- Email: [email protected]
Improvement in malaria services in an urban setting
Public Health (2002) 116, 374–378 ß R.I.P.H. 2002 www.nature.com/ph
Improvement in malaria services in an urban setting: role of staff motivation VS Raghuvanshi Bavarian Public Health Research Centre, School of Medicine, Ludwig-Maximilians University, Munich, Germany
Urban health centres and the private clinics (PCs) providing malaria services in an urban setting were compared on seven utilization-determining factors to assess why people preferred one over the other. On the other hand, motivation level of the technical staff of the corporation in the malaria services was studied to find out the extent to which the motivation level of the staff was responsible for the observed mean scores of the factors studied. It was found that PCs fared better on all of them. However, the two differed mostly on wait-in period at the outlet, distance from residence, ambience of the outlet, and getting relief. The study further showed that for the doctors and the primary health workers, the opportunity of influencing people was the strongest motivation to work in the corporation and for the subsanitary inspectors, it was affiliation. Based on this, a model is suggested to introduce changes based on motivation mix of the malaria staff. Public Health (2002) 116, 374–378. doi:10.1038=sj.ph.1900876 Keywords: malaria; corporation; technical staff; motivation; utilization
Introduction The public health sector in developing countries is often under-utilized.1 Poor services, poor facilities, negative attitude of the staff, insensitivity to the local needs etc. are some of the widely acknowledged reasons for the poor image of the public health sector.2 Since private sector cannot be the absolute substitute for the public health services due to associated problems,3 it is important to identify potential areas of improvement in the public health sector. Part of the problem could be the low motivation of the staff of the public health sector. Advances in public health have contributed greatly to the understanding of the technical aspect of disease management and control. However, all these are insufficient to bring about the desired changes. The vast human resource associated with public health calls for greater attention to the motivation levels of the employees in the organization. It might have a bearing on the performance of the health sector as a whole. Organizational behaviour theories that describe how people act within the organizations, lay significant importance on the motivation levels of the employees as the predictor of outcome or performance.4 Motivation in an organizational setting is thought to be governed by three sets of principles: interpersonal needs, intrinsic and extrinsic motivations, and basic psychological *Correspondence: VS Raghuvanshi, Bavarian Public Health Research Centre, Ludwig-Maximilians-University Munich, School of Medicine, Tegernseer Landstrasse 243, D-81549 Munich, Germany. E-mail: [email protected] Accepted 19 May 2002
needs.5 Schutz6 drew attention to inclusion, control, and affection as the three interpersonal needs. Through the Two-Factor theory, Herzberg7 emphasized the extrinsic and intrinsic motivations. According to him factors external to work, like company policies, salary, benefits etc. are important for preventing dissatisfaction but are not the motivators. On the other hand, factors associated with the work itself like, advancement, development, responsibilities, etc. are the intrinsic factors, which are the real motivators. Resembling the intrinsic principles of Herzberg and the interpersonal needs of Schutz are the basic psychological needs,5 which are six in number: achievement (sense of fulfillment), affiliation (sense of attachment), control (sense of authority), influence (on others), dependency (seeking support), and extension (drive to help others). According to Aitkinson8 each of these six needs has two dimensions, viz., approach and avoidance. Approach dimension is a positive force and avoidance a negative. Typically, ‘hope of success’ is the approach dimension and ‘fear of failure’ is the avoidance dimension. Individual motivation in an organization is the sum total of the approach and the avoidance dimensions of each of the six basic psychological needs. To assess the role of motivation of the staff in the performance of public health services in an urban setting, this cross-sectional exploratory study was conducted. To keep the study focussed and manageable, the target group of the study was the malaria staff of the urban health centres (UHC) of Surat Municipal Corporation (SMC), India. Some studies have explored the factors affecting the motivation in organizational setting,9,10 but the author could not come across any explaining what constituted
Improvement in malaria services VS Raghuyamshi
375
motivation. This study has attempted to fill this gap. As the groundwork for laying emphasis on the importance of the role of motivation in performance, the study has also compared malaria services provided by the private clinics (PC) and the UHC in one lower socio-economic locality of Surat.
Material and methods Comparison of UHC and the PCs For the comparison of malaria services of PCs and the UHC on the factors determining the choice of the facility (utilization-determining factors), a lower socio-economic locality of Surat City was chosen. The choice of the locality was based on the logistics and expectation that the utilization the UHC would be more in a lower socio-economic area. One hundred households, selected through systematic random sampling using random number table, were interviewed using a structured questionnaire. During the analysis, 10 questionnaires were incomplete or were found to have inconsistencies and hence dropped from the analysis. Thus, the total sample available for the analysis was 90 households. The sample size was calculated using the formula, n ¼ (t2pq=d2) (where t is the t statistic [for 95% confidence, t ¼ 1.96], p, the population proportion, q ¼ 1 p, and d is precision or allowable error or beta. For this study the author presumed maximum variability, hence p ¼ 0.5; q ¼ 0.5; d ¼ 0.1; and power ¼ 1 d ¼ 0.9 or 90%).11 A rapid household survey (different from this study) in the same locality was conducted to determine the utilization-determining factors. The analysis of this survey gave seven common factors that influenced the utilization of malaria services in this locality irrespective of the type of the facility. The seven factors were: wait-in period is less, outlet near home, good ambience, gets relief, doctor’s behaviour is good, doctor is good, and good medicines. To compare the UHC and the PCs the respondents were asked to rate the UHC and the PCs separately for each of the seven factors in a scale of good, average, and bad. For analysis, scale good was given the score of 3, average 2, and bad 1.
Motivation assessment To study the motivation level of the malaria staff, a standard psychological questionnaire5 (instrument), Motivational Analyses of Organizations-Behaviour (MAO-B) was used. The questionnaire assessed the six basic psychological needs (mentioned in the introduction) of the malaria staff including, both the approach and the avoidance dimensions of each of the six needs. The questionnaire comprised 60 questions, 10 each factored into six needs. (The six needs were: achievement, affiliation, control, influence, dependency, and extension.) Based on the responses Operative Effective Quotient (OEQ) of each need was calculated using the formula: OEQ ¼ P 5 100/P þ V 10, where, P and V represented the scores of approach and avoidance dimensions. The scores ranged from mean 0.5 s.d. to mean þ 0.5 s.d. The sample for assessing the motivation comprised the UHC doctors, sub-sanitary inspectors (SSI), and primary health workers (PHW) of the UHCs — staff that is traditionally engaged in malaria services. SMC had 20 UHCs, each with two doctors, one SSI, and 25 PHWs. The effort was made to cover at least 50% of the doctors, 50% of the SSIs, and 4 PHWs from each UHC. Twenty-four doctors, 12 SSIs, and 27 PHWs were interviewed. Due to number of existing vacancies and highly mobile nature of the job, it was very difficult to seek the PHWs for the interviews even after repeated visits. Therefore, a compromise was made to interview at least one PHW from each UHC.
Results Table 1 shows the mean scores of the seven factors with 95% CI, t-statistics, and the P-values. It is clear from the table that PCs got higher scores for all the seven factors. The difference between the mean scores is significant for all the factors other than good medicines. However, the difference is more marked for wait in period, vicinity from home, and good ambience. Of importance to note is that with regard to good doctor and good medicine the two were relatively more close. From the motivation point of view, it
Table 1 Comparison between the UHCSs and PCs (all the scores are out of 3) Factors Wait-in period is less Outlet near home Good ambience Gets relief Doctor’s behaviour is good Doctor is good Good medicines
PC score mean (95% CI) 2.78 2.73 2.56 2.40 2.56 2.50 2.56
(2.67, (2.62, (2.43, (2.30, (2.41, (2.37, (2.41,
2.89) 2.85) 2.68) 2.59) 2.70) 2.62) 2.70)
UHC* mean (95% CI) 1.77 1.78 2.16 2.10 2.31 2.28 2.50
(1.62, (1.61, (1.98, (1.96, (2.15, (2.12, (2.36,
1.92) 1.94) 2.33) 2.27) 2.47) 2.43) 2.64)
t-statistic
P-value
10.94 9.49 3.69 3.12 2.26 2.21 0.54
0.00001 0.00001 0.0003 0.002 0.025 0.028 0.600
(n ¼ 90). *Urban health centre. Public Health
Improvement in malaria services VS Raghuyamshi
376
is important to note that the behaviour of the doctor was found to be significantly different between the PCs and the UHC. Table 2 shows the motivation levels of the malaria staff studied. The table shows that the need to influence people was the primary motivating factor for the doctors. In the decreasing order the other needs were achievement and dependency (both having OEQ of 60), affiliation and extension (both having OEQ of 59), and control (OEQ ¼ 53). This shows that control need was the weakest motivating factor in the corporation setting for the doctors to work. For the SSIs, affiliation need was the strongest (OEQ ¼ 61) followed by extension (OEQ ¼ 58). The need dependency was the weakest (OEQ ¼ 43). For the PHWs, the drive to influence (57) people motivated them the most in the corporation setting. The levels of other needs were: extension (56), affiliation (55), achievement (54), dependency (51), and control (49) in that order.
periods. Better motivation of the doctors could at least in part improve some of these attributes.12 Besides poor motivation large volume of patients and poor appointment scheduling can also be responsible for the longer wait-in periods. However, in this study they did not appear to be the major reasons because of the fewer number of suspected malaria cases visiting the UHCs (it was seven per day13) and the existence of a well-trained staff for handling appointments. Malaria services of the UHCs were the interplay of the doctors, SSIs, and PHW. Combined behaviours of these made the visit of a patient pleasant or bad and partly decided the utilization of the UHCs. This study attempted to highlight the motivation mix of different categories of malaria staff focussing on the six basic psychological needs. From Table 2 it is clear that the gap between observed and the expected motivation levels (OEQ) was small for the doctors but large for the lower staff. This observation was consistent with a related finding of another study9 stating that employees higher in the organization reported having greater personal power in their organization compared to one in the lower positions. For the doctors, the largest gap was for influence and achievement. This meant that the influence, which the doctors wanted to have on others with respect to their job was not adequate and this might be responsible for their observed behaviour. This could be the case with the need achievement, meaning that their expected sense of achievement was not being met by being the employee of the corporation. The increased gap between the observed and the expected need levels of the lower staff suggests that all six needs were poorly met for them, which could be the reason for their perception that they have poor access to the empowerment structures of their organizations (eg corporation), as theorized by Kanter 1977.14 Public health psychologists have stressed the need to modify aspects of work environment that are associated with poor motivation and dissatisfaction.15 Management style, job structure and design, interpersonal relationship, scheduling of work etc. are some of the aspects of work
Discussion The study showed that this community considered UHC good with regard to the doctors and the medicines given there. Higher rating of the PCs on all the factors suggested the preference of PCs over the UHC. We have a situation where a lower socioeconomic community found UHC good with regards to doctors and medicine but still preferred PCs at a higher cost (UHC charged Rs. 3 for consultation, medicines, and investigation compared to PCs charging Rs. 10 only for the consultation [Rs. 46 ¼ $1]). This suggested that it was not the treatment quality and the cost alone that determined the service utilization. The results showed that the UHC was rated low on the behaviour of the doctors, similar to the wait-in period and the distance from the residence. Motivation level may affect the behaviour of the doctor that could have a role in the long wait-in period at the UHC. Poor motivation may be responsible for the indifferent attitude towards the patients, slow pace of the work, negligent behaviour etc. leading to longer wait-in
Table 2 Motivation levels of the doctors, SSIs, and the PHWs (with gaps between the observed and the expected OEQs) SSIs* (OEQ){ (n ¼ 12)
Doctors (OEQ) (n ¼ 24)
PHWs{{ (OEQ) (n ¼ 27)
Basic needs
Observed
Expected
Gap
Observed
Expected
Gap
Observed
Expected
Gap
Influence Achievement Dependency Affiliation Extension Control
64 60 60 59 59 53
65.0 60.5 60.0 59.8 59.0 53.3
1.0 0.5 0.0 0.8 0.0 0.3
50 53 43 61 58 51
57 60 46 65 61 52
7 7 3 4 3 1
57 54 51 55 56 49
62.8 59.3 55.0 62.3 61.0 54.3
5.8 5.3 4.0 7.3 5.0 5.3
(n ¼ 63). *Subsanitary inspector. { Operative effective quotient. {{ Primary health worker. Public Health
Improvement in malaria services VS Raghuyamshi
377
environment that may affect the motivation level of the employees and the over all satisfaction.16 – 18 One of the most widely studied changes in the work environment linked with improved motivation is job control.19 Job control, by providing discretion and control over the job acts as a powerful instrument to influence other elements of the work environment. Participative action research (PAR) is one of the strategies used to introduce job control that involves collaboration between the change agents and the employees to meet both the organizational goals (improving motivation and satisfaction) and the research goals (theory contribution).20 PAR gives importance to both the process and the contents of the change thus making it a participatory approach rather than top-down. A recent study by Bond and Bunce21 has shown that increased job control improved the efficiency in a large administrative setting by improving stress-related outcome, including motivation and satisfaction. The study was consistent with various occupational health psychology theories that hypothesize that job control enables the employee to learn effective ways to meet and emotionally cope with work-related challenges, ie ‘learning through control’.22 Most of the work environment intervention studies, however, have pointed out that such interventions are not able to sustain motivation and satisfaction over longer periods,16,23 thus emphasizing the need to undertake such exercises (like PAR) at regular intervals. The six basic needs assessed in this study collectively reflect the state of work environment of the employees. Influencing work environment by job control seems to have the potential to strengthen all the six basic needs by providing appropriate authority (control) and influence, which in turn improves the sense of achievement leading to better inclination towards the organization (dependency), urge to remain strongly affiliated (affiliation) to it, and a heightened desire to help others (extension). All this could improve the performance of the organization. For this study, the malaria staff can be involved in PAR in an effort to provide them greater job control and to determine what may be the most effective way of doing their jobs. Three separate PAR programmes could be instituted, one each for the doctors, SSIs, and the PHWs. Each PAR could delve on a wide range of topics. The most important outcomes of these PAR programmes could be implemented as longitudinal studies based on rigourous scientific procedures.24 There are some limitations to this study. Being a unique study that addresses the factors constituting motivation in the malaria department of the UHC of a corporation in a developing country, it was hard to come by any similar study to compare the results. However, this study is important because it is providing an important tool that has a potential to improve the utilization of public health facilities, especially in the context of a developing country by laying stress on the motivation levels of the employees, often a neglected aspect of the reform process. Availability of validity study would have definitely increased the confidence in the findings of this study, yet much stress cannot
be laid on such studies due to general concerns raised about the validity studies,25 and the specific concerns raised on the validity studies of the psychometric instruments due to strong individual differences in the functions of behaviour.26 However, the author believes that the next step of this study should be to test the instrument in different settings. Another limitation of the study was the smaller number of PHWs. There are many other variables that govern the motivation level of the staff, which are often difficult to change by modifying the work environment alone, like political will, bureaucracy, salary structure etc. Although the author has presented motivation as a variable that could improve malaria services of the UHC, there are other potential areas of improvement. Improving the image of the organization, competing financial rewards, scope for personal growth, and effective off duty planning could be some of the other ways of improving the performance in this setting.27,28 In conclusion it could be said that the assessment of the motivation level of the malaria staff in a corporation setting is possible, which could be used to develop and device interventions to improve the same. PAR could be one such way of developing and implementing such interventions. A model shown in Figure 1 is suggested that could be replicated and improvised in different settings. The finding of the study that low-income people use PCs at a much higher cost for malaria treatment compared to the UHC underscores the need to improve the utilization of the UHC. Doing that by improving the motivation level of the malaria
Figure 1
Model for the improvement of the motivational level of the malaria staff. Public Health
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378
staff is a novel idea and perhaps more economical and sustainable. References 1 World Health Organization. The world health report 2000. Health systems: improving performance. World Health Organization: Geneva, 2000. 2 Aljunid S. The role of private medical practitioners and their interactions with public health services in Asian countries. Health Policy Planning 1995; 10: 333 – 349. 3 Brugha R, Zwi A. Improving the quality of private sector delivery of public health services: challenges and strategies. Health Policy Planning 1998; 13: 107 – 120. 4 Davis K, Newstrom JW. Working with people. Human behaviour at work: organizational behaviour, 7th edn. McGraw Hill: New York, 1985. 5 Parikh U. Training instrument for human resource development. Tata McGraw-Hill: New Delhi, 1997. 6 Schutz WC. FIRO. A three dimensional theory of interpersonal behaviour. Holt, Rinehart and Winston: New York, 1958. 7 Herzberg F, Mausner B, Snyderman BB. The motivation to work, 2nd edn. Wiley: New York, 1959. 8 Aitkinson JW. An introduction to motivation. Van Nostrand: Princeton, NJ, 1964. 9 Goddard MB, Laschinger HKS. Nurse managers’ perception of power and opportunity. Can J Nurse Adm 1997; 10: 40 – 66. 10 Lima-Basto M. Challenges of Nurses professional behaviour change process. Scand J Caring Sci 1995; 9: 113 – 118. 11 Gregg MB, Dicker DR, Goodman RA. Field epidemiology. Oxford University Press: New York, 1996. 12 Simkin-Silverman LR, Wing RR. Management of obesity in primary care. Obes Res 1997; 6: 603 – 612. 13 Raghuyamshi VS. Study of malaria services provided by the Surat Municipal Corporation. Submitted to South Gujarat University, Surat, Gujarat, 2000. 14 Kanter RM. Men and women of the corporation. Basic Books. New York, 1977. 15 Parker S, Wall T. Job and work design. Sage: London, 1988.
Public Health
16 Jackson SE. Participation in decision making as a strategy for reducing job-related strain. J Appl Psychol 1983; 68: 3 – 19. 17 Lucas MD. Management style and staff nurse job satisfaction. J Prof Nurs 1991; 7: 119 – 125. 18 Vagg PR, Spielberger CD. The job stress survey: assessing perceived severiety and frequency of occurence of generic sources of stress in the work place. J Occup Health Psychol 1994; 4: 288 – 292. 19 Terry DV, Jimmieson NL. Work control and employee wellbeing: a decade review. In: Cooper CL, Robertson IT (eds). International review of industrial and psychology, Wiley: Chichester, UK, 1999. 20 Israel BA, Schurman SJ, House JS. Action research on occupational stress: involving workers as researchers. Int J Health Serv 1989; 19: 135 – 155. 21 Bond FW, Bunce D. Job control mediates changes in a work reorganization: Intervention for stress reduction. J Occup Health Psychol 2001; 6: 290 – 302. 22 Karasek R, Theorell T. Healthy work: stress, productivity and the reconstruction of working life. Basic Books: New York, 1990. 23 Griffin RW. Effects of work redesign on employee perception, attitudes, and behaviours: a long term investigation. Acad Manage J 1991; 34: 425 – 435. 24 Baron RM, Kenny DA. The moderator-mediator variable distinction in psychological research: conceptual, strategic and statistical considerations. J Pers Soc Psychol 1986; 51: 1173 – 1182. 25 Ransohoff DF, Feinstein AR. Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. N Engl J Med 1978; 299: 926 – 930. 26 Sturmey P. Assessing the functions of aberrant behaviours: a review of psychometric instruments. J Autism Dev Disord 1994; 24: 293 – 304. 27 Buchan J. Planning for change: developing a policy framework for nursing labour markets. Int Nurs Rev 2000; 47: 199 – 206. 28 Aiken L, Havens D. Shaping systems to achieve desired outcomes. J Nurs Adm 1999; 29: 14 – 20.
Improvement in malaria services in an urban setting: role of staff motivation VS Raghuvanshi Bavarian Public Health Research Centre, School of Medicine, Ludwig-Maximilians University, Munich, Germany
Urban health centres and the private clinics (PCs) providing malaria services in an urban setting were compared on seven utilization-determining factors to assess why people preferred one over the other. On the other hand, motivation level of the technical staff of the corporation in the malaria services was studied to find out the extent to which the motivation level of the staff was responsible for the observed mean scores of the factors studied. It was found that PCs fared better on all of them. However, the two differed mostly on wait-in period at the outlet, distance from residence, ambience of the outlet, and getting relief. The study further showed that for the doctors and the primary health workers, the opportunity of influencing people was the strongest motivation to work in the corporation and for the subsanitary inspectors, it was affiliation. Based on this, a model is suggested to introduce changes based on motivation mix of the malaria staff. Public Health (2002) 116, 374–378. doi:10.1038=sj.ph.1900876 Keywords: malaria; corporation; technical staff; motivation; utilization
Introduction The public health sector in developing countries is often under-utilized.1 Poor services, poor facilities, negative attitude of the staff, insensitivity to the local needs etc. are some of the widely acknowledged reasons for the poor image of the public health sector.2 Since private sector cannot be the absolute substitute for the public health services due to associated problems,3 it is important to identify potential areas of improvement in the public health sector. Part of the problem could be the low motivation of the staff of the public health sector. Advances in public health have contributed greatly to the understanding of the technical aspect of disease management and control. However, all these are insufficient to bring about the desired changes. The vast human resource associated with public health calls for greater attention to the motivation levels of the employees in the organization. It might have a bearing on the performance of the health sector as a whole. Organizational behaviour theories that describe how people act within the organizations, lay significant importance on the motivation levels of the employees as the predictor of outcome or performance.4 Motivation in an organizational setting is thought to be governed by three sets of principles: interpersonal needs, intrinsic and extrinsic motivations, and basic psychological *Correspondence: VS Raghuvanshi, Bavarian Public Health Research Centre, Ludwig-Maximilians-University Munich, School of Medicine, Tegernseer Landstrasse 243, D-81549 Munich, Germany. E-mail: [email protected] Accepted 19 May 2002
needs.5 Schutz6 drew attention to inclusion, control, and affection as the three interpersonal needs. Through the Two-Factor theory, Herzberg7 emphasized the extrinsic and intrinsic motivations. According to him factors external to work, like company policies, salary, benefits etc. are important for preventing dissatisfaction but are not the motivators. On the other hand, factors associated with the work itself like, advancement, development, responsibilities, etc. are the intrinsic factors, which are the real motivators. Resembling the intrinsic principles of Herzberg and the interpersonal needs of Schutz are the basic psychological needs,5 which are six in number: achievement (sense of fulfillment), affiliation (sense of attachment), control (sense of authority), influence (on others), dependency (seeking support), and extension (drive to help others). According to Aitkinson8 each of these six needs has two dimensions, viz., approach and avoidance. Approach dimension is a positive force and avoidance a negative. Typically, ‘hope of success’ is the approach dimension and ‘fear of failure’ is the avoidance dimension. Individual motivation in an organization is the sum total of the approach and the avoidance dimensions of each of the six basic psychological needs. To assess the role of motivation of the staff in the performance of public health services in an urban setting, this cross-sectional exploratory study was conducted. To keep the study focussed and manageable, the target group of the study was the malaria staff of the urban health centres (UHC) of Surat Municipal Corporation (SMC), India. Some studies have explored the factors affecting the motivation in organizational setting,9,10 but the author could not come across any explaining what constituted
Improvement in malaria services VS Raghuyamshi
375
motivation. This study has attempted to fill this gap. As the groundwork for laying emphasis on the importance of the role of motivation in performance, the study has also compared malaria services provided by the private clinics (PC) and the UHC in one lower socio-economic locality of Surat.
Material and methods Comparison of UHC and the PCs For the comparison of malaria services of PCs and the UHC on the factors determining the choice of the facility (utilization-determining factors), a lower socio-economic locality of Surat City was chosen. The choice of the locality was based on the logistics and expectation that the utilization the UHC would be more in a lower socio-economic area. One hundred households, selected through systematic random sampling using random number table, were interviewed using a structured questionnaire. During the analysis, 10 questionnaires were incomplete or were found to have inconsistencies and hence dropped from the analysis. Thus, the total sample available for the analysis was 90 households. The sample size was calculated using the formula, n ¼ (t2pq=d2) (where t is the t statistic [for 95% confidence, t ¼ 1.96], p, the population proportion, q ¼ 1 p, and d is precision or allowable error or beta. For this study the author presumed maximum variability, hence p ¼ 0.5; q ¼ 0.5; d ¼ 0.1; and power ¼ 1 d ¼ 0.9 or 90%).11 A rapid household survey (different from this study) in the same locality was conducted to determine the utilization-determining factors. The analysis of this survey gave seven common factors that influenced the utilization of malaria services in this locality irrespective of the type of the facility. The seven factors were: wait-in period is less, outlet near home, good ambience, gets relief, doctor’s behaviour is good, doctor is good, and good medicines. To compare the UHC and the PCs the respondents were asked to rate the UHC and the PCs separately for each of the seven factors in a scale of good, average, and bad. For analysis, scale good was given the score of 3, average 2, and bad 1.
Motivation assessment To study the motivation level of the malaria staff, a standard psychological questionnaire5 (instrument), Motivational Analyses of Organizations-Behaviour (MAO-B) was used. The questionnaire assessed the six basic psychological needs (mentioned in the introduction) of the malaria staff including, both the approach and the avoidance dimensions of each of the six needs. The questionnaire comprised 60 questions, 10 each factored into six needs. (The six needs were: achievement, affiliation, control, influence, dependency, and extension.) Based on the responses Operative Effective Quotient (OEQ) of each need was calculated using the formula: OEQ ¼ P 5 100/P þ V 10, where, P and V represented the scores of approach and avoidance dimensions. The scores ranged from mean 0.5 s.d. to mean þ 0.5 s.d. The sample for assessing the motivation comprised the UHC doctors, sub-sanitary inspectors (SSI), and primary health workers (PHW) of the UHCs — staff that is traditionally engaged in malaria services. SMC had 20 UHCs, each with two doctors, one SSI, and 25 PHWs. The effort was made to cover at least 50% of the doctors, 50% of the SSIs, and 4 PHWs from each UHC. Twenty-four doctors, 12 SSIs, and 27 PHWs were interviewed. Due to number of existing vacancies and highly mobile nature of the job, it was very difficult to seek the PHWs for the interviews even after repeated visits. Therefore, a compromise was made to interview at least one PHW from each UHC.
Results Table 1 shows the mean scores of the seven factors with 95% CI, t-statistics, and the P-values. It is clear from the table that PCs got higher scores for all the seven factors. The difference between the mean scores is significant for all the factors other than good medicines. However, the difference is more marked for wait in period, vicinity from home, and good ambience. Of importance to note is that with regard to good doctor and good medicine the two were relatively more close. From the motivation point of view, it
Table 1 Comparison between the UHCSs and PCs (all the scores are out of 3) Factors Wait-in period is less Outlet near home Good ambience Gets relief Doctor’s behaviour is good Doctor is good Good medicines
PC score mean (95% CI) 2.78 2.73 2.56 2.40 2.56 2.50 2.56
(2.67, (2.62, (2.43, (2.30, (2.41, (2.37, (2.41,
2.89) 2.85) 2.68) 2.59) 2.70) 2.62) 2.70)
UHC* mean (95% CI) 1.77 1.78 2.16 2.10 2.31 2.28 2.50
(1.62, (1.61, (1.98, (1.96, (2.15, (2.12, (2.36,
1.92) 1.94) 2.33) 2.27) 2.47) 2.43) 2.64)
t-statistic
P-value
10.94 9.49 3.69 3.12 2.26 2.21 0.54
0.00001 0.00001 0.0003 0.002 0.025 0.028 0.600
(n ¼ 90). *Urban health centre. Public Health
Improvement in malaria services VS Raghuyamshi
376
is important to note that the behaviour of the doctor was found to be significantly different between the PCs and the UHC. Table 2 shows the motivation levels of the malaria staff studied. The table shows that the need to influence people was the primary motivating factor for the doctors. In the decreasing order the other needs were achievement and dependency (both having OEQ of 60), affiliation and extension (both having OEQ of 59), and control (OEQ ¼ 53). This shows that control need was the weakest motivating factor in the corporation setting for the doctors to work. For the SSIs, affiliation need was the strongest (OEQ ¼ 61) followed by extension (OEQ ¼ 58). The need dependency was the weakest (OEQ ¼ 43). For the PHWs, the drive to influence (57) people motivated them the most in the corporation setting. The levels of other needs were: extension (56), affiliation (55), achievement (54), dependency (51), and control (49) in that order.
periods. Better motivation of the doctors could at least in part improve some of these attributes.12 Besides poor motivation large volume of patients and poor appointment scheduling can also be responsible for the longer wait-in periods. However, in this study they did not appear to be the major reasons because of the fewer number of suspected malaria cases visiting the UHCs (it was seven per day13) and the existence of a well-trained staff for handling appointments. Malaria services of the UHCs were the interplay of the doctors, SSIs, and PHW. Combined behaviours of these made the visit of a patient pleasant or bad and partly decided the utilization of the UHCs. This study attempted to highlight the motivation mix of different categories of malaria staff focussing on the six basic psychological needs. From Table 2 it is clear that the gap between observed and the expected motivation levels (OEQ) was small for the doctors but large for the lower staff. This observation was consistent with a related finding of another study9 stating that employees higher in the organization reported having greater personal power in their organization compared to one in the lower positions. For the doctors, the largest gap was for influence and achievement. This meant that the influence, which the doctors wanted to have on others with respect to their job was not adequate and this might be responsible for their observed behaviour. This could be the case with the need achievement, meaning that their expected sense of achievement was not being met by being the employee of the corporation. The increased gap between the observed and the expected need levels of the lower staff suggests that all six needs were poorly met for them, which could be the reason for their perception that they have poor access to the empowerment structures of their organizations (eg corporation), as theorized by Kanter 1977.14 Public health psychologists have stressed the need to modify aspects of work environment that are associated with poor motivation and dissatisfaction.15 Management style, job structure and design, interpersonal relationship, scheduling of work etc. are some of the aspects of work
Discussion The study showed that this community considered UHC good with regard to the doctors and the medicines given there. Higher rating of the PCs on all the factors suggested the preference of PCs over the UHC. We have a situation where a lower socioeconomic community found UHC good with regards to doctors and medicine but still preferred PCs at a higher cost (UHC charged Rs. 3 for consultation, medicines, and investigation compared to PCs charging Rs. 10 only for the consultation [Rs. 46 ¼ $1]). This suggested that it was not the treatment quality and the cost alone that determined the service utilization. The results showed that the UHC was rated low on the behaviour of the doctors, similar to the wait-in period and the distance from the residence. Motivation level may affect the behaviour of the doctor that could have a role in the long wait-in period at the UHC. Poor motivation may be responsible for the indifferent attitude towards the patients, slow pace of the work, negligent behaviour etc. leading to longer wait-in
Table 2 Motivation levels of the doctors, SSIs, and the PHWs (with gaps between the observed and the expected OEQs) SSIs* (OEQ){ (n ¼ 12)
Doctors (OEQ) (n ¼ 24)
PHWs{{ (OEQ) (n ¼ 27)
Basic needs
Observed
Expected
Gap
Observed
Expected
Gap
Observed
Expected
Gap
Influence Achievement Dependency Affiliation Extension Control
64 60 60 59 59 53
65.0 60.5 60.0 59.8 59.0 53.3
1.0 0.5 0.0 0.8 0.0 0.3
50 53 43 61 58 51
57 60 46 65 61 52
7 7 3 4 3 1
57 54 51 55 56 49
62.8 59.3 55.0 62.3 61.0 54.3
5.8 5.3 4.0 7.3 5.0 5.3
(n ¼ 63). *Subsanitary inspector. { Operative effective quotient. {{ Primary health worker. Public Health
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environment that may affect the motivation level of the employees and the over all satisfaction.16 – 18 One of the most widely studied changes in the work environment linked with improved motivation is job control.19 Job control, by providing discretion and control over the job acts as a powerful instrument to influence other elements of the work environment. Participative action research (PAR) is one of the strategies used to introduce job control that involves collaboration between the change agents and the employees to meet both the organizational goals (improving motivation and satisfaction) and the research goals (theory contribution).20 PAR gives importance to both the process and the contents of the change thus making it a participatory approach rather than top-down. A recent study by Bond and Bunce21 has shown that increased job control improved the efficiency in a large administrative setting by improving stress-related outcome, including motivation and satisfaction. The study was consistent with various occupational health psychology theories that hypothesize that job control enables the employee to learn effective ways to meet and emotionally cope with work-related challenges, ie ‘learning through control’.22 Most of the work environment intervention studies, however, have pointed out that such interventions are not able to sustain motivation and satisfaction over longer periods,16,23 thus emphasizing the need to undertake such exercises (like PAR) at regular intervals. The six basic needs assessed in this study collectively reflect the state of work environment of the employees. Influencing work environment by job control seems to have the potential to strengthen all the six basic needs by providing appropriate authority (control) and influence, which in turn improves the sense of achievement leading to better inclination towards the organization (dependency), urge to remain strongly affiliated (affiliation) to it, and a heightened desire to help others (extension). All this could improve the performance of the organization. For this study, the malaria staff can be involved in PAR in an effort to provide them greater job control and to determine what may be the most effective way of doing their jobs. Three separate PAR programmes could be instituted, one each for the doctors, SSIs, and the PHWs. Each PAR could delve on a wide range of topics. The most important outcomes of these PAR programmes could be implemented as longitudinal studies based on rigourous scientific procedures.24 There are some limitations to this study. Being a unique study that addresses the factors constituting motivation in the malaria department of the UHC of a corporation in a developing country, it was hard to come by any similar study to compare the results. However, this study is important because it is providing an important tool that has a potential to improve the utilization of public health facilities, especially in the context of a developing country by laying stress on the motivation levels of the employees, often a neglected aspect of the reform process. Availability of validity study would have definitely increased the confidence in the findings of this study, yet much stress cannot
be laid on such studies due to general concerns raised about the validity studies,25 and the specific concerns raised on the validity studies of the psychometric instruments due to strong individual differences in the functions of behaviour.26 However, the author believes that the next step of this study should be to test the instrument in different settings. Another limitation of the study was the smaller number of PHWs. There are many other variables that govern the motivation level of the staff, which are often difficult to change by modifying the work environment alone, like political will, bureaucracy, salary structure etc. Although the author has presented motivation as a variable that could improve malaria services of the UHC, there are other potential areas of improvement. Improving the image of the organization, competing financial rewards, scope for personal growth, and effective off duty planning could be some of the other ways of improving the performance in this setting.27,28 In conclusion it could be said that the assessment of the motivation level of the malaria staff in a corporation setting is possible, which could be used to develop and device interventions to improve the same. PAR could be one such way of developing and implementing such interventions. A model shown in Figure 1 is suggested that could be replicated and improvised in different settings. The finding of the study that low-income people use PCs at a much higher cost for malaria treatment compared to the UHC underscores the need to improve the utilization of the UHC. Doing that by improving the motivation level of the malaria
Figure 1
Model for the improvement of the motivational level of the malaria staff. Public Health
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