Motivation and Retentionof Midwives in

Hard-to-reach Areasof Six Selected GAVI HSS Townships

Dr. Kyawt Sann LwinLecturer

Health Policy and Management Dept.University of Public Health

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WHR 2006 reported that - properly trained and motivated workforce, and improving the retention of HWs is critical for health system performance

Work Motivation – “an individual's degree of willingness to exert and maintain an effort towards attaining organizational goals”

Retention - “continued employment of skilled and productive staff”

Introduction

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1. To describe career expectations, motivation, job satisfaction and intention to stay status of MWs working in hard to reach areas

2. To identify factors affecting motivation among MWs working in HTR areas

3. To identify factors affecting intention to stay among MWs working in HTR areas

Objectives

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Study design Exploratory cross sectional descriptive

study design Mixed method of data collection, mainly

qualitative method

Study area Hard to reach (HTR) government health

facilities (i.e. RHCs) of selected GAVI Health System Strengthening Projects Townships in Myanmar

Research methodology

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1. Hakha township, Chin State,

2. Htelin township, Magway Region,

3. Ye U township, Sagaing Region,

4. Yetarshay township, Bago East Region

5. Tharyawaddy township, Bago West Region and

6. Maung Daw township, Rakhine State.

Study townships

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Study period Between August 2011 to July 2012

Study population and data collection methods

1. MWs working in the HTR RHCs and sub-RHCs - IDI

2. Township health team supervisors: i.e. TMO or THA or THN or HA1- KII

3. Community members who live in HTR RHC villages- FGD

Research methodology (cont.)

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(20) GAVI HSS first phase townships Select purposively

Six townships From each Tsp.

10 IDI 2 KII 2FGD From six tsp.

60 IDI 12 KII 12 FGD

Flow chart of sampling and no. of interviews

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Characteristics of MWs by township

Results

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Career expectations and career ledder

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Reasons for choosing midwifery career is passion on MW career (Wa-Tha-Nar Par)

Most of them expected to take care of people’s health as well as their family members’ health

Career goal and organizational goal are similar ("Ku-tho Lee-Ya Wan-Lee Wa" )

To earn a living at the same time she can get merits (by helping those who are sick or helpless).

Career expectations and career ladder

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Figure (1) Career expectations of MW in hard-to-reach areas (among under 45 yrs.)

MW (n=49)

(n=49)

No favorable condition to attend LHV training- Decided to continue as MW (20%)

No intention to be promoted, Continue as MW (7%)

Trying to enter for LHV competitive selection exam (48%)

HA/ THN

Intention to become LHV (68%)

Intention to enter for competitive selection exam and attend further training (7%)

Intention to become Nurse (18%)

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Motivate the MW by allowing her to satisfy her need for progress, improvement and achievement

MWs' career structure is not very straight forward (i.e. first MW has to enter for competitive selection exam and then has to attend 9 months training)

giving special privilege to attend LHV or nursing training if MW from HTR areas served in that area for certain period (preferential admission for LHV training).

Career structure

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… we should give incentives to those who is working very hard. At the moment we can’t give LHV promotion directly. There is selection exam for LHV training. Actually criteria for promotion should be performance based system. (47years old, State Health Director, Chin state)

Comments from supervisors

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Motivation

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Percentage of MW with different self reported work motivation status

Fair Good Very good0

10

20

30

40

50

60

70

22

59

19

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Township Mean score

N SD P value

1.Tharyawaddy 4.28 9 0.371 0.008*

2.Hakha 4.05 11 0.512

3.Htelin 4.57 10 0.226

4. Ye U 4.52 10 0.343

5. Yetarshay 4.44 10 0.255

6. Maung Daw 4.51 10 0.231

Total 4.39 60 0.376

Mean motivational score by township

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First, there is no language, cultural and religion difference between MWs and the community – community trust and appreciation

Second, active implementation of MDG goal 4 and 5 reduction activities (like AN mobile team approach);

Third, interest and active leadership role of TMOs and

Fourth, effective supervision system implemented in these two townships

Reasons for good motivation among MWs in Htelin and Ye U tsp.

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First, civil servants received extra salary of 30,000 kyats per month and some of the HTR areas are entitled to get double salary as a privilege of special border areas,

Second, there are many INGOs providing services to community and one of the INGOs is providing support to BHS i.e. TA for CME at monthly meeting and for UCI activities

Third, implementation of GAVI HSS is getting momentum

Reasons for better motivation among MWs in Maung Daw Tsp.

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Higher mean motivational score in: MWs who are single, rural upbringing, live with extended family, older (i.e. over 40 years) and longer total service (i.e. over 15 years)

and years of service at current post (i.e. over 5 years)

Mean motivational score and MW personal factors

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who perceived the importance of her job, can live together with family; assigned in her own home town or village; received trust and respect from community, got community participation and support, got supportive supervision

Characteristics of motivated MW (qualitative findings)

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“I have 24 hour responsibility. I don’t mind of delivery cases (even coming at inconvenient time or from faraway places). When I could not help them, I even felt un-happy and couldn’t sleep that night, thinking of possible ways to help them, because in our village there is no other person who can help them. They depend on me. If a woman could deliver her baby successfully I am very happy, I think I am happier than the mother who deliveried the baby. “ (56 years old MW from Hakha township)

Perceived importance of job

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I don’t feel that there is no incentive to work hard. I am happy to do my job. When many children coming up for immunization session I am very glad about it because if only few children show up, it would be waste of my energy. Similarly I am very happy in going GAVI package tour because of this activity we can cover many more AN women. (33 year old MW from Yedarshay township)

Received community trust

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In World Health Report 2006 it is stated that "a simple and obvious, but sometimes overlooked, way to determine the actions that will create the largest and most immediate improvements is to ask the health workers themselves"

Perceived requirements for motivation

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No. Condition or Requirements for Motivation %

1. Adequate drugs and equipment 78

2. Support from community 67

3. Trust and appreciation from community 56

4. To slove transport difficulties including provision of

motorcycle

51

5. Support form supervisors or superiors 44

6. Increased pay 35

7. Travel allowance 30

8. Improved sub-center building and housing 20

Requirements for work motivation (Multiple response, n=60)

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Job satisfaction and intention to stay

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Percentage of MW with different perceived level of job satisfaction

Very satisfied Fairly satisfied Neutral Fairly dis-satisfied0

10

20

30

40

50

60

70

80

9

76

96

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Percentage of MW with different intention regarding whether or not continue

working at the current post

MW under 55yrs (n=56)

Continue to work at current post (28%)

Waiting for transfer order (48%)

Waiting to attend LHV/ Nursing training (24%)

Will work till retirement (50%) (n=56)

Will work < 5 yrs (39%)

Will work > 5 yrs (11%)

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I can’t do other job apart from this and also can’t do the hard labour. Although it is (financially) not very good, I can borrow some money and pay them back when I receive salary. (36 years old MW from Hakha Tsp.)

If the MWs from HTR areas have been supported with appropriate incentives and support mechanisms, it is hoped to improve retention in HTR areas

Majority still have intention to work as MW

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first, to be able to stay together with the family (50%),

second, to be able to stay in a place convenient for her children's education and family (13%) and

third is to be able to work in easily accessible places (8%)

Reasons for intention to leave

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“If a MW is posted to her own village, she doesn't need to depend much on the community because her own family could provide whatever she needs like the old MW from … village. She stayed for a long time at the HTR village because she stays together with family…Some MWs continue to live in the village because they got married with the (local) villagers. I think these are the main reasons of retention of MWs in HTR areas.” (40 years old, HA1, Ye U township)

Family is the main social support for a MW

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Intention to

stay

Intention to

transfer

Total

Urban 5 (23%) 17 (77%) 22 (100%)

Rural 13(41%) 19 (59%) 32 (100%)

Total 18 (33%) 36 (67%) 54 (100%)

Relationship between upbringing and intention to stay in HTR areas

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Mandatory rural HTR area service for preferential admission to MW training program

decentralization in recruitment, training and deployment MWs

Locality specific recruitment and deployment

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We want quota for NA-Ta-La (Development of Border areas and national races program) midwifery candidates to work in HTR. There are many young women who want to be a MW. As they are local women they know very well about this area. But department of medical science uses matriculation marks for selection of midwifery candidates. So they were not selected. (51 years old, THN, Maung Daw township)

Mandatory rural HTR area service for preferential admission to MW training

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To get preferential recruitment (selection), now there is a quota for states and regions in selection of Midwifery candidates. They set different cut off point of Matriculation marks for each states and regions. It is good. But still there is in-equity among townships i.e. those townships with good high schools got more candidates to attend Midwifery training. There should be equity among townships i.e. if particular township need five MWs, select five candidates from that township. So preferential recruitment should be down to township level. (47years old, State Health Director, Chin state)

decentralization in recruitment, training and deployment MWs

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More push factors than pull factors

Skills are not Internationally marketable - duration of training and pre-requisite skills is less than other countries

Less demand from private sector – urban people prefer to use doctors for delivery, rural people prefer AMW and TBA

As a nursing attendant in private sector – not a optimal utilization of MW skills

Push and Pull factors

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S.N Condition or Requirements for job satisfaction %

1. Adequate drugs and equipment 72

2. Good housing and SC building 65

3. To solve difficulties with transport including

provision of motorcycle

61

4. Community participation and support 56

5. Travel allowance 44

6. Increased pay 30

7. Trust and appreciation from community 20

8. Fair economic status 19

Requirements for job satisfaction (Multiple response, n=60)

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Strategies to improve motivation and retention

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Top requirement for both motivation and retention Basic drugs and midwifery equipments are needed

to be replenished the most commonly mentioned desire of

community from health center/SC villages In WHR 2006, it is stated that no matter how

motivated and skilled HWs are, they cannot do their jobs properly in facilities that lack clean water, adequate lighting, vehicles, drugs, working equipment and other supplies

the only trained HS, to tackle wide ranges diseases and providing health care to the whole community

Provide adequate drugs and period replenishment of reasonable quality equipment

Adequate drugs and equipment

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Second top requirement for retention

MWs have to rely on community to build or renovate their health facility and community in HTR areas are economically not affordable to provide decent housing or SC

housing provides MWs with safety, dignity, comfort and privacy

Building / renovating SC building

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the most common financial incentives favoured by MW

MWs in HTR have to bear very high expenditure on travel than those working in easy to reach areas

administratively feasible for township level officers to monitor provision TA

not only MWs' job satisfaction and motivation status will be improved but also supervision and performance appraisal system will also be improved

Travel allowance

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I am sure I would go more supervision trip if I get TA. At the moment I can't go supervision as much as I should because of the constraints of travel expense. If we are sure to have travel allowance at the end of the month, I will go even with borrowed money... If I go supervision regularly, the HA/LHV would also go supervision trips regularly. So the reporting system of MW would be improved and we can recommend hard working MWs through supervisory visits for performance awards. So first we must plan to provide enough TA. (51 years old, THN, Maung Daw township)

TA improve motivation as well as supervision

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team approach and provision of TA

difficulty in referring risk pregnant women to higher health facility – due to un-affordability for travel and hospitalization cost

sought assistance from AMW or TBA – decrease trust to MW – de-motivation for referring MW

financially support to poor patients who need hospital delivery through hospital equity fund is very essential

Influence of GAVI HSS on motivation and retention

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essential for township level supervisors to consider about the requirement of newly recruited MW and arrange necessary support for newly recruited MWs

Before assigning MW to particular HTR villages make sure that the MW will have essential drugs and equipment, suitable SC building and housing through collaboration with local authority

Provide proper induction training

Support newly recruited MW

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Majority of the MWs regarded the workload their job as overwork

Mechanism should be developed to replace vacant posts caused by MWs who are attending long term training for LHV or Nursing

to prevent de-motivation due to extra workload on remaining MWs

Fill vacant posts

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supervision system was hampered by ◦ high travelling cost, ◦ lack of funding for training and supervision system ◦ shortage of supervisors

Use of checklist in supervision and proper documentation of supervision findings and feedback system are areas needed to be strengthened

Important for motivation and establishment of performance assessment system

Strengthening supervision system and performance assessment system

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Mechanisms:◦ through filling vacant posts of supervisors, ◦ providing vehicle for transport or TA, ◦ encourage use of supervisory checklist and proper

documentation and follow up of findings from supervision

there was no regular performance assessment system and no formal method in place to show appreciation and give rewards in the study townships

Township level performance assessment and incentives system should be developed

Strengthening supervision system and performance assessment system

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should be strengthened so as to give effective "hands on" training and to produce MWs with adequate skills especially in midwifery to compete with AMWs and TBA who have already established in HTR areas

internal motivation depends on perceived chances for success (self-efficacy)

Strengthening MW training institutions

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Tsp level supervisors have limited control over MWs’ career progression and transfer mechanisms

So in reality, township level supervisors have limited mechanism to motivate his or her MWs

Still have other management tools to mange motivation and retention issues and in this study leadership and management skills of individual TMO has important influence on motivation and retention of MW

Improve role of Tsp level supervisors in transfer and promotion issues and good governmance

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Adequate supply of essential drugs and equipment t should be provided down to SC level

Necessary arrangement should be developed to give travel allowance to supervisors and MWs, and solve the transport difficulties

support newly deployed MW ◦ provide proper induction period◦ before assigning MWs make sure that the MW

would have basic drugs and equipment, suitable SC building

Recommandations

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Mechanism should be developed to replace vacant post caused by MWs who are attending long term training for LHV or Nursing

Strengthened the supervision system in HTR areas and fill the vacancies of supervisors

Should develop township level performance assessment system

To enable to implement locality specific recruitment and deployment approach, should develop mandatory rural service for preferential admission to MW training or decentralized need based recruitment system to recruit rural young women

Recommandations

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Midwifery training institution should be strengthened

Existing implementation of integrated service delivery approach and hospital equity fund of GAVI HSS project in HTR areas should be scaled up so as to improve motivation

Recommandations

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THANK YOU!