Private Provider Retention in Ethiopia
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In Ethiopia, private providers are leaving clinics and hospitals in alarming numbers. A recent investigation tried to find out the reasons for the high turnover, and what could be done about it.
To meet the health care needs of its 77 million-plus population, the government of Ethiopia is relying more and more on the private sector. Private hospitals and clinics employ more than 50% of doctors in the country. Most private facilities are located in or near the capital, Addis Ababa. PEPFAR implementing partners, including PSP-Ethiopia, have been playing a supporting role in this effort by training private-sector doctors and nurses in TB and HIV detection, care, and treatment. In a discouraging trend, however, many private hospitals and clinics are experiencing as much as 80% staff turnover per year, creating a training treadmill in order to keep sites staffed with skilled providers.
In September of this year I traveled to Addis for PSP-One to interview providers, find out about working conditions at private hospitals and clinics, and try to root out the causes of high staff turnover. Working with local staff and a local human resources consultant, we conducted more than 40 in-depth interviews in more than 20 clinics and hospitals. The sites ranged from simple “medium clinics” with rough bare flooring, dim lights, and scanty equipment, to the best hospital in the country, a rival for anything in Europe or North America. The interviews, conducted in Amharic but sprinkled with English as is typical in Addis Ababa, revealed the typical working conditions that created the “push” factors behind high turnover.
Doctor after doctor described low salaries, complete lack of benefits, and worn or absent basic equipment. Some employees even had to pay for care which was needed because of on-the-job injuries, at the very facilities in which they were injured. Others complained of receiving nothing but negative feedback, and being ignored when doing a good job: “When I do a good job for day after day, I hear nothing. When I make one small mistake he yells and reprimands me.” Another doctor cited lack of appreciation for hard work: “when I work long hours they just act as if I have no place better to go.” Another spoke in angry tones of the feeling of the hospital’s mercenary atmosphere: “If I work, I will get money. If I can’t work, I will just be thrown out!”
Where were the quitters going? Because most clinics offered the same pay, benefits, and working environment as other clinics, clinic staff tended to leave for hospitals. Doctors from hospitals were leaving for work with international NGO’s or in other countries. In an advertisement posted at the Botswana embassy in Addis Ababa, the country of Botswana was advertising for 1750 doctors, to be hired at 2-3 times the wages in Ethiopia. There are now approximately 2700 Ethiopian doctors.
What about providers who didn’t leave? What was keeping them? Long-term employees cited respect from their supervisors: “He listens to me. When I make a decision, he respects me and doesn’t countermand it. He offers opinions and good advice, but always as a colleague.” Some managers encourage employees to learn new skills, covering their position while they attended training: “learning new things makes me more valuable at the clinic, and gives me a good attitude at work.” Others who stayed on the job cited understanding managers or flexible work schedules that allowed for child care. Some hospitals offered pay increments (raises) based on good performance, which tended to keep the good performers. Other providers appreciated a “free and open” working environment.
The next step is to bring together a diverse group of stakeholders to discuss the causes of retention and turnover. The group will also brainstorm feasible interventions to slow the rampant turnover. A probable intervention, strongly endorsed by both providers and facility managers, is human resource management training for clinic owners and managers. One physician owner, asking for ideas to keep employees on the job allowed “I’m a doctor; I’ve never received any training on human resource management. I’m willing to learn techniques that will keep my people satisfied, and will keep them from leaving.”
