Based on the study objectives that guided the data analysis, the results are presented below according to the different emerging themes.
Effects of the deployment of HCWs on local health systems
Out of 611 HCWs officially deployed in the selected rural health districts in April 2017, 600 (98%) took-up duties. The distribution characteristics of these HCWs are depicted in table 2.
Female HCWs accounted for 64% of them. Assistant-nurses (39%), nurses (26%), medical doctors (20%), and midwives (12%) were the most represented socio-professional categories.
Overall, HCWs were mostly posted in health centres (69%) and district hospitals (26%). Moreover, 42% of medical doctors (49 out of 118), 71% of nurses and 76% of midwives were assigned to health centres.
Two main themes emerged from the interviews with participants when asked about the potential effects of the deployment of HCWs.
First, respondents stated that the EVD outbreak led to “job-abandonment” of many unemployed HCWs because of the fear of contracting the disease or the take-up of employment offers in epidemic control programmes, especially with international organizations. As such, according to them, the deployment of HCWs helped to fill this gap and improved staffing levels.
Second, according to participants, the deployment allowed the staffing of managerial positions with qualified HCWs owning several competencies, for example in computer processing, teaching and care delivery. This according to participants, resulted in better care organization through the sharing of task and workload among the staff but also in timely reporting of completed and good quality data.
... we have fully staffed, for the first time, our organic framework ...... Today many technical problems with our computers, or the making of patients’ consultations notebooks are solved on the spot by this personnel ... Now, the units of statistics, planning and training are held by medical doctors across the country ... it helps to the rapid [timely] reporting of completed and good quality data ... (IDI# 28 local health authority)
However, four challenges were reportedly faced by local health authorities, and health facilities and services managers during the posting process of HCWs.
First, participants reported that many HCWs were unfamiliar with delivery of primary healthcare in rural settings. This, according to participants, were due to the fact that few had experience and acquaintance with medical practice or were rather accustomed to the delivery of care in hospitals and urban settings. Some local health managers reportedly organized intensive on-sites trainings, for HCWs, on the functioning of primary healthcare facilities, especially immunization, maternal and primary curative care.
Second, the high proportion of female HCWs was another reported challenge as many were pregnant or breastfeeding at the time of the deployment. This pushed local health authorities to predominantly (re) assign female HCWs to urban or easy-to-access rural health facilities and as to compensate for it, unemployed HCWs (mainly males) were reallocated to rural and hard-to-reach areas with some incentive packages (e.g. allocation of 10-20% of healthcare facilities monthly income).
Third, some local unemployed HCW left public health facilities as a result of their frustration for not been recruited.
...We have work for several years here but the district health director never manages to recruit us as public servants ... We [eight of us] decided to create our private cabinet... we see over 300 patients per month [more than most health centres in the locality do] and the income we generate daily [from patients] is used to buy food and eat together... Patients prefer coming to us because of the trust we built with them over the years we were working in the public health facilities... (IDI# 11 health provider)
Fourth, participants reported collaboration conflicts between new and former HCWs. These were mainly sustained, according to participants, by the perceived unequal treatment of HCWs vis-a-vis appointment at positions of responsibility which were in favour of new HCWs. This impacted healthcare organization and functioning in some health districts, especially in the conduction of health services monitoring and evaluation activities.
To address collaboration conflicts, some local health authorities carried out a complete reshuffle of management positions in the frontline health facilities including sending former HCWs, especially health services managers, to places unfamiliar to them.
Finally, it emerged from interviews that HCWs were posted in local health facilities without a proper task description. According to respondents, this resulted in less accountability of HCWs and reportedly accentuated collaboration conflicts between them, as quoted below.
... it is the traditional birth attendant and assistant-nurses who have being delivering births here and that has not changed even with our presence [after our assigning] ... But it is difficult to do anything in this situation because no written document distinguishes the roles of an assistant-nurses, a nurse or a midwife... We have been parachuted here without any documentation on our roles and responsibilities and this limits us in our work and the claiming of our rights... (IDI# 6 health provider)
Barriers and enablers of the retention of health workers
This section on the barriers and enablers of HCWs retention follows the elements of attraction, installation and integration, according to Bilodeau analytical framework.
Attraction factors
Overall, respectively 85% and 68% of the new HCWs reported that they were well received by local health authorities and the local communities during the take-up of duties (Figure 2).
From the interviews, three main reasons emerged as factors attracting HCWs in rural Guinea in the post-Ebola context.
First, the desire to become a public servant was an important attraction factor for rural practice. For some participants, the advantage related to the status of public servant is that it provides a lifetime guarantee and requires fewer constraints and working time as usually required by the private sector. For some other HCWs, it offers an opportunity to become independent from the family or the spouse after several years of dependency and its related-financial implications in, for instance, supporting education and living expenditures.
... Public servant status gives a lifetime guarantee... You can still be paid even when you are sick or retired... working in the private sector represents a risk even though it pays well... (IDI#12 health provider)
Second, working in rural areas was perceived by HCWs as an opportunity to continue practising medicine and learning from another context. For some HCWs interviewed, especially nurses and midwives, health facilities in rural areas are less staffed compared with urban settings, and in that sense, offer unique learning opportunities. For instance, some nurses and midwives reported that working in rural areas provides more responsibility and help to acquire knowledge which is only dedicated to medical doctors in urban places.
... As a nurse, practising in rural areas gives a lot of learning opportunities... Here I have been taught how to examine a patient including using a stethoscope but in the national hospital I worked before, I could only inject patients or ensure their nursing ... (IDI#38 health provider)
Third, some HCWs stated that they were attracted by rural practice because of their vocation to help disadvantaged population like those living in rural areas. They justified this by their involvement in humanitarian projects in rural areas, be it their actual assigned zone or not. For this group of HCWs, they are interested working anywhere if the need arises.
Installation factors
The role of local health authorities and community representatives were repeatedly mentioned by HCWs as a favouring factor for their installation, particularly in rural areas. In some places, the facilitation of accommodation acquisition, the donation of food and cooking utensils to HCWs and provision of means of transport (administrative and personal) was reported.
However, difficulties were reported by some HCWs during their installation. These were related to lack of housing especially in urban and mining areas, the working atmosphere, and local living conditions (roads, food, etc.).
First, participants reported the difficulty in obtaining houses.
It was reported that HCWs stayed in health facilities for a while before getting an accommodation. Because of this, some HCWs temporarily left their assigned post. These participants highlighted that they were afraid of contracting nosocomial infections while they also had financial difficulties in bearing the costs of housing. They suggested that the state give installation bonuses to facilitate HCWs installation process in rural areas.
Second, some HCWs reported collaboration conflicts with former workforce in their assigned positions. This, according to them, exist because the former staff considered them a threat to their position of responsibility. The role of HCWs parents was crucial, at this stage, for motivating them not to leave their posts.
... It was not easy to work with them... It was not easy at all... I went back to Conakry and informed my parents ... they are the ones who encouraged me to come back to my post... My mother told me, it is a public service, not someone's property, you cannot leave your job because of someone attitude towards you ... (IDI#34 health provider)
Other attitudes were also adopted by HCWs to cope with this situation; the most important of which were the exclusive focus on the provision of care (financial management left to the former staff), and the avoidance of calling oneself a civil servant.
Third, with regards to living conditions, we quote below a HCW.
... I was assigned to Mixi [fictitious name] ... Cars only go there once a week... when I arrived in the village [place of deployment], I cried and I said to myself why did the state do this to me? ... my first 2 nights here, I didn't sleep at all... I took it as a punishment from the state... (IDI#12 health provider)
Integration factors
Up to 69% of HCWs surveyed were not satisfied with their living conditions. However, respectively, 62% and 74% were satisfied with their salary conditions, professional situation, and 85% felt secure at work (Figure 3).
Poor living conditions, low salaries and limited learning environment were mainly identified as factors impeding the integration of HCWs in rural areas. With regards to living conditions, the difficulties of accessing schools for children, electricity, potable water, internet and decent housing were considered major obstacles.
... Here is an island, there is no potable water... the water of the wells is salty; we have to buy the packets of water in town [sub-district located 15km away] ... (IDI#17 health provider)
Issues such as difficulties for children to readapt to the new situation of the family, the fragile health status of a family member, inaccessibility of the currently assigned zone were also reported. From some married female HCWs point of views, staying far away from ones' husband and family is not well perceived in Guinean context.
"...Being married and staying away from your husband for months is not well perceived by society... people often downgrade you... They think you are in extramarital relationships with your colleagues or managers or that you have no sense of social value... If you have a jealous husband or an annoying family-in-law, they will always ask you to choose between your work and your family... (IDI#42 health provider)
Salaries were a major concern for many participants but with a different effect depending on individual characteristics. For HCWs with many people to care of (including their children) and previous exposure to private practice (including working with international organizations before their recruitment), the major concern was the insufficiency of salaries along with the lack of alternative sources of income in rural areas to cover actual expectations and needs of the family.
In some study sites, local health facilities managers were allocating financial bonuses to HCWs to compensate for low salaries. This included the sharing of 10-20% of the healthcare facilities monthly income to HCWs as motivational bonuses. Exceptionally, in some mining zones, health facilities managers authorised HCWs to sell their medicines during night-shifts, but under the supervision of a regulatory committee which control drugs quality and sale prices.
For HCWs posted in rural and hard-to-reach areas, the lack of financial compensation for geographic distances and difficult living and working conditions were reported as factors inhibiting their integration. For example, some HCWs complained that current salary payment method was creating inequality at the disadvantages of HCWs posted in hard-to reach areas compared to their peers working at district level. HCWs posted in hard-to-reach settings have to pay part of their salaries as transportation fees for accessing them at the district health office – salaries are paid, by cash, at the district health office– while their colleagues staying in urban areas are not exposed to such extra expenses.
Other elements inhibiting the integration of HCWs was the under-utilisation of health services by communities in rural areas. According to participants, the population in remote areas utilise health services once a week and exceptionally during three months of the raining season – which corresponds to high malaria transmission period. Many midwives also supported that birth deliveries are attended in communities, by traditional birth attendants, and only a few of them are referred to them at the stage of complications.
Turnover of healthcare workers
Absenteeism
413 (69%) were present at their assigned posts 12 months later. This represented a 31% absenteeism rate among recently deployed HCWs (Fig.5).
The sociodemographic characteristics of the health workers present in their post 12 months after their deployment are presented in table 3. Absenteeism rates were more pronounced among female HCWs (33%), medical doctors (47%), nurses (31%) and midwives (29%).
Reported reasons for absenteeism
Figure 6 depicts the reasons for absenteeism of new HCWs. The reason for absenteeism from work was unknown/non-justifiable in 51% of cases meaning that these HCWs left their posts without prior request and authorization of their supervisors. Continuing training (12%), illness (10%), maternity leave (9%) and redeployment to another health district (7%) were the other most common reasons for absenteeism.
None of the above reasons was documented at local levels and interviews revealed an underlying factor: patronage attitudes of health system actors both at the central and local levels.
First, actors from the central and regional levels of the MoH were reportedly influencing decision-making processes regarding the management of some HCWs. For instance, participants reported that training leaves and redeployment acts were exclusively delivered by the central administration of the MoH and without prior consultation of local health authorities. Also, according to participants, some decision-makers from the central and regional levels were involved in leaves requests concerning their relatives, especially in district surrounding the capital Conakry.
... More than 80% of the health personnel affected in Coyah, Boffa, Kindia and Forecariah were women... And most of them have their husband working in different ministries and departments in Conakry... What can a health centre or a district health manager do when, for instance, a national director asks him to allow his wife joining him in Conakry for whatever reason? " (IDI# 8 local health manager)
Second, at district level, maternity and annual leaves were allocated by local health authorities without proper coordination with community representatives, the local administrative authorities and sometimes, local health facilities and services managers. Because of this, according to participants, some HCWs are exceptionally paid though money transfer platforms and thus, exempted from the regulatory (coercion) mechanisms currently in place such as requirements for physical presence before accessing salary.
Third, at facility level, the two above factors were influencing the attitudes of local health facilities and services managers towards absentees. Some of them pay no attention to management issues of the new HCWs either by the fear of receiving blame from supervisors (at the district, regional or central level), or for not favouring “double standard” in the management of the personnel.
... we have visitors here not health workers... they come to visit us at the end of the month to benefit their salaries and go back to Conakry... we can't blame them because they make the effort to come at the end of the month unlike others who left months ago, and in full view of all... (IDI# 65 local health facility manager)
Intention to quit the next 12 months
Overall, only 18% of HCWs present at assigned post 12 months after deployment expressed their intention to quit their position in the next 12 months (Figure 7). Private health sector and government health facilities in other locations of the country were commonly cited as their potential destination.
We identified six main factors underlying the intention to stay for the next 12 months. Some of the factors are inter-related: the sense of engagement with the state, the fear of losing the job, deployment in a preferential zone, support and cooperation of the spouse, and the holding of a position of responsibility.
For instance, some participants reported the fear of losing their job as a reason for staying at their current position. For participants of this group, they would have been more motivated to work if they were deployed in their preferential district.
I was indeed ready to come in the rural zone but I would prefer to be deployed to Kissidougou [another rural district, 601 km far from Conakry, the capital] where my Mother stays or to Siguiri where two of my Brothers live... But I had to come if not I would have lost my job... (IDI#52 health provider)
Similarly, the local salary payment serves as a coercive measure constraining health personnel to work in the deployed zones.
... Now we have a means of pressure on them [health workers] which is the salary... Several of them [health workers] had left their posts for unknown reasons and since they were prevented from receiving their salary, they have returned... At the moment, there is even a woman who had joined her husband and stayed there for more than 4 months; her salary is being frozen. Once back, she will have to stay at her post for at least 60 days before she has access to her entire salary... (IDI#89 local health authorities)
Also, the agreement and support of the family especially the spouse was also reportedly an influencing factor for taking up services. Many of these participants were married women and stated that the encouragement and support of their spouses in "family re-organization" was crucial in this process.
My husband was cooperative... he supported me and encouraged me to take up my functions here... the only challenges we faced was how to reorganise our family to the actual situation... We agreed that I came with our last born and took the two others to my sister... She is a teacher and would take care of them as her own... (IDI#21 health provider)