Strategies to Improve the Performance of Health Work Assistants at District General Hospital Kalutara

Background: A high level of performance of the employees is mandatory to improve the quality of healthcare service rendered to the patients. Performance is a function of the interaction between an individual’s motivation, ability, and environment. It was highlighted that the Health Work Assistants (HWA) working at District General Hospital (DGH) Kalutara are poorly motivated leading to underperformance. Objective: To identify strategies to improve the performance of HWAs working at DGH Kalutara. Methods: Issues related to underperformance were identified using a problem tree analysis. The underlying causes were tabulated against a set of criteria. Prioritization was done based on; the technical feasibility of the alternative interventions, and the impact of the issue on the institution and the patients. Poor employee motivation was selected for further analysis based on the prioritized value. Results: Absenteeism, unavailability of streamlined induction training and regular in-service training, poor attitudes, poor employee motivation and family and social issues were identified as the main issues related to the poor performance of HWAs working at DGH Kalutara. “Intrinsic factors” and supervisor-related factors were selected to plan interventions based on the prioritized value. Conclusion: Providing opportunities for achievements, advancements, and personal growth, through recognition for HWAs’ hard work, dedication, and achievements. Improving their sense of responsibility by improving their relationship with supervisors and improving the quality of supervision.


Introduction
District General Hospital Kalutara was first established as a Base Hospital in 1951 and owns a land area of 22 acres.At present, it is the main Tertiary Care institution in the district catering to 1.2 million population not only in the district but also beyond the district boundaries [1] .DGH Kalutara is currently in the transition process into a Teaching Hospital affiliated with the Faculty of Medicine, University of Moratuwa and rapidly expanding its services in relation to subspecialties as well.The hospital consists of a total of 1885 healthcare workers and a high level of performance of all categories of employees is mandatory to provide quality and timely services to the patients.
Performance is a function of the interaction between an individual's motivation, ability, and environment [2] .

Performance = Motivation X Ability X Environment
In other words, if the employees are motivated, if their knowledge and skills needed to perform the job (abilities) are improved and if they are provided with the resources, information, and support needed to perform well (environmental factors), their performance will be improved.
In the Sri Lankan health sector, the performance of HWAs is frequently questioned when compared to the other healthcare workers.The situation at DGH Kalutara is not that different from the other institutions where there are 447 HWAs currently employed.This was also highlighted at a meeting held with the Overseers as well.It was decided to explore the factors related to their poor performance and to suggest strategies to improve the situation.

Objective
To identify strategies to improve the performance of HWAs working at DGH Kalutara.

Methodology
Principal investigator visited the clinic complex as a non-participatory observer and had Key Informant Interviews (KIIs) with the Director, Administrative Officer, some unit in-charge Nursing Officers, Overseers and one-to-one interviews with some of the HWAs.
Issues were identified in all 03 factors (motivation, ability and environment) which have contributed to their underperformance.
Those issues were prioritized considering the technical feasibility of the alternative interventions and the impact of the issue on the institution and the patients.(Table 1) A problem tree was used to analyse the problem and to identify the root causes as well as the effects of poor employee motivation.

Results
Some key issues highlighted by the interviewees are mentioned below.Poor employee motivation was selected for further analysis based on the prioritized value.

Problem Analysis Results
The basis for the division of factors affecting employee motivation was the Herzberg two factor theory in which hygiene factors (extrinsic factors) and motivational factors (intrinsic factors) are discussed.But some researchers argue that in the modern world extrinsic factors should also be addressed to motivate the employees [3] .Therefore, the causes which come under extrinsic factors were further classified as above under government /organization related factors, supervisor related factors, financial factors, and workplace-related factors.The absence of Herzberg's "motivational factors (intrinsic factors)" was categorized under "intrinsic factors".These strategies may be helpful to improve job satisfaction, job engagement and organizational commitment with the help of healthcare staff.The disadvantage is that all these strategies target only the HWAs who come to work every day.The regular absentees are not addressed by these strategies.
2) Improving the working conditions, physical workplace, and relationship with colleagues.
This may need substantial monetary resources.Improving the relationship with colleagues is also impractical, especially with regular absentees.The impact of this strategy on patient care services is also less.
3) Strategies to improve supervisorrelated factors.a) Improving the relationship with supervisors.b) Improving the quality of supervisors.
These also can be implemented at the institutional level with appropriate commitment of healthcare staff in a short period of time.Hence, "improving the quality of supervisors" will take some time to forecast any significant results.If the soft skills of the supervisors can be improved, it might help to reduce absenteeism to certain extent.These are less feasible at the institutional level and may not be acceptable by the other categories of staff.But this may be helpful to reduce absenteeism to certain extent as well.

5) Increasing salaries, incentives and remunerations of HWAs.
This is also not feasible at the institutional level and may not be acceptable by other health and non-health staff categories in the country.A lot of financial resources will be needed in this as well.However, this may significantly motivate the employees and improve job satisfaction and performance according to the modern-day literature [3] .
The above-proposed strategies (based on the causes) were tabulated against a set of criteria for prioritization.(Table 2).
According to the total prioritized value, the "intrinsic factors" (48) and supervisor related factors (44) were the leading causes for poor employee motivation.Therefore, the strategies were planned to address those causes.

Recommendations
1. Providing opportunities for achievements, advancements, and personal growth.2. There are HWAs who are talented in recreational activities, artistic work and sometimes innovations.Those HWAs should be given opportunities to show their talents.This may improve their job satisfaction, organizational commitment, and performance.During the KIIs with the Director, overseers, and interviews with some of the HWAs the PI understood that, although there are hard-working dedicated HWAs they are not appreciated at the institutional level.Providing them with due recognition will motivate them which will improve their performance.
4. Improving their sense of responsibility.
It was emphasized by some unit in charge Nursing Officers as well as HWAs who attend to work daily that most of the HWAs do not have a sense of responsibility regarding their job.Therefore, it is recommended to improve their sense of job responsibility.This may help to improve their job engagement and performance.
5. Improving the relationship with supervisors.
Some HWAs who are regular attendees also complained that they do not have a close relationship with their immediate superiors and higher officials in the units.It is needed to address this issue.This will help to improve their job satisfaction and performance.
6. Improving the quality of supervisors.
Certain unit in-charge Nursing Officers do not empathize with their junior staff.
Although it is a challenging task it is important to improve the soft skills of the supervisors.This might help to reduce their absenteeism to some extent and improve work performance.

Conclusion
Poor employee motivation leading to poor employee work performance was identified as a key problem at DGH Kalutara.The absence of intrinsic factors of motivation as well as supervisor related factors were identified as the prioritized causes.
Providing opportunities for achievements, advancements, and personal growth, providing recognition for HWAs' hard work, dedication, and achievements, improving their sense of responsibility, Improving the relationship with supervisors, and improving the quality of supervisors were recommended to improve the situation.

Proposed strategies 1 )
Elimination of the "intrinsic factors" related to demotivation.a) Providing opportunities for achievements, advancements, and personal growth.b) Providing recognition for HWAs' hard work, dedication, and achievements.c) Improving their sense of responsibility.

Figure 1 :
Figure 1: Problem tree analysis on root causes and effects of poor employee motivation