iNATURE AND CAUSES OF EMPLOYEE RETENTION INPRIVATE AND PUBLIC HOSPITALSA CASE STUDY OF TEMEKE HOSPITAL ANDHINDUMANDAL HOSPITAL IN DAR ES SALAAMiiNATURE AND CAUSES OF EMPLOYEE RETENTION INPRIVATE AND PUBLIC HOSPITALSA CASE STUDY OF TEMEKE HOSPITAL ANDHINDUMANDAL HOSPITAL IN DAR ES SALAAMBy Ayubu 1umanneA research proposal submitted to the school of publicadministration and management in partial fulfilment of therequirement for the degree of Human Resource Management ofMzumbe UniversityLIST OF ABBREVIATIONSMHSW Ministry of Health and Social WelfareiiiWHOWorld Health OrganizationFGD Focus Group DiscussionHR Human ResourcesHRM Human Resources ManagementIC Information and Communicationechnologies !M !no"ledge Management M#CMultinational Corporation S$S%Selecti&e $ccelerated Salary %nhancement 'DSM 'ni&ersity of Dar es SalaamHHR Health Human Resource#GO #on Go&ernment Organization1CHAPTER ONEINTRODUCTION AND BACKGROUND TO THE STUDY1.1 Introductionhispart pro&idesthe(ac)groundtotheresearchtopic* statement totheresearchpro(lem*o(+ecti&esofthestudy* research,uestionsas"ell assignificanceoftheresearchtopolicy*academia* and increasing )no"ledge- 1.2 Background to the studyhere is a serious human resource crisis in the health sector in de&eloping countries* particularlyin $frica-he WorldHealthReport./0112estimatesthatthereare30countries"ithcriticalshortages e,ui&alent to a glo(al deficit of /-4 million doctors* nurses and mid"i&es and theseshortfalls are greatest in su(5Sahara $frica-he World Health Organization .WHO2 estimates that out of a total of 36-/ million full5time paidhealth "or)ers "orld"ide* 789 .:6*480*0002 are health ser&ice pro&iders and ::9 .16*830*0002are health management and support "or)ers- On an a&erage there are a(out 6-: health "or)ersper 1*000 people "orld"ide- he total health "or)force in $frica is estimated at 1*740*000* "ithan a&erage of /-: health "or)ers per 1*000 people- Of the total health "or)force in $frica* ;:9.1*:70*0002 are health ser&ice pro&iders and 189 ./;0*0002 are health management and support"or)ers .WHO* /0112-$ccording to the Ministry of Health $nd Social Welfare anzania Mainland annual report ./01/2HRH data for the three years from /006 to /011 sho" that the num(er of Medical Officers hasincreasedfrom1*;67to/*//0*representinga189increase-$ssistant Medical Officersha&e2increased from 1*7/8 to 1*6:;* a 169 increase* #urses< Mid"i&es ha&e increased from 13*730to 16*41/* a /49 increase* =harmaceutical staff and la(oratory staff ha&e also increased from4;6 to ;11 and ;14 to 1*06;* representing increases of 73-;9 and :39* respecti&ely-O&erall* ratios of health "or)ers per 10*000 populations ha&e increased from 0-48 to 0-31 forMedical Officers* from 0-40 to 0-43 for $ssistant Medical Officers* from :-;3 to 4-3 for nursesaminesindetail theout5migrationaspect of"or)ermo&ement- Out5migrationisacentralelement in the current de(ate regarding the causes and conse,uences of e>cessi&e turno&er in thehealth "or)force- Inspite of theheightened interestinthe su(+ect*a serious lac) of data onmigrant flo" ma)es measurement of the e>tent of out5migration difficult and creates a pro(lemin determining the magnitude of attrition-ypically* migration data sets are incomplete*inaccurate and do not compare "ell across countries (ecause of inconsistencies in health "or)ercategories- Wea)nesses in the a&aila(le data limit go&ernments? a(ility to manage health "or)er3migrationandrestrict international comparisons of thephenomenon.Buchan, 2003).Healthofficials often tend to act "hen the num(ers lea&ing are percei&ed to (e high- %>isting data from source and recei&ing countries nonetheless re&eal that out5migration is on therise- Of o&er 700medical graduatestrainedin@am(iasinceindependenceonly30remain.Huddart* /00:2- he Fe(ruary /010 edition of theAulletin of the WHOreports that there aremore Ghanaian doctors "or)ing outside Ghana than in the country itself- he situation is not&ery different for South $frica- $ total of ;/*/48 doctors and nurses "ere "or)ing in the pu(licsector in South $frica in /011- In that same year* another :4*7:3 South $frican5(orn "or)ers"ere practicing a medical profession in an Organisation for %conomic Co5operation andDe&elopment country .Behmann and Sanders* /01/)- Out of 3*::4 $fricans practicing in the 'Sas physicians* 4*3;8 .;792 originate from only three countriesC #igeria* Ghana and South $frica(Hagopian et al, /01/2- $ pattern is also emerging in "hich out5migration occurs not only due to migration from poor torich countries (ut also migration from poor countries to less poor countries "ithin regions- Fore>ample* there is no" a steady flo" of health "or)ers from Ghana* !enya* Mala"i and anzaniato South $frica and Aots"ana .Schrecker and Labonte, 20122-In anzania* staff turno&er* especially of clinical staff "or)ing in pri&ate hospitals has remainedpersistently high- $&aila(le data from e>it inter&ie"s indicate that o&er 479 of lea&ers in thefinancial year /006D/010 +oined go&ernment ser&ices and /010D/011 a(out 4:9 of pri&ate healthemployees +oined go&ernment hospitals .Ministry of Health /01/C1362- Similarly* Onzu(o./011C:/2 sho"ed that in 'ganda* the attrition rates of health professionals are high especially inthepri&atehospitals- $ccordingtoEum)ella./006C12* "or)er shortages arelin)edtothree4factors including decreasing student enrolment in health training institutions* delays or freezes inhiring of ,ualified professionals and the failure to retain those already employed-She furtherrecognizes the fact that the pro(lemof lo"retention of health"or)ers is costly* affectscontinuity of care and raises the intentions for turno&er of the remaining employees* "ho sufferstress and (urnout from ta)ing on the additional "or) (urden-Recruiting and )eeping the right staff are )ey challenges for health policyma)ers- In any healthsystem* health human resources .HHR2 are a central component and are essential for the deli&eryof care topatients- herefore* recruitment andretention pro(lems should(e appropriatelyaddressed* asstaffshortagesoranunmoti&atedhealth"or)forceareli)elytoha&ead&erseeffects on the deli&ery of health ser&ices and outcome of care .Whitt* /0032-Organizations in&est a lot on their employees in terms of training* de&eloping* maintaining andhence there is a need for retaining them for the organizational prosperity- herefore* managersmust minimize high employeeFs turno&er at all costs- $lthough* there is no standard frame"or)for understanding the employees turno&er process as "hole* a "ide range of factors ha&e (eenfound useful in interpreting employee turno&er .!e&in et al- /0042- heretentionof employees has (eensho"nto(esignificant tothede&elopment andtheaccomplishment of theorganization?sgoals ando(+ecti&es .$l)andari andHammad* /0062-Retentionofemployees can(ea&ital sourceofcompetiti&ead&antageforanorganization-oday* changesintechnology* glo(al economics* tradeagreements andtheli)earedirectlyaffectingemployeeDemployerrelationships- 'ntilrecently*loyalty"asthecornerstoneofthatrelationship .i(id* /0062- he loss of talented employees may (e &erydetrimental tothecompany?s futuresuccess- Outstandingemployees maylea&e anorganization(ecause they5(ecome dissatisfied* under paid or unmoti&ated .Coff* 16672* and "hile the management tries toretain employees "ithin the organization* employees may present other challenges as "ell suchas demanding higher "ages* they may decide not to comply "ith organization practices* and notinteract "ell "iththeirco5"or)ersorcomply"iththeirmanagers? directi&es- Aesidesthesepro(lems* asymmetric information or lac) of information a(out the employees? performance maycomplicate an organization?s endea&our to retain producti&e employees- It is argued that "ithoutade,uate information the organization may not (e a(le to distinguish producti&e "or)ers fromnon5producti&e ones .Coff* 16672- %mployees often may ta)e credit for the successes and deflectfailures to other employees and this is )no"n as a moral hazard pro(lem-In many instancescompanies may re"ard or punish employees for an organization outcome for "hich they had noimpact .!err* 16632-%&idence from the implementation of the Selecti&e $ccelerated Salary %nhancement .S$S%2 inanzania?sScheme adopted in /000suggeststhat departments "ere(ettera(letoattractandretain,ualifiedprofessional*technicaland managerialstaffGand encouragestaff to underta)efurther training to aspire for progression and to mo&e up the career ladder- Ho"e&er* the partialimplementation of the S$S%scheme ga&e rise to unfulfilled e>pectations* creates greaterhostility to"ards the scheme and created the perception that it "as unfair and discriminatory-Bastly* research from Mala"i* 'ganda and anzania .Wang and Ra)ner* /0032 found that lo"le&elsoffunding"erethemainconstraint onthecapacityofthethreecountriesS$S%- Inparticular* Mala"i and anzania had had pro(lems retaining health employees o&er the years andthe situation is "orse in pri&ate hospitals-61.3 Statement of the ProblemIn anzania* attrition among enrolled health "or)ers in pu(lic and pri&ate not for profit hospitalsrose from /39 in the financial year /00;D/006 to :/9 in /006D/010 (efore droping to :09 in/010D/011 and no" to /79 in /011D/01/ .Ministry of Health and Social Welfare* /01/2- Whileretention has remained a challenge to the health sector largely due to financial constraints* thea(solutenum(ers of staffhas al"ays (eenmaintainedduetorapidreplacement "ithfreshgraduates- =ro(lems caused (y the failure to retain employees therefore include loss ofemployees "ith e>perience* and the added costs of replacement .Ministry of Health and SocialWelfare* /01/2-$n analysis of "or)force trend points out that generally there is an impending shortage of healthsector employees inanzaniaandmorecriticallyhighly5s)illedemployees "hopossessthere,uisite )no"ledge and a(ility to perform at high le&els* meaning that organizations failing toretain high performers "ill (e left "ith an understaffed* less s)illed "or)force that ultimatelyhinders their a(ility to remain competiti&e .Rappaport et al-* /0062- Despite the &ast literature onemployee turno&er* "hich is aimed at identifying factors that cause employees to ,uit .Griffeth etal-* /00;2 much less is )no"n a(out the factors that compel employees to stay- Bumley et al-*./0102notedrelati&elylessretentionresearchhasfocusedspecificallyon"hyanemployeedecides to remain "ith an organization-Retention is a critical element of an organization?s moregeneral approach to talent management* "hich is regarded as Hthe implementation of integratedstrategies or systems designedtoincrease "or)place producti&ity(yde&elopingimpro&edprocesses for attracting* de&eloping* retaining* and utilizing people "ith the re,uired s)ills andaptitude to meet current and future health sector o(+ecti&es .Boc)"ood* /0062- 7Replacinge>itingemployees iscostlytoorganizationsandsometimes destructi&etoser&icedeli&ery .Reiche* /00;2- It is therefore imperati&e for management to reduce to the minimum thefre,uency at "hich employees* particularly those that are crucial to its operations lea&e-$ccordingto Samuel./00;2 employee retention(ecame a&italissueandchallengetomanyorganizations particularly in the health sector- here are factors "hich promote the employees tostay or lea&e an organization- hey may (e internal factors* e>ternal factors or a com(ination of(oth- Human resource practices count a lot in this regard .Hassan et al* /0102- Despite the factthat many studies ha&e (een carried outI in the "orld to esta(lish factors leading to employeestaying or lea&ing the organizations* employee retention remain one of the greatest challengesthat thehealthsector isfacinginanzania- Ho"e&er* thereisnopu(lishedor documentede&idence "hich indicates that the same study "as done in esta(lishing factors leading to la(ourretention in anzania pu(lic and pri&ate health sector- herefore* this study aims at identifyingmain factors for the employee retention in anzania pu(lic and pri&ate health institutions-1.4 Objectives of the Studyhe o(+ecti&es of this study are di&ided into t"o main categories namely the general o(+ecti&eand specific o(+ecti&es as follo"s-1.4.1 General objectivehe general o(+ecti&e of this study is to identify the nature and causes of la(our retention amongpu(lic and pri&ate hospitals in anzania "ith a case study of eme)e and Hindumandal Hospitalin Dar es Salaam-81.4.2 Specific objectivesi- o identify the factors percei&ed (y employees? as influencing their stay in anorganization-ii- o identify different methods used (y the organizations in retaining their (est employees-iii- o e>amine the challenges facing anzania health sector in retaining its employees-1.5 Research Questionsi- What are the factors percei&ed(yemployees? as influencingtheir stayintheirorganizationJii- What are the methods used (y eme)e and Hindumandal Hospitals in retaining theiremployeesJiii- What are the main constraints facing eme)e and Hindumandal Hospitals in retainingtheir (est employeesJ1.6 Significance of the Studyhe studyis e>pectedtoma)e contri(utions tothe limitedliterature onissues relatedtoemployee?s retention in anzania?s =u(lic and =ri&ate Hospitals- Results from the study "ill also(enefit policy ma)ers* non5go&ernmental organizations* ci&il society organizations andcommunity (ased organizations in policy ma)ing process and ad&ocacy for the (enefits of allsta)eholders in heath sector- Moreo&er the research paper "ill (e used as a reference material toother academicians "ho "ill use the research document for further reference- Future researchersmay identify the gaps a&aila(le for further studies- Furthermore* the study is e>pected to pro&ide)no"ledgeontheinfluenceof moti&ationonemployees?performanceinanzania?shealthsector- he research findings are also e>pected to come "ith suggestions on "hat ought to (edone in enhancing retention in (oth pri&ate and pu(lic hospitals in anzania-91.7 Structure of the Research Paperhis "or) has (een organized as follo"sC he first chapter focused on the introduction* research(ac)ground* and statement of the pro(lem* general o(+ecti&es* specific o(+ecti&es* and research,uestions as "ell as significance of the study- Chapter t"o dealt "ith definition of )ey concepts*theoretical studies*empirical literatures* pro&idesgapsas"ell as suggest modelto guide thestudy-he third chapter forms the Methodology of the study- his chapter gi&es details of ho"theresearch"ill (e conductedG the toolsand theresearch designto(e used in thesamplingprocedure* data collection and procedures adopted- Chapter four ga&e details of the presentationof analysis andthediscussionof datacollected- Chapter fi&ealsodealt "iththesummary*conclusion* recommendation of "hat came out of the study as "ell as further areas for research 10CHAPTER TWOLITERATURE REVIEW2.1 Introductionhis chapter is mainly di&ided into three partsC First* it descri(es the main approaches in theliterature to understand retention- he theories of Herz(erg and Maslo" "ill (e presented as theyare useful for understanding the retention mechanisms to the staff- Second* it e>plains the push5pull frame"or)"hichisoftenusedtoanalyseretention- Critics fromtheliteratureonthisframe"or) "ill (e presented- hird* it descri(es "ays of assessing the retention pro(lem andgi&ee>amplesfromtheliteratureofstrategiestoretainstaff- helast section"ill present aconceptual model "hich "ill guide this study-2.2 Definition of key Terms and Concepts2.2.1 EmployeeBa(our Relations Code defines an employee as a person employed (y an employer* and includesadependent contractor*(utdoesnotincludeaperson"ho* inthe(oard?sopinion* performsfunctionsofamanager orsuperintendent orisemployedinconfidential capacityinmattersrelating to la(our relations of personnel .$l(right* /00:2- %BR$ ./0042 defined employee as anindi&idual "ho has entered into a contract of employmentG or has entered into any other contractunder "hich the indi&idual underta)es to "or) personally for the other party to the contract- 2.2.2 Employee retention%mployeeretentionmeans)eepingtherightpeopleontheright+o(sfore&eryorganization-%mployee retention is all a(out )eeping good people- It is much to do "ith our culture and ho"11"e treatpeople-? Retentionisa&oluntarymo&e (y anorganization tocreatean en&ironment"hich engages employees for long term .Chaminade* /0082- 2.3 Theoretical PerspectivesIn the literature* there are t"o main models to understanding retentionC %conomic and holisticmodels .Aoyleet al* 166;2- Fromaneconomicpoint of &ie"* thehealthla(our mar)et isdetermined (y money* and health "or)ers "ill (e attracted to* and retained (y* the employer "hooffers the (est deal* i-e- the (est remuneration .@urn et al* /00/2- he economic approach doesnot e>plain "hy many health "or)ers are retained in their +o( in the pu(lic health sector "hilethere are (etter paid +o(s a&aila(le to them else"here- his suggests that there are other factorsthan economics "hich influence the dynamics of the health "or)force .Aoyle et al* 166;2-he holistic &ie" is that the health "or)er?s decision on "here to "or) or "hether to "or) at all*is not only influenced (y economics* (ut also (y a range of other factors originating from thesocial* cultural and political conte>t an employee li&es in .Bumley et al-* /0102- Gender relationsare especially important here .Ro(inson et al* 166;2- $ recent study among female health "or)ers in =a)istan found that if their "or) "as organizedin a "ay "hich (etter ena(led them to com(ine "or)5related and domestic responsi(ilities* thenthey "ere more li)ely to stay in the +o( .Mumtaz et al* /0032-Studies "ith a holistic approachalsota)ethehealth"or)ers? commitment totheprofessionintoconsideration- Int"orecentstudies fromtheindustrialized"orld.Aall et al* /00/2 H&ocationKor the"ishtoHma)eadifferenceK "as found to (e reasons for mid"i&es to choose to go into the profession- $ healthfacility manager .Glo(al Health rust* /00:2 in South $frica e>pressed this asC12we have a service to deliver, we have people lookin up towards us !or help, hope and !or survival and "ou have to be co##itted, and "ou have to have responsibilities to be able to push !orward in this pro!ession$In conclusion* the holistic approach seems useful in understanding anzanian health "or)ers onreasons "hich attracts employee to stay in their career-2.3.1 The role of pay in a holistic approachhe holistic approach ac)no"ledges that pay has a role in retaining staff- he ,uestion is then to"hat e>tent pay determines the employee?s decision to stay or lea&e the +o(- Herz(erg?s t"o5factor theory and Maslo"?s hierarchy of needs are useful in ans"ering that ,uestion-Herz(erg?s t"o5factor theory .16772 is(asedonfindingsfromastudyon+o(satisfactioninthe'S$-What Herz(erg found is that there are t"o distinct sets of factors "hich impact onthe "ay people feel a(out their +o(C One set (eing the so5called Hdis5satisfiersK* and the other setnamed HsatisfiersK .$rmstrong* 166;2- he Hdis5satisfiersK are the factors "hich are related to theconte>t ofthe+o(li)e* salaryand"or)ingconditions-heHsatisfiersKarefactors"hicharelin)ed to the content of the +o( such as achie&ement* appreciationDrecognition*promotionDad&ancement etc- Inorder toma)etheemployee feel neutral a(out the+o(andperform at an a&erage le&el it is essential that the Hdis5satisfiersK are met-hat is to say that the(asicssuchassalary* "or)ingconditionsetc- arepercei&edasfair (ytheemployee- Iftheemployee percei&es her salary and "or)ing conditions as unfair .i-e- the Hdis5satisfiersK are notmet2 then it is not li)ely that appreciation and promotion .i-e- HsatisfiersK2 "ill ma)e her feelsatisfied* and she may e&entually resign .Milton* 16682- he )ey thing in Herz(erg?s theory inrelation to this study is that recognition* ad&ancement* and a sense of achie&ement cannot ma)eup for inade,uate salary and "or)ing conditions* e>cept may(e in the short term-13Maslo" .164:2 suggested that people ha&e fi&e types of need* arranged in a definite hierarchy ofimportance- $ccording to Maslo"?s model* there are three Flo"er5order? or Fdeficiency? needs.physiological needs* safety needs and social needs2 and t"o Fhigher5order? or Fgro"th? needs.ego or esteem needs and Fself5actualisation? needs2- =hysiological needs include food* "ater* air*shelter* clothing* and - - - se>- .In regard to the last* "e need to note here that Maslo"?s model"as a general theory of human (eha&iour (oth "ithin and (eyond the "or)placeL2 Safety needsco&er security* sta(ility and freedom from threat- Social needs include friend5 ship* affection andacceptance- %steemor egoneeds include self5respect andrespect fromothers* "hile self5actualisationistheneedtofulfil one?shumanpotential-hesefi&eneedsareorganizedinapyramidtoreflect that thereisahierarchyamongtheneedsC Oncealo"er needhas(eensatisfied*then the indi&idual can start focusing on a higher need- #ota(ly* the needs for self5fulfilment and esteem are rarely dominant if the indi&idual is pre5 occupied stri&ing to fulfil the(asic physiological* safety and social needs .i(id2- Herz(erg?s t"o5factor theory .1677* 16;82 is in line "ith Maslo"?s needs hierarchy in the sensethat Herz(erg?s concept of Hdis5satisfiersK largely e,uals Maslo"?s (asic physiological*safetyand social needs- Bi)e"ise* Herz(erg?s HsatisfiersK are compara(le to Maslo"?s needs for esteemandself5fulfilment- hisre&ie"identifiedfe"studiesconductedinalo"incomesettingonretention of health staff- hose found* sho"ed that poor pay is a ma+or reason for resigning- Do&lo* ./00:2 states that %salar" levels are probabl" the #ost basic !actor in retention$ and he(ases this on case studies from countries such as Aots"ana and Ghana- In 'ganda* increasedsalaries for physicians ha&e impro&ed retention and e&en encouraged returning to the +o( .Da&lo*/00:2-In arecentlarge study on international nursemo(ility initiated (y the WHO*thegap(et"een pay le&els in the de&eloping and the industrialized countries "as found to (e the main14factorfornursestomigrate- Otherfactorssuchasopportunitiesforpost5(asiceducationandcareer "ere less important .Auchan* /00:2-Aased on the theories of Herz(erg and Maslo"* the i conclude that strategies to retain health"or)ers in the +o( "hich appeal to their higher needsD HsatisfiersK "hile failing to meet the (asicneedsDHdis5satisfiersK are not li)ely to ha&e a significant and sustaina(le impact on retention-2.3.2 The push-pull frameworkhe push5pull frame"or) is )no"n from a &ariety of conte>ts* ran)ing from customer sur&eys.Gerrein et al* /00:2 in the pri&ate sector to research in the nineteenth5century emigration from%urope to the $mericas .Gould* 16862- he frame"or) %McomparesI the origin and destination intermsoftheiro&erall com(inationofpushfactors.repulsions2andpull factors.attractions2K.Auchan* /00:2- In other "ords* the health "or)er is li)ely to lea&e the +o( if she percei&es thatthecom(inationofpushfactorsfromtheoriginandpull factorsfromthedestinationma)eslea&ing a fa&oura(le option .@urn et al* /00/2-Retention and migration studies typically mention the factors listed (elo" in no significant order*as push factors out of the health sector- $n unfair remuneration pac)age is a common push factor. Auchan*/00:G orrington* /00:2 he remuneration pac)age is defined as all monetary re"ardsthat the employee gets inreturnfor her contri(utiontotheorganisation* i-e- (asicsalary*allo"ances* pension etc- .Ganster et al* /00/2- It is the employee?s perception of "hether herremuneration pac)age is fair or unfair "hich is important in her decision to stay or to lea&e*rather than ho" the remuneration pac)age compares to a cost of li&ing inde> .I(id2-Delayed payment of the remuneration pac)age is another push factor .Nulia* /00;2- his can (efor se&eral months .i(id2 and is often a result of inefficiently administered payrolls .Aoyle et al*15/0002C%&entrali'ed #inor ad#inistrative procedures involve various overn#ent depart#entsand poor in!or#ation technolo" can #ake si#ple processes a !rustratin e(perience$ .i(id2Mostretentionstudieslistpoor"or)ingconditionsasapushfactor.!assongoet al* /0072-Herz(erg defines "or)ing conditions as %the ph"sical conditions o! work, the a#ount o! work orthe!acilitiesavailable!ordointhework$.Herz(erg* 16;82- SinceHerz(ergde&elopedhistheoryin1677* therehas(eenincreasinga"arenessof"or)relatedstress.orringtonetal*/00/2 pro&o)ed(y%stressorssuchashihworkloads, re)uire#ents !or workin!ast and#eetin strict deadlines, con!lictin de#ands and interruption. *roble#s are seen to arise whene(posure to such de#ands is chronic and elicits a stron enouh pattern o! responses to strainthe individual+s ph"sical and #ental resourcesK .Ganster et al* /00/2- Remotenessfromur(ancentersisacommonpro(leminmanycountriesincludinganzania.I(id2 and this is a push factor out of the pu(lic health sector .Gerein et al* /00:2- Remote* ruralpositionsin the pu(lic health sector are percei&ed as unattracti&e .$gyepong et al* /0042 andthey are thus a push factor- his is e&en more so for a female "or) forceC %Socio,cultural !actorso!ten preclude wo#en !ro# acceptin positions in rural, re#ote areas !or e(tended periods o!ti#e. -naddition, incountries that i#poserural co#pulsor"serviceas are)uire#ent !orraduation and pro!essional certi!ication, wo#en #a" not be able to raduate or e(ercise theirpro!essions$ .Dussault et al* /00:2-$nother pushfactor islac)of +o(satisfaction.Mumtaz et al* /00:2 Herz(ergfoundthatHsatisfiersK* suchasasenseofachie&ement andrecognition* should(emet inorderfortheemployee to feel satisfied "ith the +o( .!ogan* 166;2- $ pharmacist in South $frica has put is asC16%-! "ou are riht, there is silence . no reconition. -! "ou are wron . "ou hear !ro# ever"one$.Glo(al Health rust* /00:2-%>posure to HIOD$IDS in the "or) place is a push factor* especially from o(stetrics and surgery-his is against a (ac)drop of health systems stretching to cope "ith the com(ination of increasedcase load and increased attrition of staff* (oth largely due to the HIOD$IDS epidemic .!assongoet al* /0072-%-ncreasin levels o! illness, absenteeis# and death are to be e(pected a#on health workers in hih,prevalence countries, threatenin the abilit" o! health s"ste#s to provide care. /-0 trans#ission throuh needle,stick in1uries within thehospital is a s#all, but real, risk, and a sini!icant worr" !or #an" sta!!. Li#ited data suest that sta!! recruit#ent is bein adversel" a!!ected and that sel!,deplo"#ent awa" !ro# perceived risk" activities such as obstetrics and surer" is alread" takin place$ (-bid).2.3.3 The Pull factors=ull factors "ere defined slightly differently in different studiesG in some research* pull factors"ere factors "hich attract the health "or)er to the destination .@urn et al* /00/2- In other studies*the factors "hich pull the health "or)er to stay in their place of origin "ere considered as pullfactors .Aall et al* /00/2- helatter definitionis usedinthis re&ie"andalsoconsistentlythroughoutthis researchpaper-Inother "ords*pull factorsare herefactors "hichattractthehealth "or)er to stay in the pu(lic or pri&ate hospital-hesefactorsincludeG attracti&eretirement pac)age* i-e- endofser&icepaymentsof&arious)inds is a pull factor- his is illustrated in the cases of #ami(ia and Besotho- he t"o countriesremunerate health "or)ers similarly e>cept in terms of the retirement pac)agesC #ami(ia offers amore attracti&e retirement pac)age and also has (etter retention of staff .Do&lo* /00:2-Ho"e&er* studies suggest that generous retirement pac)ages are not enough to ma)e young and17middle5aged staff stay in a +o( that they are other"ise dissatisfied "ith- he retirement pac)ageis mainly a pull factor for the older employees .=ortes and Aoyle* 166;2-$ study among =a)istani female health "or)ers found that H!le(ibilit" in ti#e use, particularl" inrelationtothetakino! leave!or!a#il"co##it#ents ande#erenciescouldreducethedropout rate$ .WHO* /00:2.In a study among Aritish mid"i&es* it "as found that%#idwiveswho le!t health workerr"becauseo!their2!a#il"co##it#ents+are#orelikel"toconsiderreturninthan #idwives who le!t !or other reasons$.Aall et al* /00/2- In a recent study among pu(lic health "or)ers in the '! it "as found that +o( security attractedpeople to the sector .Dussault et al* /00:2- Ha&ing an $ccess to post5(asic training is another pull factor .Do&lo et al* /00/2- here might(e more reasons for this- First* training and professional de&elopment is a "ay of meeting theneed for esteem and self5 fulfilments as descri(ed (y Maslo" .!agan* 166;2 hus an employee"ho can de&elop and apply her potential and s)ills is more li)ely to stay in the +o(- Second*Htrainin, especiall" overseas trainin, is a hihl" priced opportunit" to increase one+s #arketvalue to co#ple#entar" e#plo"ers and to #irate to cities or even internationall"$ .Ber(ergheet al* /00;2- 2.4 Empirical Literature ReviewGlen ./0072 e>amined effecti&e* practical and holistic people strategies that addressed )ey s)illsretention* employee engagement* and employee moti&ation and attendance gaps* "ith a &ie" topositi&elyimpactingonorganizationcosts* producti&ityand(usiness performance- Healsothought to e>amine the &alue of assessment and feed(ac) in talent engagement and retention* andloo)ed at de&eloping employees &ia e>perience5(ased de&elopment initiati&es- he study18assessedthematri>of theFFhot (uttons??or FFpredictors??* "hichneededto(econsciouslymanaged "ith significant potential returns* "here managed "ell- It e>amined a holistic matri> ofnine employee engagement predictorsC processG role challengeG &aluesG "or)5life (alanceGinformationG sta)eDle&erageD re"ardDrecognitionG managementG "or) en&ironmentG and product-Reference "as made to a case study in "hich this matri> formed the (asis of the organization?speople management strategy- he study re&ealed that* a holistic &ie" of the )ey elements of the(usinessmost "ereli)elytoimpact teamengagement* moti&ation* attendanceandretention*lin)ing indi&idual assessment directly to the )ey dri&ers of the (usiness* and recognized that )eytalent "as li)ely to thri&e on e>perience5(ased career le&erage opportunities-aylor et al ./0042 in&estigated the reasons for employees lea&ing or staying- hey said that o&er1/*000academicandpractitioner studiesha&e(eenperformedrelating+o(satisfaction"ith&oluntary turno&er- Ho"e&er* researchers had (een frustrated in e>plaining more than /0 percentofthe&arianceinturno&er- heirstudypresentedthenotionthat traditional measuresof+o(satisfactionmight not fullycapturethereasonforstayingor ,uitting-$ ne"construct "aspresented that e>amined the congruence of fit (et"een the +o( and the personPs ,uality of lifegoals- heyuseda=BSstructural e,uationmodel onasampleof1:3informationsystems"or)ers-his construct "as empirically sho"n to (e a (etter predictor of &arious measures ofturno&er decision .that is thoughts of ,uitting* e>pectation of ,uitting* and intention to ,uit2 "ithan a&erage e>plained &ariance of 0-30-hereareanum(er ofgapsleft (ydifferent re&ie"edliteraturerangingfromgeographical*methodologies usedto time as "ell as the nature of organization studied- 19Hassanet al./0102 conductedastudyonemployee retentionas the&ital challengeinallorganizations- heir studyfocusedononeindustrythat "astheleather industryof=a)istan"hich "as facing the same pro(lem of retention of employees due to many reasons- Despite theirstudy rele&ance* the studies "ere conducted in =a)istan "here geographical attri(utes* politicalinclination and socio5 cultural &alues differ from anzania- Hong and !aur ./00;2 researched on a relationship (et"een organizational climate* employeepersonalityandintentiontolea&e- heir studyaimedtoe>amine the relationship(et"eenorganizational climate* employee personality and their intention to lea&e an organization in theMalaysian conte>t- hese researchers left a gap of geographical location of study as "ell astime- #goz"ana and Rugim(ana ./0102 assessed the talent retention strategies (y using a case oflarge South $frican companies .C$C2- South $frican companies operate in an ad&anced "or)ingen&ironment compared to those found in anzania- herefore their findings cannot (egeneralized to the anzania en&ironment- Despite the fact that* many studies "ere conducted toe>plore factors for the retention in "or) organizations* most of them "ere carried out in othercountries particularly those found in $sia- Fe" studies "ere carried out to in&estigate the factorsfor retention in $frican organizations including those in anzania- his study aims to fill gap left(y the pre&ious researches specifically the in&estigating the factors influencing employeeretention in anzania health sector organizations-2.5 Research Model/Conceptual Frameworkhestudy"ill (eguided(ytheresearcher?sconceptual model .Seefigure/-12asdesigned(ecause it too) into account many factors for the employees? retention including those related toorganization itself* employees as "ell as critical psychological states of the employees in "or)20organizations- Organizational factorsDstrategiesDconditions includeamongother issuesC 5 hele&els andcompetiti&enessoftheremunerationschemes- heassumptionisthat* thehealthsectororganizations"hichha&eanattracti&eremunerationpac)ageareli)elytoretaintheiremployees "hile those "ith "ea) remuneration pac)age are li)ely to lose their employees- he model "ill assume that* the organizations "hich ha&e opportunities for personalde&elopment andad&ancement ha&ealsoanad&antageinretainingitsemployees- Bi)e"ise*organizations "hich pro&ide opportunities for personal de&elopment and ad&ancement are li)elyto retain their (est employees- Similarly* organizations "hich ha&e supporti&e "or)ingen&ironment as"ellasorganizational +usticeandprestigeha&ea(ilityofretainingtheir(estemployees- On other hand* employees? retention can (e determined (y the psychological states ofthe employees-Figure 2.1: Conceptual Framework for the study (SourceC De&eloped (y the researcher* /01:221CHAPTER THREERESEARCH DESIGN AND METHODOLOGY3.1 Introductionhis chapter discusses the method used in collection of data- It specifically ta)es a critical loo) atthe research design* population* sample and sampling procedure* research instrument* and Datacollection procedure and data analysis plan- 3.2 Research Designheresearcher "ill usemi>edmethodologyinthisstudy- Mi>edmethodisaphilosophicalassumption that integrates ,ualitati&e and ,uantitati&e research approaches "ithin a su(+ect- hisstudy "ill use e>ploration and descripti&e design- Fraen)el and Wallen ./0002 pronounces that inusing descripti&e research "hich is a sur&ey research* o(taining ans"ers to a set of carefullydesignedandadministered,uestionstoalargegroupofpeopleliesat theheart ofasur&eyresearch- he researcher "ill use a descripti&e sur&ey method for the collection and analysis ofthe information in order to ans"er the ,uestions "hich "ill (e posed- 3.3 Population of study he target population of the study consists of all +unior and senior staff employees .present andpast that /01/2 personnel of eme)e Hospital and HinduMandal hospital- he t"o hospitals "ill(echosenforthisstudy(ecausetheresearcher needstoma)eacomparisonstudy(et"eenpri&ate and Go&ernment o"ned hospitals- 22heaccessi(lepopulation"ill (eall seniorstaffemployeeand+uniorpersonnel ineme)eHospital and Hindumandal hospital "ho "ill (e "illing to participate in the study- Managementand senior staff employees "ill (e selected (ecause they ser&e as )ey informants "ho could (e oftremendous help in pro&iding &ery &ital information and other preference materials necessary forthe study-3.4 Sample and Sampling Procedure he ma+or aim of this step is to determine the specific population that "ill (e sur&eyed* to decideon an appropriate sample* and to determine the criteria that "ill (e used to select the sample.Marczy)*et al*/0032- $ sample of 73 employees "ill(e usedforthestudycomprising :0senior and :3 +unior staff respecti&ely from the each hospital- $ purposi&e sampling techni,ue"ill (e used to include all employees (ecause of the nature of the research pro(lem "hich calledfor the non5re+ection of any of the respondents (ecause they are pri&y to the information that theresearcher is see)ing- he 73 respondents "ill (e selected through stratified random sampling-"ostrataofpresentandpastemployees"ill(ecar&ed- Fromeachstratumaproportionatenum(er of employees "ill (e dra"n to ma)e the total sample- Stratified random sampling "ill (eused(ecauseeach ofthepresentand past groupof employeesfrom/00/ to/01/* of"hichemployees "ill need to (e dra"n and studied to help achie&e the o(+ecti&es of the study-3.5 Research Instruments Data "ill (e collected from the management and employees of (oth hospitals- he instrumentsthat "ill (e used (y the researcher are inter&ie"and a ,uestionnaire- he researcher therefore"ill de&elopandusea ,uestionnaire tosur&eythe &ie"s of the respondents- he use of23,uestionnaire "ill ena(le employees to (e free "hile filling in the re,uired information* and "illena(le reaching a large num(er of respondents "ithin a shorter period of time- 3.6 Data Collection Procedure data typeshe researcher "ill personally administer the ,uestionnaires to the respondents- $n introductoryletter "ill (e ta)en from the 'ni&ersity of Dar es Salaam to the management of eme)e andHindumandal Hospitals to officially see)ing permission for the employees to participate in thestudy- $fter permission had (een granted the researcher "ill (rief the employees as to "hat thestudy is a(out in order to get the needed attention*support and co5operation of the staff- he,uestionnaires "ill (e hand5deli&ered to all the respondents (y the researcher- he researcherthen "ill guide the respondents to complete the instrument "ithout inferring "ith the choice ofresponses- he assistance may in&ol&e the e>planation of instructions or terminologies.Includingsometranslation2 soas toget themost &aliddatafor inclusionintheanalysis-Respondents "ill (e gi&en three "ee)s to complete the instrument- o ensure an effecti&e returnrate* follo"uptelephone calls as "ell as personal &isits "ill (e made toencourage therespondents to complete the ,uestionnaires- Secondary data for this study "ill (e collected from(oo)s* +ournals* reports and ne"spapers* (oth pu(lished and unpu(lished* as "ell as from onlinesources- Secondary data "ill (e used to support and complement the primary data in the studyfindings- 3.7 Data Analysis he data collected "ill (e edited and eliminate any incomplete ,uestionnaire- he &alid,uestionnaires"ill (ecodedtoreflect theircorrespondingcategoriesinaccordance"iththefollo"ing scoring )eyCStrongly agree51* $gree5/* Disagree5:* strongly disagree 54* #eutral53-24$fter"ard the scored ,uestionnaires "ill (e analysed usingStatistical =ac)age for SocialSciences .S=SS2 into the desired descripti&e statistics- Since a descripti&e sample sur&ey "ill (eused in gathering data* it "ill (e prudent for the researcher to use the same descripti&e method inanalysing the data that "ill (e o(tained- Descripti&e sur&eys do not typically re,uire comple>statistical analysis- Ho"e&er* descripti&e statistics .mean*standard de&iations* fre,uencies andpercentages2 "ill (e used in analysing the data that "ill (e gathered- 3.8 Unit of Analysishe unit of analysis is the ma+or entity that is (eing analysed in the study- It is the P"hatPorP"homP that is (eing studied- Insocial science research* typical units of analysis includeindi&iduals .most common2* groups* social organizations and social artefacts- 'nder this studytheunit of analysis "ill (eindi&iduals "hofilled,uestionnaires* andthosein&ol&edinaninter&ie" as "ell as those "ho "ill (e )ey informants-3.7 Reliability and Validity of studyData ,ualities "ill (e e>plored through &alidity and relia(ility of the information to (e collectedfrom the field-3.7.1 Reliability his study "ill adopt the construct &alidity to &alidate data and Cron(ach $lpha .Q2 scale tomeasure internal relia(ility- Miller et al ./00/2 confirmed that Cron(ach?s alpha .Q2 should (e atleast 0-80 or higher to retain &aria(les in ade,uate scale- he relia(ility test "ill (e performedusing S=SS and the results "ill gi&e an alpha .Q2 &alue "hich "ill determine the relia(ility of thedata- .If QR0-8* data not relia(le* if QSDT0-8* data is relia(le2-253.7.2 ValidityChurchill ./0082 defined &alidity as the e>tent to "hich the instrument accurately measures "hat"as intended and supposed to measure- he ,uestionnaires for this research "ill (e pilot5 testedto /0 employees including management and non5management cadres of eme)e Hospitalthroughinter&ie"andresults"ill (eusedtomodifythe,uestionnairessoasto(ea(letocapture the re,uired information. 26TIME SCHEDULE OF THIS PROPOSED STUDYMO#H #o&em(er Decem(er Nanuary Fe(ruary MarchW%%! 1 / : 4 1 / : 4 1 / : 4 1 / : 4 1 / : 4=roposal "riting andSu(mission=roposal Correction and finaldraft su(missionResources mo(ilizationData collection and compilationData analysis and Report"ritingFirst draft su(missionCorrection and Final draftsu(missionPROPOSED BUDGET FOR THIS STUDYSD#o I%M $MO'# .sh21 =roposal preparation Stationary 10*000 Internet ser&ices /0*000 yping and =rinting /0*000 Spiral (inding 8*000/ Field costs ra&el e>penses30*000 Daily allo"ance .,uestionnaires "or)2100*000: Data analysis* reporting 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Business 8anae#ent Ool-3 .32*pp- 13/4513/8-#goz"ana* ! and Rugim(ana* R ./0102- $ssessment of talent retention strategiesC he case of alarge South $frican company .CS$2* $frican Nournal of Ausiness Management Ool-3 .32*pp- 13/4513/8-Onzu(o* S ./0112- he Configuration of %mployee Retention =ractices in MultinationalCorporations? Foreign Su(sidiaries* -nternational Business ;eview-=op* CandAar)huizen* #./0102heRelationship(et"eenS)illsrainingandRetentionofGraduate Interns in a South $frica Information* Communication and echnologyCompany*BiteracyInformationandComputer%ducationNournal.BIC%N2*Oolume1*Issue /-31=ortes* S-N- and O-D- Aoyle .166;2- Fhe costs and (enefits of o"nershipC a theory of &ertical-=ritchard* $-M ./0062- Retaining I %mployees (y Reframing Organizational CultureC Factors toConsider Aeyond Financial Incenti&esRappaport* $G Aancroft* %and O)um* B./00:2 he aging "or)force raises ne"talentmanagement issues for employers* 4ournal o! orani'ational 3(cellence*Ool-/:* issue /*pp- 33577- Reiche* A- H- ./00;2- he %arliest He(re" Citation Inde>es* 4ournal o! the 7#erican Societ" !or-n!or#ation Science 4;* :1;5:0Riley* A-!./0032 %mployee RetentionC $n%mpirical Studyof Direct Care %mployees at$CHI%O%S* 'npu(lished Dissertation of Master Degree in =u(lic $dministration*Ainghamton 'ni&ersity-Ro(inson* H-N-* Maertz* C-=- andCampion* M-$- .166;2 /3Eears of Ooluntaryurno&erResearchC $ Re&ie" and Criti,ue- In Cooper* C-B- and Ro(ertson* I-- .eds2 InternationalRe&ie" of Industrial and Organizational =sychology* Ool- 1:- #e" Eor)C Wiley* pp- 4653;-Samuel* O-M./00;2 %mployee retention andturno&erC 'sing moti&ational &aria(les as apanacea* 7!rican 4ournal o! Business 8anae#ent Ool-: .;2* pp- 4105413-Samuel* O-M./00;2 %mployee retention andturno&erC 'sing moti&ational &aria(les as apanacea* $frican Nournal of Ausiness Management Ool-: .;2* pp- 4105413-Saunders* M-* Be"is* =- and hornhill* $ ./0082- Research methods for (usiness students-4th ed-BondonC =rentice Hall-Saunders* M-* Be"is* =- and hornhill* $ ./0082- Research methods for (usiness students- 4th ed-BondonC =rentice Hall-Schrec)er * $-M and Ba(onte* D-S ./01/2- Retaining I %mployees (y Reframing OrganizationalCultureC Factors to Consider Aeyond Financial Incenti&esSimon* H-$- .16872- $dministrati&e Aeha&iorC $Study of Decision5ma)ing =rocesses in$dministrati&e Organization* :rd ed-* Free =ress* #e" Eor)-aylor S-DandChinW-W./0042- 'nderstandingis Wor)er urno&er DecisionsC Is It No(Satisfactionor No( Fit "ith Uuality Of Bife GoalsJ7cade#" o! -n!or#ation and8anae#ent Sciences 4ournal* Oolume 8* #um(er /* /00432aylor S-DandChinW-W./0042- 'nderstandingis Wor)er urno&er DecisionsC Is It No(Satisfactionor No( Fit "ith Uuality Of Bife GoalsJ $cademy of Information andManagement Sciences Nournal* Oolume 8* #um(er /* /004erenceRMitchellG Aroo)sC- HoltomandhomasW-Bee./0012- Ho"to)eepyour(estemployeesC De&eloping an effecti&e retention policy* $cademy of Management%>ecuti&e* /001* Ool- 13* #o-4he Glo(al Health trust* he Millennium De&elopment Goals Report /008* #e" Eor) /00:-orrington* W- M ./00:2- he research methods )no"ledge (ase ./nd %d-2- Retrie&ed Octo(er/0* /007* from """-socialresearchmethods-netD)(Oanden(ergR-N- and#elsonN-A.16662- Disaggregating the Moti&es 'nderlying urno&erIntentionsC WhenDoIntentions =redict urno&er Aeha&iorJKHumanRelations* &ol-3/.102* pp-1:1:51::7-Wang R-N- and Ra)ner N-A ./0032- Disaggregating the Moti&es 'nderlying urno&er IntentionsCWhen Do Intentions =redict urno&er Aeha&iorJK/u#an ;elations* &ol- 3/.102*pp-1:1:51::7-Westlund G-S and Hannon C- N ./00;2 Retaining alentC $ssessing No( Satisfaction FacetsMostSignificantly Related o Soft"are De&eloperurno&er Intentions* Nournal of Informationechnology Management* Oolume ZIZ* #um(er 4*Whitt* W ./0032- he Impact of Increased %mployee Retention upon =erformance in a CustomerContact Center* Colum(ia 'ni&ersity* #e" Eor)* #E 100/8Whitt* W ./0032- he Impact of Increased %mployee Retention upon =erformance in a CustomerContact Center* Colum(ia 'ni&ersity* #e" Eor)* #E 100/8WHOheHealthSectorHumanResourceCrisisreport for $fricaC$nissuepaper-DaresSalaam* anzania- /011WHO* a)ing Stoc)C Health "or)er shortages and the response to $IDS- HIOJ$IDS=rogramme* World Health Organization* /010-Eum)ella* A-! ./0062 %mployee RetentionC $n %mpirical Study of Direct Care %mployees at$CHI%O%S* 'npu(lished Dissertation of Master Degree in =u(lic $dministration*Ainghamton 'ni&ersity-33@urn !-A-* Westlund G-S and Hannon C- N ./00/2 Retaining alentC $ssessing No( SatisfactionFacetsMost Significantly Related o Soft"are De&eloperurno&er Intentions* 4ournal o!-n!or#ation 9echnolo" 8anae#ent* Oolume ZIZ* #um(er 4*