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ctive Health Matters.ts reserved.atters 2009;17(33):80–90

$ – see front matter080 (09 ) 33443-6 www.rhmjournal.org.uk

Understanding job satisfaction amongst mid-level cadresin Malawi: the contribution of organisational justice

Eilish McAuliffe,a Ogenna Manafa,b Fresier Maseko,c Cameron Bowie,d Emma Whitee

a Senior Lecturer, Centre for Global Health, Trinity College, University of Dublin, Ireland.E-mail: eilish.mcauliffe@tcd.ie

b Project Manager, Centre for Global Health, Trinity College, University of Dublin, Irelandc Research Officer, College of Medicine, University of Malawi, Blantyre, Malawid Associate Professor, College of Medicine, University of Malawi, Blantyre, Malawie Research Fellow, School of Nursing and Midwifery, Trinity College, University of Dublin, Ireland

Abstract: The migration of doctors and nurses from low- to high-income countries has left manycountries relying on mid-level cadres as the mainstay of their health delivery system, Malawi beingan example. Although an extremely important resource, little attention has been paid to themanagement and further development of these cadres. In this paper we use the concept oforganisational justice – fairness of treatment, procedures and communication on the part ofmanagers – to explore through a questionnaire how mid-level cadres in jobs traditionally done byhigher-level cadres self-assessed their level of job satisfaction. All mid-level health workers presenton the day of data collection in 34 health facilities in three health districts of Malawi, one districteach from the three geographical regions, were invited to participate; 126 agreed. Perceptions ofjustice correlated strongly with level of job satisfaction, and in particular perceptions of how wellthey were treated by their managers and the extent to which they were informed about decisionsand changes. Pay was not the only important element in job satisfaction; promotion opportunitiesand satisfaction with current work assignments were also significant. These findings highlight theimportant role that managers can play in the motivation, career development and performance ofmid-level health workers. ©2009 Reproductive Health Matters. All rights reserved.

Keywords: mid-level providers, organisational justice, job satisfaction, health planning and management,health worker attitudes, Malawi

THE human resources crisis has severelyimpacted on the health systems of manyAfrican countries, creating high vacancy

rates for almost all cadres of health workers.Malawi has been particularly affected, with latestfigures showing vacancy rates of 77% for spe-cialist doctors, 45% for medical officers, 80%for nursing officers and 44% for nursing sis-ters.1 However, Malawi has a history of employ-ing cadres of health workers with shorter periodsof training, for example, enrolled nurse-midwives,clinical officers and medical assistants, whohave become the mainstay of the health deliv-ery system. Staffing figures for the districts, for

example, show that whilst there were a total of872 enrolled nurse-midwives employed in 2006,only 127 registered nurses were in post. Likewisethere were 232 clinical officers and 300 medicalassistants but only 16 medical officers.2 In theprocess, much of the obstetric work traditionallycarried out by doctors has been shifted to clinicalofficers, who perform as much as 93% of majoremergency obstetric operations in governmenthospitals and 78% in mission facilities, with com-parable post-operative outcomes.3,4Despite these successes, most of the attention

in addressing the human resource crisis hasfocused on increasing the capacity of training

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institutions to produce more doctors and regis-tered nurses to fill vacancies. In addition there isan assumption that cadres such as enrollednurses, clinical officers and medical assistantsare somehow non-poachable, because they lackinternationally recognised qualifications.The human resource crisis is also due to con-

siderable in-country migration between thepublic and private health sectors, including tointernationally funded programmes that payhigher salaries, between urban and rural areas,and between tertiary and primary health care.Increasing health worker migration into private,urban, tertiary facilities is undermining provi-sion of appropriate public, rural, primary care. Incountries that do have enough doctors, while theremay be a 1:500 doctor–patient ratio in the city,remote districts suffer from a 1:100,000 ratio.5African doctors, nurses, pharmacists and medicaltechnicians prefer to work in urban hospital set-tings where professional camaraderie is readilyavailable and promotion more probable. Theavailability of good housing, schooling for theirchildren and leisure is also an important consid-eration. The urban location of most hospitalsmakes it inevitable that health workers mostlywork in the cities.6 In Ghana, Guinea and Senegal,more than 50% of physicians are concentratedin the capital, where less than 20% of the popu-lation live.7 In the capital region of Chad in 2002,there were 71 doctors per 100,000 people, whilein the Charai-Baguirmi region the ratio was2:100,000.8 In Ghana, 55% of pharmacists arein the Greater Accra region, which has 16% ofthe population and 2% in the Northern region,with 10% of the population.7With 31 countries failing to meet the “Health

for All” standard of one doctor per 5,000 people,9alternative models of service delivery need to beexplored, along with greater efforts to under-stand and reverse health worker outflows fromareas where they are desperately needed.Among its considerable attempts to address

the human resources crisis, Malawi developeda Six-Year Emergency Training Plan for healthworkers10 and an Emergency Human ResourcesProgramme,11 aimed at improving staff recruit-ment and retention through salary top-ups andincreased training. In 2005 the governmentintroduced a 52% salary top-up which, combinedwith further increases, made health workers thehighest paid civil servants. Additional incentives

took the form of rural allowances, housing andtransport, based on the premise that increasedremuneration and benefits retain people in theirjobs.12,13 Yet research demonstrates that salary isnot the only or most important factor influencingretention.14 Maternal health nurses, for example,ranked improved working environments andconditions (such as good facility managementand adequate equipment) as high as or higherthan financial incentives in one study.15Most African countries have focused on pro-

ducing more expensive (less cost-effective)cadres of health workers relative to their diseaseburden and to what they can afford. Some expertshave pointed out that as much as two-thirds ofAfrica's disease burden could be addressed bycommunity health nurses. Malawi's govern-ment, with strong urging from the nurses andmidwifery council, abolished the enrolled nurs-ing programme in the early 1990s to focus onprofessional nurses. Education/training ofenrolled and auxiliary nurses was also bannedin Zambia and Ghana. By 1998 the nursing short-age in Malawi had reached crisis point and thedecision was rescinded. Enrolled nurses are nowbeing trained as part of the Emergency Pre-Service Training Programme (2001) (Phoya A.Personal communication, Lilongwe, 2008). TheChristian Health Association of Malawi con-tinues to receive government funding for thetraining of enrolled nurses, and cites this asone of the reasons its health facilities are betterstaffed than the public facilities (Mukiwa R. Per-sonal communication, Lilongwe, 2006).Studies addressing the perceptions of these

mid-level cadres and the factors that influencetheir motivation, performance and retentionwithin health care systems are scarce.16 How-ever, recent research indicates that these cadresare becoming demotivated due to poor careerdevelopment and promotion prospects, and lackof positive supervision, feedback and recogni-tion, which leave them feeling unsupported andundervalued.17,18 There is concern that quality ofcare will suffer if they are not properly supportedand motivated.16,18–21One concept that connects how employees are

treated with motivation and job satisfaction isthat of organisational justice,22 which generallyencompasses three components: distributive jus-tice, procedural justice and interactional justice.23Distributive justice refers to how fairly employees

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feel they are treated (in comparison to others)with regards to the distribution of resourcesand outcomes.23,24 Does the person think theyare getting the workload, work schedule, salarylevel, promotion and allowances they deserve?Do they perceive that outcomes are fair, e.g. thattheir opportunities for further training are fair incomparison to those afforded their colleagues?Procedural justice is the perceived consistencyand fairness of procedures that are used,25 e.g.how employees are selected for training, or howdecisions are taken about which employeesdeserve promotion. Interactional justice relatesto the dignity and respect afforded individualsin interpersonal communication relating to orga-nisational procedures.23Two meta-analyses of mainly US studies26,27

showed that greater perceived organisational jus-tice was associated with higher satisfaction,greater commitment to the workplace and moreextra-role behaviour. Paying attention to justicetherefore seems important to improving perfor-mance and retention of health workers. In thisstudy, carried out in March to May 2007, we uti-

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lised the concept of organisational justice toexplore the relationship between how enrollednurses, clinical officers and medical assistantsfelt they were being treated by their managersand the impact on their workplace behaviourand job satisfaction.

Sampling and methodsAll health facilities34 in three districts in Malawi(one from each of the three geographical regions)were included in the sampling frame. The sampleconsisted of those willing to participate at thetime the data collectors visited the facilities(Box 1). This paper analyses their responses. Of374 health workers invited to participate, 153agreed (response rate 41%), of whom 126 weremid-level providers – clinical officers, medicalassistants and enrolled nurses – performing taskstraditionally undertaken by doctors and registerednurses/midwives. Although data were also col-lected from registered nurses, these were excludedfrom the analysis as we did not examine whetherthey did tasks traditionally performed by doctors.Data collected on work environment are reportedelsewhere.21 The majority of the participants wereunder 35 years of age and in full-time permanenthealth service employment (Table 1).

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Organisational justice was measured usingNiehoff & Moorman's justice scale,28 a five-point likert-type scale that measures attitudeson distributive, procedural and interactionaljustice along a continuum from strongly dis-agree to strongly agree. Distributive justice wasmeasured using five items (Table 3) assessing thefairness of different work outcomes, includingpay, workload, work schedule and job responsi-bilities. Procedural justice was measured in rela-tion to formal procedures and interactions. Sixformal items (Table 2, items 10–15) measuredthe degree to which employees felt their opinionwas considered when decisions were made. Nineinteractional items (Table 2, items 1–9) mea-sured the degree to which employees felt theirneeds were considered and adequate explana-tions given for decisions. Reported reliabilitiesfor this scale were above 0.90 for all three dimen-sions of justice.29Workplace behaviour was measured using a

five-dimension organisational citizenship behav-

iour scale developed by Podsakoff & McKenzie,30which measures being helpful and conscientiousand performing duties beyond those normallyexpected and generally improving aspects of thejob.28,31,32 The model identifies five dimensions ofcitizenship behaviour that emerged with reportedreliabilities over 0.70 for each dimension.28Job satisfaction was explored through several

items with scaled responses. None of the jobsatisfaction scales in the extant literature cov-ered intention to leave and perceived likelihoodof finding another job. The items used wereidentified from existing questionnaires, relevantliterature and suggestions from researchers andpolicymakers with expertise in the area. A likertscale ranging from strongly disagree (assigned anumeric value of 1) to strongly agree (assigneda numeric value of 5) was used to measureresponses to each item. All analysis was carriedout using SPSS 16.0. (Further details of themethodology can be obtained from the corre-sponding author.)

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FindingsProcedural and interactional justice andjob satisfactionThe first nine items on the scale measured inter-actional justice. Staff were divided on whethertheir managers showed concern for their rights,with slightly more agreeing than disagreeingwith the statement. However, for items 2–7measuring perceptions of interactions withmanagers, almost twice as many of the healthworkers agreed as disagreed that their managersshowed consideration and sensitivity whendealing with them (Table 2). One-quarter to one-third of health workers surveyed did not believetheir managers showed consideration and sensi-tivity when dealing with them. Interestingly, theresults were very different for items 8–9, whichwere concerned with the honesty and fairness oftheir managers; they were more divided in theiropinions, with only slightly more agreeing thandisagreeing. Item 11, on procedure rather than

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interaction, is also about the honesty of managersand showed a similar response. By contrast staffwere more positive about managers providingexplanations for decisions or explanations forchanges to work practices.Principal components analysis found that one

factor explained 45% of the variation in responses.This factor (comprising eight items) was “man-agerial consideration” and reflected a considerate,caring and respectful style of interaction betweenmanagers and others. Two other componentsemerged which accounted for 10% and 8% ofthe variance, but because of the higher predic-tive power of “managerial consideration”, we willfocus only on it when exploring the relationshipwith job satisfaction.Figure 1 shows how perceptions of justice or

fairness interacted with job satisfaction, withmean scores for the eight aspects of “managerialconsideration” plotted against degree of jobsatisfaction. The increasing mean scores moving

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from “very dissatisfied” to “very satisfied” showevidence of a positive relationship between jus-tice and reported levels of job satisfaction foralmost all items on the procedural justice scale.The more considerate the health workers believetheir manager/supervisor is, the more they are

likely to be satisfied in their job. This effect isstrongest for the item “my manager considers myviews” and the item “my manager is honest andcandid about the reasons for decisions”. The steeprise in the graph for almost all items, from “verydissatisfied” to “a little dissatisfied” scores for jobsatisfaction, are an indication that how they weretreated by their manager played a critical role inthe degree of dissatisfaction experienced.The two items that relate to honesty show

interesting differences. Having a manager whois honest and candid about the reasons for deci-sions is likely to lead to greater job satisfaction,whereas honesty generally in the managerseems to be less important to health workers.The other six items related to “managerial con-sideration” concerned the degree to which themanager takes the needs, concerns and viewsof the employee into account, all examples ofinteractional justice.

Distributive justice and job satisfactionTable 3 shows the extent of satisfaction withpay, workload, opportunity for promotion, workschedule and job responsibilities from the dis-tributive justice scale. The highest levels of dis-agreement were to do with satisfaction with theirpay (107 people disagreed or strongly disagreed)

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and with promotion opportunities (84 disagreedor strongly disagreed). The highest levels ofsatisfaction were to do with relationships withcolleagues (92 agreed or strongly agreed). Morethan half agreed that all in all they were satisfiedwith their job, though dissatisfaction with payand promotion show the danger of taking thisat face value.Exploring responses on the distributive justice

scale in more depth gives a better understand-ing of which particular components of the jobaccounted for feelings of dissatisfaction amongststaff. Figure 2 plots the mean scores across thesample for each of these items against responseson the job satisfaction scale (very dissatisfied tovery satisfied). Satisfaction with the job waspositively correlated with satisfaction with pay(Pearson r=0.222; p<.05), promotion (Pearsonr=0.232; p<.05) and current assignments (Pearsonr=0.313; p<.01). However, satisfaction with cur-rent assignments was more strongly correlatedwith job satisfaction than the other two items.Staff were asked to indicate the extent to which

they agreed or disagreed with three statementson promotion, as shown in Figure 3. Againsatisfaction with the job was strongly correlatedwith “the promotion opportunities I have arefair” (Pearson r=0.287; p<.01); “the opportunitiesI receive are fair” (Pearson r=0.319; p<.01); and“compared to others doing similar work, myopportunities for promotion are fair” (Pearsonr=0.257; p<.01). Interestingly, the greatest numberof staff disagreed with the statement “comparedto others doing similar work, my opportunitiesfor promotion are fair”. It is the comparison withothers that leads to a sense of being treatedunfairly, suggesting inequity in the distributionof promotion opportunities rather than a lack ofopportunites per se.

Workplace behaviourThe organisational citizenship behaviour scale,which measures being helpful and conscientiousand doing more than is normally expected,found that the majority of participants had posi-tive perceptions of their own behaviours. Thestatement that had the highest levels of dis-agreement (Table 4) was “I go out of my wayto make newer co-workers feel welcome” (27 staffdisagreed or strongly disagreed). The numberof staff agreeing that they helped co-workerswas much higher than the number who agreed

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that they made newer co-workers feel welcome,suggesting that they act out of professionalobligation to their work rather than any senseof camaraderie.

DiscussionPerceptions of justice correlated strongly withlevel of job satisfaction, and in particular percep-tions of how well mid-level providers were treatedby their managers and the extent to which theywere informed about decisions. Pay was not theonly important element in job satisfaction; pro-motion opportunities and satisfaction with cur-rent work assignments were also significantlycorrelated with job satisfaction. Interestingly,the strongest correlation with job satisfaction onthe distributive justice scale occurred with “satis-faction with current work assignments”. The factthat mid-level providers who were satisfied withtheir job assignments were also reporting highlevels of job satisfaction provides some evidence

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that task shifting is not only working in terms ofmaintaining quality of service,3,4 but is also havinga positive effect on health worker motivation.Although the research team invited all staff

on duty in the facilities selected to take part,some 60% declined. While the results may ormay not be biased, depending on the views ofthose who refused to participate, the spread ofscores across the job satisfaction scales wouldsuggest that this was not the case. While wecannot draw conclusions about job satisfactionamong mid-level providers as a whole, as ourfocus was on factors influencing job satisfac-tion, this is less of a concern.Distributive justice is often associated with per-

ceptions of fair outcome for fair effort or input.However, our data show that when distributivejustice is measured in terms of fair outcome forthese health workers in comparison with othersdoing similar work, the effect is heightened. Thisis a particularly important finding in the healthcare context and culture in Malawi, as elsewhere,where inter-professional rivalry is a strong fea-ture. Dovlo argues that as mid-level cadres havedeveloped, and as delegation of tasks has beenaccompanied by delegation of responsibility,“initial hostility changed to fruitful collabora-tion and to mutual recognition of new profes-sional turfs”.16 This has not always been thecase in Malawi, however, as found in two previousstudies, one of mid-level providers working inmaternal and obstetric care18 and another ofmid-level providers' work environment.21 In theformer, tensions between clinical officers and doc-tors were found, and in the latter, which was con-ducted with the same sample as this study,nursing cadres expressed more job satisfactionthan clinical officers and medical assistants, whoreported poorer working relationships.Our findings emphasise the important contri-

bution of managers to improving the motivationand performance of mid-level health workers.Other studies have also found that proceduraljustice was related to job attitudes,25,33,34including organisational commitment and trustin management and that inadequate manage-ment support and a sense of not being valuedby their managers were strong features of theenvironment. Yet the role of managers in moti-vating and retaining staff is something that haslargely been ignored in attempts to address themigration of health workers, even though man-

agers who are unsupportive or inconsiderate canbe a strong push factor.21 Improving the attitudesof managers towards health workers is a rela-tively inexpensive approach that could have asignificant impact on performance and retention.Conventional research shows significant posi-

tive links between all dimensions of justice andperformance or organisational outcomes.29,35 Ifstaff feel they are being treated fairly and justly,they are likely to perform better. If they aretreated unfairly they will try to restore justiceby holding back performance.36 However, themajority of health workers in our study agreedthat they were engaged in citizenship behav-iours, especially on items such as performingtheir duties with special care and helping co-workers solve problems. The lower number claim-ing they went out of their way to “make newerco-workers feel welcome” may indicate tensionsbetween themselves (many of whom have manyyears of experience) and newly recruited doctorsand nurses (with little or no practical experience).However, further research would be needed toconfirm this. Our study used self-assessmentmeasures of performance and extra-role behav-iour. An independent assessment of performancemight paint a different picture.Penn-Kekana et al37 make the point that con-

text shapes how local health systems operate andstress the importance of interaction betweenhuman actors. The resource-poor context andpoor salaries in the Malawian health systemcould be expected to affect responses and maybe different to those found in high-income set-tings. Apart from resource variations, managerialattitudes towards employees can also vary bycontext. This study provides evidence for thecritical role that interaction between healthworkers and their managers play in job satisfac-tion. We believe that that may also ultimatelyaffect retention. Developing national strategiesand incentive packages, as has been done bythe Malawian government, is one step towardsaddressing the human resources crisis. However,without the right conditions and positive work-place relationships, whether these will have suf-ficient effect remains to be shown. Penn-Kekanaet al argue that:

“…the development of programmes and policythat improve outcomes for users therefore requiresdirect engagement with context and with howformal organisational structures, intended incentives

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and management procedures interact with infor-mal structures, behaviours and relationships onthe ground.”37

This is particularly important in improving mater-nity care in Malawi, where the majority of pro-viders are mid-level providers such as clinicalofficers and enrolled nurses. Mid-level providersare health professionals who seem to have noformal career structures, and little opportunityfor promotion.18 We have shown that their jobsatisfaction is influenced by their work assign-ments, how they perceive their promotion oppor-tunities relative to others doing the same workand how they are treated by their managers.

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Unless these largely hidden behavioural aspectsof the work environment are addressed, thesecadres, who are currently the mainstay of mater-nal health provision in Malawi, are likely to leavethe health sector for more attractive employmentopportunities elsewhere. Changing this is at leastpartly within the power of local health facilitymanagers to address.

AcknowledgementsWe would like to thank the Advisory Board ofIrish Aid for funding this study. We are alsoextremely grateful to all of the health care pro-viders who participated in the study.

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ración de médicos y enfermerasjos ingresos a países de altoss países, como Malaui, tienenlos prestadores de servicios de

como el pilar del sistema de salud.recurso sumamente importante,o mucha atención al manejo yte grupo de profesionales. Enutiliza el concepto de justiciaen el trato, los procedimientos ypor parte de los administradores –ediante un cuestionario cómode nivel intermedio en trabajos

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realizados tradicionalmente por profesionalesde nivel superior autoevaluaron su nivel desatisfacción laboral. Se invitó a participar a todoslos trabajadores de salud de nivel intermediopresentes el día de la recolección de datos en34 establecimientos de salud, en tres distritos desalud de Malaui, uno de cada región geográfica;126 accedieron. Las percepciones de justiciaestaban muy correlacionadas con el nivel desatisfacción laboral, en particular las percepcionesde cuán bien eran tratados por sus supervisoresy hasta qué grado se les informaba sobre lasdecisiones y los cambios. La paga no era el únicoelemento importante en la satisfacción laboral;las oportunidades de ascenso y la satisfacción con lasasignaciones laborales también eran significativas.Estos hallazgos resaltan el importante papel quepueden desempeñar los administradores en lamotivación, el desarrollo profesional y el desempeño

dévolus aux cadres supérieurs évaluent leursatisfaction professionnelle. Tous les soignantsde niveau intermédiaire présents le jour du recueildes données dans 34 établissements de santédu Malawi, sélectionnés dans un district pourchacune des trois régions géographiques, ont étéinvités à participer ; 126 ont accepté. La manièrede concevoir la justice était fortement corréléeavec le niveau de satisfaction professionnelle,en particulier dans quelle mesure les cadresmoyens estimaient être bien traités par leursuperviseur et être informés des décisions et deschangements. Le salaire n'était pas le seul élémentdéterminant : les possibilités d'avancement et lasatisfaction quant aux tâches professionnellesactuelles avaient aussi une influence. Ces conclusionssoulignent le rôle important que les superviseurspeuvent jouer dans la motivation, les perspectivesde carrière et les performances des soignants de

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de los trabajadores de salud de nivel intermedio.niveau intermédiaire.

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