to health clinics in Bangladesh that sought to ascertain the propor- 81