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Copyright UCT
Human Resource Management Practices in the South African
Public Health Sector: Assessing their impact on the Retention of
South African Doctors at an Eastern Cape Hospital Complex
A Research Report
presented to
The Graduate School of Business
University of Cape Town
In partial fulfilment
of the requirements for the
Masters of Business Administration Degree
by
Dr Bruce Longmore
December 2012
Supervised by: Dr Linda Ronnie
Copyright UCT
Human Resource Management Practices in the South African Public Health Sector:
Assessing their impact on the Retention of South African Doctors
University of Cape Town Masters of Business Administration Research Report
Contents
Plagiarism Declaration .................................................................................................... 5
Acknowledgements ........................................................................................................ 6
1. Introduction ................................................................................................................ 71.1 Research Question ........................................................................................................................ 71.2 Background ................................................................................................................................... 71.3 Research Purpose .......................................................................................................................... 91.4 Research Significance ................................................................................................................... 91.5 Topic Limitations ........................................................................................................................ 10
2. Literature Review ..................................................................................................... 112.1 Exploring factors contributing to the retention of medical doctors ............................................ 11
2.1.1 Financial Incentives ............................................................................................................ 142.1.2 Career Development ............................................................................................................ 142.1.3 Hospital or Clinic Management .......................................................................................... 152.1.4 Educational Opportunities .................................................................................................. 152.1.5 Hospital Infrastructure and Resource Availability ............................................................. 152.1.6 Recognition and Appreciation ............................................................................................. 16
2.2 Factors affecting the retention of knowledge workers ................................................................ 162.2.1 Retention of Knowledge workers ......................................................................................... 17
2.2.2 Merging the Concepts .............................................................................................................. 182.3 Understanding the role of human resource management practices in the retention of medical doctors............................................................................................................................................... 192.4 Conclusion .................................................................................................................................. 20
3. Research Methodology ............................................................................................. 213.1 Research Approach and Strategy ................................................................................................ 21
3.1.1 Justification of Research Approach ..................................................................................... 213.2 Research Design ......................................................................................................................... 21
3.2.1 Research Questions ............................................................................................................. 223.2.2 Limitations of the Study Design ........................................................................................... 22
3.3 Sampling Details ......................................................................................................................... 233.3.1 Response Rate ...................................................................................................................... 23
3.4 Data Collection ........................................................................................................................... 243.4.1 Data Collection Strategy ..................................................................................................... 243.4.2 Pilot Study ........................................................................................................................... 243.5 Data Gathering Sequence ....................................................................................................... 25
3.6 Data Analysis .............................................................................................................................. 253.7 Research Validity ........................................................................................................................ 26
3.7.1 Triangulation ....................................................................................................................... 263.7.2 Thick Description ................................................................................................................ 26
8.8 Ethical Considerations ................................................................................................................ 273.9 Researcher Bias .......................................................................................................................... 27
4. Findings and Analysis ................................................................................................ 284.1 Introduction ................................................................................................................................. 284.2 Head of Department (HOD) Interview Results .......................................................................... 29
4.2.1 Interview 1 ........................................................................................................................... 294.2.2 Interview 2 ........................................................................................................................... 294.2.3 Interview 3 ........................................................................................................................... 304.2.4 Interview 4 ........................................................................................................................... 30
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Human Resource Management Practices in the South African Public Health Sector:
Assessing their impact on the Retention of South African Doctors
University of Cape Town Masters of Business Administration Research Report 3
4.3 Survey Findings: Demographic Characteristics of Respondents ................................................ 314.4 Survey Findings Theme 1: Human Resource Practices .............................................................. 32
4.4.1 Salary ................................................................................................................................... 324.4.2 Document Filing and Storage System ................................................................................. 344.4.3 Communication ................................................................................................................... 364.4.4 Value and Respect ............................................................................................................... 374.4.5 Re-imbursement for Courses and Conferences ................................................................... 39
4.5 Survey Findings Theme 2: Human Resource Characteristics ..................................................... 404.5.1 Task Competence ................................................................................................................. 414.5.2 Accountability ...................................................................................................................... 434.5.3 General Process Efficiency ................................................................................................. 454.5.4 Salary Adjustment Efficiency ............................................................................................... 464.5.5 Availability .......................................................................................................................... 47
4.6 Conclusion .................................................................................................................................. 48
5. Discussion ................................................................................................................. 495.1 Introduction ................................................................................................................................. 495.2 Demographic Characteristics of Respondents ............................................................................ 495.3 Human Resource Practices ......................................................................................................... 51
5.3.1 Salary ................................................................................................................................... 515.3.2 Document Filing and Storage System ...................................................................................... 525.3.3 Communication ........................................................................................................................ 535.3.4 Value and Respect .................................................................................................................... 545.3.5 Re-imbursement for Courses and Conferences ........................................................................ 555.4 Ranking Human Resource Characteristics .................................................................................. 56
5.4.1 Task Competence ................................................................................................................. 565.4.2 Accountability ...................................................................................................................... 575.4.3 General Process Efficiency ................................................................................................. 585.4.4 Salary Adjustment Efficiency (PMDS and OSD) ................................................................. 585.4.5 Availability .......................................................................................................................... 59
5.5 Conclusion .................................................................................................................................. 60
6. Conclusion ................................................................................................................ 616.1 Important HRM Practices that Influence Doctor Retention at the ELHC .................................. 626.2 Measuring the Performance of the ELHC HRM Practices ......................................................... 636.3 The Most Important HR Practices .............................................................................................. 636.4 Rating of the ELHC HR Practice Performance .......................................................................... 646.5 The Most Important HR Characteristics ..................................................................................... 646.6 Rating the ELHC HR Characteristic Exhibition ......................................................................... 656.7 HRM at the ELHC and its Impact on the Retention of Doctors ................................................. 666.8 HRM in the Public Health Sector and its Impact on the Retention of Doctors .......................... 676.9 Limitations of the Study ............................................................................................................. 676.10 Future research .......................................................................................................................... 68
7. References ................................................................................................................ 69
8. Appendices ............................................................................................................... 73Appendix 1: Authorisation from The Chief Executive Officer at the ELHC ................................... 73Appendix 2: UCT Ethical Clearance Form ....................................................................................... 74Appendix 3: Head of Department Questionnaire .............................................................................. 75Appendix 4: Survey Page 1 .............................................................................................................. 76Appendix 5: Survey Page 2 .............................................................................................................. 77Appendix 5: Survey Page 3 .............................................................................................................. 78Appendix 6: Daily Dispatch Newspaper Article .............................................................................. 79
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Assessing their impact on the Retention of South African Doctors
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List of Figures Figure 1: Number of Medical Practitioners per 10000 population in each sector, by
province, 2010.............................................................................................................. 10Figure 2: Occurrence of Theme in the 20 studies Reviewed ............................................... 14Figure 4: Performance Rating for Timeous Salary Payment ............................................... 33Figure 5: Performance Rating of Document Management .................................................. 34Figure 6: Performance Rating of HR communication Efforts ............................................. 37Figure 7: Performance Rating of HR Interaction Quality .................................................... 38Figure 8: Performance Rating of Continued Education Facilitation ................................... 39Figure 9: Rating of Task Competence of HR Staff .............................................................. 42Figure 10: Rating of HR Staff Accountability ..................................................................... 44Figure 11: Rating of General Process Efficiency of HR Staff ............................................. 45Figure 12: Rating of HR Staff Efficiency toward OSD and PMDS .................................... 46Figure 13: Rating of HR Availability .................................................................................. 47
List of Tables Table 1: Retention Gap for Health Professional Graduates 2002-2010 ................................ 8Table 2: Factors Influencing the Retention of Healthcare Workers .................................... 12Table 3: Factors affecting the Motivation and Retention of Healthcare Workers in
Developing Countries .................................................................................................. 13Table 4: Demographic Characteristics of Respondents ....................................................... 31Table 5: Importance Ranking of Human Resource Practices .............................................. 32Table 6: Importance Ranking of Human Resource Characteristics ..................................... 40Table 7: Doctors Willingness to Stay at the Complex ......................................................... 48
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Human Resource Management Practices in the South African Public Health Sector:
Assessing their impact on the Retention of South African Doctors
University of Cape Town Masters of Business Administration Research Report 5
Plagiarism Declaration
1. I know that plagiarism is wrong. Plagiarism is to use another’s work
and pretend that it is one’s own.
2. I have used the American Psychological Association 6 convention for
citation and referencing. Each contribution to, and quotation in, this
report from the work(s) of other people has been attributed, and has
been cited and referenced.
3. This report is my own work.
4. I have not allowed, and will not allow, anyone to copy my work with
the intention of passing it off as his or her own work.
5. I acknowledge that copying someone else’s assignment or essay, or part
of it, is wrong, and declare that this is my own work.
Signature ______________________________
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Human Resource Management Practices in the South African Public Health Sector:
Assessing their impact on the Retention of South African Doctors
University of Cape Town Masters of Business Administration Research Report 6
Acknowledgements
I would like to acknowledge the following people for their contributions to this research:
Dr. Linda Ronnie, supervisor, lecturer and friend, for her patient guidance and assistance in
every step of this research report. It has been both a pleasure and an honour to work with
her and an experience that I will not forget.
The ELHC Head of Departments for generously giving up time out of their busy days to be
interviewed.
Viyonne Longmore, my wife, my best friend and my biggest support, for her unconditional
love and encouragement throughout this project and over the past year. She is truly a
blessing from God for which I will be ever grateful.
A wife of noble character who can find?�
She is worth far more than rubies.
Her husband has full confidence in her
and lacks nothing of value.
She brings him good, not harm,�
all the days of her life.
Proverbs 31: 10-12 NIV Bible
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Human Resource Management Practices in the South African Public Health Sector:
Assessing their impact on the Retention of South African Doctors
University of Cape Town Masters of Business Administration Research Report
1. Introduction On the 30th May 2012, the Eastern Cape was described as having a healthcare crisis (Eager,
2012). “Non-payment of staff, drug stock-outs and shortages of basic medical supplies”
were labeled as manifestations of what was believed to be “widespread systemic failures in
the management and financing of services in the province” (Eager, 2012). At the heart of
this crisis, lay two key issues, namely poor management and severe staff shortages.
It may be apparent that sound Human Resource management of healthcare workers is
critical for the functioning of a healthcare system, but its importance is seemingly
overlooked. As in the case of the Eastern Cape’s hospital system, one of the most
concerning factors facing healthcare is the province’s struggle to effectively retain doctors.
Although this retention issue seems to be multi-faceted, of particular concern is the role
that human resource management seems to have. This can be seen in the “delayed or non-
payment of critical healthcare workers” that is being cited as the reason causing doctors
and other staff to abandon their public healthcare posts (Eager, 2012).
It is this distressing scenario that plays a substantial role in the formation of this thesis,
which focusses on an Eastern Cape Hospital Complex’s Human Resource management
practices and their impact on the retention of doctors.
1.1 Research Question The question that this research attempts to answer is: What Human Resource management
practices positively and negatively influence doctor retention capabilities at the East
London Hospital Complex?
1.2 Background There has been a significant migration of doctors away from South Africa (Grant, 2006).
One of the results of this is the retention gap, the difference between the number of
healthcare professionals qualifying and the growth of the public sector. As can be seen in
Figure 1 the South African retention gap for doctors between 2002 and 2010 is at a
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Human Resource Management Practices in the South African Public Health Sector:
Assessing their impact on the Retention of South African Doctors
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staggering 62.4% (HRH Strategy, 2011). Effectively this means that the state is managing
to retain less than 40% of doctors that it is producing.
Table 1: Retention Gap for Health Professional Graduates 2002-2010
2002 – 2010
Profession Graduate Output Public Sector
post increases
Retention Gap Retention
Gap %
MBChB 11700 4403 7297 62.4%
Dentistry 2140 248 1892 88.4%
Pharmacy 3645 1960 1685 46.2%
Physiotherapy 2934 497 2437 83.1%
OT 1827 410 1417 77.6%
SLP + Audiology 1413 265 1148 81.2%
Dietetics 657 502 155 23.6%
Source: Human Resources for Health South Africa. HRH Strategy for the Health Sector: 2012/13 –
2016/17. Version 1: Released 11th October 2011
These statistics require further exploration in order to understand their basis and the reason
for doctor migration. Mejia, Pizurki and Royston (1979) define migration as the interplay
of a variety of forces found on both ends of the migratory axis. The forces found in the
donor country are generally referred to as push factors and those on the opposite side of the
axis, in the receiving country, are known as pull factors (Mejia et al., 1979). Problems
relating to the retention of doctors are often naively explained as being a result of the
financial appeal of the private sector or the “green pasture” attraction of opportunities
beyond our borders. These are primarily pull factors but as Willis-Shatuck, Bidwell,
Thomas, Wyness, Blaauw, and Ditlopo, (2008) found in their systematic review of 20
studies pertaining to the retention of doctors in developing countries, financial incentives
on their own are insufficient to motivate healthcare workers. They concluded that financial
reward, career development and management concerns remain at the core of health worker
retention. It is the author’s contention that if the latter two practices are poorly executed,
they can become significant push factors driving away potential doctors.
Thus in summary, some doctors do leave the public sector in search of financial gain but
this is not always the case. Doctors are unquestionably drawn to the public sector for
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Human Resource Management Practices in the South African Public Health Sector:
Assessing their impact on the Retention of South African Doctors
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numerous reasons; however the institutional inertia surrounding advertising posts and
hiring new doctors, merged with the poor HR management of individuals, seems to be
successfully transforming this attraction into a significant push factor. Sadly the net result
of these migratory patterns is the perpetuation of South Africa’s proverbial and crippling
“brain drain”, something that Hagopian, Thompson, Fordyce, Johnson, and Hart, (2004)
recognised as particularly damaging to the health systems of the source countries due to the
appreciable effects on the doctor-to-population ratio.
1.3 Research Purpose
These staffing battles face not only the Eastern Cape but also South Africa as a whole and
it is therefore critical to understand which factors play a role in the retention strategies of
doctors and to what degree these are important. Without this knowledge and understanding,
significant amounts of effort could be channelled in the wrong direction and therefore
potentially create the situation where critical opportunities to retain doctors are missed.
Thus with this research, the intended purpose is to explore and quantify the impact that
various human resource management practices have on the retention of public sector
doctors.
1.4 Research Significance Although the present health minister has recognised that human resources is a problem
facing the health system and has included its improvement in the Health department’s 10-
Point Strategy plan, the concern is that insufficient effort is being channeled timeously (SA
DoH Strategy Plan, 2010). As recently as 31 May 2012 in a SABC article titled “E Cape
doctor shortage prompts Motsoaledi to intervene”, Health Minister, Aaron Motsoaledi was
quoted as saying that, “he will have to intervene to deal with the problem of the shortage of
doctors in the Eastern Cape” (SABC, 2012). This response was in particular reference to
“the reported non-payment of a number of doctors” and the article further went on to say
that “the incident was reported as if it was widespread, thus his ministry will have to
intervene and probe”. The Eastern Cape (EC) is in particular, one of the worst effected
areas and the magnitude of doctor shortages can be seen in figure 2. In 2010 the EC at 2.97
public doctors per 10 000 population was one of the lowest in the country (HRH Strategy,
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Assessing their impact on the Retention of South African Doctors
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2012). This shortage seems to have been worsening over the past two years as highlighted
in the province’s recent poor publicity.
Figure 1: Number of Medical Practitioners per 10000 population in each sector, by province, 2010.
Source: Human Resources for Health South Africa. HRH Strategy for the Health Sector: 2012/13 –
2016/17. Version 1: Released 20th January 2012
1.5 Topic Limitations The area of doctor retention in the South African context is a complex and multi-faceted
problem (Kotzee & Cooper, 2006; Padarath et al. 2003). To improve our understanding,
each of these facets requires comprehensive research and analysis. This thesis explores the
HRM practices with a view to adding to the body of knowledge and understanding of this
complex issue.
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Human Resource Management Practices in the South African Public Health Sector:
Assessing their impact on the Retention of South African Doctors
University of Cape Town Masters of Business Administration Research Report
2. Literature Review The review of the literature is presented in three sections. The first section aims to discover
what factors are important in the retention of doctors in developing countries. The second
section makes a claim for doctors as knowledge workers and considers retention factors in
the broader context. Lastly the literature surrounding the importance of the role of human
resource management in the public sector is reviewed.
2.1 Exploring factors contributing to the retention of medical doctors According to Padarath et al., (2003), there are a multitude of push and pull factors that
impact on the movement of healthcare workers. The notion of push and pull factors, when
referring to retention and motivation, was initially described by Mejia, Pizurki and Royston
in 1979. These authors explain that “pull factors” are primarily factors of attraction and
“push factors” are those that support the movement away from an institution or country
(Mejia, Pizurki & Royston, 1979). These factors are the forces behind worker migration
and in the healthcare industry these forces result in migratory patterns, including rural to
urban, public to private, and from poorer nations to wealthier ones (Padarath et al. 2003).
The push and pull factors at work here can be further categorised into those factors
occurring within the health system or endogenous factors, and those beyond the realms of
the health system or exogenous factors (Padarath et al. 2003).
In their review of more than fifty studies investigating healthcare worker (HCW) migration,
Padarath et al., (2003) encountered common dynamics that influenced these HCW
movements. Endogenous push factors include low remuneration levels, work associated
risks including diseases like HIV/AIDS and TB, inadequate human resource planning with
consequent unrealistic workloads, poor infrastructure and sub-optimal conditions of work
(Padarath et al., 2003). Exogenous push factors include political insecurity, taxation levels,
crime, repressive political environments and falling service standards. The pull factors
included aggressive recruitment by wealthier countries, improved quality of life, study and
specialisation opportunities and improved remuneration (Padarath et al., 2003).
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Assessing their impact on the Retention of South African Doctors
University of Cape Town Masters of Business Administration Research Report 12
Lastly the study stresses the importance of “stick” and “stay” factors. The “stick” factors
improve retention and include family ties, migration costs, psychological links with home,
language and other social and cultural influences. However the inertial nature of these
factors can manifest in the lives of the healthcare workers in the recipient countries. They
then become what Padarath et al (2003) refer to as ‘stay’ factors and these then affect the
decision to remain in recipient countries to avoid disruption to family life and schooling or
loss of a higher standard of living. A lack of employment opportunities in host countries,
also seem to play a role here (Padarath et al., 2003).
The table below summarises the factors that influence the retention of HCW.
Table 2: Factors Influencing the Retention of Healthcare Workers
Source: Padarath et al. (2003)
Push Pull Stick Stay
Endogenous Exogenous Opposite to Push factors
Low remuneration levels
Political insecurity Aggressive recruitment by wealthier countries
Family ties Not disrupt family life and schooling
Work associated risks - including diseases like HIV/AIDS and TB
Taxation levels Improved quality of life
Time-consuming and costly migration and “re-qualification” factors
Lose their higher standard of living
Lack of further education and career development opportunities
Quality of life and crime
Study and specialisation opportunities
Psychological links with home
Lack of employment opportunities in host country
Poor infrastructure and sub-optimal conditions of work
Repressive political environments
Improved remuneration
Language
Lack of job satisfaction
Falling service standards
Safer working environment
Other social and cultural influences
Poor human resource planning with consequent unrealistic work loads
Lack of education opportunities for children
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Assessing their impact on the Retention of South African Doctors
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Although serious, the exogenous factors are most often beyond the management capacity
of healthcare systems. Endogenous factors on the other hand are what need to be at the
centre of the developing country’s focus. The South African Government needs to reduce
the intensity of the push factors and in doing so improve the endogenous pull factors. The
focus of this study is primarily to understand not only what Human Resource practices will
assist in retaining doctors in the South Africa, but also more importantly what will keep
doctors in the public sector.
Willis-Shattuck et al. (2008) conducted a systematic review of articles exploring factors
that pertain to the motivation and retention of health care workers in developing countries.
This systematic review concentrated on endogenous factors and appears to support the
endogenous factors highlighted by Padarath et al. (2003). Table 3 identifies these factors.
Table 3: Factors affecting the Motivation and Retention of Healthcare Workers in Developing Countries
Retention Factor
Financial Incentives
Career Development
Hospital and Clinic Management
Availability of resources
Continuing Education
Recognition and appreciation
Hospital Infrastructure
Source: Willis-Shattuck et al. (2008) These seven factors occurred in varying frequency in the 20 studies reviewed by Willis-
Shattuck et al. (2008) and are reproduced in Figure 2 below.
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Human Resource Management Practices in the South African Public Health Sector:
Assessing their impact on the Retention of South African Doctors
University of Cape Town Masters of Business Administration Research Report 14
Figure 2: Occurrence of Theme in the 20 studies Reviewed
Source: Willis-Shattuck et al. (2008)
Each of these factors is explored in further depth in the paragraphs that follow.
2.1.1 Financial Incentives
Remuneration and financial incentives play an important role in the retention and
motivation of healthcare workers with 90% of studies highlighting its importance (Willis-
Shattuck et al., 2008). If this aspect of motivation and retention is ignored, it tends to
make HCWs feel undervalued and demotivated (King & McInerney, 2006). Emerging
from this importance is the common perception that financial incentive on its own is the
principal factor affecting the retention of doctors; however financial incentives were found
to be insufficient on their own to prevent health workers from migrating (Kotzee & Cooper,
2006; Mathauer & Imhoff, 2006).
2.1.2 Career Development Career development was identified as being important in 85% of studies. Kotzee and
Cooper (2006), in their study on rural doctors, found that health workers were reluctant to
work in these areas as career furthering opportunities were typically less than in urban
areas. The majority of literature indicates that HCWs thrive off the opportunity to progress
and this is most definitely the case in the South African setting where positions are linked
to remuneration scales (Reid, 2004; Kotzee & Couper, 2006; Manongi, Marchant &
Bygbjerg, 2006).
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2.1.3 Hospital or Clinic Management Willis-Shattuck et al. (2008) consistently found that management plays an extremely
important role in both the retention and motivation of HCWs. Kotzee and Couper (2006)
specifically found that non-medical management, who were not supportive and did not
treat doctors satisfactorily, frustrated doctors. Personnel departments were identified as a
specific problem area and doctors expressed anger toward promotion issues and
communication. In settings with scarce human resources, management positions were
given to poorly trained individuals who failed to adequately represent and lobby for their
staff. This factor influenced motivation levels directly and as a result staff retention
(Willis-Shattuck et al., 2008).
2.1.4 Educational Opportunities Linked directly to career development, continued education is vital to prevent HCW’s from
leaving healthcare facilities. Training and development enables HCW’s to assume greater
levels of responsibilities and to achieve personal goals and professional development
(Mathauer & Imhoff, 2006). Reid (2004) highlights that young health professionals feel
more confident in their roles and abilities when they received adequate postgraduate
practical training. This continued training is not only important for the individual but the
system as a whole and relies heavily on management to ensure it occurs regularly.
Integrating these educational and progressive efforts with the individual’s career growth is
vital to ensure that the individual’s development plans reflect their department or hospital's
future development needs (Kock & Burke, 2008).
2.1.5 Hospital Infrastructure and Resource Availability Improving working conditions, hospital infrastructure and medical equipment availability,
were among the top three most important interventions to retain doctors, with a lack of the
above facilities cited as a specific factor for doctors leaving (Kotzee & Couper, 2006).
Particular effort must be made to ensure that HCW’s are able to fulfil their roles and utilise
their skills and knowledge to the fullest and that this should be an integral part of any
retention plan (Willis-Shattuck et al., 2008). Poor infrastructure does not promote
confidence in the HCW’s ability nor does it instil confidence in the patients that they are
attempting to treat (Willis-Shattuck et al., 2008). Huddart, Picazo and Duale (2003), in
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Assessing their impact on the Retention of South African Doctors
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their study in Zimbabwe, confirmed the critical nature of this factor by showing that a
common cause for HCWs resigning from public posts was their inability to offer effective
care to patients due to austere conditions in the healthcare facilities.
2.1.6 Recognition and Appreciation The final factor determined as an important factor in the motivation and retention of
HCW’s was that of recognition and appreciation from management, colleagues or the
community (Willis-Shattuck et al., 2008). This aspect was noted in 70% of studies and was
mentioned as the most important factor in six of these. HCW’s want to make a difference,
be encouraged by results of their work and appreciated as being useful to and trusted by a
community. Addressing these issues assists significantly in retaining doctors in these often
challenging environments (Dieleman, Toonen, Toure & Martineau, 2006; Manongi,
Marchant & Bygbjerg, 2006).
As can be seen the factors influencing the retention of doctors is multifaceted and complex,
however in recent years, as industry and society have changed, a body of research has been
established that may assist to better understand this complexity. This research has been
around the management of so-called “knowledge” workers (KW’s), and its potential use is
born out of the similarity between KW’s and doctors. Coined by Drucker (1989), this term
“knowledge worker” was created to describe a part of the workforce who possesses
knowledge as a formidable resource, which they, rather than the organisation own. In the
next section the factors that influence the retention of KW’s are reviewed.
2.2 Factors affecting the retention of knowledge workers Davenport (2005, p. 10) defines KW’s as those individuals that “have high degrees of
expertise, education, or experience, and the primary purpose of their jobs involves the
creation, distribution or application of their knowledge”. This definition shows the
potential to incorporate HCW’s and particularly doctors within its scope. Further support
to this likeness comes in the form of Despres and Hiltrop’s (1995) description of
knowledge workers. This description includes the notion that KW’s have careers that are
developed externally as a result of many years of formal education as opposed to internal
organisational advancement. KW’s have a large degree of loyalty to their profession and
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Human Resource Management Practices in the South African Public Health Sector:
Assessing their impact on the Retention of South African Doctors
University of Cape Town Masters of Business Administration Research Report 17
play a critical role in the long term success of an organisation rather than the day-to-day
operational efficiency (Despres & Hiltrop,1995).
Thus, with this similarity between HCW’s and KW’s, the exploration of the literature
surrounding KW’s and the Human Resource management of these individuals may provide
key insights into the management of HCW’s.
2.2.1 Retention of Knowledge workers
De Villiers (2006) opines that the importance of employee commitment and loyalty has
become a significant focus of management today, as the “war for talent” is rife, due to
skilled employees have a greater choice of employment both locally and globally. South
Africa's Public Service is not exempt from this war, and in fact, the war for talent is
particularly fierce, due to a severe skills crisis (Kock & Burke, 2008).
With this increased competition for talent, organisations have to work hard to hold on to
skilled individuals. Horwitz, Heng and Quazi (2003) conducted a study seeking to
determine the best or most effective human resource practices for managing KW’s. Their
study clarified the distinctive role played by the human resource function in organisations
in the acquisition, motivation and retention of KW’s. The passive role in which HR
functioned in the past is exactly that, past. The residual effects of this way of thinking
however seems to remain at the heart of the South African public sector and its necessary
restructuring, has been acknowledged as critical for improving performance in the public
service (Kock & Burke, 2008).
Baron and Hannan (2002) in their suggestions on KW management, include three key
areas for the successful attraction and retention of KW’s. These are compensation, quality
of work and work group community. Horwitz et al. (2003) propose three similar albeit
slightly different areas: these being compensation, environment and opportunities. Figure 2
represents their suggested scheme for retention strategies.
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Human Resource Management Practices in the South African Public Health Sector:
Assessing their impact on the Retention of South African Doctors
University of Cape Town Masters of Business Administration Research Report 18
Source: Horwitz et al. (2003)
Each of these areas incorporates various factors, all of which play crucial roles for
successful retention. One factor that must not be overlooked is how acquisition, motivation
and retention combine to create an overarching HR strategy. The overlap between these
three areas is significant and the manner in which they influence each other is paramount.
This relationship and the successful execution of these factors in the workplace, needs to
be managed. The responsibility of this falls onto HR management and emphasises the
importance of the role this function plays.
2.2.2 Merging the Concepts A substantial degree of overlap exists between the literature surrounding knowledge
workers and healthcare workers. Financial compensation and career development (which
could possibly include continued education for the purposes of the discussion) are common
and prominent in both categories. However the remaining HCW factors that Willis-
Shattuck et al. (2008) identified, being hospital and clinic management, availability of
resources, recognition and appreciation and hospital infrastructure, differ considerably to
the environmental factors posited by Horwitz et al. (2003).
This variance can likely be attributed to the difference between private and public sector
institutions. The vast majority of studies concerning KW acquisition, motivation and
retention have been within the private sector where workers have the privilege of working
Top management, leadership and support
Conducive Environment Fun place to work Informality Flexible work
practices Funding further
studies
Opportunities Promotions
Compensation Transparent pay
decisions Lucrative share
options Performance
bonus
Figure 3: Proposed Scheme for Managing Knowledge Workers
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in a fully functioning and sufficiently stocked environment. This differs greatly to the
austere conditions that plague public institutions of developing countries, ones that are
compounded by the institutions inability to compete adequately in the remuneration aspect
of the retention strategies (Willis-Shattuck et al., 2008). However the researcher suggests
that creating a conducive environment does not always require great deals of capital input
and minor changes can often impact the working lives of many.
2.3 Understanding the role of human resource management practices in the retention of medical doctors The aforementioned literature has demonstrated the complexity of retention of skilled
professionals, a group of individuals that includes medical doctors. The management of
this complexity has fallen to the human resource function of institutions and new systems
and skills need to be developed to successfully employ and retain these individuals
(Horwitz et al., 2003). Although these systems and skills are needed within the changing
area of healthcare, there seems to be a distinct paucity of literature regarding the specific
link between human resource practices and the retention of medical doctors.
Studies have been conducted that explore the impact that HRM has on general hospital
outputs (Buchan, 2004; Hyde et al., 2006; Harris, Cortvriend & Hyde, 2007), but these lack
specificity toward retention especially with regard to doctor retention.
This may be a result of the lag that exists between the private and public sector systems,
born out of the private sector’s need to competitively fight to retain skilled employees
(Horwitz et al., 2003). Whatever the reason is, the importance to make an active effort to
address this deficiency in knowledge and practice, it is more necessary than ever before as
the medical vacancies in the South African public sector soar beyond 4000 (Breier &
Wildschut, 2007).
In the public health sector, Human Resource management practices persist as being
problematic, struggling to cope with current expectations, resulting in the afore mentioned
deficiencies (Kotzee & Couper, 2006). One of these expectations that is of particular
concern is the responsibility of human resource planning. Arnold (2005) contends that this
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planning is critical to successful employee retention, as employees becoming overworked
due to staff shortages or employees being laid off due to staff surpluses, both reduce
employee morale and may result in unnecessary resignations.
Sudair (2003) argues that investing in human resources, which is employing more HCW’s,
is a vital component of developing South Africa’s strategies to improve health outcomes.
He adds that if the human resource shortage is not addressed, it may constrain the ability to
achieve our desired health outcomes, something affecting all citizens of our country. This
statement raises the question of whether investing in employing more HCWs will resolve
the problem or just add to the systems already strained retention capabilities. This study
explores whether it may not be necessary to improve the management of existing
employees before this investment occurs.
2.4 Conclusion Despite the paucity of literature on healthcare specific human resource practices that effect
doctor retention, the literature review has revealed both the extensiveness and complexity
of HCW retention and the need for an improved understanding of the influences at play. In
addition, the literature has exposed the need for further exploratory research into the role
that Human Resource practices play in the retention of doctors and in particular their
relative importance.
Along with the findings from a series of interviews, the variety of factors highlighted by
the literature review will be an important component in the development of a research
questionnaire. It is the researcher’s intention that the findings of this research may add to
the body of literature pertaining to the retention of medical doctors in the public health
sector of South Africa.
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Human Resource Management Practices in the South African Public Health Sector:
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3. Research Methodology
3.1 Research Approach and Strategy The purpose of this research was to explore the impact that Human Resource management
practices have on the retention capacity of doctors in the public sector. In order to explore
this, a mixed methods approach, combining both qualitative and quantitative strategies,
was used on a sample from a public hospital in the Eastern Cape province of South Africa.
The nature of the study was exploratory and descriptive. This was done in order to gather
new insights and a better understanding of HR practices influencing retention of doctors,
and describe and quantify these factors’ impact on the hospital’s retention capacity.
The study incorporated both qualitative and quantitative elements, something that Bryman
and Bell (2007) confirm, “can be fruitfully combined within a single project” (p28). This
strategy gave rise to what is known as triangulation, which Denzin (as cited in Jick, 1979,
p602) defines as “the combination of methodologies in the study of the same phenomenon”.
3.1.1 Justification of Research Approach
The reason for choosing an explorative and descriptive strategy using an inductive mixed
methods approach was due to the paucity of literature surrounding human resource
practices and the retention of doctors. As a result this did not facilitate the confirmation of
theory but rather left a void for inductive research to seek new insight surrounding the
topic.
3.2 Research Design The research was conducted in two distinct phases: the first stage was carried out in order
to extract variables to be used in the questionnaire-based survey in the second phase of the
study. The first phase identified pertinent Human Resource practices affecting retention of
doctors through an exploration of the literature and the interviewing of four departmental
head doctors (HOD) in the hospital. These HODs are at the forefront of the challenge
regarding staff retention and thus it was identified that they would be able to provide
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invaluable information about various HR practices that are affecting the retention
capabilities of the hospital complex.
The second phase comprised of a survey of a representative sample of doctors working in
the hospital complex. The survey questions were formulated from the insight gained in the
interviews and attempted to confirm or negate as well as quantify the sentiment held
towards the various Human Resource practices being performed and their effects on
retention.
This approach assisted in the synthesis of an inductive and exploratory thesis of the
following research questions.
3.2.1 Research Questions
What are the most important Human Resource management practices that influence
doctor retention in the ELHC?
How well is the ELHC HRM performing these practices?
3.2.2 Limitations of the Study Design
Due to the focused nature of the research design employed, the results are unlikely to be
generalisable. Leedy and Ormrod (2005) note however, that if the context of the study is
clearly identified, it will assist readers to make conclusions as to whether or not the results
may be applicable to other situations.
Another limitation of the research design exists as a result of the limited time frame over
which the data collection occurred. The research therefore captured the opinions and
perceptions of individuals in a specific moment in time, one that may have been affected
by the respondents’ particular emotional state at the time of survey completion. This
concern was supported by Leedy and Ormrod (2005), who termed it a necessary hazard to
extrapolate conclusions drawn from one transitory collection of data.
The study was also somewhat limited in gaining a better understanding of the problem that
plagues the province and does not make an attempt to resolve it. This said, a better
understanding will optimistically assist to provide suggestions that might aid in resolving
the doctor retention issue facing hospitals in South Africa.
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3.3 Sampling Details The study was conducted in the context of the East London Hospital Complex (ELHC) in
the Eastern Cape province of South Africa. This hospital complex is within the South
African public sector and is currently experiencing staffing difficulties.
The HOD interviewees were chosen as follows: two from large core departments, one from
a medium sized department and one from a smaller specialised department. By doing this,
the researcher could ensure that differences in department size were accounted for during
the research process. The importance of this representation was due to the varying staffing
difficulty that the departments possessed due to the differing requirements for the number
of doctors needed. Smaller departments may also have different retention struggles, as the
doctors they seek to employ and retain tend to be more specialised and harder to source.
The survey sample population was drawn from the population of 300 professional doctors
working in the ELHC. This number could only be estimated, as the hospital complex could
not supply accurate numbers of currently employed doctors. The methodology of sampling
was entirely random, as a request was made electronically to all members of the population
to take the survey. The population was not subdivided along any characteristics and thus
demonstrated simple random sampling where each member of the population had an equal
probability of being included in the sample (Bryman & Bell, 2007). Leedy and Ormrod
(2005) advocate this use of random sampling in order to acquire a representative sample
that is crucial to draw inferences about an entire population.
3.3.1 Response Rate
Due to the nature of the study, it was anticipated that not all members of the sample
population would be willing to participate. Leedy and Ormrod (2005) suggest a 50%
response rate is considered acceptable given the challenges of online surveying.
The online survey ran for a period of two weeks. During this time numerous reminders
were emailed and SMSed to doctors urging them to complete the survey. At the end of the
two-week period, the survey yielded 93 responses but unfortunately 18 of these responses
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were incomplete and as a result had to be discarded. This left 75 responses, which equates
to a response rate of 25%.
Although this is lower than the desired 50%, the response rate was comparable to a similar
survey based study into job satisfaction of doctors by Pillay (2002), which achieved a final
response rate of 20%.
3.4 Data Collection
3.4.1 Data Collection Strategy
Data collection occurred in two phases. The first interview phase was performed remotely
and consisted of telephonic semi-structured interviews with four HODs. Prior to beginning
the interview, the interviewees were informed of complete confidentiality and received a
brief explanation of the research intention. Interviews were then recorded using a digital
voice recorder and subsequently transcribed for analysis. An interview schedule, consisting
of a series of open-ended questions, was compiled from particular trends and commonly
occurring issues distilled from the findings of the literature review (See Appendix 3).
The second phase comprised of a survey consisting of strategically formulated questions
(See Appendix 4). First and foremost the participant demographics were captured. These
included age, gender, duration at the complex and category of doctor. This was in an effort
to make deductions between age, position and employment duration, and the varying
opinions and perceptions. Further survey questions were constructed from the
interpretations of the interview questions and took the form of Likert Scale questions and
interspersed open-ended questions. According to Brace (2008), the Likert scale, when
measuring attitudinal dimensions, is one of the more commonly used questioning scales
and is easy to administer in self-completion questionnaires. The Likert Scale questions
attempted to quantify the responses while the open-ended ones provided further insight
into the personal construal of the respondents’ answers.
3.4.2 Pilot Study Prior to the distribution of the survey request, a pilot study with 7 doctors was conducted.
Bryman and Bell (2007) advocate the use of piloting, especially in self-completion
questionnaires, and report that its function is to ensure that the research instrument as a
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whole functions well. In this pilot, the researcher aimed to ensure that questions were clear
and understandable and that the survey was not too time-consuming. Four of the seven
doctors surveyed provided feedback regarding question clarity and survey structure. These
comments were utilised and the survey altered appropriately. All doctors did however
comment that the process was not too time-consuming and the open questions were
appropriate. Once the changes were made, all approximately 300 doctors were requested
via email and SMS to take the survey. The survey was completed entirely online and at the
will of the participant. There was thus no coercion to participate, which thus avoided any
degree of sample bias.
3.5 Data Gathering Sequence From To Activity 10 September 18 September Interviews conducted with all four Heads of
Departments 06 October 07 October Pilot Study using Survey 08 October 26 October Survey Conducted
3.6 Data Analysis
The interview transcripts were analysed, firstly to establish, and then compare the
stakeholder’s different perceptions of the problem. Through thematic coding of data, the
researcher clustered response themes into common HR practice groups (Leedy & Ormrod,
2005). The response themes then formed the basis on which the survey questions were
constructed.
Survey responses were reviewed individually and collectively. All demographics and Likert
scale responses were electronically entered into a database. This quantitative data was then
graphically exhibited in an attempt to demonstrate the frequency rates of responses. Open
question responses were read and analysed for common themes or for new perspectives.
Excerpts from the responses were categorised into the subthemes and used to support
quantitative findings.
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3.7 Research Validity According to Bryman and Bell (2007) “validity refers to the issue of whether or not an
indicator (or a set of indicators) that is devised to gauge a concept really measures that
concept” (Bryman & Bell, 2007, p159); in other words validity is primarily concerned with
the integrity of the conclusions that are generated from a piece of research. Traditionally
four types of validity are examined in the preparation and planning of research. These are
measurement validity, internal validity, external validity and ecological validity (Bryman
& Bell, 2007). Over the past decade, the use of these forms of validity in qualitative
research have been questioned. Other suggestions put forward include triangulation,
extensive time in the field, negative case analysis, thick description and respondent
validation (Creswell & Miller, 2000; Leedy & Ormrod, 2002). Due to the design of this
study, the latter were utilised to ensure outcomes were valid.
3.7.1 Triangulation Triangulation is a validity method where the researcher seeks convergence among multiple
and different sources of information to form themes or categories in a study (Creswell &
Miller, 2000). In this research, in order to mitigate against validity failure, triangulation
was utilised. This involved gaining more than one perspective about HR practices and then
comparing them for consistency in outcome (Leedy & Ormrod, 2005). By doing this, the
researcher attempted to ensure that the conclusions drawn from the study are valid.
3.7.2 Thick Description Thick description seeks to establish credibility for the research. The manner in which this
is done is to describe the setting, the participants and the themes of a qualitative study in
meticulous detail (Creswell & Miller, 2000). In doing this, readers can draw their own
conclusions from the data presented and decide whether or not the results may be
applicable to other situations (Leedy & Ormrod, 2005). In the case of this study, the
researcher attempted to ensure that a thick description of all three elements of the study
was clearly presented.
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8.8 Ethical Considerations Prior to commencing with the research, permission was sought from the Chief Executive
Officer of the East London Hospital Complex. This permission was granted after full
disclosure was made regarding the intention and details of the research. See appendix 1 for
authorised agreement.
Participation in the interviews as well as the survey was entirely voluntary and thus no
coercion whatsoever occurred. Prior to interviewing or the survey completion, each
participant was made aware of the intention of the research. The researcher gathered verbal
consent from all interviewees at the start of the interview.
In order to ensure complete confidentiality of all participants in the study, personal identity
was not required to complete the survey and interviewee identity was kept completely
anonymous. This intention was reiterated to the respondents prior to the commencement of
the interview and through the emailed link to the survey.
UCT Ethical Clearance was granted by the UCT Graduate School of Business Ethics
Committee prior to commencement of the data collection (See Appendix 2).
3.9 Researcher Bias The researcher has worked as a medical doctor in the East London Hospital Complex. This
aided with the logistics of arranging the research and gaining permission to perform both
the interviews and the survey. This previous work experience however has the ability to
influence the interviews and the formation of questions for the survey.
In an attempt to reduce bias, no personal experiences were introduced into the interviews
and survey questions were grounded within the responses of the interviews and the
literature. The researcher sought to maintain a high level of professionalism and remained
acutely aware of the potential of bias throughout the research process.
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4. Findings and Analysis
4.1 Introduction The first phase of the data collection began with the four head of department interviews.
These were done telephonically and were conducted in a semi-structured fashion. The
primary goal of these interviews was to extract themes, which could be used in the
development of the survey questions.
After completion of the four interviews, the transcriptions were thematically coded. Two
broad themes emerged initially and on preliminary inspection appeared to overlap
significantly. However, as the coding progressed the two themes became clearer and
consisted of firstly, human resource practices and their effects on retention, and secondly
human resource characteristics and their effects on retention.
The first theme, HR practices, consolidated into five practices that the department
performed while managing doctors in the complex. These included matters around
communication, salary related issues, continued education practices, document collection
and storage and whether interactions with HR were conducted in a helpful and respectful
manner. Each of these practices is elaborated on in the sections to follow.
The second theme consisted of HR characteristics and again incorporated five qualities that
the department demonstrated. These were made up of the availability of staff, HR task
competence, salary level adjustment efficiency, accountability and process efficiency. As
with the previous theme, these characteristics are detailed in the sections that follow.
Using these two themes, each consisting of five subcategories, a survey questionnaire was
designed and built. A section that established respondent demographics preceded the
thematic questions and formed the first page of the survey.
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4.2 Head of Department (HOD) Interview Results
4.2.1 Interview 1 The first interview was conducted with the HOD of a smaller more specialised department.
Regarding positive aspects of the ELHC, the interviewee explained that they did not have
any. The interview revealed multiple salient points however the overall theme that came
through strongly was that this doctor believes the HR staff at the complex do not
understand the importance of their job. This doctor suggested that regular meetings should
be held with HR and clinical staff in the same room so that both staff components are on
the same team.
The other points raised in this interview surrounded accountability of HR staff and this
possibly being the reason behind the repeated document losses that occur in the HR
department. Another issue that the interviewee brought up was that there is a complete lack
of professionalism in the department. The doctor also believes that this has profound
impacts on the respect for doctors, HR-doctor communication and enthusiasm to assist
with problems.
The doctor went on to describe that there is a fundamental flaw in the structure of the
department with no one person being responsible for each doctor. It is believed that this
lack in personalised service causes delays in decision-making, erosion of trust and timeous
problem resolution. The doctor suggested that assigning each doctor to a member of the
HR department would improve accountability and have significant positive impacts in all
problem areas.
4.2.2 Interview 2 The second interviewee was with the HOD of a larger core department in the ELHC. The
interviewee spent a significant amount of time explaining the frustrations of HR. Pertinent
issues raised included things such as salary payment problems, OSD and PMDS failures,
the complete breakdown of trust and a perceived incompetence of HR staff. The doctor
made reference to a lack of professionalism with interactions with HR staff being plagued
with rude and unhelpful service.
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Bureaucracy was something that this HOD felt was at the core to the gross process
inefficiency that occurred in the department, as well as the complete lack of accountability
that existed among the staff. The doctor continued to explain that the staff structure was
incredibly confusing and that doctors often complained of not knowing whom to contact in
order to solve a problem. There was also a distinct communication problem that was
highlighted and this seemed to be implicated in many of the problems mentioned. This
doctor also felt that the careless attitude of staff towards submitted documents and the
information they contained was the primary reason for the spate of identity theft fraud that
gripped the complex.
4.2.3 Interview 3 This HOD was extremely emotional about the impact that HR was having on his/her large
and busy department. Delays in application processing and persistent documentation losses
were cited as the main reasons for his/her constant staffing problems. This doctor
explained that one of his staff members had resigned recently and that the primary reason
for this employee’s departure was the poor HRM in the complex.
Other issues raised by this HOD included salary payment problems, a far-reaching lack of
communicative effort, and a significant loss in clinical time due to the inefficiencies of the
HR department. The doctor offered that the cumbersome processes that the department
followed were not conducive to efficiency and sound service delivery. This doctor was also
greatly distressed about the dissociation between the clinical staff and the HR staff. It was
suggested that this dichotomy was a likely reason that HR staff failed to understand the
importance of the role they place in the hospital complex.
4.2.4 Interview 4 The last interview was held with the HOD of another large department. Like the other
HOD’s, this doctor’s responses were infused with despondency. In fact at the outset of the
interview the doctor explained that the battle against staff shortages was over. He/she
stated that too many of the experienced doctors had left, leaving a young and
inexperienced complement of staff. These resignations were linked directly to poor HRM
practices and the frustrations that the doctors experienced. The HOD described that
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communication was at the core of the problem with a complete lack of respect for the
doctors that are currently employed in the hospital complex.
The doctor also explained that doctors often become frustrated about the lack of course and
conference payment. He suggested that the HR department should prioritise these as it
improves the clinical capacity of the department and hospital staff.
Below are the findings and analysis of each of the components of the survey.
4.3 Survey Findings: Demographic Characteristics of Respondents Table 4 below shows the demographic characteristics of the survey respondents. As can be
noted, there were marginally more male respondents than female respondents and the
majority of responses came from the Gen Y age group of 25-32 (Lyons, 2004). Medical
Officers forms the biggest group of respondents with 31%, closely followed by interns and
then community service doctors. Almost 74% of the survey respondents report that they
have worked at the complex for less than 5 years.
Table 4: Demographic Characteristics of Respondents
Variable Segments %
Gender Female 40
Male 60
Age 25-32 68
33-50 17
51-66 11
>67 4
Current Position Intern 28
Community Service 19
Medical Officer 31
Registrar 8
Consultant 15
Duration at the complex 0 to <2 yrs 38.7
>2 to <5 yrs 34.7
>5 to <10 yrs 10.7
More than 10yrs 16.0
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4.4 Survey Findings Theme 1: Human Resource Practices This component of the survey began by requesting respondents to rank the five identified
HR practices according to their perceived importance to the individual. For each of the five
statements, an average ranking was calculated and then used for analysis purposes. The
results of this process are tabulated below (Table 5).
Table 5: Importance Ranking of Human Resource Practices
The most fundamental HR practice, this being punctual monthly salary payment, is ranked
as the most important of the five practices. An adequate document collection, filing and
storage system follows this with the need for effective communication closely behind. To
be respected, valued and receive friendly helpful service is ranked as the 4th most important
practice and the lowest ranked item is the re-imbursement for courses and conferences.
Each of these factors is individually reviewed below with each section incorporating a
rating of the doctors’ perception of how well this specific HR department is performing
this practice. Pertinent excerpts from the qualitative responses are integrated into the
analysis in order to support the quantitative data and provide specific illustrative examples.
4.4.1 Salary
Doctors ranked this practice as the most important HR practice, with salary-related issues
being mentioned more than 45 times in the open question responses. These salary related
problems spanned a number of issues. Some of these include not receiving a salary over a
period of time (up to 6 months), receiving only part payment of salary or delayed monthly
salary payment. Some of the statements made by respondents include; “My first�salary as
1st Monthly salary paid on time
2nd An adequate document collection, filing and storage system
3rd Good communication e.g. Post availability, status of requests made the department, and the whereabouts of submitted documents.
4th To be respected and valued by HR staff and receive friendly and helpful service
5th Re-imbursement for courses/conferences attended, and processing of special leave requests.
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a community service officer was only paid in my fourth �month of my contract” and “(I
am a) victim of salary being paid late”. Other concerns comprised of receiving incorrect
salaries for extended period of time. A common complaint from doctors was never
receiving additional overtime pay in excess of regular overtime hours. One of the medical
officers declared, “I’m currently being paid the wrong salary and have been fighting
unsuccessfully for two and a half years to have it changed”.
What is very apparent in the responses is the emotional distress that the doctors are
experiencing around the insecurity and uncertainty that these previously mentioned issues
cause. One of the respondents claimed, “Security in my job is most basic; I need to know
that my ability to pay my expenses and other commitments and invest my savings
is�secure”. This security or lack thereof is spoken of countless times and each of these
statements is laden with despondency and frustration. “You can only hope they pay you
every month.”
“To pay salaries correctly and on time is one of the most basic functions on HR - it is
insulting and frustrating when this does not happen.”
Figure 4: Performance Rating for Timeous Salary Payment
Figure 4 above corroborates this insecurity and frustration by representing the performance
rating given by the doctors to the HR department’s management of salaries. As can be seen
80% of respondents rate this below very good with 16% dubbing this critical HR practice
as unacceptable. One of the responses sum the salary issues up well; “Most doctors just
want to�be paid fairly, as agreed to when signing contracts. It would also lessen
our�frustrations which are already vast in a crumbling public health system”.
16%
36%28%
20%
0%
20%
40%
60%
80%
100%
Unacceptable Acceptable Good Very Good
Performance Rating of the Statement "Monthly Salary Paid on Time"
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4.4.2 Document Filing and Storage System
The majority of interactions with the HR department result in some form of document
submission by the doctors. These documents, most often certified copies, are often
misplaced or discarded resulting in the doctors needing to repeatedly resubmit copies of
items such as identification documents, matric certificates, HPCSA Certification (Health
Professions Council of South Africa) and degrees. This seems to cause significant amounts
of frustration, which was corroborated in the results of the survey.
In fact 84% of respondents felt that the second most importantly ranked HR practice (Table
5) was performed unacceptably (figure 3). There was not one response that rated the
document collection, filing and storage system as good or very good. Supporting responses
within the open questions included statements such as “Submitted documents get lost most
of the time and have to be resubmitted”, and “I've had MANY documents lost or
mismanaged”.
It is clear that there is a link between the salary issues and the submission of
documentation. Failure to submit documents was often cited as the reason for unpaid
salaries with one medical officer stating, “We are often threatened with salary delays if we
do not do this”. At first glance this may seem like a failure on the side of the doctor to
submit forms on time but the results from the survey refuted this. Both the quantitative and
qualitative data combines to show a fundamental lack in documentation management.
Figure 5: Performance Rating of Document Management
84%
15% 0% 0%0%
20%
40%
60%
80%
100%
Unacceptable Acceptable Good Very Good
Performance Rating of the Statement "An adequate document collection, filing and storage system
"
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One individual when arriving at the complex for Community Service cited, “I had to
submit some forms twice, as people misplaced my forms. The eventual excuse that I was
given was that my papers were in the desk of someone who had gone on maternity leave.”
The incidents of documents being lost or mismanaged did not stop there, with one
individual finding his documents on the floor of the HR department and another being
unable to trace the original copy of her IRP5 form.
What is also of concern is the need to repeatedly resubmit documents. The underlying
reason for this is unclear but whatever the case may be, the reality is that, “You have to
resubmit ALL your documents again and again. I think I�have done that 3 times already;
surely they should have a file with my name on and keep referring to that instead of asking
for new documents each time?” (Registrar)
The effects of this inadequate document management extend beyond salary influences and
frustrating resubmissions. It has disastrous effects for new applicants that apply to work
within the hospital complex. A consultant within a department leadership role claimed that,
“[My department] has had about 50% of applications lost over the last few years”. Another
doctor highlighted that; “The doctors do not feel welcome here and become easily
despondent about the constant failure of HR to process their applications. Documents
are�regularly lost, misplaced or even put aside by incompetent staff to such an�extent
that many jobs remain unfilled and the junior applicants find better avenues.” The effect of
this is devastating for staff morel and the attempts being made to curtail the threat of the
HR crisis in the public health sector.
As said eloquently by a medical officer, “Adequate documentation management is
fundamental for a system to run smoothly”. She was supported in her suggestion by a
consultant that identified that, “Good administrative support and effective processing of
paperwork goes a long way in�keeping an employee happy.”
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4.4.3 Communication
Communication forms a fundamental part of the relationship between doctors and the HR
department. HOD interviews revealed the importance of this practice and its direct
implications on the retention of staff. The heads of departments also highlighted that
communication is a multifaceted practice that requires a great deal of attention.
In the survey, communication was ranked as the third most important item when it came to
dealings with HR (Table 5). Many responses found communication to in fact be central to
many of the issues relating to HR practices. One doctor explained that his salary had not
been paid because HR had not notified him that they needed documents resubmitted.
Another senior doctor attributed the poor communication and the time taken to process
applications as the main reason that leads to many doctors taking posts elsewhere. This
doctor noted that, “This results in staff shortages and often drags the name of our complex
even further through the mud.”
Communication also played a key role regarding the solving of doctor’s problems and the
rectification of HR related errors. “They never update you on how far the status is of your
query/problem” and “No one updates me on the progress and each time I enquire no
progress has been made” were just two of the statements made regarding this. The latter
statement refers to an issue that the doctor has been trying to resolve for the preceding five
years.
It is clearly evident that the communication between HR staff and the doctors in the
Complex appears poor. A medical officer illustrated one of the effects of this poor
communication in her statement saying; “Part of the reason I have decided to leave the
ELHC was the failure of communication especially regarding the application for registrar
posts.”
Within the suggestions put forward by respondents, the centrality of communication is also
apparent. “I think that many of the core issues surrounding HR / staff relations could be
resolved with improving communication between HR and staff”, “If there were a good
communication system in place a lot of the other issues would be fixed.”
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Figure 6: Performance Rating of HR communication Efforts
Unfortunately this solution through improved communication is not likely to be occurring
as the overwhelming majority of doctors declared the HR efforts as unacceptable (Figure
6). Only 16% of respondents decided otherwise and rated the communication efforts as
acceptable (15%) or good (1%). There was however not one doctor that perceived this
crucial issue as very good.
4.4.4 Value and Respect This item describes the nature of the interaction of doctors with HR staff. It enquired into
the importance of being valued and respected and whether helpful friendly service was of a
high priority to doctors. This question was developed out of the literature surrounding
knowledge workers in the private sector and seemingly had a reduced importance in this
setting being ranked fourth behind communication (Table 5).
Although lower down on the importance ranking, this statement was rated by 64% of
doctors as being unacceptably performed with only 4% rating it “good” (Figure 7). The
statements made in the open questions seemed to validate this poor performance and
included remarks such as, “If we were valued they would not treat us with such disrespect
and would care more” and “The staff are generally unfriendly and are not aware of what’s
going on.”
84%
15% 1% 0%0%
20%
40%
60%
80%
100%
Unacceptable Acceptable Good Very Good
Performance Rating of the Statement "Good communication e.g. Post availability, status of
requests made the department, and the whereabouts of submitted documents"
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Figure 7: Performance Rating of HR Interaction Quality
Other responses were more emotional as evidenced by reports such as, “Helpful service is
non-existent despite the best lip service”, and “I have had NO helpful interaction, EVER,
with ANYBODY (apart from one in HR and one person from the frontline office) in ALL
my dealings�with our HR department over the last 8 and a bit years. Neither has my wife
[also a doctor]. The HR department is staffed with people that are not qualified or able to
do the most basic of tasks. I know that being negative is of no help, but I put this as
euphemistically as I could.”
It was however very apparent that the issue of being valued and respected was more than
just courteous service. A medical officer remarked, “My biggest problem with HR is their
total lack of respect for you as a colleague. There is such a hostile atmosphere and you are
made to feel like�a nag for just checking if you have all necessary documentation or
checking�leave or salary problems. NO ONE is friendly and willing to help.” This topic of
collegial respect is one that is mentioned repeatedly and said to be a “common courtesy”
that has been unacceptably neglected.
Other doctors feel a lack of respect and value not from what HR do, but rather what they
do not do. They feel that if respected and valued their concerns would be looked after
timeously and they would strive to be more efficient. A statement corroborating this is, “If
we were valued as staff then our requests would be seen to ASAP”.
64%
32%
4% 0%0%
20%
40%
60%
80%
100%
Unacceptable Acceptable Good Very Good
Performance Rating of the Statement "To be respected and valued by HR staff and receive
friendly and helpful service "
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4.4.5 Re-imbursement for Courses and Conferences Continued education and training was a topic that was founded in the literature
surrounding both the motivation of healthcare workers and the retention of knowledge
workers. It was not mentioned in the interviews with the HOD’s but did receive multiple
mentions in the open responses in the survey.
When it came to ranking the statement, it was labelled by doctors as the least important HR
practice in relation to the former factors that have been highlighted (Table 5). What is
noteworthy is that despite being on average the lowest ranked factor, course and
conference reimbursement was ranked first and second by 16% of respondents. Its
importance can thus not be overlooked and may have more bearing on certain age and
professional groups than others.
This can be seen in two statements. The first of these was made by a consultant who wrote,
“10 years at the ELHC, only once succeeded to get reimbursed for expenses incurred to
attend the annual [specialty] congress.” The other comment was made by a registrar and
reads, “It took more than 12 months to be reimbursed for the College exam fees”. To these
individuals, this factor was noticeably important and thus an influential retention factor.
Figure 8: Performance Rating of Continued Education Facilitation
When it came to rating the performance of “Re-imbursement for courses/conferences
attended, and processing of special leave requests", 43% of doctors rated it good or
acceptable with 55% feeling that it needed substantial improvement and put it in the
unacceptable category (Figure 8).
55%
39%
4% 0%0%
20%
40%
60%
80%
100%
Unacceptable Acceptable Good Very Good
Performance Rating of the Statement "Re-imbursement for courses/conferences attended, and
processing of special leave requests"
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4.5 Survey Findings Theme 2: Human Resource Characteristics This theme of human resource characteristics incorporates five qualities or characteristics
that the department demonstrates. These characteristics were developed from the HOD
interviews and were made up of the availability of staff, HR task competence, salary level
adjustment efficiency, accountability and general process efficiency.
This component of the survey began similarly to section one, with respondents requested to
rank these five HR characteristics according to their perceived importance to the individual.
Table 6 below expresses the outcomes of this ranking question.
Table 6: Importance Ranking of Human Resource Characteristics
The characteristic that doctors felt most important was the task competence of the HR staff.
This was followed by the accountability of staff for queries made or documents submitted
and then general process efficiency. OSD and PMDS specific efficiency was ranked fourth
with the availability of staff during tea and lunch times being perceived as the least
important HR characteristic.
Each of these factors is individually reviewed below with each description incorporating a
rating of the doctors’ perception of how well this specific HR department is exhibiting the
various characteristics. Relevant extracts from the open responses are incorporated into the
analysis in order to support the quantitative data and provide specific clarifying examples.
1st The task competence of HR staff
2nd The accountability of HR staff for queries made or documents submitted
3rd General HR process efficiency
4th OSD* Salary level adjustments and PMDS** efficiency
5th The availability of HR staff during tea and lunch times
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4.5.1 Task Competence The characteristic that received the highest ranking in this section was that of task
competence of HR staff (Table 6). This means that the majority of doctors felt that it was
most important to them for the HR staff to be competent in the tasks required for effective
HRM. Both the HOD interviews and the survey results revealed evidence that these tasks
incorporate a wide variety of functions from the paying of salaries to the resolution of
problems.
Examples of this, included statements such as, “It is annoying not to be paid on time,
because this reflects administrative incompetence” and “I find it difficult to get HR staff to
explain the various packages or options in a coherent and simple way”. Another doctor
mentioned that, “There is nothing as�frustrating as going to HR the third or fourth time to
find out that nothing has been done in regards to certain requests.”
Other respondents were less specific and remarked that there was a widespread and distinct
lack of required skills with the “general competency of the average HR staff member
[being] poor”. The responses identified that this lack of competence and knowledge of
fundamentals, “makes everything difficult and prolongs all requests”.
This topic of task competence seemed to generate a significant amount of emotion with
one senior doctor remarking, “They are inefficient, corrupt and incompetent and have no
idea what is expected of them. They do not care and they are the main reason, together
with� Bisho, that I hear my doctors say; ‘We will never come back to this place’.” This
was followed by another respondent stating that, “They're also not of any help because NO
ONE KNOWS WHAT I AM SUPPOSED TO DO!!!”
It appears that the lack of competence of the HR staff manifests in inefficient and
ineffective visits by doctors to the department. Comments included, “I feel so
frustrated�when they cannot answer my questions and then send me from pillar to post”,
and “They usually refer you to someone else, even though you’d expect them to know
certain things”. One more unique case involved a doctor that had acquired drug resistant
Tuberculosis and needed to apply for special leave. This doctor revealed that, “You have to
walk everywhere, from one point to the next attempting to sort out the issue. Despite
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feeling ill I still did this as I didn't trust anyone with my documents as I know it would take
ages to reach its destination or it could possibly get lost in translation”.
This lack of competence may be contributing to a fundamental collapse of trust between
the doctors and the HR department. A medical officer remarked that, “Overall, it appears
that I cannot trust HR for doing the job correctly. Several times I have been asked to re-
document my personal details since it has�been lost. This is at a point now, where I
provisionally, make copies of all my�dealings with HR just so that I have a "back-up" in
case they lose it.”
Figure 9: Rating of Task Competence of HR Staff
The doctors proposed, “Our HR needs training in basic tasks”. They feel that “Competent
HR staff [are] very important… They are there to make the administrative part of our jobs
easier”. What is clear is that this opinion regarding task competence does not only belong
to a select few. Figure 9 illustrates that 77% of doctors felt the same way and believed the
task competence was “unacceptable”
Sadly, results like this can paint all HR staff with the same brush but it must be noted that
this is not always true. This is supported by a doctor replying, “Unfortunately their
reputation of incompetence clouds the occasional individual [doing a] good job.”
77%
19% 3% 0% 1%0%
10%20%30%40%50%60%70%80%90%
100%
Unacceptable Acceptable Good Very Good N/A
Rating of the task competence of HR Staff
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4.5.2 Accountability This characteristic measures the accountability of HR staff for queries made or documents
submitted. When asked to rank the importance of this factor, doctors at the ELHC placed
this second behind that of task competence (Table 6).
Statements in support of this ranking read, “They are not held accountable for anything, if
a salary is not paid they aren't willing to find out why” and “Unfortunately they are not
held accountable for their inefficiency”. One doctor even remarked, “I have no faith in
HR's accountability”. This link between document loss and accountability featured
numerous times in the responses with observations such as, “HR is constantly asking you
to resubmit documents. No one is held accountable for losing documents.”
Another of the junior doctors identified that this lack of accountability possibly has an
origin in departmental structure. She stated, “There is a lack of titles in the HR i.e. Who is
in charge of community service doctors and interns and someone else who is in charge of
medical officers�etc. Together with that there is no one senior in the HR department
who�oversees everyone and no one senior to speak to if there are problems and salaries
that haven't been paid”. Another doctor replied, “HR always passes the buck, and there is
always another signature or stamp that must be done by another person, or by Bisho and it
is NEVER the fault� of the person sitting in front of you that your request is not
completed”. This frustration with accountability appeared to be generalisable with 81% of
doctors rating the accountability of HR staff as unacceptable (Figure 9).
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Figure 10: Rating of HR Staff Accountability
Accountability was at the core of some recommendations put forward by doctors. One
doctor suggested, “This�communication should be between the staff member and an
individual, �named HR provider - which would encourage greater staff participation and
assist with HR accountability’. Another senior doctor explained a situation where one
individual “took responsibility for the issue and personally saw it to completion.” He
concluded saying, “It was fantastic knowing that the 'buck stopped' with them, and that
they were on my side and willing to keep me up to date with where things stood.”
81%
16% 1% 0% 0%0%
10%20%30%40%50%60%70%80%90%
100%
Unacceptable Acceptable Good Very Good N/A
Rating of the Accountability of HR staff for queries made or documents submitted
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4.5.3 General Process Efficiency The characteristic of general process efficiency was rated by 87% of responding doctors as
unacceptable with not one individual perceiving this characteristic as very good (Figure
11). This view was despite being recognised as the third most important amongst the five
characteristics offered to respondents (Table 6).
Figure 11: Rating of General Process Efficiency of HR Staff
Indications as to why doctors felt this way could be found scattered throughout the
responses. A medical officer reported that, “Most of my dealings with HR seem to involve
multiple visits and a huge amount of effort on my part to accomplish fairly simple matters”.
Another registrar felt that, “HR is in general just non-efficient”; while two other doctors
concurred that system inefficiency was crippling process efficiency. A head of department
exemplified this by reporting, “The mechanism in place to complete tasks is so
cumbersome that it is often self-defeating. I have examples of doctors who applied to work
in my�department who, when finally offered a post, had already been working in
an�alternative post elsewhere for over 6 months.”
Numerous doctors recognised efficiency as playing a pivotal role in HR management.
“Efficiency is ultimately the most important for saving employees time and rendering
adequate services”, remarked a junior doctor. Another response echoed this argument; “A
HR department needs to provide a friendly and efficient service to the employees of a
business. It is the link between the employers and employees in organisations especially
where there is minimal communication between management to employees”.
87%
12% 1% 0% 0%0%
10%20%30%40%50%60%70%80%90%
100%
Unacceptable Acceptable Good Very Good N/A
Rating of the General Process Efficiency
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4.5.4 Salary Adjustment Efficiency OSD and PMDS are two financial incentivising tools used in the public sector to attract,
motivate and retain staff. Their role in retention capability of the hospital complex is thus
paramount, however the efficient management of these two processes was ranked by
responding doctors as the fourth most important characteristic of HR (Table 6). 17% of
respondents did however feel that this was the most important function and rated it number
one.
One of the doctors pointed out the fact that “The OSD system has been fully implemented
in much of the country with exception to the Eastern Cape Province” with another stating
that “Salary progression in the Eastern Cape does not happen and as a result [medical]
employees of the Eastern Cape are unsatisfied”.
Figure 12: Rating of HR Staff Efficiency toward OSD and PMDS
Not being placed on the correct level or not being promoted when appropriate, causes a
significant amount of unhappiness. 51% of respondents perceived this service to be
unacceptable but when the results were filtered to medical officers, registrars and
consultants, due to their greater involvement with OSD and PMDS, this “unacceptable”
figure rose to 71% with no one rating this HR practice as very good (Figure 12).
51%
27%12% 1% 9%
0%
20%
40%
60%
80%
100%
Unacceptable Acceptable Good Very Good N/A
Rating of the OSD* Salary level adjustments and PMDS** efficiency
(*Occupation Specific Dispensation)(**Performance Management and Development System)
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4.5.5 Availability
Availability refers to the doctors’ ability to access HR staff during specific times of the day.
This characteristic was initially not included in the survey; however three of the
respondents in the pilot study commented on its absence and suggested that it should be
incorporated. In the open responses, multiple doctors alluded to the necessity of physically
visiting the HR department on numerous occasions. This however causes much distress, as
doctors need to take time out of their working day to attend to HR matters. One of the key
issues with regard to this necessity is that the Cecilia Makiwane Hospital is situated 20km
away and does not have a compliment of staff to deal with HR related queries. This means
that doctors need to ask for special permission to leave early or come in late in order to
visit the HR department situated on the Frere Hospital grounds.
From this concern arose the issue of HR staff availability during tea and lunch times when
doctors could visit HR and avoid losing clinical practicing time. One doctor remarked,
“We can only go to the office during certain hours and then they are on tea or lunch”,
while another stated, “It’s not always easy to do admin during certain hours”.
One of the registrars that responded perceived this issue differently and concluded, “I can
still try and make time to see them (would prefer if our lunch times didn't overlap, though),
if only they would do their tasks well!!! Then we wouldn’t have to take time to go there
over and over”.
Figure 13: Rating of HR Availability
65%
28%
3% 0% 4%0%
20%
40%
60%
80%
100%
Unacceptable Acceptable Good Very Good N/A
Rating of the availability of HR staff during tea and lunch times
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When it came to rating the complex’s availability of HR staff (Figure 13) during lunch and
tea, 65% reported that this was unacceptable with a further 28% terming it just acceptable.
4.6 Conclusion The results to this survey have revealed a number of pertinent issues with regard to the HR
management of doctors in the EL Hospital Complex. What must be kept in mind is that
HRM plays a critical role in the retention of employees and attention must be paid to the
consequences of poor service. Although not specific to the effects of HRM, 45% of doctors
surveyed confirmed that they were not willing to stay in the complex (Table 3). Add this
figure to the 23% who were unsure about their willingness and one can see that 68% of
ELHC doctors are not prepared to commit to remain working at the two hospitals.
Table 7: Doctors Willingness to Stay at the Complex
Willing to stay at the Complex %
Yes
32
No 45
Unsure 23
In conclusion, this chapter has endeavoured to present and analyse all findings from phase
one, two and three of the data collection process. The next chapter continues from this
point to discuss these results and relate them to the literature that exists in this area.
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5. Discussion
5.1 Introduction The focus of this study was primarily to understand what Human Resource management
practices strengthen and erode doctor retention capabilities in the South African Public
Health Sector. As the research process has unfolded, HR interaction with doctors has been
categorised into management practices and into department characteristics. Both these
facets play a substantial role in HRM and as a result influence retention capabilities. This
categorisation has also enabled a more thorough exploration of the various practices and
characteristics and their perceived importance to the workforce in question.
The research has also allowed for the opportunity to not only understand the importance of
the various practices and characteristics but also to quantify how well they are being
performed in a South African setting that is currently facing significant retention
challenges. It is the researcher’s contention that a better understanding of this Hospital
Complex’s HRM might allow extrapolation of this data to a national level to facilitate the
retention of doctors in South Africa and more specifically the public sector of South Africa.
Below is a discussion of the findings of the research and various practices and
characteristics.
5.2 Demographic Characteristics of Respondents
Lyons (2004) generational classification was used when selecting age categories for
respondents to choose from in the survey. This was done intentionally so as to determine if
there were generational variations in the responses to the survey. Generation Y or
individuals from 25 to 32 years of age formed the largest group of respondents making up
almost 70% of responses. This is interesting for a number of reasons. The first is that if the
sample population is representative of the whole, then a significant portion of the ELHC
medical workforce is made up of a generation that is proving difficult to manage (Eisner,
2005).
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The literature surrounding the management of Gen Y is extensive and the resounding
agreement points towards a growing challenge. In a news article, intergenerational
management authority Bruce Tulgan explained the resulting challenges of managing Gen
Y workers in this way: "Gen Y'ers are like X'ers on steroids . . . They are the most high-
maintenance generation to ever enter the work force" (Breaux, 2003, p. 2).
Francis-Smith, (2004) highlights that Gen Y tends to favour an inclusive style of
management. They also dislike slowness, and desire immediate feedback about
performance. Eisner (2005) adds that Gen Y’ers place a high importance on respect and are
willing to earn it. This therefore poses a significant challenge to health managers. As soon
in this study the workforce is being significantly infiltrated with Generation Y doctors and
thus management styles and in particular HRM needs to be revised to cater for changing
needs.
In the next section of demographical data, respondents were asked to state their current
position in the hospital. This question revealed that the most number of responses came
from the medical officer group. This group is particularly important as is forms the bulk of
the doctor compliment. They therefore form the most vital target for retention strategies.
Community service doctors and interns are also of extreme importance both from a clinical
capacity and retention target point of view. These individuals are mandated by the state to
complete two years of internship and one year of community service. They thus are
unlikely to leave the complex during this time; however they are under no obligation to
stay once their three years are complete. Often these doctors are undecided as to their next
step after community service and therefore form a crucial target for the complex to retain.
They generally move into medical officer posts and, if treated well, may stay for an
extended period of time. This aids in expanding the workforce, which is critical for the
delivery of quality service.
The contrary to this is also true. Treat these doctors poorly and they will move off to other
towns and cities with virtually no chance of returning at a later stage. Reid (2001) in fact
suggests that these community service doctors who express an interest in long-term service
should be encouraged to do so through contractual agreements with provincial health
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departments. He suggests that these agreements should include incentives, as the long-term
benefit for the public health system is immense. It is thus vital to firstly understand this
Gen Y dominated group of doctors and the context they find themselves in and then tailor
HRM practices to suit them.
This argument is supported by the fact that 74% of doctors have been working at the
complex for 5 years or less. This means that only 26% of staff remain for longer than 5
years. From this alarming statistic the question needs to be asked, “What is causing doctors
to leave?”
The reason for this high rate of staff turnover in the public sector is described by Kotzee
and Couper (2006) as multidimensional; however judging by the substantial amount of
frustration and antagonism expressed toward HRM in this research, the role that HR plays
in this challenge cannot be discounted. Thus while retention deficiencies cannot be entirely
attributed to poor HRM, this deficiency can be said to be contributing to this struggle.
5.3 Human Resource Practices
5.3.1 Salary Remuneration plays an important role in the retention and motivation of healthcare
workers (Willis-Shattuck et al., 2008). The findings from this research corroborate this
importance by revealing that timely salary payment is the practice that most doctors feel is
of utmost importance. King and McInerney (2006) support this sentiment by stating that if
this aspect of motivation and retention is ignored, it tends to make HCWs feel undervalued
and demotivated. This can be witnessed repeatedly in the qualitative responses that link
these remuneration issues with a perceived lack of respect and doctors feeling undervalued.
Although financial incentives were found to be insufficient on their own to facilitate
motivation (Kotzee & Cooper, 2006; Mathauer & Imhoff, 2006), it can be said that
individuals require financial security in order to remain in an institution (Pfeffer, 1998).
Elsner (2005) echoes this sentiment when referring to Generation Y and states that this
generation find making a lot of money to be less important than contributing to society.
Pfeffer (1998) also continues to say that it is employment security that is the most
important aspect of retention. This importance is understandable as Maslow (1943), in his
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research into basic human needs, placed employment security on a primary level with other
issues of safety.
With this importance noted, the researcher opines that an institution such as the ELHC
should be striving for a rating regarding remuneration accuracy of nothing less than very
good. If doctors experience or are under the impression that the institution does not place a
high value on this fundamental HRM practice, there will be a substantial erosion of
organisational retention capacity, as noted in the recent ELHC staffing difficulties.
5.3.2 Document Filing and Storage System
Document submission is an unfortunate necessity for HR department functioning and
something with which all employed personnel are familiar. From the findings of this
research, it is clear that it is not the need to submit documents that frustrates doctors but the
manner in which the submitted documentation is handled. As can be seen in the qualitative
data, documents are often lost and mismanaged. This situation results in HR staff requiring
repeated submissions of specific documents which causes the doctors a great deal of
frustration.
Document mismanagement seems to have two effects on doctors. The first is that it causes
substantial irritation and the second is that it erodes the trust that needs to be in place for
employment security to exist. This was demonstrated in the qualitative responses and by
the fact that doctors ranked this practice as the second most important issue.
Document management in an HR setting should be bound by strict protocols to safeguard
not only the physical documentation but also the information that these documents carry.
This information is extremely sensitive, and its protection is of paramount importance
(Hazen, 2010). In the latter half of 2011, the ELHC was plagued by more than fifty cases
of identity theft in which doctors’ identities were used to fraudulently open credit cards and
insurance policies (see appendix 6). Hazen (2010) remarks that reclaiming a lost identity is
exhausting, time consuming and expensive. This was apparent amongst the identity theft
victims and caused a significant amount of anger to be directed towards the HR department
who had failed in the task of safeguarding their information. Hazen (2010, p2) advises that,
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“An ounce of prevention is worth a pound of cure with issues of sensitive information and
identity theft.”
5.3.3 Communication
Kotzee and Cooper (2006), in their study on rural doctors, found that HR departments were
a particular problem area with regard to promotion issues and communication. This
problem was highlighted by the findings of this research, in which 84% of doctors
surveyed rated the ELHC communication efforts as unacceptable. With such a poor
demonstration of a fundamental HR practice, multiple areas of the ELHC HRM have been
affected. These areas include both internal and external post advertisements, remuneration
related failures and neglecting to communicate with doctors regarding the status of
requests and grievance resolutions.
In both the interviews and the survey responses, poor communication is cited as a
quintessential contributor to staff shortages for of a number of reasons. Firstly, new
applicants are not informed about the status of their applications and as a result seek
alternate employment. Secondly, doctors employed by the complex who are willing to stay,
are often not informed about post vacancies and leave without applying. Lastly, the poor
communication offered by the HR department contributes to the administrative frustration
that is experienced by doctors, making the decision to leave the complex easier.
Padarath et al. (2003) in their meta-analysis on HCW migration, state that a lack of
employment opportunities in host countries often precipitates immigration. In relation to
South Africa and particularly the ELHC, this begs the question of whether there are
insufficient opportunities or whether there is a fundamental failure of the public sector to
recruit and retain doctors. An organisation that has emerged in order to assist with this
failure is a not-for-profit company called African Health Placements (AHP). This company
is attempting to recruit and assist doctors for public sector posts. Below is an excerpt from
their 2011-2012 organisational profile.
“When AHD first came into being, it was driven by the insight that we needed to
fight fire with entrepreneurial fire. If developed nations were capitalising on our
brain drain by attracting our local professionals with the promos of money and
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security, we needed to counter this trend by finding ways to market our region to
local and international talent. With little research, we discovered that the region
offered,
1. Far greater scope for gaining relevant experience
2. The satisfaction of making a difference
3. Unparalleled lifestyle experience, especially in rural areas
The challenge however, was that getting people to South Africa involved a
laborious and inefficient administrative process. Our response: gather a team of top
notch recruiters and administrators, build a high performance culture, then work
with local and national government to streamline the relevant systems and process.
Our work has reduced the average lag time to placement from 2 years to as little as
3-6 months. Since our inception in 2006, we have helped hundreds of health
facilities to render better service to their communities by placing over 2500
healthcare workers” (AHP Organisational Profile 2011-2012).
As can be seen, AHP recognised the communicative and administrative failure of the
public health HR system and have developed an entire company to assist with its
shortcomings.
5.3.4 Value and Respect Generation Y are said to place a high value on respect (Eisner, 2005), yet 55% of Gen Yers
ranked this as the fourth or fifth most important HR practice. This incongruity may be the
result of doctors placing more priority on the basic HR functions ahead of softer practices
such as value and respect. In the interviews, the HOD’s remarked that doctors in the public
sector, in particular the ELHC, have had to get used to being treated badly. Young doctors
coming straight out of university are also unaware of what reasonable HR management
entails. It is only when these individuals are contacted by the developed countries that they
experience what it is to be truly valued (Padarath et al., 2003).
What is of note is that the doctors that did rank this statement fairly high, highlighted that
if the staff of HR respected and valued them, then this would be seen through on-time
payment, improved document safeguarding, more effective communication and the
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prioritising of continued education. This was reiterated by a doctor who stated that all five
of the practices are vitally important and should be ranked evenly.
What is important with these findings is that the reader must not be misled into thinking
that valuing and respecting doctors is not important. It is the researcher’s opinion that these
findings occur in an incredibly strained context and that if the basic HR functions are
improved then a respectful and friendly service will take a higher priority. If this occurs, it
can only aid in the ELHC and the public sector retaining doctors.
5.3.5 Re-imbursement for Courses and Conferences Career development is important in 85% of studies regarding HCW motivation yet this
research has indicated that continued education is the least important practice for HR to
facilitate (Padarath et al., 2003). While it is clearly apparent from the literature that HCWs
thrive off the opportunity to progress (Reid, 2004; Kotzee & Couper, 2006; Manongi,
Marchant, & Bygbjerg, 2006), the case of the ELHC may be more convoluted than other
institutions that have managed to perform the basic HR functions well. Similarly to value
and respect, doctors seem to want the basic practices performed consistently well before
“extras” are added.
Continued education is not only important to the doctor but also to the hospital in which
they work. Mathauer and Imhoff (2006) state that training and development enables
HCW’s to assume greater levels of responsibilities. Continued education expands the
doctor’s clinical ability and this together with this increase responsibility allows for
improved healthcare delivery. The costs of continued education are far outweighed by
these benefits provided that the doctor remains in the hospital complex or state sector. This
retention is thus paramount and all efforts must be made to value these doctors because
after all it is they who hold the ability to add value to the community as a whole.
Kock and Burke (2008) suggest that for maximum dual benefit, integrating these
educational efforts with the individual’s career growth can ensure that the individual’s
development plans reflect their department or hospital's future development needs. In this
way the ELHC can safeguard against both staff and skills shortages.
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5.4 Ranking Human Resource Characteristics
5.4.1 Task Competence The task competence of HR staff involves all basic practices that were highlighted in the
first section of this research. It is thus understandable that 80% of doctors surveyed felt that
this was the first or second most important characteristic of HR. If one assumes that the
rating of this characteristic is indicative of an average rating of the five practices in theme
one, then 77% of doctors feel that this is unacceptable.
This therefore means that there are a significant number of doctors that are disgruntled and
frustrated with the ELHC HR department.
It was clear from the survey responses that many doctors felt that the staff of the HR
department needed basic training in tasks required to perform personnel management.
This may possibly be the case as Buchan (2004) indicates, that HRM in the health sector is
inherently a challenge as the workforce is large, diverse, and comprises separate
occupations. Be this as it may, HR staff should carry the ability to adequately address all
employee needs no matter how complex they may be. One example of this is PMDS,
where the nature of the system implementation for doctors is complicated and difficult.
Here HR staff should be sufficiently trained to handle this procedural complexity in order
to avoid frustrating confrontations with doctors.
This was clearly not the case in the ELHC as depicted by the both the qualitative and
quantitative data. It was in fact clear that this lack in staff competence had resulted in a
complete erosion of trust, where doctors fundamentally believed that the HR staff did not
hold the ability to resolve their grievances. Multiple doctors mentioned the need to take
problems into their own hands and drive to Bisho (Headquarters of EC Health) to
personally deal with matters and ensure their resolution. This is an inefficient and
ineffective means to overcome the incompetence found in the local HR department. One
of the doctors depicted this picture well by saying, “You wouldn’t go back to a doctor who
shrugged [his/her] shoulders and said that they couldn’t help you because they didn’t know
how to write a script for medicine”
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What was clear in a number of responses was how well doctors responded to competent
individuals. They were both appreciative and impressed at how well their concern had been
dealt with. Unfortunately all these comments were followed by remarks mentioning that
there were only a handful of individuals who held these capabilities and that as a result
these individuals were inundated with requests for assistance.
5.4.2 Accountability This characteristic received a significant number of emotive responses in the qualitative
findings. Doctors were noticeably angered at the lack of accountability of HR staff for any
tasks that they were given. This sentiment carried through into the quantitative data that
revealed an alarming 81% of doctors rating this characteristic as unacceptable.
This characteristic however seems intimately linked to the issue of task competence.
Doctors perceived that because skills levels were so low, HR would not take responsibility
and instead “always pass the buck”. There were also many mentions made of doctors not
being able to trace who was responsible for carrying out specific processes. Possible
reasons for this lack of accountability are the bureaucratic nature of the department and the
resultant multistep processes. Doctors described that this was the most commonly used
excuse for delays and documentation losses.
Some insight shared from the older more experienced doctors was that a complete
dissociation has developed between the HR department and the clinical staff. They
explained that HR staff were unaware of the pressures of day-to-day clinical work and
therefore did not realise how difficult it is for doctors to visit the HR department. They also
stated that this dissociation did not allow HR staff to understand the importance of their job
when it came to recruitment and retention of staff. The doctors felt that there was a need
for HR staff to witness the pressures of staff shortages and understand the desperate need
for accurate new application processing. They concluded that they felt like HR staff were
not on the same team as the medical professionals and thus were not striving for the
common goal of quality healthcare delivery.
Doctors suggested that a solution to the HR problem plaguing the ELHC lay in the
designation of a small number of doctors to one HR member. They proposed that this
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individual would be entirely responsible for all issues relating to the particular group of
doctors and that this person would be the first point of call if they needed something. This
way doctors would know that someone was looking out for them and striving to ensure
their occupational wellbeing.
5.4.3 General Process Efficiency This characteristic received the lowest rating of the entire survey with an alarming 87% of
doctors rating it as unacceptable. The effects of this inefficiency are far-reaching with
doctors attributing this directly to staff shortages. This characteristic was repeatedly
mentioned as a fundamental failure of not only the ELHC HR department but also the
broader Eastern Cape Department of Health.
Bureaucracy and institutional geographic distribution were the most common reasons cited
for this failure. With the ELHC being comprised of two hospitals separated by 20km, HR
staff seem to struggle extensively with the timely processing of tasks. There is also only a
skeleton of staff that manage a small HR department at CMH who are often rendered
helpless when documents need to be signed or submitted. All tasks thus need to flow
through the Frere HR department; however this department is required to work intimately
with the main HR function that is situated in Bisho more than 60km from East London.
This sheer distance, combined with a paper dependent bureaucracy, facilitates the poor
accountability and opens the ELHC department up to complete process efficiency failure.
Doctors felt that the only way to overcome this problem was to move towards an electronic
system with status monitoring and automatic feedback capability. This feedback is
important for both the doctors and the HR staff because “productivity must be measured so
that performance feedback can occur” (Grobler & Warnich, 2011, p. 153).
5.4.4 Salary Adjustment Efficiency (PMDS and OSD) PMDS combines two integral human resource management (HRM) processes namely, pay
progression and performance bonus (PSA Union, 2010). These two processes come
together to play an incredibly important role in the attraction, motivation and retention
capability of staff within the public sector. With this importance understood, one can
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understand the need for the system’s success as its failure can potentially have long-lasting
effects that could cripple the hospital system.
Working conditions in the public system are often challenging and doctors and nurses
working in these institutions need to be carefully looked after and valued. National
government thus proposed and implemented these PMDS and OSD systems. From the
qualitative and quantitative findings of this research, doctors do not feel that this system is
being implemented effectively. Cases of not being paid OSD increases are numerous and
the interviews with the HOD’s exposed that PMDS has been a categorical failure with not
one doctor receiving PMDS payment since the systems’ inception more than four years
ago.
Some doctors have postulated that the PMDS and OSD system failures have been as a
result of HR staff not holding the capability of correctly interpreting the policies mandated
from national administration. An example of this has occurred with intern doctors who,
despite been allocated a salary increase in their second year of service, have not received it
since the system’s implementation in 2008.
Although the PMDS and OSD systems were designed to improve the retention and
motivation through pay progression and incentive bonuses, the ELHC appears to have
failed in the delivery of these with the result that these potential retention tools have been
transformed into a frustrating fantasy for many doctors. This claim is underpinned by the
fact that an immense 71% of medical officers, registrars and consultants rated OSD and
PMDS efficiency as “unacceptable”.
This problem does not seem to be unique to the ELHC, with a large majority of the 14000
public sector doctors being affected in some way (Batemen, 2010). The link between OSD
failure and retention is apparent with a senior doctor admitting this; “With 10years’
experience I now earn very little more than comserves (Community Service Doctors)�– I
must say it makes you feel a bit undervalued” (Batemen, 2010, p. 272).
5.4.5 Availability
As previously mentioned, the geographic separation of the two hospitals in the ELHC complex
poses a multitude of problems. As seen with this research, availability of staff is one of them.
Doctors’ attempts to complete administrative tasks during tea and lunch are often met with
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resistance and apathy. This is proven by the quantitative statistic that 65% of doctors feel that HR
can improve on this characteristic.
Although in the ranking of HR characteristics, this was categorised as the fifth most important
practice, remedying this issue may require virtually no effort and may have a substantial impact on
the doctors’ ability to sort out day–to-day problems.
5.5 Conclusion
From the alarming performance ratings of all ten facets of HRM, the findings to this
research leave little doubt that HRM in the ELHC with regard to doctors is far less than
optimal. The consequences of this poor performance are far reaching and appear to have a
direct impact on the complex’s retention capacity. This impact is enunciated in the last
demographic question, which although not specific to the effects of HRM, revealed that
68% of ELHC doctors are not prepared to commit to remain working at the two hospitals.
It is clear that doctors in this sample simply want the basic HR functions performed
consistently well.
In conclusion this discussion has attempted to overlay the results of this study onto the
existing literature in this field. The next chapter summarises the entire research process in
order to draw conclusions and make recommendations.
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6. Conclusion Human resources, in the form of doctors, are an expensive commodity that all countries
cannot do without. Understanding how to prevent immigration and movement away from
the host country’s public sector is thus something that all developing countries should be
trying to master (Padarath et al., 2003). South Africa is no exception with the number of
doctors leaving the South African public sector reaching dangerous proportions (Grant,
2006; Hagopian et al., 2004).
Between 2002 and 2010 the retention gap for doctors broke 62% (HRH Strategy, 2011).
This retention gap is driven by doctors leaving the public sector to take up posts in the
private sector or to immigrate, usually to one of the developed nations. The forces
responsible for this movement are complex and include a multitude of so-called push and
pull factors (Mejia, Pizurki & Royston, 1979). These factors have over the years been
rigorously studied across the globe however this rigor has not gravitated through into
specifically trying to understand doctor retention in the South African public sector. This
has therefore left a void of knowledge that, if not filled, will bear witness to the downfall
of South Africa’s health system (Grant, 2006).
An institution and province that has been particularly affected by staffing shortages is the
East London Hospital Complex (ELHC), which can be found in the Eastern Cape. During
2012, this complex and province have experienced severe staffing difficulties with
“delayed or non-payment of critical healthcare workers” being cited as one of the reasons
causing doctors and other staff to abandon their public healthcare posts (Eager, 2012).
This situation as a result exposes the relationship between human resource management
and retention and highlights the need to assess and understand the impact of their
correlation.
It is has been suggested that this facet of the public health system holds the ability play an
active part in fighting the exodus of doctors and the crippling “brain drain” (Buchan, 2004).
With this potential in mind, this research has therefore attempted to explore the
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relationship between HRM and retention and in doing so, add to the body of knowledge
concerning the retention of doctors in the South African public health sector. While
attempting this investigation, the research has facilitated the exploration of not only the
role and impact of HRM on doctor retention but also the evaluation of how well these
practices are being performed in the South African context.
6.1 Important HRM Practices that Influence Doctor Retention at the ELHC
To answer the main research question, the ELHC with its current staffing difficulties was
identified as a potential organisation in which to perform the research. The research design
consisted of a mixed methods approach, which combined both qualitative and quantitative
strategies. Bryman and Bell (2007) consider this a valid approach that allows for the
triangulation of data (Jick, 1979). This facilitated the exploratory and descriptive study to
be conducted within in the doctor complement.
The way this was done was through a three-stage process. The first stage consisted of a
vigorous review of the literature and revealed a paucity of studies surrounding HRM
practices and their impacts on retention of HCW’s in the public health sector. Studies
regarding the forces underpinning HCW migration (Padarath et al., 2003) and surrounding
HCW motivation (Kotzee & Couper, 2006; Willis-Shattuck et al., 2008) were therefore
drawn on to begin the research process. With the ultimate goal of a multiple doctor survey,
the researcher embarked on a semi-structured interview process of four of the complexes
clinical heads of department. These interviews were undertaken to shed light onto the
understanding of the role of HR and the impact of their practices.
With this information, and the findings from the literature, the third and final part of the
research, a survey questionnaire, was built. Following a small pilot study, the survey was
administered anonymously via an electronic platform following an email and SMS request
to all approximately 300 doctors in the complex. Responses to the survey trickled in over
a two-week period. During this time, the full doctor complement was reminded repeatedly
via email and SMS to complete the survey. At the time of closing 93 responses were
entered, however only 75 of these were complete. This thus yielded a 25% response rate
from an estimated sample population of 300.
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6.2 Measuring the Performance of the ELHC HRM Practices
This questionnaire separated HRM into two distinct parts, the first being HR practices and
the second being HR characteristics. Following a short section on demographics,
respondents were asked to rank five identified HR practices in order of importance. This
was then followed by an open question enquiring about their highest ranked practice, with
a Likert Scale question, thereafter requesting doctors to rate the performance of the ELHC
HR department in the five practices. This template was repeated once more for the second
theme, that being the five HR characteristics.
Due to the focused nature of the research design employed, the results are unlikely to be
generalisable; however following the advice of Leedy and Ormrod (2005), the context of
the study was clearly identified in order assist readers to make conclusions as to whether or
not the results could be applicable to the broader South African public health sector.
6.3 The Most Important HR Practices
Most doctors felt that being paid on time and being paid correctly was the most important
HR practice. Much emotion surrounding remuneration inconsistencies and financial
security was conveyed with doctors feeling that it is simply not acceptable to fail to pay
salaries timeously. Documentation management and communication, both essential HR
components, were ranked by responding doctors as second and third respectively. Like
salary errors, documentation loss and failing communication was detested and resulted is
extreme amounts of frustration by doctors.
Ranking fourth, being respected and valued by HR staff, was something that doctors felt
was less important than fulfilling the basic HR functions well. One doctor in fact ranked
this practice as first and stated, “If the staff of HR respected and valued us then they would
pay us on time, keep our documents safe, strive to communicate effectively and place
priority on our continued education.” This last practice, that is, continued education,
although playing a critical role in both the doctors’ development and the clinical
functioning of the hospital complex, was ranked by doctors as the least important practice.
This, like value and respect, was trumped by the importance of the basics: salary payment,
documentation management and communication.
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6.4 Rating of the ELHC HR Practice Performance
Judging from both the quantitative and qualitative data collected, the ELHC’s performance
in all five HR practices is lacklustre to say the least. Salary payment accuracy, with its
critical role in employee security, was mentioned as a problem 45 times in the open
responses. Multiple doctors had fallen victim to some form of late or inaccurate payment
and numerous others feared non-payment on a monthly basis. Quantitative data revealed a
spread of responses for a practice that in the private sector is a complete non-negotiable. It
is thus clear that the poor execution of this practice still provides doctors at the ELHC with
a substantial amount of frustration.
With both practices being rated by 84% of doctors as unacceptable, document management
and communication efforts by the ELHC HR staff are dismal. Doctors felt that the efforts
made by the HR department to fulfil these practices were completely insufficient and this
opinion was supported by numerous cases of repeated document loss, identity fraud and
communicative failure.
For the practice ranked as the fourth most important practice, 64% of doctors felt that they
were not respected and valued by HR staff. This was corroborated by the qualitative
findings in both the interview and survey responses. As mentioned above, the crucial
nature of continued education and career development, although ranked least important
still received an alarming vote of unacceptable by 55% of responding doctors.
In summary, all HR practices in the ELHC require substantial improvement. From
correlating the qualitative responses with the performance rating, doctors in the ELHC are
clearly frustrated by the poor levels of HRM execution. It is this frustration that is
unfortunately bound to have negative effects on the institution’s retention capacity.
6.5 The Most Important HR Characteristics The second research theme of HR characteristics was categorically dominated by doctors
ranking task competence of HR staff, as the most important factor. It was clear that doctors
were annoyed by and frustrated when HR staff could not exhibit a high degree of
competence when dealing with their concerns. This characteristic was followed in the
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importance ranking by accountability. This was a characteristic that doctors perceived to
be a driver of excellence and quality.
The third ranked characteristic that doctors felt was important for HR staff to exhibit was
general process efficiency. It was emphatically emphasised that process efficiency allows
for timeous handling of critical activities such as application processing, problem
identification and failure resolution. This importance was confirmed by the fourth ranked
characteristic, salary adjustment efficiency relating to OSD and PMDS. Here doctors
experienced a significant amount of valuing and affirmation when salary adjustment was
correctly carried out.
In relation to the other five characteristics, HR staff availability was ranked the lowest. As
a result of a substantial clinical load, interview findings showed that doctors struggled to
visit the HR department at times outside of their tea and lunch times. These tea and lunch
visits were however only possible if staff were available during these times.
6.6 Rating the ELHC HR Characteristic Exhibition
With 77% of doctors rating the task competence of HR staff as unacceptable, it was
apparent that there was a deficiency in this characteristic. Many doctors felt that this was
the greatest failure of the HR department and believed the solution to the problems of poor
HRM lay in the training of HR staff. This failure was noticeably the most frustrating for
doctors as it impacted them on a daily basis.
The second and third ranked characteristics, these being accountability and general process
efficiency, were very poorly rated by the responding doctors. Both of these characteristics
were alarmingly perceived to be unacceptable by 81% and 87% of doctors respectively.
There were multiple examples of doctors being affected by these failures however the most
distressing comments was made by a senior doctor who stated, “I have examples of doctors
who applied to work in my�department who, when finally offered a post, had already been
working in an�alternative post elsewhere for over 6 months.”
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OSD and PMDS performance, although lower down on the importance ranking, was also
rated by 51% of doctors as unacceptable. From the responses, this crucial tool for
incentivising doctors is now noted to in fact, be more of a frustration and dreamlike fantasy
for doctors. Lastly the availability of HR staff during tea and lunch times, received a vote
of unacceptable by 65% of respondents.
It is clear from these findings that the identified characteristics are all being performed
unacceptably despite the relative importance rankings. As with the first theme, doctors
were overwhelmingly pessimistic towards the exhibition of characteristics by the ELHC
HR staff with virtually all written responses being negative.
6.7 HRM at the ELHC and its Impact on the Retention of Doctors
In light of the human resource crisis that is occurring in the ELHC and the Eastern Cape,
this research has revealed that the HR function of the ELHC is doing insufficient to curb
the flow of doctors leaving. The study has in fact shown that the HR department and its
fundamental failings have caused a substantial degree of frustration to and devaluing of
doctors. This seemingly has had a direct impact on doctors’ willingness to remain at the
complex with only 32% of the surveyed doctors willing to commit to continue working at
the ELHC. This influence can thus only be perpetuating the staffing problems that plague
the institution.
HRM in the health sector is known to be an enormous challenge (Buchan, 2004), and
although many of the problems in this research have been attributed to the staff within the
department, the influence of the cumbersome system inefficiencies that have been
implemented cannot be discounted. Staff within the ELHC HR may in fact be hamstrung
in their ability to enhance their productivity and may be as frustrated in their limited
capability as are the doctors who they attend to. An investigation into this aspect of HR
may be a sound follow-on to this research, the results of which would augment our
understanding of public health HRM significantly.
This said however, if HR is going to play an active part in retaining doctors at the ELHC,
then substantial improvement, in all areas, needs to occur as a matter of urgency. As the
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workforce of doctors changes to predominating that of members of Generation Y,
managing, motivating and most importantly retaining these individuals is set to become
more and more challenging. HRM improvement is thus not only critical to alleviate the
immediate staffing concerns but also to prepare for the diverse generational blend of
HCW’s that is set to pose a distinct management challenge in the future (De Meuse &
Mlodzik, 2010).
6.8 HRM in the Public Health Sector and its Impact on the Retention of Doctors
In conclusion, this research has revealed that the ELHC HR department through
unacceptable HRM appears to be perpetuating the doctor shortage and not assisting with its
mitigation. The link between sound HRM and doctor retention is thus clearly evident and
the importance of this relationship must be acknowledged and addressed.
South African public hospitals need to strive to become “magnet hospitals” (Buchan, 2004),
ones where doctors from all over the world jostle with our locally qualified doctors for the
opportunity to experience our impressive clinical practice. This however will never happen
unless these doctors together with our locally qualified professionals can work knowing
that all administration has been taken care of by highly trained and passionate HR staff
members.
6.9 Limitations of the Study This research was conducted on a single public hospital complex in South Africa. The
results of this research may thus not be generalisable to the broader public health sector.
The context that the research exists in is also very particular in terms of timing and the
current nature of the staffing crisis. Responses thus may be jaded by current circumstances
that the doctors find themselves in. Lastly this research has been primarily focused on
understanding the relationship between HRM and retention of doctors. As a result an
improvement strategy cannot be recommended in order to resolve the problems identified.
Further analysis and interpretation would need to be conducted to generate this type of
intervention.
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6.10 Future research This research lends itself to multiple areas for future investigation. First and foremost the
researcher opines that an investigation into the perspectives held by the HR staff is
paramount in further understanding the problem at hand. Both local and national HR staff
opinions would assist with isolating the cause for the problems and highlight the areas that
would need attention.
Secondly the generational complexity of the workforce is increasing and the public sector
especially the public health sector, must fully comprehend and plan for this progression. It
would be naïve to assume that management of these institutions can continue as is. It is
therefore suggested that a study be undertaken to investigate this change in composition of
the public health workforce in order to understand how best to manage these new HCW’s.
Lastly, it would be very pertinent to overcome the poor generalisability of this study by
investigating the perspectives of doctors from multiple institutions and provinces. This
would aid in not only determining the extent of the problem but, if a site of excellence is
found, may also facilitate an enquiry into what is driving this superior functioning.
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Assessing their impact on the Retention of South African Doctors
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8. Appendices
Appendix 1: Authorisation from The Chief Executive Officer at the ELHC
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Assessing their impact on the Retention of South African Doctors
University of Cape Town Masters of Business Administration Research Report 74
Appendix 2: UCT Ethical Clearance Form
21 September 2012
To whom it may concern, Re: Ethical clearance for research proposed by Bruce Longmore This is to certify that the GSB Ethics in Research Committee has considered the subject and the methodology of the research proposed by Bruce Longmore, for the project titled, “Human resource management practices in the South African public health sector: Assessing their impact on the retention of South African doctors,” and has given ethical clearance on the basis of guidelines and rules provided by the UCT Faculty of Commerce. Please let us know if you have any comments or queries.
Kind regards,
Ralph Hamann
Chair of the GSB Ethics in Research Committee
Ralph Hamann
Associate Professor & Research Director
T: +27 (0)21 406 1503
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Appendix 3: Head of Department Questionnaire
Head of Department Questionnaire
1. With regard to the management of doctors:
a. What management practices do the HR department utilise that you feel
positively influence doctors to stay at the complex?
i. Of these mentioned which ones have the greatest impact?
b. What management practices do the HR department perform that you feel
reduce the potential for doctors to stay at the complex?
i. Of these mentioned which ones have the greatest impact?
2. With regard to the way the HR functions as a department:
a. What inherent HR activities encourage positive interaction between Doctor
and HR?
b. What inherent HR activities frustrate doctors and negatively affect the
Doctor/HR relationship?
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Appendix 4: Survey Page 1
Page 1
Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)
Please note responses are FULLY ANONYMOUS.
5. If South African, what is your province of origin?5. If South African, what is your province of origin?5. If South African, what is your province of origin?5. If South African, what is your province of origin?
6. Curent Position6. Curent Position6. Curent Position6. Curent Position
Section 1 of 3 : Demographic Information
1. What is your gender?1. What is your gender?1. What is your gender?1. What is your gender?*
2. Age Group2. Age Group2. Age Group2. Age Group*
3. Race (As per the Employment Equity Act, 3. Race (As per the Employment Equity Act, 3. Race (As per the Employment Equity Act, 3. Race (As per the Employment Equity Act, 1998) OPTIONAL1998) OPTIONAL1998) OPTIONAL1998) OPTIONAL
4. Nationality4. Nationality4. Nationality4. Nationality*
*
7. How long have you been working at the ELHC?7. How long have you been working at the ELHC?7. How long have you been working at the ELHC?7. How long have you been working at the ELHC?*
8. Do you intend staying at the 8. Do you intend staying at the 8. Do you intend staying at the 8. Do you intend staying at the ELHC?ELHC?ELHC?ELHC?
*
Female Male
25-32 33-50 51-66 +67
African Coloured Indian White
Other (please specify)
South African
Other
Intern Community Service
Medical Officer
Registrar Consultant
0 to 2 yrs 2 to 5 yrs 5 to 10 yrs More than 10yrs
Yes No Unsure
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Appendix 5: Survey Page 2
Page 2
Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)
9. Please RANK the following HR practices in order of their importance to 9. Please RANK the following HR practices in order of their importance to 9. Please RANK the following HR practices in order of their importance to 9. Please RANK the following HR practices in order of their importance to you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)
10. With reference to your most important practice above, please provide a 10. With reference to your most important practice above, please provide a 10. With reference to your most important practice above, please provide a 10. With reference to your most important practice above, please provide a brief description of why you feel this way.brief description of why you feel this way.brief description of why you feel this way.brief description of why you feel this way.
11. On a scale of 111. On a scale of 111. On a scale of 111. On a scale of 1----4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex HR department performs these tasks.HR department performs these tasks.HR department performs these tasks.HR department performs these tasks.
12. Any other comments or factors not raised above?12. Any other comments or factors not raised above?12. Any other comments or factors not raised above?12. Any other comments or factors not raised above?
Section 2 of 3 : HR Practice Importance
*
1. To be respected and valued by HR staff and receive friendly and helpful service
2. Monthly salary paid on time
3. An adequate document collection, filing and storage system
4. Good communication E.g. Post availability, status of requests made the department, and the whereabouts of submitted documents.
5. Re-imbursment for courses/conferences attended, and processing of special leave requests.
*
*
UnacceptableAcceptable GoodVery Good
To be respected and valued by HR staff and receivefriendly and helpful service
An adequate document collection, filing and storage system
Re-imbursment for courses/conferences attended, and processing of special leave requests.
Monthly salary paid on time
Good communication E.g. Post availability, status of requests made the department, and the whereabouts of submitted documents.
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Appendix 5: Survey Page 3
Page 3
Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)
13. Please RANK the following HR practices in order of their importance to 13. Please RANK the following HR practices in order of their importance to 13. Please RANK the following HR practices in order of their importance to 13. Please RANK the following HR practices in order of their importance to you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)
14. With reference to your most important practice above, please provide a 14. With reference to your most important practice above, please provide a 14. With reference to your most important practice above, please provide a 14. With reference to your most important practice above, please provide a brief description of any situation that has contributed to you feeling this way.brief description of any situation that has contributed to you feeling this way.brief description of any situation that has contributed to you feeling this way.brief description of any situation that has contributed to you feeling this way.
15. On a scale of 115. On a scale of 115. On a scale of 115. On a scale of 1----4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex HR department performs these tasks.HR department performs these tasks.HR department performs these tasks.HR department performs these tasks.
16. Any other Comments or factors that this survey has failed to raise16. Any other Comments or factors that this survey has failed to raise16. Any other Comments or factors that this survey has failed to raise16. Any other Comments or factors that this survey has failed to raise
Section 3 of 3 : HR Practice Importance
* 1. The task competence of HR staff
2. The accountability of HR staff for queries made or documents submitted
3. General HR process efficiency
4. The availability of HR staff during tea and lunch times
5. OSD* Salary level adjustments and PMDS** efficiency (*Occupation Specific Dispensation, **Performance Management and Development System)
*
UnacceptableAcceptableGoodVery Good
N/A
The accountability of HR staff for queries made ordocuments submitted
The task competence of HR staff
The availability of HR staff during tea and lunch times
General HR process efficiency
OSD* Salary level adjustments and PMDS** efficiency (*Occupation Specific Dispensation, **Performance Management and Development System)
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Appendix 6: Daily Dispatch Newspaper Article