THE EFFECT OF WORKING ENVIRONMENT ON WORKERS PERFORMANCE: THE CASE OF REPRODUCTIVE AND CHILD HEALTH CARE PROVIDERS IN TARIME DISTRICT

THE EFFECT OF WORKING ENVIRONMENT ON WORKERS PERFORMANCE: THE CASE OF REPRODUCTIVE AND CHILD HEALTH CARE PROVIDERS IN TARIME DISTRICT

TABLE OF CONTENTS
CERTIFICATION …………………………………………………………………………………………….. ii
DECLARATION………………………………………………………………………………………………. iii
ACKNOWLEDGEMENT …………………………………………………………………………………. iv
DEDICATION…………………………………………………………………………………………………… v
ABSTRACT ……………………………………………………………………………………………………… vi
LIST OF TABLES ………………………………………………………………………………………….. xiii
LIST OF APPENDICES ………………………………………………………………………………….. xii
LIST OF FIGURES ………………………………………………………………………………………… xiv
ABREVIATIONS …………………………………………………………………………………………….. xv
OPERATIONAL DEFINITIONS ……………………………………………………………………. xvi

CHAPTER ONE ……………………………………………………………………………………………….. 1
1.0 INTRODUCTION………………………………………………………………………………………… 1
1.1 Statement of the Problem …………………………………………………………………………….. 3
1.2 Rationale of the Study …………………………………………………………………………………. 4
1.3 Conceptual Framework ……………………………………………………………………………….. 5
1.4 Research Question ………………………………………………………………………………………. 7
1.5 Objectives ………………………………………………………………………………………………….. 7
1.5.1 Broad Objective ……………………………………………………………………………………. 7
1.5.2 Specific Objectives ……………………………………………………………………………….. 8

CHAPTER TWO ………………………………………………………………………………………………. 9
2.0 LITERATURE REVIEW ..…………………………………………………………………………… 9
2.1 Working environment …………………………………………………………………………………. 9
2.2 Health provider performance………………………………………………………………………. 10
2.3 Performance indicators as per WHO definition …………………………………………….. 11
2.3.1 Availability ………………………………………………………………………………………… 11
2.3.2 Competence ……………………………………………………………………………………….. 12
2.3.3 Responsiveness …………………………………………………………………………………… 13
2.3.4 Productivity………………………………………………………………………………………… 13
2.4 Working environment factors that influence Health provider performance ………. 14
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2.4.1 Goal-setting………………………………………………………………………………………… 14
2.4.2 Physical factors (Office building) ………………………………………………………….. 15
2.4.3 Performance feedback …………………………………………………………………………. 15
2.4.4 Workplace incentives…………………………………………………………………………… 15
2.4.5 Comfort level ……………………………………………………………………………………… 16
2.4.6 Supervisor support ………………………………………………………………………………. 16
2.4.7 Job aids ……………………………………………………………………………………………… 17

CHAPTER THREE …………………………………………………………………………………………. 19
3.0. METHODOLOGY ……………………………………………………………………………………. 19
3.1 Study Site ………………………………………………………………………………………………… 19
3.2. Study type ……………………………………………………………………………………………….. 20
3.3 Study Population ………………………………………………………………………………………. 20
3.4 Sample size estimation for Clients receiving RCH services. …………………………… 20
3.5 Inclusion and exclusion criteria …………………………………………………………………… 21
3.5.1 Inclusion and exclusion criteria for Health facilities. ……………………………….. 21
3.5.2 Inclusion and exclusion criteria for clients ……………………………………………… 21
3.5.3 Inclusion and exclusion criteria for Nurses. ……………………………………………. 21
3.6 Sampling Procedure ………………………………………………………………………………….. 22
3.6.1 Selection of Healthcare providers ………………………………………………………….. 22
3.6.2 Selection of Clients ……………………………………………………………………………… 22
3.7 Selection and training of research assistants …………………………………………………. 22
3.8 Data collection techniques and Instruments ………………………………………………….. 23
3.9 Questionnaires ………………………………………………………………………………………….. 23
3.10 Reliability test of instruments …………………………………………………………………… 24
3.11 Pre-testing ………………………………………………………………………………………………. 24
3.12 Data collection Procedure ………………………………………………………………………… 24
3.13 Data Management …………………………………………………………………………………. 25
3.14 Study variables ……………………………………………………………………………………….. 25
3.15 Data processing and Analysis …………………………………………………………………… 26
3.16 Ethical consideration ……………………………………………………………………………….. 26
3.17 Limitation of the study …………………………………………………………………………….. 27

CHAPTER FOUR ……………………………………………………………………………………………. 28

4.0 RESULTS ………………………………………………………………………………………………….. 28
4.1 Socio- demographic characteristic of the study population …………………………….. 28
4.1.1 Socio- demographic characteristic of Health workers respondents …………….. 28
4.1.2 Socio- demographic characteristic of the Exit interview Respondents ……….. 30
4.2 Validity and Reliability analysis of Health Workers Performance Concepts …….. 32
4.3 The effect of office building space on availability performance of reproductive and child health care provider ………………………………………………………………………….. 34
4.4 Availability of drugs in relation to competence performance of Reproductive and Child Health care provider ………………………………………………………………………… 36
4.5 Availability of equipment in relation to competence performance of Reproductive and Child Health care provider …………………………………………………………………… 37
4.6 Presence of privacy in relation to competence performance of reproductive and child health care provider ………………………………………………………………………….. 37
4.7 The effects of Noise on health workers‟ Responsiveness Performance …………… 38
4.8 Relationship between Composite Performance and working environment factors and socio-demographic characteristics of RCH workers ……………………………….. 39
4.9: Relationship between health workers‟ self rated performance, their socio- demographic characteristics and working environment factors ………………………. 40
4.10 Clients‟ Perception on Elements of Performance (Availability, Competence, Productivity and Responsiveness) ………………………………………………………………. 43
4.10.1 Clients‟ Reporting on RCH Workers Availability …………………………………. 43
4.10.2 Clients‟ Reporting on RCH Workers Competence …………………………………. 44
4.10.3 Clients‟ Reporting on RCH Workers Productivity …………………………………. 44
4.10.4 Clients‟ Reporting on RCH Workers Responsiveness ……………………………. 45
4.11 Summary of major findings from the health worker questionnaires and clients exit interview …………………………………………………………………………………………… 45
CHAPTER FIVE …………………………………………………………………………………………….47
5.0 DISCUSSION …………………………………………………………………………………………….. 47
5.1Working Environment factors affecting performance of Health care providers ….. 47
5.1.1 The effect of comfort level (office building space) on Availability Performance of reproductive and child health care provider……………………………… 47
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5.1.2 The effect of level of interaction (interaction with fellow worker) on health workers Productivity Performance ………………………………………………………………… 48
5.1.3 Availability of drugs in relation to the Competence Performance of Reproductive and Child Health care provider …………………………………………………. 48
5.1.4 Availability of equipment in relation to the competence performance of Reproductive and Child Health Clinic ……………………………………………………………. 49
5.1.5 The availability of office layout (presence of privacy) in relation to health provider Competence Performance ……………………………………………………………….. 50
5.1.6 The effect of noise on health workers‟ responsiveness performance. …………. 50
5.1.7 Relationship between composite performance and working environment factors and social demographic characteristics of RCH workers ……………………….. 51
5.1.8 Relationship between health workers‟ self rated performance, working environment factors and their socio- demographic characteristics……………………… 51
5.1.9 Clients‟ perception on elements of performance (availability, competence, productivity and responsiveness) …………………………………………………………………… 52

CHAPTER SIX ……………………………………………………………………………………………….. 54
6.0 CONCLUSION AND RECOMMENDATIONS …………………………………………… 54
6.1 Conclusion ……………………………………………………………………………………………….. 54
6.2 Recommendations …………………………………………………………………………………….. 54

REFFERENCES ……………………………………………………………………………………………… 55
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LIST OF APPENDICES
Appendix 1: Informed consent (English Version) ………………………………………………….. 61
Appendix 2: Informed Consent (Swahili version) …………………………………………………. 63
Appendix 3: Questionaire (English version) …………………………………………………………. 65
Appendix 4: Exit enterview Guide (English version) …………………………………………….. 70
Appendix 5: Questionaire (Swahili version) …………………………………………………………. 74
Appendix 6: Exit enterview Guide (Swahili version) …………………………………………….. 78
Appendix 7: Cronbach‟s Alpha Reliability Test. ……………………………………………………. 82
Appendix 8: Ethical Clearance Letter…………………………………………………..83
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LIST OF TABLES
Table 1: Type of health facility by ownership ………………………………………….19
Table 2: Socio –demographic characteristics of the Reproductive and Child Health Care provider by sex………………………………………………………………..29
Table 3: Socio- demographic characteristic of Clients who were interviewed in RCH unit by level of health facility …………………………………………………31
Table 4: Validity and Reliability Analysis of Health Workers‟ Performance Measures after dropping some of the items ……………………………………………..33
Table 5: Coefficients of regression on the effect of office building space on availability performance of reproductive and child health care provider …………………35
Table 6: Coefficients of regression of how health provider interaction with fellow worker affects health workers‟ productivity performance ……………………35
Table 7: Coefficients of regression availability of drugs in relation to competence performance of reproductive and child health care provider …………………36
Table 8: Coefficients of regression on availability of equipment in relation to competence performance of reproductive and child health care provider ……37
Table 9: Coefficients of regression on presence of privacy in relation to health provider competence performance ……………………………………………………..38
Table 10: Coefficients of regression on how noise affects health workers‟ responsiveness performance …………………………………………………………………..39
Table 11: Relationship between composite performance, working environment factors and socio -demographic characteristics of RCH workers …………………….40
Table 12: Definition of variables ………………………………………………………41
Table 13: Relationship between health workers‟ self rated performance, their socio-demographic characteristics and working environment factors ………………42
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LIST OF FIGURES
Figure 1: Conceptual Framework: Effects of Working Environment on RCH Health Workers Performance ……………………………………………………………………………. 6
Figure 2: Clients Reporting on RCH health providers‟ availability ………………………….. 43
Figure 3: Clients Reporting on RCH health providers‟ competence. ………………………… 44
Figure 4: Clients Reporting on RCH health providers‟ productivity. ………………………… 44
Figure 5: Clients Reporting on RCH health providers‟ Responsiveness ……………………. 45
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ABBREVIATIONS
BCC : Behaviour Change Communication
FP : Family Planning
FBO : Faith Based Organisation.
HR : Human Resource
IEC : Information Education Communication
IUD : Intra Uterine Device
JLI : Joint Learning Initiative
LMICs : Low and Middle Income Countries
M & E : Monitoring and Evaluation
MCH : Maternal and Child Health
MDGs : Millennium Development Goals
MHSW : Ministry of Health and Social Welfare
MUHAS : Muhimbili University of Health and Allied Sciences
NGOs : Non Government Organizations
OPRAS : Open Performance Review and Appraisal System
PIF : Performance Improvement Fund
PIM : Performance Improvement Model
RBM : Result Based Management
RCH : Reproductive and Child Health
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OPERATIONAL DEFINITIONS
For the purpose of this study:
1. Performing health providers is defined as a workforce that “works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given the available resources and circumstances” [1]. 2. Performance is considered as the Composite of the four elements namely availability, productivity, competences and responsiveness of health provider .Improvement of these four elements indicate improved performance [2, 3].
3. Availability refers to as presence of health worker measured by presence of health provider in his place of work as well as availability of working tools and drugs [3].
4. Productivity is defined as the relationship between health outcomes and human resource input measured by the health worker work load [3].
5. Competence is defined as ability, knowledge and traits of health provider to perform given work measured by Adherence to standard operating procedures and communication with patients [3].
6. Responsiveness is considered as how well the health system meets the legitimate expectation of both clients and health providers, measured by health workers‟ satisfaction and clients‟ satisfaction [3].
7. Working environment is considered as the composite of the two components; physical and behavioral. The physical environment consists of elements that relate to the office occupiers‟ ability to physically connect with their office environment. The behavioral environment consists of components that relate to how well the office occupiers connect with each other [4].
8. Comfort level is defined as the degree to which health provider is comfortable in his work measured by availability of Office building space, Infrastructure (water and electricity), availability of working tools and medical supplies [4].
9. Office layout is considered as the way office is arranged measured by presence of privacy [4].
10. Level of interaction is considered as the way health worker interacts with fellow worker and his/her employer [4].
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CHAPTER ONE
1.0 INTRODUCTION
The human resources crisis coupled with poor performance of health workers in the health sector in low and middle-income countries (LMICs) like Tanzania, is receiving increased global attention [1]. This has resulted into policymakers and planners realizing that it is simply not possible to achieve the Millennium Development Goals (MDGs) if health workers’ availability and performances are not addressed more effectively [1]. Poor performance leads to inappropriate care, which contributes to reduced health outcomes, as people do not use services or are mistreated when they do.
In the process of improving healthcare system, Tanzania faces challenges such as shortage of health workers, increased case loads for health workers due to migration of skilled health personnel, double burden of disease and the HIV/AIDS scourge that affect both the general population and health personnel hence it is vital for Tanzania to have a well function health system with a well motivated staff that carries out their work according to standard set by the system [3], within the existing organizational structure.
The working environment in health care comprises of two major components, namely, physical and psycho-social. During early days of development of health organization psychology only physical environment in work place was given importance and was considered as a predominant determinant of employees‟ performance. Earlier studies examined the effect of illumination, temperature, noise, and atmospheric conditions on performance of the workers [5]. However, no consistent relationship could be noted between these components of physical work environment and performance. Studies in health care psychologists have further examined social and psychological environment and its effects on employees‟ performance [5].
The recognition of the significant role of psycho-social environment led to the emergence of organizational psychology, and furthers the concept of „quality of worklife‟. The importance of physical work environment has now been realized. Therefore, the modern health care industries are making all possible efforts to make work environment more comfortable, safe and healthy.
In Tanzania, the government through the Ministry of Health and Social Welfare (MoHSW) has the same concern as other Africans countries which are to ensure health and social welfare services are of high quality, effective, accessible and affordable, delivered by a well performing and sustainable national health and welfare system that encourages responsiveness to the needs of the people [6].One of the strategy used was the introduction of a Result Based Management (RBM) using a home grown rubric referred to as Performance Improvement Model (PIM). This is an integrated approach to performance management. This approach, among other things, requires all public service institutions to plan, implement, monitor, evaluate, and report on performance, and finally carry out performance reviews. From the year 2000 to 2006 performance improvement model was installed in all Ministries, independent Departments, Executive Agencies and Regional Secretariats [4].
Also the public service introduced a number of processes, tools and mechanisms in order to facilitate the institutionalization of a performance management system. The specific tools for performance management include strategic and operational planning, client service charters, service delivery surveys, self assessment programmes, performance budgets, the introduction of Open Performance Review and Appraisal System (OPRAS) and comprehensive Monitoring and Evaluation (M&E) system. Furthermore the Performance Improvement Fund (PIF) was established and implemented to support changes identified in Strategic Plans however all these seem to be failing into improving health workers performance [4]. Taking this fact into consideration this study focused on working environment factors which have positive or negative effect on health care performance in Reproductive and child health services the question which the researcher was trying to answer was, what is the effect of working environment on performance level of Reproductive and child health care provider in Tarime District?
This dissertation is therefore organized as follows: It starts with the introduction, review of available literature concerning the study, study methodology, results, and discussion of results and finally it ends with conclusion and recommendation.

1.1 Statement of the Problem
Poor health-worker performance in low and middle income countries is particularly exacerbated by human resources (HR) shortages that reached critical levels in many resource-poor settings, especially in rural areas like Tarime and has been a major concerned in these countries health sector.
Since the start of the Joint Learning Initiative (JLI), in 2003, the human resources crisis in low-income countries (LICs) has received global attention, particularly the crisis in sub-Saharan Africa. In Tanzania less than 50% of the required staff is available to serve rural populations; while at times health care is provided by non-qualified staff [7, 8]. This situation seriously compromises the health status of the communities. The poor performance has been attributed to poor diagnosis and even death of the sick people.
Although there is no conclusive evidence concerning the relationship between health outcomes and the number of human resources (HR) available for health care, it is clear that qualified and motivated human resources are essential for adequate health service provision[9]. Low performance can be determined by poor knowledge to perform a given work, poor working condition and poor communication between employer and employee and employee themselves.
Determinants of poor performance can be influenced in a variety of ways, The 2006 World health report describes three levels to influence workforce performance this include job-related interventions that focus on individual occupations, support-system related interventions and interventions that create an enabling environment and focus on managerial culture and organizational arrangements [7].
To improve the performance of health care, supportive working environment is needed. This encompasses more than just having sufficient equipment and supplies. It also includes systems issues, such as decision-making and information-exchange processes, and capacity issues such as workload, support services and infrastructure [10]. Although it is logical to link poor performance to poor working conditions, there is limited documentation showing how poor working conditions influence health provider productivity, competence and responsiveness.
While some of the reviewed studies done in the country have looked at health worker performance and working environment factors, most of these studies focus on how motivation, supervision, skills to perform the given work, and availability of working tools affect performance [11,12,13],and rarely into the role of working environment and performance of health workers especially focusing on how working environment affect the availability, competence, productivity and responsiveness combined as they affect elements of performance of health workers in reproductive and child health care. This study tried to examine whether there is a relationship between working environment and performance level of the health care provider or otherwise.
Therefore, specifically, this study investigated the effect of working environment on performance level of health care providers in Tarime district. The study examined how working environment affects workers performance and evaluated the extent to which working environment would contribute to encouraging or discouraging health care provider to perform well.

1.2 Rationale of the Study
This study has produced information on the relationship between working environment and health worker performance that might be used to understand how performance of health workers in the Reproductive and Child Health care is affected by working environment that need special attention in the reduction of maternal and infant mortality on health care provider‟s area. Furthermore, the research findings could be used to inform the district on working environmental factors influencing performance of health care provider. It also serves as background information for promoting and advocating good environment for improved performance of health care worker in Tarime district. More over it serves as background information for future research of the same topic.

1.3 Conceptual Framework
This conceptual framework tries to explain how working environment influences health workers performance. It assumes that working environment consists of two components that are physical environment and behavior component.
Physical environment comprises the comfort level (presence of office building and working tools) which influences health provider‟s availability, productivity and competence. Also there is an office layout (presence of privacy) which influences health workers productivity and competence. The behavior component of environment (how workers interact with each other and absence of noise) tends to influence productivity and responsiveness, and in totality they may improve or decrease health workers performance. (See illustration in figure 1)
Figure 1: Conceptual Framework: Effects of Working Environment on RCH Health Workers Performance

WORKING ENVIRONMENT FACTORS
a) PHYSICAL COMPONENT OF WORK ENVIRONMENT.
1. COMFORT LEVEL
• Office building space and Infrastructures (water and electricity).
• Presence of working tools and medical supplies.
2. OFFICE LAYOUT
• Presence of Privacy
b) BEHAVIOUR COMPONENT OF WORK ENVIRONMENT
1. LEVEL OF INTERACTION.
• Work interaction
2. DISTRUCTION
• Absence of noise
2. PRODUCTIVITY
 Health worker workload
3. COMPETENCE
• Adherence to standard operating procedures
• Communication with patients
4. RESPONSIVENESS
• Clients‟ and health workers‟ satisfaction
Improve/ decrease health workers performance in Reproductive and Child Health Clinic.
PERFORMANCE INDICATORS
1. AVAILABILITY
 Drugs availability.
 Health worker availability
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1.4 Research Question
What is the effect of working environment on performance level of the health care providers?
Specifically the research aims at answering the following questions:
1. What is the effect of office building space on health providers‟ availability performance in Tarime district?
2. How does health provider interaction with fellow worker affect health workers‟ productivity performance in Tarime district?
3. How availability of drugs affect the competence performance of reproductive and child health care providers in Tarime district?
4. How availability of equipment (BP – machine) affect the competence performance of reproductive and child health care provider in Tarime district?
5. What is the effect of presence of privacy on health workers‟ competence performance in Tarime district?
6. What is the effect of noise on health workers‟ responsiveness performance in Tarime district?
7. What are the Clients‟ perceptions on elements of performance (availability, competence, productivity and responsiveness)?

1.5 Objectives
This study focused on the following broad and specific objectives.
1.5.1 Broad Objective
To explore the relationship between working environment and performance level of health care provider working in reproductive and child health unit (RCH) in Tarime district.
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1.5.2 Specific Objectives
1. To explore the effect of office building space on availability performance of reproductive and child health care provider.
2. To assess how health provider interaction with fellow worker affects health workers‟ productivity performance.
3. To explore availability of drugs in relation to competence performance of reproductive and child health care provider.
4. To explore availability of equipment (BP- machine) in relation to competence performance of reproductive and child health care provider.
5. To assess presence of privacy in relation to health provider competence performance.
6. To find out how noise affects health workers‟ responsiveness performance.
7. To explore Clients‟ perception on elements of performance (availability, competence, productivity and responsiveness).

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THE EFFECT OF WORKING ENVIRONMENT ON WORKERS PERFORMANCE: THE CASE OF REPRODUCTIVE AND CHILD HEALTH CARE PROVIDERS IN TARIME DISTRICT