Healthcare Workers' Perceptions towards Hospital

Leadership and Institutional Structure in Chiro and

Gelemso Hospitals, West Hararghe Zone, East

Ethiopia

By

Ayalew Aklilu

Second Draft Thesis to Be Submitted to The Department of Health Services

Management College of Public Health and Medical Sciences, Jimma University in

Partial Fulfillment of the Requirements for the Degree of Masters of Public Health

in Health Service Management

August, 2012

Jimma University

i

Healthcare Workers' Perceptions towards Hospital

Leadership and Institutional Structure in Chiro and

Gelemso Hospitals, West Hararghe Zone, East

Ethiopia

By

Ayalew Aklilu

Advisors:

Shimeles Ololo (BSc.PH, MPH)

Berhane Megersa (BSc.PH, MSc)

August, 2012

Jimma University

ii

Abstract

Background: The perception of health worker have an enormous impact for the successful

implementation of health sector reform thus identifying factors that affect their perception

have a significant importance for amending some of the organizational structure and

advancing strategies to achieve organizational goals. However, what is happening in

developing country like Ethiopia is, contrary to this and identifying factors that affects

perception of health workers have eminent roles for mangers in order to improve and create a

motivated health care provider.

Objective: The ultimate objective of this study is to investigate perception of healthcare

workers towards the institutional structure and leadership.

Methods: A cross sectional quantitative study was undertaken to assess the perception of

health workers towards their institutional structure and leadership in Chiro and Gelemso

hospitals, West Hararghe zone, East Ethiopia, from May 15 to 30, 2012. A total of 204 health

workers agreed to participate in the study out of 218 yielding a response rate of 93.6%. Self

administered structured questionnaires were used to collect data. The instrument had good

internal consistency with Cronbach’s alpha =0.927 and 0.906 respectively. Data were entered

and analyzed using SPSS Version 16. Multiple linear regressions were applied once after the

assumptions checked and adjusted R2

were used to explain the variation in the outcome by

independent variables. The issue of ethical clearance and confidentiality were maintained.

Results: The overall perception of institutional structure and leadership in this study were

37.2% and 31.6% respectively. About 59.3% of the respondents perceived that as their

Hospital did not give enough emphasis on the quality of service it provides and a majority of

the health workers (69.6%) perceived that there were inadequate facilities, 59.8 % of the

respondents perceived that their hospitals did not have adequate staff in all key positions and

only 32.8% of the respondents perceived that there is a formal problem solving in the

hospital.

Conclusion and Recommendation: The overall perception of health workers towards

institutional structure and leadership is very low. In order to improve this Management body

of the two hospitals should have to promote health workers based on their performance and

strength and maintain their Facilities and equipment.

.

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Acknowledgement

I would like to present my jovial salutation to my advisors Mr. Shimeles Ololo and Ms.

Berhane Megersa for their momentous support during the course of proposal development

and final thesis preparation. I am also indebted to Ato Reta Bekele, who is the Managing

Director of RVUC for his unlimited support. My special thank go to Mr. Shimeles Hussein

for the initial motivation to start this journey.

I am most grateful to my family, to my mom and dad, I want reminds you, as you are always

so special to me.

I would like to extend my heartfelt gratitude to the staff Chiro and Gelemso Hospitals,

Managers of both hospitals and Administrators of West Hararghe Zonal Health department

for their magnificent cooperation.

May this work bring glory to God, my Strength and my Redeemer is through Jesus Christ. I

owe my life to Him.

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Table of content

Abstract ...................................................................................................................................... ii

Acknowledgement ................................................................................................................... iii

Table of content ........................................................................................................................ iv

List of Tables ............................................................................................................................ vi

List of Figures .......................................................................................................................... vii

Acronyms ............................................................................................................................... viii

Chapter 1: Introduction .............................................................................................................. 1

1.1. Background ................................................................................................................. 1

1.2. Statement of the problem ............................................................................................ 2

Chapter 2: Literature Review ..................................................................................................... 4

Conceptual Frame work ............................................................................................................. 6

Chapter 3: Significance of the study ...................................................................................... 8

Chapter 4: Objectives of the study ......................................................................................... 9

General Objective ................................................................................................................. 9

Specific Objective .................................................................................................................. 9

Chapter 5: Methods and Materials ........................................................................................... 10

5.1 Study area and period ................................................................................................ 10

5.2 Study design .............................................................................................................. 10

5.3 Population.................................................................................................................. 10

5.3.1 Source population and study population ............................................................ 10

5.3.2 Inclusion and Exclusion Criteria ........................................................................ 10

5.4 Sample size and sampling techniques ....................................................................... 11

5.5 Data collection process and measurements ............................................................... 11

5.5.1 Development of data collection tools ................................................................ 11

5.5.2 Personnel recruitment and training .................................................................... 11

5.5.3 Data collection procedures ................................................................................. 11

5.5.4 Study Variables .................................................................................................. 12

5.6 Operational definition ............................................................................................... 13

5.7 Data analysis ............................................................................................................. 15

5.8 Data quality management .......................................................................................... 16

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5.9 Ethical Consideration ................................................................................................ 16

5.10 Limitation ion of the study ........................................................................................ 17

5.11 Dissemination plan .................................................................................................... 17

Chapter Six: Results ................................................................................................................. 17

Chapter Seven: Discussion ...................................................................................................... 30

Chapter Eight: Conclusion and Recommendation ................................................................... 33

8.1. Conclusion ..................................................................................................................... 33

8.2. Recommendation ........................................................................................................... 34

References ................................................................................................................................ 35

ANNEXES: I ........................................................................................................................... 39

Questionnaire ........................................................................................................................... 39

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List of Tables

1. Table1: Age and service year of health workers of Chiro and Gelemso hospitals, east

Ethiopia, 2012

2. Table 2: Other Basic Characteristics of health workers of Chiro and Gelemso hospitals,

east Ethiopia, 2012

3. Table 3: Health worker perception towards organizational climate of Chiro and Gelemso

Hospitals, east Ethiopia, 2012

4. Table 4: Perception of health workers towards infrastructure of Chiro and Gelemso

Hospitals, east Ethiopia, 2012

5. Table 5: Perception of health workers towards human resources of Chiro and Gelemso

Hospitals, east Ethiopia, 2012

6. Table 6: Perception of health workers towards Leadership of Chiro and Gelemso

Hospitals, east Ethiopia, 2012

7. Table 7: Variation of the outcome variable explained by predictors, east Ethiopia, 2012

8. Table 8: predictors of perception of health workers towards institutional structure , east

Ethiopia, 2012

9. Table 9: predictors of perception of health workers towards institutional leadership, east

Ethiopia, 2012

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List of Figures

1. Figure 1: Conceptual framework using variables in health worker perceptions towards

Leadership and Organizational Structure: a case of Chiro and Gelemso Hospitals, 2012.

2. Fig.2: A Histogram that show the distribution dependent variable against the predictors

3. Fig.3: A P-P that show the distribution dependent variable against the predictors

4. Fig. 4: A Histogram that show the distribution outcome variable against the predictor

5. Fig.5: A P-P that show the distribution dependent variable against the predictor

viii

Acronyms

1. AIDS - Acquired immune-deficiency syndrome

2. AOR: Adjusted Odds Ratio

3. FMOH - Federal Ministry of health

4. HIV- Human immune-deficiency virus

5. HSD- Health sector development

6. HSR- Health sector reform

7. HW – Health worker

8. HWP- Health worker perception

9. LB - Leadership Behavior

10. MDGs- Millennium development goals

11. OR: Odds Ratio

12. RHB- Regional Health Bureau

13. RVUC – Rift Valley University College

14. WHO- World Health organization

1

Chapter 1: Introduction

1.1. Background

Until recently, human resources have been overlooked during the course of health sector reforms

(1, 2). A number of factors ranging from the individual to national level operate together to

influence how health workers take up interventions to improve their work practices. Often this

influence works through the local personal, educational, professional, community, or institutional

environment in which work takes place or the social, cultural, economic, and political

environments more generally. At the individual health worker level, many of these influences are

understood to affect a worker's perception to act in desired ways. Thus, understanding those

factors that influence worker perception is important when trying to explain why interventions

that rely on changing worker behavior succeed or fail (3).

Today, African health systems are experiencing one of the greatest staff shortages and clinical

staff is currently faced weak institutional frameworks and distortive incentive structures,

ineffective management practices and adverse work environments at systemic and organizational

level, resulting in an overburdened health workforce (4).

Employees desire to feel that they are a part of something substantial. When this occurs,

employees find enthusiasm for their future and that of their organization. One method of

achieving this is through a united vision where employees are empowered by their leaders to

work toward the vision and within a value system that is congruent with their own (5).

However, worker perception and its influence on changing clinical practices of health workers in

low-income settings is rarely explored as a major factor that may mediate or modify the effects

of interventions . More usually, studies of health worker's perception explore determinants of

perception by examining the subjective feeling and attitude of health workers either to

understand effects of health sector reforms on worker performance or influences of

performance management on worker perception (6).

2

1.2. Statement of the problem

During the past 15 years in sub-Saharan Africa, many countries have been undergoing health

sector and civil service reforms that directly influence the design of the public health care system

and the use of human resources (7). For more than a decade, Ethiopia has been implementing

health sector reform which is now in its fourth phase of strategic planning but studies revealed

that the ability of any institution attract, retain and maintain competent and satisfied staff into its

employment is very challenging (8). And to strengthen this idea, the World development report

2004 state, without improvements to the human resources situation, the health-related

Millennium Development Goals cannot be achieved (9).

Other study also emphasizes the importance and impact of employee perception on turnover

intent as an area which should not be neglected (10).A study in the field of organization had

been done on employees’ attitude and behavior on organization effectiveness and revealed as

various factors affect employee perception, such as the job characteristic, the leadership and

organizational structure (11).

In a study which was conducted in 499 health workers of Nigeria four hospital revealed that

about 64% of the respondents disagreed or strongly disagreed that their hospitals had adequate

staff in all key positions for health sector reform, 53% of the respondents disagreed or strongly

disagreed that compensation is adequate for attracting, 57% of the respondents agreed or strongly

agreed that opportunities exist for staff professional development and on-the-job training and

keeping key staff, 69.9% perceived that there were inadequate facilities and 39.5% line of

reporting and authority are clear (12).

Parallel to this, a study of 551 health care workers perception in Ghana in January 2002, reported

that 75% mentioned lack of essential equipment, tools and supplies as a workplace issue

affecting staff performance and 94% mentioned low salary as a workplace obstacle affecting

staff performance (13).

Another study in klang valley, Malysia showed that perception of health workers was influenced

by age that older employees have favorable perception towards organizational culture. In

3

addition to this, Jobs position, education and income also affect the perception of health workers

(14).

Most study suggested that, increasing salaries and benefits, better working and living conditions,

management and supervision, career advancement and training and keeping staff healthy are

significant to keep staff and to have favorable perception. But, According to motivational

theorists such as Herzberg, increasing salaries, providing support for staff, and good health and

safety at work are not motivators and they do not enhance job satisfaction or positive

environment.

However, what is happening in developing country is, contrary to this. There is poor level of

health worker perception, which has a negative impact on the performance of individual health

workers, facilities and the health system as a whole. Moreover, it adds to the push factors for

migration of health workers, both from rural areas to the cities and out of the country (15, 16).

So in our country as to my knowledge there is no published article which clear describe the level

of health workers perception and factor that affect it, though Ethiopia is among under developed

country by which high staff attrition is very high.

4

Chapter 2: Literature Review

Health sector reform (HSR) is one of the topical issues on the policy agenda of many developed

and developing countries worldwide. A research that was conducted in Nigeria four hospitals

shown that, as the overall perception of institutional structure for health sector reform was 52.5%

(12).

Institutional structure, also called institutional formation is defined as the components and

resources that an institution has to deliver its services and generate external support. It is the

embodiment of purpose of an institution. It is important because it should reflect and support the

vision, mission, values, goals and strategy of the institution. It clearly defines and differentiates

roles and functions in the institution, untangles lines of communication and accountability, and

ensures that decision-making procedures are transparent and functional. The institutional

structure is put in place to protect, support and enable the chosen vision, strategy and culture of

the institution. The structure adopted in any institution will depend on the objectives of the

institution, its environment and context, including technology and size (12).

Several countries in Africa have embarked on health reform, but most research has focused on

the impact of reforms on recipients, particularly vulnerable groups. Very little has been written

on the impact on health worker motivation. The health sector is labor intensive and the success

of the reforms depends on, among other things, the behavior of those implementing the policies

on the ground. Research in developed countries has shown, for example, that 80% of health costs

in hospitals are a result of doctors’ diagnosis and therapy patterns. Health workers’ motivation,

manifested in their behavior in the work place, greatly affects the outcome of health reforms

(17). Health systems cannot function without trained health workers, yet until recently

researchers and policymakers paid relatively give little attention to their role in developing

countries (18).

An understanding of the perceptions of healthcare professionals and managers of the institutional

structure of their respective hospitals and its ability to facilitate the fulfillment of the HSR

objectives is important due to the central roles played by the staff members in promoting and

sustaining the changes associated with a health sector reform (HSR). There were reports of failed

HSR even in developed countries such as the United States of America during the Bill Clinton

administration due to the opposition of major stakeholders like the medical professionals (12).

5

Research reports along this line have indicated that workers with negative perceptions of safety

climate (e.g., high workload, work pressure) tend to engage in unsafe acts, which in turn

increases their susceptibility to accidents (19, 20). Similarly, workers who have indicated job

insecurity, anxiety and stress, have exhibited a drop in safety motivation (21) and recorded a

relatively higher accident involvement rate (22, 23, 24). In contrast, workers with positive

perceptions regarding safety climate have expressed greater job satisfaction (25) and registered

fewer accidents (26).

According to Shore L., workers with higher perceptions regarding management’s contributions,

support and concern for their wellbeing have a greater job satisfaction (27). Additional research

revealed that, organizational support will affect differently workers’ perceptions (28).

A Study examining health worker motivation in two hospitals in the Hashemite Kingdom of

Jordan on 264 health workers disclosed that, respondents reported generally positive perceptions

of hospital characteristics; only “job and career opportunities” fell far below a neutral rating.

Overall, the mean responses of different respondent groups (i.e., worker, supervisor, and

manager) were similar, although workers showed a non-significant tendency to report lower

(more negative) responses than supervisors and managers. Only the perception of “management

openness” showed a significant difference among the various levels, with workers disagreeing

with this characterization of management, while supervisors agreed with the statement, and

managers agreed even more strongly that they were open to suggestions from workers.

Comments from respondents indicated that some of this unresponsiveness may be due to MOH

regulations that are beyond the purview of hospital management. There are Statistical

interactions between hospital and types of worker were found for pride/reputation and

management openness. Other workers (allied health professionals and service/administrative

workers) at Al-Ramtha hospital were most likely to respond positively on pride/reputation, while

nursing staff at Al-Ramtha were more likely to have negatively perceptions on management

openness than others at Al-Ramtha, or at Al-Basheer (29).

6

Conceptual Frame work

Figure 1: Conceptual framework using variables in health worker perceptions towards

Leadership and Organizational Structure: a case of Chiro and Gelemso Hospitals, 2012.

As work motivation is a transactional process, a worker’s motivation is contingent upon the

organizational context in which the worker is situated. The organization must provide

complementary inputs (such as drugs and medical supplies), as well as clear, efficient systems.

Organizational structures and processes will affect workers’ experience of outcomes and the

nature of feedback that a worker receives from colleagues and supervisors within the health

system. Human resource management systems affect workers’ capability and their perception of

that capability, through such mechanisms as training, supervision, and more concrete incentives

such as remuneration, promotion, and performance review processes (30).

7

In addition to this, Good leadership is important for the success of any organization. In a

healthcare organization, good leadership is more than just important—it is absolutely critical to

the organization’s success (31). This may entail, as the issue of leadership determines worker

perception for their organization.

8

Chapter 3: Significance of the study

One of the critical challenges in today’s dynamic and turbulent organizations is to retain

capable workforce for the maintenance and improvement of firm’s and Research has shown

employee commitment is an indicator of effective relationship among boss, team members, and

subordinates. It is also identified that employee perception for their organization influences

critical organizational outcomes such as job performance, employee commitment, job

satisfaction, teamwork, and turnover (32). And other study had shown that, when an employee

perceives that he is treated fairly, it is logical that he consequently feels satisfied with the job

(14).

Since, there is no study done on this issue, knowing the level of perception and factor that affect

it has an eminent role. For administrators of the two hospitals, help to amend their organizational

structure, to advance strategies and to be aware and take a decisive measure to improves

perception of health worker that helps to build a satisfied and motivated health worker.

The findings of this study will also gives as a way for West Hararghe zonal health department to

realize factors that affect the perception of health worker and enable them to made scientific

based judgment. In addition to this it has a great benefit researchers, students or policy maker to

utilize as base line information.

9

Chapter 4: Objectives of the study

General Objective

To assess the perception of healthcare professionals towards the institutional structure

and Leadership of Chiro and Gelemso hospitals, 2012

Specific Objective

To assess perception of health worker towards Institutional structure.

To measure health worker perception towards the Institutional leadership.

To determine factors that affect perception of health worker towards their Institutional

structure.

To determine factors that affect perception of health worker towards the organizational

leadership.

10

Chapter 5: Methods and Materials

5.1 Study area and period

The study was conducted in Chiro and Gelemso Hospitals from April 15 – 30, 2012. Chiro

Hospital is located at Chiro Town, West Hararghe zone, 320 km away from Addis Ababa in the

east direction on the main high way to Harar and Dire Dawa Cities while Gelmso Hospital is

situated in west Hararghe zone, but in Gelemso town. The town is found 52 km away in the

southwest direction from Chiro. The hospitals have different units and render services

approximately 2,300,000 population of the zone and are the only hospitals found in the zone.

Chiro and Gelemso Hospitals have 107and 113 health workers respectively.

5.2 Study design

Cross-sectional study designs using quantitative method were employed.

5.3 Population

5.3.1 Source population and study population

All health workers of Chiro and Gelemso Hospitals who were at work during the study period

were considered both source and study populations for this study.

5.3.2 Inclusion and Exclusion Criteria

Inclusion Criteria:

Health workers who served for more than 6 months in the hospitals.

Exclusion Criteria:

Health worker who were ill and unable to respond during the study period

Health worker on maternal and annual leave

Employee of NGO but who serves in hospital

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5.4 Sample size and sampling techniques

Since, the study populations are small; the study was conducted on all health workers who fulfill

the inclusion criteria.

5.5 Data collection process and measurements

5.5.1 Development of data collection tools

Data collection tool development was mainly based on the issues the study wish to address. The

questioner had two parts and prepared in English version. The first part of the questioner was

aimed to comprise socio-demographic characteristics of health worker that are important for

analysis, and the second part of the questioner comprised of rating scale items which enable to

collect information on the perception of health worker towards their institutional structure and

leadership, and they were adopted from related research undertaken at four hospitals in Nigeria,

and some of them were adopted and modified from a guide Enhancing Organizational

Performance: a Toolbox for Self-Assessment published by the International Development

Research Centre (14,33).

5.5.2 Personnel recruitment and training

One data collectors for each hospital who had diploma and work in Chiro Primary school having

two years experience were used. The data collectors was recruited and trained for one day on the

objectives of the study, instrument, how to collect data and how to conduct supervision, at Rift

Valley University College, Chiro town.

5.5.3 Data collection procedures

Structured self administered questioner was used to collect data. The questionnaires had two

parts. Part one has some closed-ended questions that help to assess socio-demographic

characteristic and part two questions are answered on a 5-point Likert scale i.e., 1 = strongly

Disagree, 2 = Disagree, 3 = undecided, 4 = agree and 5 = Strongly Agree and helps to assess the

perception of health worker towards institutional structure and leadership.

Data collectors gathered information from health workers willing to participate based on the

inclusion and exclusion criteria stated. During data collection, close supervision was carried out

to overcome any mistakes from data collectors. On each data collection day, the collected data

12

was reviewed; and principal investigator was responsible to coordinate the overall activities of

data collection.

5.5.4 Study Variables

Dependant variables

Health workers perception towards institutional structure

Health workers perception towards organizational leadership

Independent variables

Age

Sex

Marital Status

Level of Education

Profession

Position

Hospital

Income

Service Year

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5.6 Operational definition

Leadership: the ability of administrative body of the two hospitals to influence, motivate, and

enable others to contribute toward the effectiveness and success of the organizations of which

they are members and have the following quality

o Communicates the vision or goal with employees

o Ability to create and maintain a culture of safety and quality throughout the

hospital.

o Makes space and equipment available as needed for the provision of care,

treatment, and services.

o Have a knowledge needed for their role

o helps an organization to be successful and create the future it wants

Health worker Perception: a process by which individuals organize and interpret their sensory

impressions in order to give meaning to their environment and not necessarily based on reality,

but is merely based on perspective of health worker towards

Institutional structure and

Leadership of Chiro and Gelemso hospitals’.

There were 26 items used to assess perception of health worker towards institutional structure

and leadership. Among 26 item, 17 item were used to asses’ institutional structure and the

remaining for institutional leadership. These 26 items were measured on a 5-point likert scale for

responses (Strongly disagree, Disagree, Undecided, Agree and strongly agree). For descriptive

analysis Response strongly agrees and agrees had taken as positive response and responses

undecided, disagree and strongly disagree considered as negative response.

To explore factors that affect perception of health workers, the assigned weights “1” for

strongly disagree to “5” for strongly agree were added together. Then by using the summated

scale multiple linear regressions were used in order to identify the predictors for the outcome

variable.

14

Perception of Institutional structure: is defined as perception of health worker of Chiro or

Gelemso towards

• Organizational climate

• Human resource

• and Infrastructure

Perception of Organizational climate: denotes perception of health workers of Chiro or

Gelemso Hospitals whether the Hospitals are pleasant place to work, Values their employees ,

give enough emphasis on the quality of service it provides and open to their ideas.

Perception of Human resource: denotes perception of health workers of Chiro or Gelemso

Hospitals whether the Hospitals have adequate staff , Compensation is fair, recruitment and

hiring policy is clear and Staff are held accountable for getting work done according to clear

performance standard.

Perception of Infrastructure: perception of health workers of Chiro or Gelemso Hospitals

whether the Hospitals: have needed technological resources for health sector reform, manage its

technological resource effectively, have Adequate facilities and equipment and Facilities and

equipment well maintained.

Health worker: are health professionals who are at work in Gelemso or Chiro Hospitals and

include

Specialist

Medical doctor

Nurses

Health officer

Laboratory Technologist/Technician

Dentists

Pharmacy Technician/pharmacist

Other who are graduated with health science

15

Facility: a place where health worker carry out their tasks. It includes;

o Availability of necessary materials( the hospital have of all the

necessary materials or instrument used to perform procedures)

o Adequacy of materials (no shortage of material that are needed to

provide care for patient, such as, delivery set, glove, antiseptic )

o Cleanness of the working environment( room does not have

offensive odor, well ventilated and regularly cleaned by cleaners)

Training and Development: the hospital staff development program. It includes;

o Academic career development( offer opportunity to upgrade their

status)

o Encourage gap feeling program( provide training for health

worker to become aware on new approaches and program)

o Make informed health worker with new guide line as necessary

o refresh health worker to maintain their knowledge

Staff Promotion: It implies a raise in pay, benefits, and responsibility in relation with staff

performance.

Technological Resources: it implies existence of essential technologies that are expected the

hospital to have, such as, Electricity, refrigerators, X-ray machine, various examinations sets…..

Position: role of health worker in an organization. It could be;

Ward head

Matron

Case team leader or other

5.7 Data analysis

The collected data was critically checked for its completeness, and then coded, edited, entered,

and cleaned using SPSS version 16. Reliability tests were employed on SPSS to check the

instrument internal consistency.

16

Univariate analysis was used to describe each individual variable using mean, median, standard

deviation and other methods. Multiple Linear Regression ware applied to explore effects of

independent variables on an outcome. Adjusted R2 (Coefficient of determination) used to

Measure a total variation in outcome which was explained by all regression variables, Variables

with a p value less than 0.05 had taken in to the fit model. And the General formula with k

exposure variables is:

y = β0 + β1x1 + β2x2 + … + βkxk

β0 = constant

β1, β2,… βk = adjusted regression coefficients

Finally data were interpreted and summarized using simple frequency tables, graphs and charts.

5.8 Data quality management

One-day training for data collectors was given. Questionnaires were checked by principal

investigator for omissions and incomplete answers. Responses were then carefully coded, with

verification.

After checking all questionnaires for consistency and completeness the supervisors had

submitted the filled questionnaire to the principal investigator. And, prior conducting the actual

study, 5% of the questionnaire/tool was pre-tested in Bishoftu hospital for precision, sequence,

simplicity and soundness.

5.9 Ethical Consideration

Ethical clearance was obtained from Ethical Review Board Jimma University College of Public

Health and Medical Sciences. Both hospital were well informed about the study and agreed and

allowed for the study to be conducted. Informed consent was obtained from all study subjects

before conducting the actual study.

Name of the study subjects remain anonymous or any identification had not written on

questioner. The respondent was assured that the information taken from them was kept

confidential and informed as data is only for the study purpose.

17

5.10 Limitation ion of the study

Some study unit were unwilling to participate

Social desirability Bias

5.11 Dissemination plan

The findings of the study will be submitted to Jimma University College of Public Health and

Medical Sciences. Following submission, the results will be publicly defended in the University.

After the approval of the findings by the Department of Health Services Management, copies

will be distributed to Chiro and Gelemso hospital and west Hararghe Zonal health department

and Oromia regional health bureau. Efforts will be made to publish the finding

in reputable journals.

17

Chapter Six: Results

1. Basic characteristic of the respondents

A total of 204 health workers agreed to participate in the study out of 218 giving a response rate

of 93.6%. About 84% of the respondents were between 21 and 30 years. The minimum and

maximum age of the participant was 21 and 54 respectively, the median age of the participants

were 25 with a SD of 6.1(table1). About 80% of the participants were less than six years service

and SD of 3.8 years and the maximum service year was 25 years.

Table1: Age and service year of Chiro and Gelemso hospitals health workers, east

Ethiopia, 2012

Variables Mean Median Std. Deviation Range Minimum Maximum N=204

Age 27.34 25.00 6.157 33 21 54

Service Year 4.4608 3.0000 3.81641 23.00 2.00 25.00

There were more Males 50.5% than Females which accounts 49.5%, Majority of Chiro Hospital

health workers were females which accounts 56.2% while majority of Gelemso hospital health

workers were Males which accounts 56.5% (Table2).

About 50% of the respondents were single. Just about 67% of the respondents were Nurses;

Majority of the respondents (52.9%) was from Gelemso hospital and only 27 health workers had

position in the hospital (Table 2).

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Table 2: Basic Characteristics of health workers of Chiro and Gelemso hospitals, east

Ethiopia, 2012

Sex Frequency

N=204 Percent

Male 103 50.5%

Female 101 49.5%

Marital Status

Single 102 50.0

Married 95 46.6

Divorced & Widowed 7 3.5

Religion

Muslim 59 28.9

Orthodox 93 45.6

Protestant 34 16.7

Catholic 11 5.4

Others 7 3.4

Ethnicity

Oromo 92 45.1

Amhara 69 33.8

Others 43 21.1

Hospital

Chiro 96 47.1

Gelemso 108 52.9

Profession

Physician 15 7.4

Nurse 136 66.7

Others 53 26.0

Position

Staff 177 13.2

Head 27 86.8

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2. Institutional structure and leadership

The instrument used to asses perception of health worker towards institutional structure and

leadership had a good internal consistency with a Cronbach’s of alpha =0.927 and 0.906

respectively.

2.1 Perception of Health workers towards Institutional structure and Leadership of

Gelemso and Chiro Hospitals

There were twenty six (26) items on the perception of institutional structure and leadership. The

items with the highest and lowest perception were listed under the infrastructure dimension. The

institution has needed technological resources for health sector reform had the highest perception

(58.3) and Facilities and equipment well maintained had lowest perception (21.1%) (Table: 4).

The percentage ratings of the healthcare workers’ responses to the statements on the four

dimensions of institutional structure and leadership of Chiro and Gelemso Hospitals are indicated

in the tables below.

2.1.1 Perception of Organizational Climate

About 46.1% of the respondents agreed and strongly agreed that their hospitals had “a pleasant

place to work” (mean= 3.03, SD= 1.137). More than 61% of the respondents perceived that as

their hospitals did not Values its employees. 40.7% of the respondents perceived that their

hospitals would give enough emphasis to the quality of service it provides (mean=3.029,

SD=1.17). 69.1 % of the respondents perceived that as their hospital didn’t pay competitive

salary. The vast majority (66.6%) of the respondents perceived that as their hospitals didn’t give

an equal opportunity to employees (mean= 2.70, SD= 1.30) (Table 3).

2.1.2 Perception of Infrastructure

A majority (58.3%) of the respondents perceived that their hospitals had “needed technological

resources for health sector reform” (mean=3.28, SD=1.12). 65.2% of the respondents perceived

that their hospitals did not manage its technological resource effectively (mean=2.96, SD=1.13)

(Table 4).

20

2.1.3 Perception of human resources

About 59.8% of the respondents did not perceived that their hospitals had “adequate staff in all

key positions for health sector reform” (mean=2.86, SD=1.21). Only 36.3% of the respondents

perceived that “staff are qualified and considered competent” (mean=2.90, SD=1.06). 63.7% of

the respondents did not perceived that their hospital had “opportunities exist for staff

development and training” (mean=2.81, SD=1.16) (Table 5).

2.1.4 Perception of Institutional leadership

About 37.8% of the respondents perceived that their hospital had “leaders that the organization

needs to be successful”. 67.2% of respondents did not perceived that “There is a formal problem

solving in the hospital” (mean=2.70, SD=1.17). About 43.7% of the respondents disagreed or

strongly disagreed that the “The hospital’s have clear structure and the decision-making process”

(mean=2.83, SD=1.14) (Table 6).

21

Table 3: Health worker perception of organizational climate of Chiro and Gelemso Hospitals, East Ethiopia, 2012

organizational climate Item

Strongly

Disagree

Disagree Undecided Agree Strongly

Agree

Mean Median Std.

Deviation

N

The Hospital is a pleasant place to work 9.3 29.4 15.2 40.7 5.4 3.0343 3.0000 1.13771 204

The Hospital Values its employees 13.7 31.4 16.7 29.4 8.8 2.8824 3.0000 1.22610 204

The Hospital can give enough emphasis on the

quality of service it provides

9.8 27.9 21.6 30.9 9.8 3.0294 3.0000 1.17407 204

The Hospital pay competitive salary 24.0 27.9 17.2 29.4 1.5 2.5637 2.0000 1.18731 204

The organization is open to my ideas and

suggestions

16.2 31.9 23.0 21.6 7.4 2.7206 3.0000 1.18503 204

The Hospital give an equal opportunity employees 20.1 33.3 13.2 23.0 10.3 2.7010 2.0000 1.30320 204

22

Table 4: Health worker perception of Infrastructure of Chiro and Gelemso Hospitals, East Ethiopia, 2012

Infrastructure Item Strongly

Disagree

Disagree Undecided Agree Strongly

Agree

Mean Median Std.

Deviation

N

The institution has needed technological resources for

health sector reform

7.4 23.0 11.3 50.5 7.8 3.2843 4.0000 1.12629 204

The Hospital manage its technological resource

effectively

9.8 27.5 27.9 26.0 8.8 2.9657 3.0000 1.13337 204

Adequate facilities and equipment are available to support

operations for the health sector reforms

9.3 34.8 25.5 22.5 7.8 2.8480 3.0000 1.11481 204

Facilities and equipment well maintained 11.8 33.3 33.8 18.6 2.5 2.6667 3.0000 .99093 204

23

Table 5: Health worker perception of Human Resource of Chiro and Gelemso Hospitals, East Ethiopia, 2012

Human Resource Item Strongly

Disagree

Disagree Undecided Agree Strongly

Agree

Mean Median Std.

Deviation

N

The Hospital has adequate staff in all key position for

health sector reform

15.2 29.4 15.2 33.8 6.4 2.8676 3.0000 1.21855 204

Staff are adequate and considered competent 6.4 37.7 19.6 31.4 4.9 2.9069 3.0000 1.06727 204

Compensation is adequate and for attracting and

keeping key staffs

9.8 23.0 31.9 28.4 6.9 2.9951 3.0000 1.08957 204

The Hospital support staff training and development 14.2 30.9 18.6 31.4 4.9 2.8186 3.0000 1.16663 204

The Hospital recruitment and hiring policy is fair 15.2 36.8 14.7 24.5 8.8 2.7500 2.0000 1.23226 204

Staff are held accountable for getting work done

according to clear performance standard

6.9 17.6 27.9 40.7 6.9 3.2304 3.0000 1.04144 204

Promotions are based primarily on performance 11.8 24.0 22.5 30.4 11.3 3.0539 3.0000 1.21243 204

24

Table 6: Percentage rating of the perception of health workers towards Leadership of Chiro and Gelemso Hospitals,

2012

Leadership Item Strongly

Disagree

Disagree Undecided Agree Strongly

Agree

Mean Median Std.

Deviation

N

We have the leaders that the organization need to be

successful 15.7 24.0 22.5 30.9 6.9 2.8922 3.0000 1.20268 204

My supervisor treat all employees in my work unit

equitably 13.2 36.8 27.0 20.1 2.9 2.6275 2.5000 1.04029 204

There is a formal problem solving in the hospital 15.7 36.3 15.2 27.9 4.9 2.7010 2.0000 1.17603 204

A shared plan among members to achieve the goal 10.3 28.4 30.4 29.4 1.5 2.8333 3.0000 1.01305 204

The governing body are ultimately accountable for the

safety and quality of care, treatment, and services 12.3 30.4 25.0 28.4 3.9 2.8137 3.0000 1.09841 204

The governing body have the knowledge needed for

their roles in the hospital 16.2 35.8 21.1 24.5 2.5 2.6127 2.0000 1.09726 204

The hospital’s have clear structure and decision-making

process 11.8 31.9 25.0 23.5 7.8 2.8382 3.0000 1.14827 204

Work closely with health workers to create the

hospital’s mission, vision, and goals. 15.2 31.4 21.1 26.5 5.9 2.7647 3.0000 1.17172 204

The hospital provides the resources needed 10.8 27.0 25.0 32.4 4.9 2.9363 3.0000 1.10568 204

25

5.2. Factors that affect perception of Health workers towards institutional

structure and leadership

2.2.1 Factors that affect perception of health workers towards institutional structure

Hence, distribution residual is normal as shown in the Histogram and P-P plot, the relationship between

outcome and explanatory variable is linear and observations are Independent, multiple linear regression

were applied.

Fig.2: A Histogram that show the distribution dependent variable against the predictors

Fig.3: A P-P that show the distribution dependent variable against the predictors

26

Table 7: Variation of the outcome variable explained by predictors, East Ethiopia, 2012

Model R R Square Adjusted R Square

Std. Error of the

Estimate

1 .305a .093 .089 12.73410

2 .343b .117 .109 12.59216

3 .370c .137 .124 12.48248

a. Predictors: (Constant), Educational status of the respondent

b. Predictors: (Constant), Educational status of the respondent, Position of the respondent

c. Predictors: (Constant), Educational status of the respondent, Position of the respondent,

Experience they have in the hospital

d. Dependent Variable: Perception of health worker towards institutional structure

27

Table 8: predictors of perception of health workers towards institutional structure, East Ethiopia, 2012

a. Dependent Variable: Perception of health worker towards institutional structure (PHWI)

b. “0” for Some position in the hospital and “1” for staff

c. “0” for health worker who have bachelorette/Master and “1” for Diploma/Level IV

PHWI = 51.76 - .49(age) + 6.13(position) – 8.83(Edustatus)

From this;

One year increase in age will decrease the perception of 0.49 after making all other independent variables

under control

Being staff will increase the perception of health workers towards institutional structure by 6.13after making

all other independent variables under control

Having Diploma/Level IV holder will lessen the perception health workers towards institutional structure by

8.83 after making all other independent variables under control

Model Unstandardized Coefficients Standardized

Coefficients Sig. 95% Confidence Interval for B

B Std. Error Beta Lower Bound Upper Bound

Constant 51.763 2.751 .000 46.338 57.187

Experience -.490 .230 -.140 .034 -.943 -.037

Position 6.139 2.599 .156 .019 1.015 11.263

Edustatus -8.833 1.827 -.320 .000 -12.436 -5.231

28

2.2.1 Factors that affect perception of health workers towards institutional structure

Hence, distribution residual is normal as shown in the Histogram and P-P plot, the relationship between

outcome and explanatory variable linear and observations were Independent, multiple linear regression

were applied.

Fig. 4: A Histogram that show the distribution outcome variable against the predictor

Fig.5: A P-P that show the distribution dependent variable against the predictor

29

Table 9: predictors of perception of health workers towards institutional leadership, East Ethiopia, 2012

a. Dependent Variable: Perception of health worker towards leadership

b. “0” for health worker who have bachelorette/Master and “1” for Diploma/Level IV

PHWL = 26.77 – 2.05(hospital) + 2.18(Edustatus)

From this;

Serving in Gelemso hospital would lessen the perception of health workers towards institutional

leadership by 2.05 after making all other independent variables under control

Model Unstandardized Coefficients Standardized

Coefficients Sig. 95% Confidence Interval for B

B Std. Error Beta Lower Bound Upper Bound

(Constant) 26.779 1.740 .000 23.347 30.211

Hospital -2.052 1.077 -.135 .008 -4.175 .072

Edustatus 2.180 1.115 .139 .012 .019 0.378

30

Chapter Seven: Discussion

7.1. Perception of health workers towards institutional structure and leadership

This study was identified the perception of health worker towards their institutional structure and

leadership and factor that are associated with it. The overall perception of institutional structure

and leadership in this study were 37.2% and 31.6% respectively. Out the three dimension

perception to human resource have the highest perception which accounts 38.67% while

perception to organizational climate and Infrastructure accounts 36.36% and 36.12%

respectively. This perception of health workers towards their institutional structure was very

much lower than the situation in Nigeria which accounts 52.2 % (12).

Perception of Organizational Climate

The overall Perception of Organizational Climate was 36.36%. About 59% of the respondents

perceived that as their Hospital did not give enough emphasis on the quality of service it provides.

About 69.1% of the respondents perceived that as their hospital were not pay competitive salary for

its employees.

In the study by Agyepong and others in Ghana, in January 2002, 94% out of 551 healthcare

workers and 95% out of 614 in August 2003 mentioned low salary as a workplace obstacle

affecting staff performance (36).

This finding is quite similar with countries like Namibia, Nigeria and Ghana. In Namibia, One of

the most significant complaints pointed out by most categories of health professionals were lack

of competitive salary, which makes them very dissatisfied and enable them to develop

unfavorable perception towards institutional structure (34).

Perception of Infrastructure

A total perception of infrastructure was 36.12% and majority of the health workers (69.6%)

perceived that there were inadequate facilities and equipment in their hospitals and a very high

proportion (78.9%) perceived that the available facilities and equipment were poorly maintained.

A study which was conducted in Nigeria four Hospitals revealed that a majority of the healthcare

workers (69.9%) perceived as there were inadequate facilities and equipment in their hospitals

and a similar proportion (69.4%) perceived that the available facilities and equipment were

31

poorly maintained (12). In a study of 551 health care workers in Ghana in January 2002,

Agyepong et al. reported that 75% mentioned lack of essential equipment, tools and supplies as a

workplace issue affecting staff performance (36).

The rather low perception of health workers may be a reflection of the poor state of the

infrastructure available to deliver health care services in Chiro and Gelemso.

Perception of Human Resource

The overall Perception of Human Resource was about 39%. Amongst the items that make up the

human resources dimension, 59.8 % of the respondents perceived that their hospitals did not

have adequate staff in all key positions. This is similar to the report from a study of 614 health

care workers in Ghana in August 2003. Agyepong et al. reported that 63% mentioned inadequate

staffing as a workplace obstacle affecting staff performance and Nigeria which was also revealed

71.1% of the respondents perceived that their hospitals did not have adequate staff in all key

positions (12, 36). Another 74% of the respondents in this study also perceived as poor

compensation had an issue that hinder the recruitment and retention of staff and a similar finding

was obtained from the study conducted in Nigeria where 73.4% of health care workers

perceived as poor compensation as an issue hindering the recruitment and retention of staff(12).

Perception of Leadership

The overall Perception of In this study was 31.6%, only 32.8% of the respondents perceived that

there is a formal problem solving in the hospital. Only 27 % (mean=2.61, SD=1.09) of the

respondent had perceived that as the governing body have the knowledge needed for their roles

in the hospital. And it was also revealed that as the hospital leadership is very poor, these was

mainly contributed to knowledge of the governing party and lack a shared plan had also a major

problem in this study which account about 69.1%. But, study in Nigeria was revealed only

33.6% of the respondents perceived that the span of control and supervision was not reasonable

(12), which is much better from the finding in this study by which 68.7% health workers did not

perceived that The hospital’s have clear structure and decision-making process .

32

7.2. Factors that affects Perception of health professionals towards institutional structure

and Leadership

Variables Age, Position and Educational status had an independent effect on perception of

health workers towards institutional structure.

And Place of work (Hospital) and Educational status were an independent explanatory variable

for the perception of health workers towards institutional leadership.

33

Chapter Eight: Conclusion and Recommendation

8.1. Conclusion

General speaking, perception of health worker towards their institutional structure is

poor. This is substantiated as, majority of the health workers from two hospitals had

perceived as their hospitals

were not pleasant place to work

would not pay competitive salary

as recruitment and hiring policy was not fair

Promotions were not based primarily on performance

Staff were not held accountable for getting work done according to clear

performance standard

Staff were not adequate and considered competent

Would not Values its employees

Likewise, perception of health worker towards institutional leadership is not good enough

this was authenticated because of the majority of health workers from both hospitals

perceived

o As they would not have leaders that the organization needs to be successful

o There were no formal problem solving in the hospital

o Would not have clear structure and the decision-making process

Educational status, age and position are the factors that are identified in this study which

determine the perception of health workers towards their institutional structure while

work place and Educational status for institutional leadership

34

8.2. Recommendation

For Administrators of the Two Hospitals:

They hospitals should have to promote health workers primarily based on their

performance.

They have to give formally the role and responsibilities of health workers in order to

make staffs accountable for the thing they did it.

They should have to give an equal opportunity to their employees on staff training and

development.

They have to strength and maintain their Facilities and equipment.

They have to work closely with health workers to create the hospital’s mission, vision,

and goals.

For Zonal health Department and Regional health bureau

Should have to create a Compensation mechanism, for example increasing per diem for

duty work.

Have to Work closely with Chiro and Gelemso hospital in order to identify staffs which

are not competent and fill their gap via providing comprehensive staff training.

Have to support on equipping the facility of the two hospitals.

Have to undertake a study to know perception health workers who work at health center

and health posts.

35

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39

ANNEXES: I

Questionnaire

Dear respondent, this study is carried out to assess your perception toward the organization

institutional structure and leadership. Undertaking this study may help to identify the factors that

affect the perception of health worker towards their institutional structure and leadership and

provide a recommendation primed to improve the health service that enhances quality of the

organization.

Over and above, I want to remind you that, all the information that you offer for me is very

substantial and kept confidential. To make this reliable your name is not written in this

questioner.

At last, I benevolently request your voluntary co-operation on answering the questions here

under, it will take only 15 – 20 minutes and you have the right not participate on the study.

If you decided and fascinated, let us begin!! If no!! Thank you!!!

Thank you, for your time!

40

Part One: Background Information

501.What is name of the hospital?

1. Chiro

2. Gelemso

502.What is your position in the hospital? (Title)

1. Head Nurse

2. Medical Director

3. Staff

4. Matron

5. If other, specify______________

503.What is your profession?

1. Physician

2. Nurse

3. Health Officer

4. Laboratory

Technician/Technologist

5. Pharmacist/ Pharmacy Technician

6. If other specify,____________

504.Educational Level

1. Master

2. BSC

3. Diploma

4. Level IV

5. Other specify__________

505.Sex

1. Male

2. Female

506.Marital Status

1. Married

2. Single

3. Divorced

4. Widowed

507.Religion______________

508.Ethnicity_____________

509.How long have you been working in this hospital? _______

510.How old are you? _________ Years old(complete year)

511.How much is your monthly income? _______________

41

Part Two:

Session One

Session Two

I would like to find out how you feel about the organizational climate. Please help me by answering the

following questions. (perception of Health worker towards organizational climate)

Sr.

No.

Strongly

Disagree(1)

Disagree(2) Undecided(3) Agree(4) Strongly

Agree(5)

501 The Hospital is a pleasant place to work

502 The Hospital Values its employees

503 The Hospital can give enough emphasis

on the quality of service it provides

504 The Hospital pay competitive salary

505 The organization is open to my ideas and

suggestions

506 The Hospital give an equal opportunity

employees

I would like to find out your perception on Infrastructure that the health sector have

Sr.

No.

Strongly

Disagree(1)

Disagree(2) Undecided(3) Agree(4) Strongly

Agree(5)

507

The institution has needed

technological resources for health sector

reform

508 The Hospital manage its technological

resource effectively

509 Adequate facilities and equipment are

available to support operations for the

health sector reforms

510 Facilities and equipment well

maintained

42

Session three

I would like to find out your perception of Human resource

Sr.

No.

Strongly

Disagree(1)

Disagree(2) Undecided(3) Agree(4) Strongly

Agree(5)

511 The Hospital has adequate staff in all

key position for health sector reform

512 Staff are adequate and considered

competent

513 Compensation is adequate and for

attracting and keeping key staffs

514 The Hospital support staff training

and development

515 The Hospital recruitment and hiring

policy is fair

516 Staff held accountable are held

accountable for getting work done

according to clear performance standard

517 Promotions are based primarily on

performance

43

I would like to find out your perception towards the Institutional leadership

Sr.

No.

Strongly

Disagree(1)

Disagree(2) Undecided(3) Agree(4) Strongly

Agree(5)

518 We have the leaders that the

organization need to be successful

519 My supervisor treat all employees in

my work unit equitably

520 There is a formal problem solving in

the hospital

521 A shared plan among members to

achieve the goal

522

The governing body are ultimately

accountable for the safety and

quality of care, treatment, and

services

523

The governing body have the

knowledge needed for their roles in

the hospital

524 The hospital’s have clear structure

and the decision-making process

525

The governing bodies work closely

with health workers to create the

hospital’s mission, vision, and goals.

526

The hospital provides the resources

needed for data and information use,

including staff, equipment, and

information systems.

Session four

44