Roles, norms and incentives influencing the performance of clinical officers in Kenyan rural hospitals
Date
2013-01-24
Authors
Mbindyo, Patrick Mutinda
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Abstract
This work explored perceptions regarding the roles, norms and incentives influencing the performance of Clinical Officers (COs) in rural district hospitals in Kenya. In order to improve access to health care mainly in rural areas, COs are increasingly being used to perform tasks that were previously the preserve of physicians. The assumption underlying their use is that they are a viable option to doctors. Studies have shown with reference to HIV care and obstetric and gynaecological surgical tasks that COs’ performance is comparable to that of physicians. Other studies also show that the care offered by COs is cost effective when compared with the costs associated with physicians and obstetricians care. However, there is emerging work which shows that COs are not happy in their assigned role in the health system. These studies report CO’s dissatisfaction with the low remuneration, poor career progress and limited career options inherent their jobs as compared with those accorded to physicians. As revealed by a systematic review of mid-level worker literature, addressing these issues is at present difficult due to gaps in our understanding of CO functioning. The existence of these gaps is explained by the limited empirical work on COs in general. The aim of this thesis was to address this issue by exploring issues that affect their routine functioning in a typical rural hospital setting going beyond the fact that they are technically competent.
To investigate these issues, a conceptual framework was adopted that explores the tension between what institutions demand and what individuals within them feel able to do. Qualitative methods comprising of interviews, participant observation, review of official policy and hospital level documents on COs, and review of hospital statistics were used. A comparative approach was adopted that sought to; (1) examine perceptions regarding influences on the performance of COs from a variety of sources (COs, doctors, nurses, supervisors, hospital managers, policy makers and policy documents); (2) compare perceptions of respondents based in three faith-based hospitals with those in three government facilities; and, (3), explore features of different work settings (outpatient department, specialist clinics and vertically supported clinics) within these hospitals that encouraged good CO performance. Preliminary findings were reported back to respondents in the six study hospitals.
Analysis of the data showed three major issues. First, perceptions of CO roles are problematic despite an acknowledgement of the important function performed by COs in the health system. This is revealed by the variety of images regarding their roles that highlights the need for a redefinition of CO roles. An example of this is shown by the inconsistency between their importance as the ‘backbone of the health system’ versus the poor remuneration and career prospects that their position attracts. Second, there were differences in the norms of CO performance that have resulted in variations regarding what is expected of them. While there was much attention paid to norms of performance about technical aspects of work, less attention focussed on non-technical aspects of work. The adoption of a holistic approach to the notion of CO performance is needed that will enable facilities and the system to meet the needs of the CO which should prompt COs to reciprocate by working better. Third was the issue that there were minimal incentives were attached to COs work. In the public sector, there were some incentives but their availability depended on the work settings. For example, while COs in vertical clinics got training their colleagues in the outpatient department had few chances to get training opportunities. Faith-based hospitals did provide performance related bonuses that encouraged health workers to perform better although notably basic salaries in faith-based hospitals were no better than those given in the government sector. However, major incentives such as salary and promotions in the public sector are handled by the central government giving public sector hospital managers little opportunity to utilise such incentive mechanisms. Where hospital managers may have some leeway in implementing actions at the local level to improve performance, for example through improving CO recognition and working conditions, it was observed that public sector managers were generally less engaged in utilising such incentives. Therefore while it is important to consider and address system level factors that influence CO performance such as salaries and promotions, among others, facility managers would also appear to have some scope to improve performance.
In discussing these issues, it is becoming clear that the assumption that COs are altruistic and will continue to work flawlessly in their assigned niche presents a naïve view of COs. This thesis shows that COs are also influenced by self–interest and find ways to overcome or work around any perceived barriers to their growth, some of which may work against the institution. This calls for a re-examination of who COs are, what they do and how they should be managed. Ways of resolving the tension that exists between COs and the health institution exist and can be derived from examining the coping mechanisms that COs have adopted to make their lives better. These coping mechanisms show areas that need attention. Further, there should be greater consideration of the important role that facility managers play in mediating and/or modifying system level influences by creating local environments suitable for better staff performance. Underlying all this is the fact that a long term view of COs is needed. The long term view must go beyond the notion of ‘substitute physician’ as Kenya has made huge investments in this cadre over the last 40 years or more and, with other countries, is likely to continue to rely on such a cadre for much clinical care. This thesis therefore concludes with recommendations that seek to address issues identified with the performance of COs in the Kenyan health system focusing on potential hospital level and system level solutions. Also included is a reflection of the relevance of findings for countries similar to Kenya that are currently using or seek to use COs as a physician substitute.