Health Workers retention in Togolese Healthcare System:the role of remuneration

作者简介：Nakpakpere Bante，管理硕士，单位：首都经济贸易大学企业管理专业，工商管理学院，研究方向：组织行为与人力资源管理。

Abstract：Supported by an ever increasing body of literature，it is clear that the challenge of today any health care system is to implement a good policy of workers satisfaction in the aim to retain them more in the organization.Workers retention has become a center of debate of Enterprises HRM Strategy and still a topical issue in todays health care system.Specifically，the phenomenon is more encounters in the health systems of developed countries where workers retention is seen to be the thorny problem of managers.

So，a poor system of retention in health sanitary system particularly in Togolese health sanitary system led to a high staff-turnover health professional from public sector to private sector and to developed countries.This situation is not isolated；it is related in general to dissatisfaction，demotivation of health workers.Indeed，the salary levels are low and does not respect national and international standard，to the poor management，missing of medical equipment，and the facilities.

To shed this problem of health sanitary system，it is imperative to optimize the sanitary management system.Additionally its vital to develop equity and transparency method，that includes more heath employees in the management system and to review their remuneration regularly.

Key words：Human resource management，retention，Motivation，Health workers，Healthcare system

Background

“More than other institution，the hospital reflects the economic and scientific situation of any state，technical and social situation of the society in which it operates”.The health of any population must be placed in government priority policy action.It is important to implement a real policy of human resources in the health sector.That means increasing the numbers of health workers，motivate them and provide them best working conditions encourage them，in order to ensure their fundamental mission，which is to supply to the poor and the rich people，continuous and integrated quality care.

However，it can easily notice today，repetitive strikes that succeeded over the years in Togolese health care system，and the daily difficulties that face the human resources management department.These movements of strikes，have a negative effect on the patient.It lead to the decrease in the rate of attendance in the public hospitals.This dsituation can be explain by the lack of commitement in the public hospital than the private.There is a fact that actually，the healthcare workers prefer more and more activities outside of the hospital，this led to the arrangement with patients who receive care at domicile and in private health institution.

Recently Togos health system as other develop countries has to face the most difficulties that WHO considers as a global problem.It is the shortage of health personnel.The report reveals an estimated shortage of almost 4.3 million doctors，midwives，nurses and support workers worldwide.This shortage can be explained by the insufficiency of medical staff trained in these countries，but another main reason remain the departure of the medical agents to the developed country and to the private sectors where the remuneration seems to be very important or very high.As an example we can remind that in United States，the number of physicians trained abroad which succeed the stage three of the USMLE examination procedure（Step needed to see if the physicians qualification is fully recognized in the United States）has increased by 70% between 2001 and 2008.Over the same period，the flow of temporary migration of the physicians has been multiplied by two in Australia and grew by 40% in Canada.Even in some countries，the expatriation rate of physicians is greater than 50%.Among these countries we have Mozambique，Angola，Sierra Leone，United Republic of Tanzania and Liberia.For several French speaking African countrie the high expatriation rates is greater than 40%.In Togo，40% of Togolese physicians work in France.

The question is how to retain or how to improve the health workers retention in those countries especialy in Togo？

Methods

In our research，we were interested at the first moment to the exploitation of writing document which are related to health human resource management in Central and south African countries.We were focus mostly on articles and thesis relate it to the field.This allows us to discover the conclusion which has been made.The reports emanating from the organizations such as the WHO，the World Bank，USAID，GTZ，Ministry of Health，and from the management of the health system was very useful.

Secondly，in-depth study design entailed structured qualitative interviews with health workers from public，and private health sector in north main town of Togo.We process to an elaboration of a questionnaire in the aim of collecting the reliable information on the variables of workers motivation and retention in the health care system.The questionnaire designed consists of multiple choice questions，and an open question.

The sample set takes into account the main actors of the health system，such as workers in medical imaging services，laboratory，emergency and operating rooms.A target of 50 health workers was set.Out this number，the majority of people reached by the study are particularly the nurses，midwives，medical assistants and health technicians.These represent the largest workforce in the health system in Togolese healthcare system.

The data obtained for the questionnaire was processed using software Spss.The analysis of the results obtained from this treatment with those obtained to the interview and the literature allow us to offer some suggestions as solutions to the retention issues facing human resource managers in the health system.

4- Results and Discussion

Satisfaction of employees

At the end of our study，our survey population，about 100% of health professional surveyed declared that they are satisfied with their work.With regard to the satisfaction of the remuneration obtained，i.e.the level of wages，the answer was once again an unanimous “no”.For them，the salary level is low and does not match their efforts.If the wage level does not hinder their function，it can be a source of de-motivation for the majority of workers.

Remuneration policy as a source of encouragement and workers retention.

The data analysis obtained showed that 93.33% of employees supported the idea that the various remuneration namely：salary，bonuses and other rewards paid to them are a source of incentive and play a major role to maintain them in the work.Only 6.67 % of the survey are rejected this idea.This is once more checked the universal character of remuneration on the employees retention at work.In Togo，wages in public sector are very low and not likely encouraging the health system human resources.

Method of allocating of variables compensations

For this item，professionals survey，opinions are shared.The half of professional surveys allowed to give bonuses or others awards according to the merit of various tasks accomplished，that is core skills-based pay and competence-based pay.Over 33% would like to give these bonuses according to additional hours of works performed.Only the minority of the workforce survey，whether 6，67% agree that bonuses must be given to all employees，finally the other 10% of the workforce would like to give theses bonuses according to work seniority.The workers expressed here the desire for fair treatment from their hierarchy.

The impact of supervision，participation and control by the hierarchy

Over 93% of professionals surveyed believed that supervision and control of the activities by hierarchy are a kind way of encouraging，reassuring and retain worker against 7 % of surveys population.Indeed the feedback of the hierarchy that is obtained from this activity allowed employees to assess themselves and strengthen their self-confidence.These activities also created an interface between the manager and the professional，this interface becomes permanent place for any professionals resourcing and quality assurance.

The impact of congratulation of employees by the hierarchy

Our study also revealed that 85% of the populations believe that receiving the congratulations from their superiors boosts self-confidence，motivate and increase workers retention against 15% of professionals survey.Recognize the effort and the work，appreciate the potential of employees and congratulate workers，let them mobilized all their energies to earn more trust from their superiors.

More than 66，45% affirmed not to get or have encouragement from their hierarchy after accomplishing a work，13% affirmed to have received positive feedback from their staff after accomplishing a work and 20，55% of professionals survey often received positive feedback.

Training employees

Training is the only way that enables professionals to consolidate their gain，their knowledge，skills，their competencies，and learn about the evolution of scientific knowledge.Our research indicates that the majority of professional over 67% of respondents assert did not benefit from additional training offered by their departments.Only 33% of them affirmed receive an extra training.The study shows clearly that the direction does not have a continuous training program for its employees.

The impact of medical equipment on caregivers

The study has shown that more than 63% of professional surveys supported that，the state of medical equipments；it means that their insufficiency compounded by their low quality make their work difficult.This condition is not a nature to motivate and retain the new generation of caregivers，against only 37% of population concerned.Indeed，the medical equipment can prevent caregivers to provide better quality care，which may tarnish the department image causing loss of income.

5.Recommendations

Based on documentary data and especially on professionals surveys opinions，some suggestions have been formulated，that can be applied to all the institutions of Togolese public sectors.

Finances are the stone spear，the effective foundation of Human Resources Management.In fact investing in HRM enables today organizations to easily achieve their objectives that were fixed.Workers retention and a good performance are always based on a good motivation.So to achieve its objectives，the government must improve and develop practices that allowed employees to be kept satisfy and motivated for their work.To do so，the authorities must establish new salary scales that take into account the national and international current living standards.In the short term，the HR manager can apply the indirect remuneration condition also called performance remuneration which is linked to an individual or a collective merit.

The HR managers should advocate the same policy，i.e.it should apply equity policy in managing of health workers.All of discriminatory nature likes the nepotism，friendships；ethnic，religious or political must be avoided.

The supervision and control of the activities must be complete with serenity.The managers should relax controls by making its less apparent as usual，and by making a feedback to workers.

Develop an effective network communication between staff and between staff and their hierarchy.This allows developing the cohesion and the interpersonal relationships in the health system.A good cohesion assures the full integration of employee.Indeed，personnel who are well integrated into its jobs will feel more satisfy，motivated in his work than an employee who is not integrated.

Managers are expected to develop recognition policy in the health system.Indeed recognize the efforts of health workers，their skills，their results and praise is very important and has a direct impact on employee.HR management must take training as a policy of personnel incitation.

The leadership must be developed in the health institutions，and the number of mangers increased.Then it must implement the human resource management tools，such us recognition policy，reward，award，bonus policy，congratulation policy which are very important and has a direct impact on the employees loyalty，motivation and retention.

6.Conclusion

The main goal of our studies was to provide in-depth analysis of factors which motivate and increase workers retention in Togolese healthcare system.Based on our investigation，two variables were selected：remuneration and a better use of management tools are those that contributed to the improvement of health workers retention in Togos healthcare system.

The results of this research without the pretension of being exhaustive can serve as a basis or can contribute to initiate reflection on motivation of health professionals and especially contribute to an improvement of management in Togolese health institutions.

The decentralization process initiated by the government with the support of international organizations should be finalized to allow an autonomous management of health institutions.The assistance of foreign partners would be welcome but it would henceforth regard as a necessity.

Finally，improvement of health workers retention would not be reached without the change in management style，especially through increased financial incentive.（作者单位：首都经济贸易大学）

References

[1]“Strengthening of leadership and health system management in Togo：What lesson drawn” Ministry of public Health of Togo.

[2]Three orientation to limit physician shortage in Africa” Mathieu Loitron，April 2007

[3]“Nurse Retention and recruitment：developing a motivated workforce”.Pascal Zun，Carmen Dolea，Barbara Stilwell.WHO.

[4]“Study of nurses work satisfaction：case of the Alfarabi d’Oujda- Angads hospital.（1999），Yahya Mouqla.

[5]Vujicic M，Zurn P，Diallo K，Adams O，Dal Poz M：The role of wages in the migration of health care professionals from developing countries.（2004）.