THE CONCEPT OF DECENTRALISATION OF HEALTH SERVICES

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CHAPTER 2  LITERATURE REVIEW

 INTRODUCTION

Health workers‟ performance is a complex area to address because of a variety of influencing issues at different levels of health care. These issues are rooted in the ministries of health, districts, health facilities, individual health workers, and the communities. Health care delivery is highly dependent on manual labour. It needs skilled, competent, committed, responsive, and productive workers to achieve the mission and goals. As such, health workers are crucial to the delivery of health services. They manage other resources and a big percentage of the annual national health budget is spent on them (JLI 2004:21). Despite the achievements made since the introduction of market reforms in Uganda, little is known and published about the performance of health workers. Most of the studies done worldwide are focusing on performance of health systems and are not specifically targeted to health workers. In order to improve the health status of Ugandans and performance of health workers, policymakers need evidence to make informed decisions.
This research aims at developing a performance management framework that health sector stakeholders can use to improve service delivery. Its main contribution is geared towards the formulation of a framework for performance management that is specific to health workers. Performance management in the health sector is still deficient in Uganda and its implementation is not well documented. The performance management and appraisal guidelines used by health workers are similar to those used by other professionals in public service. Therefore, there is a need to have guidelines that are specific to health profession due to the complexity involved in health service delivery.
This chapter presents a review of existing literature relevant to the study. The review is aimed at identifying what is already known about performance of health workers in order to assist in identifying the grey areas that could be addressed by this study. The researcher identified and clarified the various determinants that influence performance of health workers. Since there is insufficient information about performance of health workers in Uganda, this review presented performance from a general perspective. The following are the main areas of focus:

• The description of the components of the theoretical model which is illustrated in Figure 1.2.
• The concept of decentralisation of health services.
• The importance of human resources management practices as tools for managing performance.
• The discussion of the health workforce performance dimensions which include health workers availability, competence, productivity, and responsiveness.
• Performance management and appraisal of health workers.
• The role of leadership in guiding performance of health workers.

DESCRIPTION OF THE THEORETICAL FRAMEWORK

The researcher based this study on the „strategic performance model‟ adapted from Noe et al (2008:345) as illustrated in Figure 1.2. The „strategic performance model‟ guided literature review, data analysis and presentation of results. The model makes reference mainly to the following concepts: individual attributes and behaviours, organisational strategy, performance dimensions and situational constraints. Noe et al (2008:345) describe individual attributes as key drivers of performance. These attributes must be translated into individual behaviours for performance to occur. The individual attributes and behaviours are influenced among other things by the organisational strategy and the situational constraints.

Individual attributes

These are characteristics that make individuals unique and differentiate them from others. These can be related to what Armstrong (2009:300) and Baines, Asch, Hadfield, Mason, Fletcher and Kay (2005:496) describe as factors that influence individual performance since they are unique for every individual. Such factors include skills and abilities, self-monitoring abilities, intrinsic motivation, organisational commitment, worker experience, values and beliefs. Further attributes include personality, demographics, physiology and cognition. These factors influence performance in a number of ways. For example, skills and abilities dictate the capability of an individual to perform tasks as required (Kahya 2007:517). The extent to which an employee keeps his performance in check (self-monitoring) and his ability to take corrective action when performance falls below acceptable standards is vital. The cognitive ability can contribute directly to overall job performance through its effects on knowledge and skills acquisition (Kahya 2009:101; Ree, Earles & Teachout 1994:518). Additionally, Hackman and Oldham (1976:255) mention that the state of motivation such as job satisfaction is positively related to individual performance.
Authors like Baines et al (2005:499), Kahya (2007:515), and Viswesvaren and Ones (2000:223) emphasise that general cognitive ability and personality dimension of precision are strongly related to work performance. Moreover, they indicate that personality traits such as interpersonal skills, training and turnover are essential for performance of workers. Other writers such as Suliman and Iles (2000:415) and Van Scotter (2000:93) argue that in addition to the individual characteristics, several circumstantial and attitudinal factors are positively associated with work performance through motivation. Organisational commitment, job satisfaction and work-related attitudes, values and beliefs are particularly important factors for performance. The demographics and physiological factors such as age and gender are also relevant for work performance (Baines et al 2005:498; Kahya 2007:516).

Individual behaviour

Behaviour is the way individuals conduct themselves in a specific situation and at a particular point in time. Armstrong (2009:301) emphasises that individual behaviour at work is dependent on both the personal characteristics (abilities, intelligence, personality, attitudes, and emotions) and the situation in which they work. Individual behaviours have a crucial role to play in determining work role performance (Kahya 2009:96). Health workers need specific behaviours to contribute to the desired health outcomes. Such behaviours are not directly under the control of central or local governments but are controlled at both the individual and organisational levels. These behaviours are directly related to performing job tasks (work roles) (Fritzen 2007:[2]; Perkins, Jensen, Jaccard, Gollwitzer, Oettingen, Pappadopulos & Hoagwood 2007:343).
In this study, the researcher investigated the work role performance behaviour of health workers as individuals (individual task behaviour), members of teams and organisations (team and organisation membership behaviours), and client-oriented behaviour. Murphy and Jackson (1999:335) and Kahya (2009:96) describe work roles as „…the total set of performance responsibilities associated with one‟s employment‟. These responsibilities are carried out in conjunction with the behaviours just listed. Based on this definition, Griffin, Neal and Parker (2007:330) proposed a model of positive work role performance behaviours which address effectiveness in uncertain and interdependent organisational contexts. Griffin et al (2007:330), cross-classified the three levels at which work role behaviours contribute to effectiveness (individual, team, and organisation) and the three different forms of behaviour (proficiency, adaptability, and pro-activity) into sub-dimensions of work role performance. The researcher would like to use a similar approach in this study since it is a grey area especially in public health.
Individual task proficiency describes behaviours which fulfils the known expectations and requirements of the roles of an individual. Team proficiency behaviour reflects the degree to which the individual meets the expectations and requirements of his roles as a member of a group. Organisation proficiency behaviours refer to how the individual contributes to the expectations and requirements as a member of the organisation (Griffin et al 2007:331). Kahya (2009:102) notes that behaviours involving cooperation, creativity, and self development contribute to performance.
Individual task adaptability describes the degree to which employees cope with or respond to changes that affect their roles. On the other hand, team member task adaptability, reflects how the individuals respond to changes that affect their roles as members of the group. Organisation member adaptability describes how the individuals cope with changes that affect their roles in an organisation (Griffin et al 2007:331-332).
Task pro-activity refers to extent to which individuals themselves or within a teams and organisation engage in self-directed and future oriented behaviour and toward changes in work situations. Such behaviour ensures that the organisation as a whole develops and innovates rather than promote change only within a department (Griffin et al 2007:332). Kahya (2009:102) explains the strong relationship that exists between creative performance and innovative effectiveness. The workers who score highly on creative performance generally obtain high outcomes in innovative effectiveness (Kahya 2009:102).
Another important variable for individual behaviour is the client-oriented (customer-oriented) behaviour. The term client orientation has been used constantly in marketing literature to explain an organisational posture in which the clients are main focus for the organisational strategy design (Noor & Muhamad 2005:126; Saura, Contri, Berenguer, Taulet & Velázquez 2005:497). At individual level client orientation is the willingness of the service providers to adjust their services delivery according to the needs, problems, and circumstances of the customers (Daniel & Darby 1997:272; Lanjananda & Patterson 2009:8). On the other hand, Hartline, Maxham and McKee (2000:35) and Noor and Muhamad (2005:126) define client (customer)-orientation at the organisational level as „…the set of standards that puts the clients‟ interests at the forefront , in order to develop a sustainable and profitable enterprise‟.
Other scholars like Lanjananda and Patterson (2009:8) refer to client-oriented behaviour as „…the specific behaviours displayed by employees during service encounters that lead to satisfied customers. These behaviours may include empathy, assurance, responsiveness, authenticity, listening, dedication and civility (Lanjananda & Patterson 2009:9). According to Berry and Bendapudi (2007:111), health care is perhaps the most personalised service that clients search for. However, many studies document variations in the quality of care provided. Hence, the behaviours of front-line health workers such as nurses, clinical officers and medical doctors are critical for both patient satisfaction and successful health outcomes. It is therefore important to understand what behaviours predict the performance of health workers. This research, attempted to explain the performance of front-line health workers by simultaneously examining the individual attributes and behaviours, the situational constraints, and the organisational strategy.

Performance

Performance has many dimensions. It involves delivering favourable results on time, within budget, and according to set standards (Department of Industrial Relations, Public Sector & Employee Relations (DIRPSER) 2005:5). Armstrong (2009:136) mentions that the notion of performance covers what has been achieved and how it is achieved. In this study, performance refers to availability, productivity, competence and responsiveness of the health workers (WHO 2006:68).
Whereas producing better health outcomes is important so is the aptitude to respond efficiently and effectively to the emerging challenges in the health sector. Since client satisfaction is a critical component of perfomance, it is important to create and maintain this ability. Performance management is concerned with the management of key relationships with clientele, work-mates, higher-ranking managers and legislators. The realisation of performance targets and client satisfaction are both dependent upon employee performance. Therefore, performance is composed of efficiency and effectiveness of internal organisational procedures and ultimately depends on individual employee commitment. Managing health workers‟ perfomance, obtaining feedback regularly about workers‟ satisfaction with management procedures as well as monitoring the institutional environment are all crucial perfomance dimensions (DIRPSER 2005:5). The dimensions of health workers‟ performance are discussed in detail in sub-section 2.5.

Organisational strategy

This refers to the direction the organisation wants to take to achieve its goals (Noe et al 2008:69). Thompson, Strickland and Gamble (2010:6) define a strategy as „…the management‟s action plans for running the business and conducting operations‟. Performance management is critical in supporting the formulation and implementation of the organisational strategy. The formulation of a strategy involves the establishment of five major components which include the organisation‟s mission, strategic goals, external analysis, internal analysis and the strategic choice (Noe et al 2008:75). The organisation‟s mission specifies the reason for existence and the strategic goals reflect on what the organisation intends to achieve. External analysis provides information about the threats and opportunities that exist within the organisation‟s environment whereas the internal analysis provides information about the organisation‟s strengths and weaknesses. Lastly, the strategic choice is the organisation‟s chosen plan that stipulates the way the mission and strategic goals will be achieved (Noe et al 2008:77). Hence,employee input and alignment of organisational activities to the mission is vital to strategy formulation and implementation.
Noe et al (2008:80) mention five variables that influence the success of strategy implementation. These include organisation structure, type of information and information systems, task design, selection, training and development, and employee reward systems. The last three variables are the direct responsibility of human resource management function and the first two variables are influenced by human resources. Therefore, a performance management system provides a mechanism for steering organisations towards achieving their goals by facilitating the monitoring of existing strategies to ascetain the achievement of desired outcomes. When circumstances warrant change, performance management systems provide managers with a powerful tool to ensure the rapid change implementation (DIRPSER 2005:5).

Situational constraints

Situational constraints are contextual factors within and outside the organisation that are likely to affect the performance of health workers. These factors may also influence individual characteristics and behaviours (Noe et al 2008:346). Situational constraints may include organisation factors, working environment, and economic factors. Therefore, when evaluating performance of health workers, it is important to scrutinise situational factors that are likely to positively or negatively affect performance. These factors may either motivate or de-motivate health workers. As illustrated in Figure 1.2, the researcher‟s focus is on the following situational constraints: organisational culture, community expectations, performance management style, working environment, leadership, rewards and sanctions, and decentralisation. For example, Kahya (2007:515) reports that poor working conditions (physical efforts, environmental conditions and hazards) may decrease employee performance. Such factors may consist of rigid organisational rules, lack of cooperation among co-workers in solving complex tasks, and absenteeism among others.

Justification for using the chosen theoretical framework

The „strategic performance‟ model provides a strong conceptual basis for this study as it emanates from the strategic management process. This model is built on the premise that a clear link must be established between the overall organisation‟s strategy and its human resource management strategy. The result of this endearvour is human resource practices geared towards the attainment ,of the organisation‟s goals and objectives. Similarly, human resource management practices must be aligned to performance (Armstrong 2009:146). Human resources management practitioners like Armstrong (2009:147) have established that well executed human resources management (HRM) practices positively influence employee performance.
The use of the „strategic performance model‟ is justified in this study because it guided the researcher‟s quest to achieve the research objectives. The model helped the researcher answer the question of what factors impede or enhance the performance of health workers. Could it be that health workers do not understand the mission, goals and objectives of their organisation or the top management does not support employee skills advancement through training, development and proper employee retention policies?

CHAPTER 1 ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND INFORMATION ABOUT THE RESEARCH PROBLEM
1.3 STATEMENT OF THE RESEARCH PROBLEM
1.4 AIM AND OBJECTIVES OF THE STUDY
1.5 SIGNIFICANCE OF THE STUDY
1.6 DEFINITION OF KEY CONCEPTS
1.7 FOUNDATIONS OF THE STUDY
1.8 RESEARCH DESIGN AND METHODOLOGY
1.9 SCOPE AND LIMITATIONS OF THE STUDY
1.10 STRUCTURE OF THE THESIS
1.11 CONCLUSION
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION
2.2 DESCRIPTION OF THE THEORETICAL FRAMEWORK
2.3 THE CONCEPT OF DECENTRALISATION OF HEALTH SERVICES
2.4 HUMAN RESOURCE MANAGEMENT
2.5 PERFORMANCE OF HEALTH WORKERS
2.6 PERFORMANCE MANAGEMENT
2.7 THE ROLE OF LEADERSHIP IN PERFORMANCE MANAGEMENT
2.8 CONCLUSION
CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY
3.1 INTRODUCTION
3.2 RATIONALE OF THE STUDY
3.3 THE SCOPE OF THE STUDY
3.4 RESEARCH DESIGN
3.5 LEVEL 1: QUANTITATIVE RESEARCH METHODS
3.6 LEVEL 2: QUALITATIVE RESEARCH METHODS
3.7 ETHICAL CONSIDERATIONS
3.8 CONCLUSION
CHAPTER 4 ANALYSIS, INTERPRETATION, AND DISCUSSION OF QUANTITATIVE DATA (LEVEL 1)
4.1 INTRODUCTION
4.2 RESPONSE RATE
4.3 DATA ANALYSIS
4.4 DEMOGRAPHIC INFORMATION OF THE PARTICIPANTS
4.5 FINDINGS RELATED TO OBJECTIVE ONE
4.6 FINDINGS RELATED TO OBJECTIVE TWO
4.7 FINDINGS RELATED TO OBJECTIVE THREE
4.8 CONCLUSION
CHAPTER 5 ANALYSIS, INTERPRETATION, AND DISCUSSION OF QUALITATIVE DATA (LEVEL 2)
5.1 INTRODUCTION
5.2 RESEARCH METHODOLOGY
5.3 DATA COLLECTION
5.4 DATA ANALYSIS
5.5 PRESENTATION OF FINDINGS FROM SECTION A OF THE INTERVIEW GUIDE
5.6 PRESENTATION, INTERPRETATION AND DESCRIPTION OF FINDINGS FROM SECTION B OF THE INTERVIEW GUIDE
5.7 CONCLUSION
CHAPTER 6 CONCLUSIONS, LIMITATIONS, AND RECOMMENDATIONS
6.1 INTRODUCTION
6.2 THE AIM AND OBJECTIVES OF THE STUDY
6.3 RESEARCH DESIGN AND METHODOLOGY
6.4 CONCLUSIONS
6.5 LIMITATIONS OF THE STUDY
6.6 RECOMMENDATIONS
6.7 CONTRIBUTION OF THE STUDY
6.8 CONCLUDING REMARKS
BIBLIOGRAPHY
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