“Once The Government Employs You, She Forgets You”: Mid-level Health Workers’ Perceptions.


By Eddie Miaway Farngalo MPH, RN, BSN

In low income countries like Liberia, Human resource for health catastrophes is one of the fears for health system performance. The health and development goals (safe pregnancy and delivery services to mothers) of countries are weakened by this crisis (WHO). Lack of motivation, incentives, misdistribution, and migration of health workers within and outside the country, top the causes of shortages of health workers.

Even-though the causes are known, they receive little attention and are poorly addressed in health related policies (Dubois, 2003; Muhimbili University of health and Allied Sciences Analysis; Wyss, 2004).

Often, shortages in the health workforce are addressed merely by recruitment and deployment of similar cadres in remote areas. Retention and performance including personnel motivation, work environment, personnel management system and work organization process are overlooked (Dubois and Dussault, 2003; Muhimbili University of health and Allied Sciences Analysis; Prytherch et al., 2012; Manongi et al., 2006; Dieleman and Hammeijer, 2006; Willis et al., 2008).

Understanding the influence of working conditions (combination of compensation, non-financial incentives and workplace safety) on health workers’ performance is cardinal in addressing human resource for health as well as achieving both international and national health goals (WHO, 2006).

Lehnman et al. (2008) and Leshabari et al. (2008) discovered positive working environment, open communication, career advancement opportunities as well as recognition and rewarding of hard working health workers as major underlying factors for staff  management/retention while minimizing migration as well (Lehnman et al., 2008; Leshabari et al., 2008). For this to work, Dieleman and Hammeijer (2006), Willis et al. (2008) concluded that strengthening human resource management systems coupled with  serious consideration is needed in the role of governance in addressing human resource management (Dieleman & Hammeijer, 2006; Willis et al.,2008).

In Liberia, factors mentioned above are numerous-with many important players who have higher percentage (5346 (68%) out of 8553) (Liberia Human Resource for health data, 2009) in the health care delivery system being marginalized on one hand, and minority but well attended to on the other. Such unequitable distribution of resources continues to create tension and dissatisfaction within the country’s relatively low number of health workforce. This has a propensity to further fragment the health care system of Liberia.

With inconstancy in maternal mortality rates (994; 700 etc) over the years, and with the current MMR at 1,072 (meaning 1,072 out of 100,000 women died during child birth) (LDHS, 2013), sadly, the subset of the health workforce (Nurse Anaesthetists) who is specialized in reducing or minimizing such disaster and providing critical cares, lack recognition and career ladder.

Nurse anesthetists are registered nurses with minimal qualification of an associate degree who are mostly sent to the Phebe Para-Medical School by County Health Teams base on need. They are trained for two years to administer anesthesia (sleeping medicine for operations) with the objective of reducing maternal death as well as providing critical cares for patients with extreme disease complication (s).

I believe the goals and objectives of training nurse anesthetists in this country are to produce qualify and competent anesthesia providers who will help to reduce motility especially maternal and neonatal by providing safe anesthesia with careful monitoring and management of any complications.”

Contrary to the Memorandum of Understanding (MoU) signed between the students and the County Health Teams (CHTs), most of them get deleted from government’s payroll. As a result, they are left with no option but to go through this major and intensive lifesaving training at their own expense. Even, after completion of the study, there is usual fallout between the graduates and the CHTs. This is because CHTs “failed” to recognize them as important cadres in emergencies and as people who are specialized, unlike general nurses, medical doctors, physician assistants, etc., who often serve as managers for this group.

“I applied for study leave for anesthesia since there was a need for anesthetists in Kolahun, Foya and Vahun districts including certain parts of Vonjama district that might have obstetrics emergency cases that fall in the catchment of Kolahun Hospital. A Memorandum of Understanding was signed for support and I must spend two years with the hospital before seeking for another job elsewhere. Everything came fruitless with my name deleted on payroll and incentives which is performance based.”

Work done by nurse anesthetists cannot be ethically executed by mere doctors (doctors with no specializations) who are in higher demand and mainly situated doubtfully in hospitals. Those anesthetists are on 24 hour calls like resident doctors. They are routinely called to assist on inpatient wards, in the emergency rooms (ER) whenever nurses are faced with hospital related difficulties as well as critical care.

“Just imagine what will happen if anesthetists in this country decide to leave the various hospitals for just 30 minutes. There will be a complete massacre for our mothers in this country. Not even counting other conditions. What kinda country is this?”

“Why will you want an anesthetist to work for 24 hours and be paid an eight-hour salary and doing most of the doctor’s work? Incentive not coming at all. Even if it comes, it’s late (several months). The fact is we are the most ignored group in the health delivery system of this country.

“We are the most ignored group in the health sector. Most of our doctors in the ministry were once in the operating rooms doing surgery…These people know that they never had any good and successful surgery without good and efficient nurse anesthetists. But they have all ignored us because they are now on top and don’t care who an anesthetist is.”

Lack of recognition for this profession had led to sub-standard theaters being operated (no anesthetic drugs, outdated anesthetic machines) mostly in rural parts of the country. Yet still, unrecognized and un-incentivized, nurse anesthetics are “playing magic” to save patients’ lives especially maternal (big belly) cases.

“For me I work in the rural area as the only anesthetist for over four years. The lack of anesthesia machine, oxygen, anesthesia drugs and gas, not receiving my incentive and salary as per my qualification after I have presented all necessary documents, and being alone in the county…are some of the problems I have been faced with over the years.”

Perpetually, many health workers (across mid-level) who have advanced themselves receive incentives for previous positions or degree obtained (Nurse, Nurse Aid, etc.). Consequently, performance at the job site is highly diminished.

“I was nurse aid and then I went to nursing school and got a B.Sc. Since I came back 5 years now, I am still taking the old incentives. For this reason, I don’t care to go to work every day because I need to survive.”

“When I graduated as a nurse, I was sent by the hospital to the anesthetist school in Phebe. Since I came back, I have submitted all my documents to the HR office but nothing better. I am still making my old nurse’s incentive.”

“After going through an intensive six months training as a mental health clinicians, I am still paid as an ordinary nurse. I have no office for me to meet my patients. I am working on the ward.” (Mental Health clinician)

This type of human resource for health errors has made those groups or individuals’ significant role in reducing life threatening consequences or deaths, especially big belly, as irrelevant.

Realistically speaking, such constant errors had become a norm while stalling career development and ladder, but making the health workforce obsolete in the 21st century.

Suffering from similar elementary errors by HRH are the mental health clinicians who are trained by the Carter Center–Liberia chapter. After six months of intensive preparation, those clinicians and their expertise in managing daily psychological challenges coupled with Post Traumatic Stress Disorders (PTSD) due to the 14 years of civil crisis, during which over 250,000 lives were lost, and the just ended Ebola outbreak (were lost). As such, knowledge gained is lost due to lack of recognition and incentives by local health authorities.

Worst, the national human resource for health census conducted in 2009 did not capture Nurse Anesthetics, Environmental Health Technicians, and Mental Health clinicians as a profession. Evidence that lack of recognition is affecting those groups are of national consensus (involving the government).

“Anesthesia in Liberia is like tea without sugar if I may say. Our leaders (anesthetist leaders) have not done us any justice…more anesthetists in Liberia are seeking greener pastures for better life… We decided to go into this area because we want to help reduce fetus/maternal mortality in our country, but our efforts are not recognized at all, my brother…if you read the national health plan of Liberia, there is no portion that talks about anesthesia. There have been numerous meetings in and out of Liberia concerning fetal/maternal mortality, but I can’t remember any involving anesthetists.”

Can the continued poor and weak health system be confounded by some of these HRH errors? Or the sharp increase in the maternal mortality rate that is disproportionate to funding received? Or it the reasons why many youths are called “trouble youth” because they lack psycho-social counseling?

Passing an act and its implementation are two different things. Even though acts attaching relevance to post basic programs have been passed by legislators, they (acts) sit on the shelves to collect dust without being operationalized.

Because of this, overall performances and working conditions of health workers in immediate rural areas are impaired by those challenges. The government and its regionalized structures should be responsible for creating a conducive working and living environment, address health workers’ dissatisfactions timely, fairly and equitably, encourage career advancement especially in areas of specialization, create a “bottom to top” communication channels where frustrated health workers can voice and share with top management.

To accomplish this, efforts must be focused on refining the governance of the human resource management system that will take into account the stewardship role of the government in handling human resources carefully and responsibly, provide just benefits, housing near the health facilities for emergency health workers (Lab tech, Nurse Anesthetist, Midwives) because they are on 24-hour call instead of administrators whose works are basically limited to 8am-4 pm, and improve incentives since those individuals are specialized.

Finally, research exclusively focusing on health workers’ motivation must be conducted as soon as possible. This will inform policy directed towards health system strengthening to be rooted in evidence.

The Author: Eddie Miaway Farngalo a trained and registered nurse who practiced at the Jackson F. Doe Memorial Regional Referral Hospital, he returned to graduate school and completed a Master of Public Health degree in Health Services Planning and Management (Ghana); served as a Health Training Specialist and Surveillance Assistant, Grand Gedeh County (IOM); triage nurse at the Sinje ETU; Community Support Officer for Ebola Community Care Center, Karnplay, Nimba County (Project Concern International). He is currently a researcher.


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