human resource management practices in the south...

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Human Resource Management Practices in the South African

Public Health Sector: Assessing their impact on the Retention of

South African Doctors at an Eastern Cape Hospital Complex

A Research Report

presented to

The Graduate School of Business

University of Cape Town

In partial fulfilment

of the requirements for the

Masters of Business Administration Degree

by

Dr Bruce Longmore

December 2012

Supervised by: Dr Linda Ronnie

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Human Resource Management Practices in the South African Public Health Sector:

Assessing their impact on the Retention of South African Doctors

University of Cape Town Masters of Business Administration Research Report

Contents

Plagiarism Declaration .................................................................................................... 5

Acknowledgements ........................................................................................................ 6

1. Introduction ................................................................................................................ 71.1 Research Question ........................................................................................................................ 71.2 Background ................................................................................................................................... 71.3 Research Purpose .......................................................................................................................... 91.4 Research Significance ................................................................................................................... 91.5 Topic Limitations ........................................................................................................................ 10

2. Literature Review ..................................................................................................... 112.1 Exploring factors contributing to the retention of medical doctors ............................................ 11

2.1.1 Financial Incentives ............................................................................................................ 142.1.2 Career Development ............................................................................................................ 142.1.3 Hospital or Clinic Management .......................................................................................... 152.1.4 Educational Opportunities .................................................................................................. 152.1.5 Hospital Infrastructure and Resource Availability ............................................................. 152.1.6 Recognition and Appreciation ............................................................................................. 16

2.2 Factors affecting the retention of knowledge workers ................................................................ 162.2.1 Retention of Knowledge workers ......................................................................................... 17

2.2.2 Merging the Concepts .............................................................................................................. 182.3 Understanding the role of human resource management practices in the retention of medical doctors............................................................................................................................................... 192.4 Conclusion .................................................................................................................................. 20

3. Research Methodology ............................................................................................. 213.1 Research Approach and Strategy ................................................................................................ 21

3.1.1 Justification of Research Approach ..................................................................................... 213.2 Research Design ......................................................................................................................... 21

3.2.1 Research Questions ............................................................................................................. 223.2.2 Limitations of the Study Design ........................................................................................... 22

3.3 Sampling Details ......................................................................................................................... 233.3.1 Response Rate ...................................................................................................................... 23

3.4 Data Collection ........................................................................................................................... 243.4.1 Data Collection Strategy ..................................................................................................... 243.4.2 Pilot Study ........................................................................................................................... 243.5 Data Gathering Sequence ....................................................................................................... 25

3.6 Data Analysis .............................................................................................................................. 253.7 Research Validity ........................................................................................................................ 26

3.7.1 Triangulation ....................................................................................................................... 263.7.2 Thick Description ................................................................................................................ 26

8.8 Ethical Considerations ................................................................................................................ 273.9 Researcher Bias .......................................................................................................................... 27

4. Findings and Analysis ................................................................................................ 284.1 Introduction ................................................................................................................................. 284.2 Head of Department (HOD) Interview Results .......................................................................... 29

4.2.1 Interview 1 ........................................................................................................................... 294.2.2 Interview 2 ........................................................................................................................... 294.2.3 Interview 3 ........................................................................................................................... 304.2.4 Interview 4 ........................................................................................................................... 30

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University of Cape Town Masters of Business Administration Research Report 3

4.3 Survey Findings: Demographic Characteristics of Respondents ................................................ 314.4 Survey Findings Theme 1: Human Resource Practices .............................................................. 32

4.4.1 Salary ................................................................................................................................... 324.4.2 Document Filing and Storage System ................................................................................. 344.4.3 Communication ................................................................................................................... 364.4.4 Value and Respect ............................................................................................................... 374.4.5 Re-imbursement for Courses and Conferences ................................................................... 39

4.5 Survey Findings Theme 2: Human Resource Characteristics ..................................................... 404.5.1 Task Competence ................................................................................................................. 414.5.2 Accountability ...................................................................................................................... 434.5.3 General Process Efficiency ................................................................................................. 454.5.4 Salary Adjustment Efficiency ............................................................................................... 464.5.5 Availability .......................................................................................................................... 47

4.6 Conclusion .................................................................................................................................. 48

5. Discussion ................................................................................................................. 495.1 Introduction ................................................................................................................................. 495.2 Demographic Characteristics of Respondents ............................................................................ 495.3 Human Resource Practices ......................................................................................................... 51

5.3.1 Salary ................................................................................................................................... 515.3.2 Document Filing and Storage System ...................................................................................... 525.3.3 Communication ........................................................................................................................ 535.3.4 Value and Respect .................................................................................................................... 545.3.5 Re-imbursement for Courses and Conferences ........................................................................ 555.4 Ranking Human Resource Characteristics .................................................................................. 56

5.4.1 Task Competence ................................................................................................................. 565.4.2 Accountability ...................................................................................................................... 575.4.3 General Process Efficiency ................................................................................................. 585.4.4 Salary Adjustment Efficiency (PMDS and OSD) ................................................................. 585.4.5 Availability .......................................................................................................................... 59

5.5 Conclusion .................................................................................................................................. 60

6. Conclusion ................................................................................................................ 616.1 Important HRM Practices that Influence Doctor Retention at the ELHC .................................. 626.2 Measuring the Performance of the ELHC HRM Practices ......................................................... 636.3 The Most Important HR Practices .............................................................................................. 636.4 Rating of the ELHC HR Practice Performance .......................................................................... 646.5 The Most Important HR Characteristics ..................................................................................... 646.6 Rating the ELHC HR Characteristic Exhibition ......................................................................... 656.7 HRM at the ELHC and its Impact on the Retention of Doctors ................................................. 666.8 HRM in the Public Health Sector and its Impact on the Retention of Doctors .......................... 676.9 Limitations of the Study ............................................................................................................. 676.10 Future research .......................................................................................................................... 68

7. References ................................................................................................................ 69

8. Appendices ............................................................................................................... 73Appendix 1: Authorisation from The Chief Executive Officer at the ELHC ................................... 73Appendix 2: UCT Ethical Clearance Form ....................................................................................... 74Appendix 3: Head of Department Questionnaire .............................................................................. 75Appendix 4: Survey Page 1 .............................................................................................................. 76Appendix 5: Survey Page 2 .............................................................................................................. 77Appendix 5: Survey .............................................................................................................. 78Appendix 6: Daily Dispatch Newspaper Article .............................................................................. 79

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List of Figures Figure 1: Number of Medical Practitioners per 10000 population in each sector, by

province, 2010.............................................................................................................. 10Figure 2: Occurrence of Theme in the 20 studies Reviewed ............................................... 14Figure 4: Performance Rating for Timeous Salary Payment ............................................... 33Figure 5: Performance Rating of Document Management .................................................. 34Figure 6: Performance Rating of HR communication Efforts ............................................. 37Figure 7: Performance Rating of HR Interaction Quality .................................................... 38Figure 8: Performance Rating of Continued Education Facilitation ................................... 39Figure 9: Rating of Task Competence of HR Staff .............................................................. 42Figure 10: Rating of HR Staff Accountability ..................................................................... 44Figure 11: Rating of General Process Efficiency of HR Staff ............................................. 45Figure 12: Rating of HR Staff Efficiency toward OSD and PMDS .................................... 46Figure 13: Rating of HR Availability .................................................................................. 47

List of Tables Table 1: Retention Gap for Health Professional Graduates 2002-2010 ................................ 8Table 2: Factors Influencing the Retention of Healthcare Workers .................................... 12Table 3: Factors affecting the Motivation and Retention of Healthcare Workers in

Developing Countries .................................................................................................. 13Table 4: Demographic Characteristics of Respondents ....................................................... 31Table 5: Importance Ranking of Human Resource Practices .............................................. 32Table 6: Importance Ranking of Human Resource Characteristics ..................................... 40Table 7: Doctors Willingness to Stay at the Complex ......................................................... 48

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Plagiarism Declaration

1. I know that plagiarism is wrong. Plagiarism is to use another’s work

and pretend that it is one’s own.

2. I have used the American Psychological Association 6 convention for

citation and referencing. Each contribution to, and quotation in, this

report from the work(s) of other people has been attributed, and has

been cited and referenced.

3. This report is my own work.

4. I have not allowed, and will not allow, anyone to copy my work with

the intention of passing it off as his or her own work.

5. I acknowledge that copying someone else’s assignment or essay, or part

of it, is wrong, and declare that this is my own work.

Signature ______________________________

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Acknowledgements

I would like to acknowledge the following people for their contributions to this research:

Dr. Linda Ronnie, supervisor, lecturer and friend, for her patient guidance and assistance in

every step of this research report. It has been both a pleasure and an honour to work with

her and an experience that I will not forget.

The ELHC Head of Departments for generously giving up time out of their busy days to be

interviewed.

Viyonne Longmore, my wife, my best friend and my biggest support, for her unconditional

love and encouragement throughout this project and over the past year. She is truly a

blessing from God for which I will be ever grateful.

A wife of noble character who can find?�

She is worth far more than rubies.

Her husband has full confidence in her

and lacks nothing of value.

She brings him good, not harm,�

all the days of her life.

Proverbs 31: 10-12 NIV Bible

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1. Introduction On the 30th May 2012, the Eastern Cape was described as having a healthcare crisis (Eager,

2012). “Non-payment of staff, drug stock-outs and shortages of basic medical supplies”

were labeled as manifestations of what was believed to be “widespread systemic failures in

the management and financing of services in the province” (Eager, 2012). At the heart of

this crisis, lay two key issues, namely poor management and severe staff shortages.

It may be apparent that sound Human Resource management of healthcare workers is

critical for the functioning of a healthcare system, but its importance is seemingly

overlooked. As in the case of the Eastern Cape’s hospital system, one of the most

concerning factors facing healthcare is the province’s struggle to effectively retain doctors.

Although this retention issue seems to be multi-faceted, of particular concern is the role

that human resource management seems to have. This can be seen in the “delayed or non-

payment of critical healthcare workers” that is being cited as the reason causing doctors

and other staff to abandon their public healthcare posts (Eager, 2012).

It is this distressing scenario that plays a substantial role in the formation of this thesis,

which focusses on an Eastern Cape Hospital Complex’s Human Resource management

practices and their impact on the retention of doctors.

1.1 Research Question The question that this research attempts to answer is: What Human Resource management

practices positively and negatively influence doctor retention capabilities at the East

London Hospital Complex?

1.2 Background There has been a significant migration of doctors away from South Africa (Grant, 2006).

One of the results of this is the retention gap, the difference between the number of

healthcare professionals qualifying and the growth of the public sector. As can be seen in

Figure 1 the South African retention gap for doctors between 2002 and 2010 is at a

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staggering 62.4% (HRH Strategy, 2011). Effectively this means that the state is managing

to retain less than 40% of doctors that it is producing.

Table 1: Retention Gap for Health Professional Graduates 2002-2010

2002 – 2010

Profession Graduate Output Public Sector

post increases

Retention Gap Retention

Gap %

MBChB 11700 4403 7297 62.4%

Dentistry 2140 248 1892 88.4%

Pharmacy 3645 1960 1685 46.2%

Physiotherapy 2934 497 2437 83.1%

OT 1827 410 1417 77.6%

SLP + Audiology 1413 265 1148 81.2%

Dietetics 657 502 155 23.6%

Source: Human Resources for Health South Africa. HRH Strategy for the Health Sector: 2012/13 –

2016/17. Version 1: Released 11th October 2011

These statistics require further exploration in order to understand their basis and the reason

for doctor migration. Mejia, Pizurki and Royston (1979) define migration as the interplay

of a variety of forces found on both ends of the migratory axis. The forces found in the

donor country are generally referred to as push factors and those on the opposite side of the

axis, in the receiving country, are known as pull factors (Mejia et al., 1979). Problems

relating to the retention of doctors are often naively explained as being a result of the

financial appeal of the private sector or the “green pasture” attraction of opportunities

beyond our borders. These are primarily pull factors but as Willis-Shatuck, Bidwell,

Thomas, Wyness, Blaauw, and Ditlopo, (2008) found in their systematic review of 20

studies pertaining to the retention of doctors in developing countries, financial incentives

on their own are insufficient to motivate healthcare workers. They concluded that financial

reward, career development and management concerns remain at the core of health worker

retention. It is the author’s contention that if the latter two practices are poorly executed,

they can become significant push factors driving away potential doctors.

Thus in summary, some doctors do leave the public sector in search of financial gain but

this is not always the case. Doctors are unquestionably drawn to the public sector for

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numerous reasons; however the institutional inertia surrounding advertising posts and

hiring new doctors, merged with the poor HR management of individuals, seems to be

successfully transforming this attraction into a significant push factor. Sadly the net result

of these migratory patterns is the perpetuation of South Africa’s proverbial and crippling

“brain drain”, something that Hagopian, Thompson, Fordyce, Johnson, and Hart, (2004)

recognised as particularly damaging to the health systems of the source countries due to the

appreciable effects on the doctor-to-population ratio.

1.3 Research Purpose

These staffing battles face not only the Eastern Cape but also South Africa as a whole and

it is therefore critical to understand which factors play a role in the retention strategies of

doctors and to what degree these are important. Without this knowledge and understanding,

significant amounts of effort could be channelled in the wrong direction and therefore

potentially create the situation where critical opportunities to retain doctors are missed.

Thus with this research, the intended purpose is to explore and quantify the impact that

various human resource management practices have on the retention of public sector

doctors.

1.4 Research Significance Although the present health minister has recognised that human resources is a problem

facing the health system and has included its improvement in the Health department’s 10-

Point Strategy plan, the concern is that insufficient effort is being channeled timeously (SA

DoH Strategy Plan, 2010). As recently as 31 May 2012 in a SABC article titled “E Cape

doctor shortage prompts Motsoaledi to intervene”, Health Minister, Aaron Motsoaledi was

quoted as saying that, “he will have to intervene to deal with the problem of the shortage of

doctors in the Eastern Cape” (SABC, 2012). This response was in particular reference to

“the reported non-payment of a number of doctors” and the article further went on to say

that “the incident was reported as if it was widespread, thus his ministry will have to

intervene and probe”. The Eastern Cape (EC) is in particular, one of the worst effected

areas and the magnitude of doctor shortages can be seen in figure 2. In 2010 the EC at 2.97

public doctors per 10 000 population was one of the lowest in the country (HRH Strategy,

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2012). This shortage seems to have been worsening over the past two years as highlighted

in the province’s recent poor publicity.

Figure 1: Number of Medical Practitioners per 10000 population in each sector, by province, 2010.

Source: Human Resources for Health South Africa. HRH Strategy for the Health Sector: 2012/13 –

2016/17. Version 1: Released 20th January 2012

1.5 Topic Limitations The area of doctor retention in the South African context is a complex and multi-faceted

problem (Kotzee & Cooper, 2006; Padarath et al. 2003). To improve our understanding,

each of these facets requires comprehensive research and analysis. This thesis explores the

HRM practices with a view to adding to the body of knowledge and understanding of this

complex issue.

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2. Literature Review The review of the literature is presented in three sections. The first section aims to discover

what factors are important in the retention of doctors in developing countries. The second

section makes a claim for doctors as knowledge workers and considers retention factors in

the broader context. Lastly the literature surrounding the importance of the role of human

resource management in the public sector is reviewed.

2.1 Exploring factors contributing to the retention of medical doctors According to Padarath et al., (2003), there are a multitude of push and pull factors that

impact on the movement of healthcare workers. The notion of push and pull factors, when

referring to retention and motivation, was initially described by Mejia, Pizurki and Royston

in 1979. These authors explain that “pull factors” are primarily factors of attraction and

“push factors” are those that support the movement away from an institution or country

(Mejia, Pizurki & Royston, 1979). These factors are the forces behind worker migration

and in the healthcare industry these forces result in migratory patterns, including rural to

urban, public to private, and from poorer nations to wealthier ones (Padarath et al. 2003).

The push and pull factors at work here can be further categorised into those factors

occurring within the health system or endogenous factors, and those beyond the realms of

the health system or exogenous factors (Padarath et al. 2003).

In their review of more than fifty studies investigating healthcare worker (HCW) migration,

Padarath et al., (2003) encountered common dynamics that influenced these HCW

movements. Endogenous push factors include low remuneration levels, work associated

risks including diseases like HIV/AIDS and TB, inadequate human resource planning with

consequent unrealistic workloads, poor infrastructure and sub-optimal conditions of work

(Padarath et al., 2003). Exogenous push factors include political insecurity, taxation levels,

crime, repressive political environments and falling service standards. The pull factors

included aggressive recruitment by wealthier countries, improved quality of life, study and

specialisation opportunities and improved remuneration (Padarath et al., 2003).

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Lastly the study stresses the importance of “stick” and “stay” factors. The “stick” factors

improve retention and include family ties, migration costs, psychological links with home,

language and other social and cultural influences. However the inertial nature of these

factors can manifest in the lives of the healthcare workers in the recipient countries. They

then become what Padarath et al (2003) refer to as ‘stay’ factors and these then affect the

decision to remain in recipient countries to avoid disruption to family life and schooling or

loss of a higher standard of living. A lack of employment opportunities in host countries,

also seem to play a role here (Padarath et al., 2003).

The table below summarises the factors that influence the retention of HCW.

Table 2: Factors Influencing the Retention of Healthcare Workers

Source: Padarath et al. (2003)

Push Pull Stick Stay

Endogenous Exogenous Opposite to Push factors

Low remuneration levels

Political insecurity Aggressive recruitment by wealthier countries

Family ties Not disrupt family life and schooling

Work associated risks - including diseases like HIV/AIDS and TB

Taxation levels Improved quality of life

Time-consuming and costly migration and “re-qualification” factors

Lose their higher standard of living

Lack of further education and career development opportunities

Quality of life and crime

Study and specialisation opportunities

Psychological links with home

Lack of employment opportunities in host country

Poor infrastructure and sub-optimal conditions of work

Repressive political environments

Improved remuneration

Language

Lack of job satisfaction

Falling service standards

Safer working environment

Other social and cultural influences

Poor human resource planning with consequent unrealistic work loads

Lack of education opportunities for children

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Although serious, the exogenous factors are most often beyond the management capacity

of healthcare systems. Endogenous factors on the other hand are what need to be at the

centre of the developing country’s focus. The South African Government needs to reduce

the intensity of the push factors and in doing so improve the endogenous pull factors. The

focus of this study is primarily to understand not only what Human Resource practices will

assist in retaining doctors in the South Africa, but also more importantly what will keep

doctors in the public sector.

Willis-Shattuck et al. (2008) conducted a systematic review of articles exploring factors

that pertain to the motivation and retention of health care workers in developing countries.

This systematic review concentrated on endogenous factors and appears to support the

endogenous factors highlighted by Padarath et al. (2003). Table 3 identifies these factors.

Table 3: Factors affecting the Motivation and Retention of Healthcare Workers in Developing Countries

Retention Factor

Financial Incentives

Career Development

Hospital and Clinic Management

Availability of resources

Continuing Education

Recognition and appreciation

Hospital Infrastructure

Source: Willis-Shattuck et al. (2008) These seven factors occurred in varying frequency in the 20 studies reviewed by Willis-

Shattuck et al. (2008) and are reproduced in Figure 2 below.

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Figure 2: Occurrence of Theme in the 20 studies Reviewed

Source: Willis-Shattuck et al. (2008)

Each of these factors is explored in further depth in the paragraphs that follow.

2.1.1 Financial Incentives

Remuneration and financial incentives play an important role in the retention and

motivation of healthcare workers with 90% of studies highlighting its importance (Willis-

Shattuck et al., 2008). If this aspect of motivation and retention is ignored, it tends to

make HCWs feel undervalued and demotivated (King & McInerney, 2006). Emerging

from this importance is the common perception that financial incentive on its own is the

principal factor affecting the retention of doctors; however financial incentives were found

to be insufficient on their own to prevent health workers from migrating (Kotzee & Cooper,

2006; Mathauer & Imhoff, 2006).

2.1.2 Career Development Career development was identified as being important in 85% of studies. Kotzee and

Cooper (2006), in their study on rural doctors, found that health workers were reluctant to

work in these areas as career furthering opportunities were typically less than in urban

areas. The majority of literature indicates that HCWs thrive off the opportunity to progress

and this is most definitely the case in the South African setting where positions are linked

to remuneration scales (Reid, 2004; Kotzee & Couper, 2006; Manongi, Marchant &

Bygbjerg, 2006).

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2.1.3 Hospital or Clinic Management Willis-Shattuck et al. (2008) consistently found that management plays an extremely

important role in both the retention and motivation of HCWs. Kotzee and Couper (2006)

specifically found that non-medical management, who were not supportive and did not

treat doctors satisfactorily, frustrated doctors. Personnel departments were identified as a

specific problem area and doctors expressed anger toward promotion issues and

communication. In settings with scarce human resources, management positions were

given to poorly trained individuals who failed to adequately represent and lobby for their

staff. This factor influenced motivation levels directly and as a result staff retention

(Willis-Shattuck et al., 2008).

2.1.4 Educational Opportunities Linked directly to career development, continued education is vital to prevent HCW’s from

leaving healthcare facilities. Training and development enables HCW’s to assume greater

levels of responsibilities and to achieve personal goals and professional development

(Mathauer & Imhoff, 2006). Reid (2004) highlights that young health professionals feel

more confident in their roles and abilities when they received adequate postgraduate

practical training. This continued training is not only important for the individual but the

system as a whole and relies heavily on management to ensure it occurs regularly.

Integrating these educational and progressive efforts with the individual’s career growth is

vital to ensure that the individual’s development plans reflect their department or hospital's

future development needs (Kock & Burke, 2008).

2.1.5 Hospital Infrastructure and Resource Availability Improving working conditions, hospital infrastructure and medical equipment availability,

were among the top three most important interventions to retain doctors, with a lack of the

above facilities cited as a specific factor for doctors leaving (Kotzee & Couper, 2006).

Particular effort must be made to ensure that HCW’s are able to fulfil their roles and utilise

their skills and knowledge to the fullest and that this should be an integral part of any

retention plan (Willis-Shattuck et al., 2008). Poor infrastructure does not promote

confidence in the HCW’s ability nor does it instil confidence in the patients that they are

attempting to treat (Willis-Shattuck et al., 2008). Huddart, Picazo and Duale (2003), in

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their study in Zimbabwe, confirmed the critical nature of this factor by showing that a

common cause for HCWs resigning from public posts was their inability to offer effective

care to patients due to austere conditions in the healthcare facilities.

2.1.6 Recognition and Appreciation The final factor determined as an important factor in the motivation and retention of

HCW’s was that of recognition and appreciation from management, colleagues or the

community (Willis-Shattuck et al., 2008). This aspect was noted in 70% of studies and was

mentioned as the most important factor in six of these. HCW’s want to make a difference,

be encouraged by results of their work and appreciated as being useful to and trusted by a

community. Addressing these issues assists significantly in retaining doctors in these often

challenging environments (Dieleman, Toonen, Toure & Martineau, 2006; Manongi,

Marchant & Bygbjerg, 2006).

As can be seen the factors influencing the retention of doctors is multifaceted and complex,

however in recent years, as industry and society have changed, a body of research has been

established that may assist to better understand this complexity. This research has been

around the management of so-called “knowledge” workers (KW’s), and its potential use is

born out of the similarity between KW’s and doctors. Coined by Drucker (1989), this term

“knowledge worker” was created to describe a part of the workforce who possesses

knowledge as a formidable resource, which they, rather than the organisation own. In the

next section the factors that influence the retention of KW’s are reviewed.

2.2 Factors affecting the retention of knowledge workers Davenport (2005, p. 10) defines KW’s as those individuals that “have high degrees of

expertise, education, or experience, and the primary purpose of their jobs involves the

creation, distribution or application of their knowledge”. This definition shows the

potential to incorporate HCW’s and particularly doctors within its scope. Further support

to this likeness comes in the form of Despres and Hiltrop’s (1995) description of

knowledge workers. This description includes the notion that KW’s have careers that are

developed externally as a result of many years of formal education as opposed to internal

organisational advancement. KW’s have a large degree of loyalty to their profession and

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play a critical role in the long term success of an organisation rather than the day-to-day

operational efficiency (Despres & Hiltrop,1995).

Thus, with this similarity between HCW’s and KW’s, the exploration of the literature

surrounding KW’s and the Human Resource management of these individuals may provide

key insights into the management of HCW’s.

2.2.1 Retention of Knowledge workers

De Villiers (2006) opines that the importance of employee commitment and loyalty has

become a significant focus of management today, as the “war for talent” is rife, due to

skilled employees have a greater choice of employment both locally and globally. South

Africa's Public Service is not exempt from this war, and in fact, the war for talent is

particularly fierce, due to a severe skills crisis (Kock & Burke, 2008).

With this increased competition for talent, organisations have to work hard to hold on to

skilled individuals. Horwitz, Heng and Quazi (2003) conducted a study seeking to

determine the best or most effective human resource practices for managing KW’s. Their

study clarified the distinctive role played by the human resource function in organisations

in the acquisition, motivation and retention of KW’s. The passive role in which HR

functioned in the past is exactly that, past. The residual effects of this way of thinking

however seems to remain at the heart of the South African public sector and its necessary

restructuring, has been acknowledged as critical for improving performance in the public

service (Kock & Burke, 2008).

Baron and Hannan (2002) in their suggestions on KW management, include three key

areas for the successful attraction and retention of KW’s. These are compensation, quality

of work and work group community. Horwitz et al. (2003) propose three similar albeit

slightly different areas: these being compensation, environment and opportunities. Figure 2

represents their suggested scheme for retention strategies.

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Source: Horwitz et al. (2003)

Each of these areas incorporates various factors, all of which play crucial roles for

successful retention. One factor that must not be overlooked is how acquisition, motivation

and retention combine to create an overarching HR strategy. The overlap between these

three areas is significant and the manner in which they influence each other is paramount.

This relationship and the successful execution of these factors in the workplace, needs to

be managed. The responsibility of this falls onto HR management and emphasises the

importance of the role this function plays.

2.2.2 Merging the Concepts A substantial degree of overlap exists between the literature surrounding knowledge

workers and healthcare workers. Financial compensation and career development (which

could possibly include continued education for the purposes of the discussion) are common

and prominent in both categories. However the remaining HCW factors that Willis-

Shattuck et al. (2008) identified, being hospital and clinic management, availability of

resources, recognition and appreciation and hospital infrastructure, differ considerably to

the environmental factors posited by Horwitz et al. (2003).

This variance can likely be attributed to the difference between private and public sector

institutions. The vast majority of studies concerning KW acquisition, motivation and

retention have been within the private sector where workers have the privilege of working

Top management, leadership and support

Conducive Environment Fun place to work Informality Flexible work

practices Funding further

studies

Opportunities Promotions

Compensation Transparent pay

decisions Lucrative share

options Performance

bonus

Figure 3: Proposed Scheme for Managing Knowledge Workers

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in a fully functioning and sufficiently stocked environment. This differs greatly to the

austere conditions that plague public institutions of developing countries, ones that are

compounded by the institutions inability to compete adequately in the remuneration aspect

of the retention strategies (Willis-Shattuck et al., 2008). However the researcher suggests

that creating a conducive environment does not always require great deals of capital input

and minor changes can often impact the working lives of many.

2.3 Understanding the role of human resource management practices in the retention of medical doctors The aforementioned literature has demonstrated the complexity of retention of skilled

professionals, a group of individuals that includes medical doctors. The management of

this complexity has fallen to the human resource function of institutions and new systems

and skills need to be developed to successfully employ and retain these individuals

(Horwitz et al., 2003). Although these systems and skills are needed within the changing

area of healthcare, there seems to be a distinct paucity of literature regarding the specific

link between human resource practices and the retention of medical doctors.

Studies have been conducted that explore the impact that HRM has on general hospital

outputs (Buchan, 2004; Hyde et al., 2006; Harris, Cortvriend & Hyde, 2007), but these lack

specificity toward retention especially with regard to doctor retention.

This may be a result of the lag that exists between the private and public sector systems,

born out of the private sector’s need to competitively fight to retain skilled employees

(Horwitz et al., 2003). Whatever the reason is, the importance to make an active effort to

address this deficiency in knowledge and practice, it is more necessary than ever before as

the medical vacancies in the South African public sector soar beyond 4000 (Breier &

Wildschut, 2007).

In the public health sector, Human Resource management practices persist as being

problematic, struggling to cope with current expectations, resulting in the afore mentioned

deficiencies (Kotzee & Couper, 2006). One of these expectations that is of particular

concern is the responsibility of human resource planning. Arnold (2005) contends that this

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planning is critical to successful employee retention, as employees becoming overworked

due to staff shortages or employees being laid off due to staff surpluses, both reduce

employee morale and may result in unnecessary resignations.

Sudair (2003) argues that investing in human resources, which is employing more HCW’s,

is a vital component of developing South Africa’s strategies to improve health outcomes.

He adds that if the human resource shortage is not addressed, it may constrain the ability to

achieve our desired health outcomes, something affecting all citizens of our country. This

statement raises the question of whether investing in employing more HCWs will resolve

the problem or just add to the systems already strained retention capabilities. This study

explores whether it may not be necessary to improve the management of existing

employees before this investment occurs.

2.4 Conclusion Despite the paucity of literature on healthcare specific human resource practices that effect

doctor retention, the literature review has revealed both the extensiveness and complexity

of HCW retention and the need for an improved understanding of the influences at play. In

addition, the literature has exposed the need for further exploratory research into the role

that Human Resource practices play in the retention of doctors and in particular their

relative importance.

Along with the findings from a series of interviews, the variety of factors highlighted by

the literature review will be an important component in the development of a research

questionnaire. It is the researcher’s intention that the findings of this research may add to

the body of literature pertaining to the retention of medical doctors in the public health

sector of South Africa.

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3. Research Methodology

3.1 Research Approach and Strategy The purpose of this research was to explore the impact that Human Resource management

practices have on the retention capacity of doctors in the public sector. In order to explore

this, a mixed methods approach, combining both qualitative and quantitative strategies,

was used on a sample from a public hospital in the Eastern Cape province of South Africa.

The nature of the study was exploratory and descriptive. This was done in order to gather

new insights and a better understanding of HR practices influencing retention of doctors,

and describe and quantify these factors’ impact on the hospital’s retention capacity.

The study incorporated both qualitative and quantitative elements, something that Bryman

and Bell (2007) confirm, “can be fruitfully combined within a single project” (p28). This

strategy gave rise to what is known as triangulation, which Denzin (as cited in Jick, 1979,

p602) defines as “the combination of methodologies in the study of the same phenomenon”.

3.1.1 Justification of Research Approach

The reason for choosing an explorative and descriptive strategy using an inductive mixed

methods approach was due to the paucity of literature surrounding human resource

practices and the retention of doctors. As a result this did not facilitate the confirmation of

theory but rather left a void for inductive research to seek new insight surrounding the

topic.

3.2 Research Design The research was conducted in two distinct phases: the first stage was carried out in order

to extract variables to be used in the questionnaire-based survey in the second phase of the

study. The first phase identified pertinent Human Resource practices affecting retention of

doctors through an exploration of the literature and the interviewing of four departmental

head doctors (HOD) in the hospital. These HODs are at the forefront of the challenge

regarding staff retention and thus it was identified that they would be able to provide

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invaluable information about various HR practices that are affecting the retention

capabilities of the hospital complex.

The second phase comprised of a survey of a representative sample of doctors working in

the hospital complex. The survey questions were formulated from the insight gained in the

interviews and attempted to confirm or negate as well as quantify the sentiment held

towards the various Human Resource practices being performed and their effects on

retention.

This approach assisted in the synthesis of an inductive and exploratory thesis of the

following research questions.

3.2.1 Research Questions

What are the most important Human Resource management practices that influence

doctor retention in the ELHC?

How well is the ELHC HRM performing these practices?

3.2.2 Limitations of the Study Design

Due to the focused nature of the research design employed, the results are unlikely to be

generalisable. Leedy and Ormrod (2005) note however, that if the context of the study is

clearly identified, it will assist readers to make conclusions as to whether or not the results

may be applicable to other situations.

Another limitation of the research design exists as a result of the limited time frame over

which the data collection occurred. The research therefore captured the opinions and

perceptions of individuals in a specific moment in time, one that may have been affected

by the respondents’ particular emotional state at the time of survey completion. This

concern was supported by Leedy and Ormrod (2005), who termed it a necessary hazard to

extrapolate conclusions drawn from one transitory collection of data.

The study was also somewhat limited in gaining a better understanding of the problem that

plagues the province and does not make an attempt to resolve it. This said, a better

understanding will optimistically assist to provide suggestions that might aid in resolving

the doctor retention issue facing hospitals in South Africa.

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3.3 Sampling Details The study was conducted in the context of the East London Hospital Complex (ELHC) in

the Eastern Cape province of South Africa. This hospital complex is within the South

African public sector and is currently experiencing staffing difficulties.

The HOD interviewees were chosen as follows: two from large core departments, one from

a medium sized department and one from a smaller specialised department. By doing this,

the researcher could ensure that differences in department size were accounted for during

the research process. The importance of this representation was due to the varying staffing

difficulty that the departments possessed due to the differing requirements for the number

of doctors needed. Smaller departments may also have different retention struggles, as the

doctors they seek to employ and retain tend to be more specialised and harder to source.

The survey sample population was drawn from the population of 300 professional doctors

working in the ELHC. This number could only be estimated, as the hospital complex could

not supply accurate numbers of currently employed doctors. The methodology of sampling

was entirely random, as a request was made electronically to all members of the population

to take the survey. The population was not subdivided along any characteristics and thus

demonstrated simple random sampling where each member of the population had an equal

probability of being included in the sample (Bryman & Bell, 2007). Leedy and Ormrod

(2005) advocate this use of random sampling in order to acquire a representative sample

that is crucial to draw inferences about an entire population.

3.3.1 Response Rate

Due to the nature of the study, it was anticipated that not all members of the sample

population would be willing to participate. Leedy and Ormrod (2005) suggest a 50%

response rate is considered acceptable given the challenges of online surveying.

The online survey ran for a period of two weeks. During this time numerous reminders

were emailed and SMSed to doctors urging them to complete the survey. At the end of the

two-week period, the survey yielded 93 responses but unfortunately 18 of these responses

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were incomplete and as a result had to be discarded. This left 75 responses, which equates

to a response rate of 25%.

Although this is lower than the desired 50%, the response rate was comparable to a similar

survey based study into job satisfaction of doctors by Pillay (2002), which achieved a final

response rate of 20%.

3.4 Data Collection

3.4.1 Data Collection Strategy

Data collection occurred in two phases. The first interview phase was performed remotely

and consisted of telephonic semi-structured interviews with four HODs. Prior to beginning

the interview, the interviewees were informed of complete confidentiality and received a

brief explanation of the research intention. Interviews were then recorded using a digital

voice recorder and subsequently transcribed for analysis. An interview schedule, consisting

of a series of open-ended questions, was compiled from particular trends and commonly

occurring issues distilled from the findings of the literature review (See Appendix 3).

The second phase comprised of a survey consisting of strategically formulated questions

(See Appendix 4). First and foremost the participant demographics were captured. These

included age, gender, duration at the complex and category of doctor. This was in an effort

to make deductions between age, position and employment duration, and the varying

opinions and perceptions. Further survey questions were constructed from the

interpretations of the interview questions and took the form of Likert Scale questions and

interspersed open-ended questions. According to Brace (2008), the Likert scale, when

measuring attitudinal dimensions, is one of the more commonly used questioning scales

and is easy to administer in self-completion questionnaires. The Likert Scale questions

attempted to quantify the responses while the open-ended ones provided further insight

into the personal construal of the respondents’ answers.

3.4.2 Pilot Study Prior to the distribution of the survey request, a pilot study with 7 doctors was conducted.

Bryman and Bell (2007) advocate the use of piloting, especially in self-completion

questionnaires, and report that its function is to ensure that the research instrument as a

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whole functions well. In this pilot, the researcher aimed to ensure that questions were clear

and understandable and that the survey was not too time-consuming. Four of the seven

doctors surveyed provided feedback regarding question clarity and survey structure. These

comments were utilised and the survey altered appropriately. All doctors did however

comment that the process was not too time-consuming and the open questions were

appropriate. Once the changes were made, all approximately 300 doctors were requested

via email and SMS to take the survey. The survey was completed entirely online and at the

will of the participant. There was thus no coercion to participate, which thus avoided any

degree of sample bias.

3.5 Data Gathering Sequence From To Activity 10 September 18 September Interviews conducted with all four Heads of

Departments 06 October 07 October Pilot Study using Survey 08 October 26 October Survey Conducted

3.6 Data Analysis

The interview transcripts were analysed, firstly to establish, and then compare the

stakeholder’s different perceptions of the problem. Through thematic coding of data, the

researcher clustered response themes into common HR practice groups (Leedy & Ormrod,

2005). The response themes then formed the basis on which the survey questions were

constructed.

Survey responses were reviewed individually and collectively. All demographics and Likert

scale responses were electronically entered into a database. This quantitative data was then

graphically exhibited in an attempt to demonstrate the frequency rates of responses. Open

question responses were read and analysed for common themes or for new perspectives.

Excerpts from the responses were categorised into the subthemes and used to support

quantitative findings.

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3.7 Research Validity According to Bryman and Bell (2007) “validity refers to the issue of whether or not an

indicator (or a set of indicators) that is devised to gauge a concept really measures that

concept” (Bryman & Bell, 2007, p159); in other words validity is primarily concerned with

the integrity of the conclusions that are generated from a piece of research. Traditionally

four types of validity are examined in the preparation and planning of research. These are

measurement validity, internal validity, external validity and ecological validity (Bryman

& Bell, 2007). Over the past decade, the use of these forms of validity in qualitative

research have been questioned. Other suggestions put forward include triangulation,

extensive time in the field, negative case analysis, thick description and respondent

validation (Creswell & Miller, 2000; Leedy & Ormrod, 2002). Due to the design of this

study, the latter were utilised to ensure outcomes were valid.

3.7.1 Triangulation Triangulation is a validity method where the researcher seeks convergence among multiple

and different sources of information to form themes or categories in a study (Creswell &

Miller, 2000). In this research, in order to mitigate against validity failure, triangulation

was utilised. This involved gaining more than one perspective about HR practices and then

comparing them for consistency in outcome (Leedy & Ormrod, 2005). By doing this, the

researcher attempted to ensure that the conclusions drawn from the study are valid.

3.7.2 Thick Description Thick description seeks to establish credibility for the research. The manner in which this

is done is to describe the setting, the participants and the themes of a qualitative study in

meticulous detail (Creswell & Miller, 2000). In doing this, readers can draw their own

conclusions from the data presented and decide whether or not the results may be

applicable to other situations (Leedy & Ormrod, 2005). In the case of this study, the

researcher attempted to ensure that a thick description of all three elements of the study

was clearly presented.

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8.8 Ethical Considerations Prior to commencing with the research, permission was sought from the Chief Executive

Officer of the East London Hospital Complex. This permission was granted after full

disclosure was made regarding the intention and details of the research. See appendix 1 for

authorised agreement.

Participation in the interviews as well as the survey was entirely voluntary and thus no

coercion whatsoever occurred. Prior to interviewing or the survey completion, each

participant was made aware of the intention of the research. The researcher gathered verbal

consent from all interviewees at the start of the interview.

In order to ensure complete confidentiality of all participants in the study, personal identity

was not required to complete the survey and interviewee identity was kept completely

anonymous. This intention was reiterated to the respondents prior to the commencement of

the interview and through the emailed link to the survey.

UCT Ethical Clearance was granted by the UCT Graduate School of Business Ethics

Committee prior to commencement of the data collection (See Appendix 2).

3.9 Researcher Bias The researcher has worked as a medical doctor in the East London Hospital Complex. This

aided with the logistics of arranging the research and gaining permission to perform both

the interviews and the survey. This previous work experience however has the ability to

influence the interviews and the formation of questions for the survey.

In an attempt to reduce bias, no personal experiences were introduced into the interviews

and survey questions were grounded within the responses of the interviews and the

literature. The researcher sought to maintain a high level of professionalism and remained

acutely aware of the potential of bias throughout the research process.

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4. Findings and Analysis

4.1 Introduction The first phase of the data collection began with the four head of department interviews.

These were done telephonically and were conducted in a semi-structured fashion. The

primary goal of these interviews was to extract themes, which could be used in the

development of the survey questions.

After completion of the four interviews, the transcriptions were thematically coded. Two

broad themes emerged initially and on preliminary inspection appeared to overlap

significantly. However, as the coding progressed the two themes became clearer and

consisted of firstly, human resource practices and their effects on retention, and secondly

human resource characteristics and their effects on retention.

The first theme, HR practices, consolidated into five practices that the department

performed while managing doctors in the complex. These included matters around

communication, salary related issues, continued education practices, document collection

and storage and whether interactions with HR were conducted in a helpful and respectful

manner. Each of these practices is elaborated on in the sections to follow.

The second theme consisted of HR characteristics and again incorporated five qualities that

the department demonstrated. These were made up of the availability of staff, HR task

competence, salary level adjustment efficiency, accountability and process efficiency. As

with the previous theme, these characteristics are detailed in the sections that follow.

Using these two themes, each consisting of five subcategories, a survey questionnaire was

designed and built. A section that established respondent demographics preceded the

thematic questions and formed the first page of the survey.

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4.2 Head of Department (HOD) Interview Results

4.2.1 Interview 1 The first interview was conducted with the HOD of a smaller more specialised department.

Regarding positive aspects of the ELHC, the interviewee explained that they did not have

any. The interview revealed multiple salient points however the overall theme that came

through strongly was that this doctor believes the HR staff at the complex do not

understand the importance of their job. This doctor suggested that regular meetings should

be held with HR and clinical staff in the same room so that both staff components are on

the same team.

The other points raised in this interview surrounded accountability of HR staff and this

possibly being the reason behind the repeated document losses that occur in the HR

department. Another issue that the interviewee brought up was that there is a complete lack

of professionalism in the department. The doctor also believes that this has profound

impacts on the respect for doctors, HR-doctor communication and enthusiasm to assist

with problems.

The doctor went on to describe that there is a fundamental flaw in the structure of the

department with no one person being responsible for each doctor. It is believed that this

lack in personalised service causes delays in decision-making, erosion of trust and timeous

problem resolution. The doctor suggested that assigning each doctor to a member of the

HR department would improve accountability and have significant positive impacts in all

problem areas.

4.2.2 Interview 2 The second interviewee was with the HOD of a larger core department in the ELHC. The

interviewee spent a significant amount of time explaining the frustrations of HR. Pertinent

issues raised included things such as salary payment problems, OSD and PMDS failures,

the complete breakdown of trust and a perceived incompetence of HR staff. The doctor

made reference to a lack of professionalism with interactions with HR staff being plagued

with rude and unhelpful service.

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Bureaucracy was something that this HOD felt was at the core to the gross process

inefficiency that occurred in the department, as well as the complete lack of accountability

that existed among the staff. The doctor continued to explain that the staff structure was

incredibly confusing and that doctors often complained of not knowing whom to contact in

order to solve a problem. There was also a distinct communication problem that was

highlighted and this seemed to be implicated in many of the problems mentioned. This

doctor also felt that the careless attitude of staff towards submitted documents and the

information they contained was the primary reason for the spate of identity theft fraud that

gripped the complex.

4.2.3 Interview 3 This HOD was extremely emotional about the impact that HR was having on his/her large

and busy department. Delays in application processing and persistent documentation losses

were cited as the main reasons for his/her constant staffing problems. This doctor

explained that one of his staff members had resigned recently and that the primary reason

for this employee’s departure was the poor HRM in the complex.

Other issues raised by this HOD included salary payment problems, a far-reaching lack of

communicative effort, and a significant loss in clinical time due to the inefficiencies of the

HR department. The doctor offered that the cumbersome processes that the department

followed were not conducive to efficiency and sound service delivery. This doctor was also

greatly distressed about the dissociation between the clinical staff and the HR staff. It was

suggested that this dichotomy was a likely reason that HR staff failed to understand the

importance of the role they place in the hospital complex.

4.2.4 Interview 4 The last interview was held with the HOD of another large department. Like the other

HOD’s, this doctor’s responses were infused with despondency. In fact at the outset of the

interview the doctor explained that the battle against staff shortages was over. He/she

stated that too many of the experienced doctors had left, leaving a young and

inexperienced complement of staff. These resignations were linked directly to poor HRM

practices and the frustrations that the doctors experienced. The HOD described that

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communication was at the core of the problem with a complete lack of respect for the

doctors that are currently employed in the hospital complex.

The doctor also explained that doctors often become frustrated about the lack of course and

conference payment. He suggested that the HR department should prioritise these as it

improves the clinical capacity of the department and hospital staff.

Below are the findings and analysis of each of the components of the survey.

4.3 Survey Findings: Demographic Characteristics of Respondents Table 4 below shows the demographic characteristics of the survey respondents. As can be

noted, there were marginally more male respondents than female respondents and the

majority of responses came from the Gen Y age group of 25-32 (Lyons, 2004). Medical

Officers forms the biggest group of respondents with 31%, closely followed by interns and

then community service doctors. Almost 74% of the survey respondents report that they

have worked at the complex for less than 5 years.

Table 4: Demographic Characteristics of Respondents

Variable Segments %

Gender Female 40

Male 60

Age 25-32 68

33-50 17

51-66 11

>67 4

Current Position Intern 28

Community Service 19

Medical Officer 31

Registrar 8

Consultant 15

Duration at the complex 0 to <2 yrs 38.7

>2 to <5 yrs 34.7

>5 to <10 yrs 10.7

More than 10yrs 16.0

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4.4 Survey Findings Theme 1: Human Resource Practices This component of the survey began by requesting respondents to rank the five identified

HR practices according to their perceived importance to the individual. For each of the five

statements, an average ranking was calculated and then used for analysis purposes. The

results of this process are tabulated below (Table 5).

Table 5: Importance Ranking of Human Resource Practices

The most fundamental HR practice, this being punctual monthly salary payment, is ranked

as the most important of the five practices. An adequate document collection, filing and

storage system follows this with the need for effective communication closely behind. To

be respected, valued and receive friendly helpful service is ranked as the 4th most important

practice and the lowest ranked item is the re-imbursement for courses and conferences.

Each of these factors is individually reviewed below with each section incorporating a

rating of the doctors’ perception of how well this specific HR department is performing

this practice. Pertinent excerpts from the qualitative responses are integrated into the

analysis in order to support the quantitative data and provide specific illustrative examples.

4.4.1 Salary

Doctors ranked this practice as the most important HR practice, with salary-related issues

being mentioned more than 45 times in the open question responses. These salary related

problems spanned a number of issues. Some of these include not receiving a salary over a

period of time (up to 6 months), receiving only part payment of salary or delayed monthly

salary payment. Some of the statements made by respondents include; “My first�salary as

1st Monthly salary paid on time

2nd An adequate document collection, filing and storage system

3rd Good communication e.g. Post availability, status of requests made the department, and the whereabouts of submitted documents.

4th To be respected and valued by HR staff and receive friendly and helpful service

5th Re-imbursement for courses/conferences attended, and processing of special leave requests.

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a community service officer was only paid in my fourth �month of my contract” and “(I

am a) victim of salary being paid late”. Other concerns comprised of receiving incorrect

salaries for extended period of time. A common complaint from doctors was never

receiving additional overtime pay in excess of regular overtime hours. One of the medical

officers declared, “I’m currently being paid the wrong salary and have been fighting

unsuccessfully for two and a half years to have it changed”.

What is very apparent in the responses is the emotional distress that the doctors are

experiencing around the insecurity and uncertainty that these previously mentioned issues

cause. One of the respondents claimed, “Security in my job is most basic; I need to know

that my ability to pay my expenses and other commitments and invest my savings

is�secure”. This security or lack thereof is spoken of countless times and each of these

statements is laden with despondency and frustration. “You can only hope they pay you

every month.”

“To pay salaries correctly and on time is one of the most basic functions on HR - it is

insulting and frustrating when this does not happen.”

Figure 4: Performance Rating for Timeous Salary Payment

Figure 4 above corroborates this insecurity and frustration by representing the performance

rating given by the doctors to the HR department’s management of salaries. As can be seen

80% of respondents rate this below very good with 16% dubbing this critical HR practice

as unacceptable. One of the responses sum the salary issues up well; “Most doctors just

want to�be paid fairly, as agreed to when signing contracts. It would also lessen

our�frustrations which are already vast in a crumbling public health system”.

16%

36%28%

20%

0%

20%

40%

60%

80%

100%

Unacceptable Acceptable Good Very Good

Performance Rating of the Statement "Monthly Salary Paid on Time"

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4.4.2 Document Filing and Storage System

The majority of interactions with the HR department result in some form of document

submission by the doctors. These documents, most often certified copies, are often

misplaced or discarded resulting in the doctors needing to repeatedly resubmit copies of

items such as identification documents, matric certificates, HPCSA Certification (Health

Professions Council of South Africa) and degrees. This seems to cause significant amounts

of frustration, which was corroborated in the results of the survey.

In fact 84% of respondents felt that the second most importantly ranked HR practice (Table

5) was performed unacceptably (figure 3). There was not one response that rated the

document collection, filing and storage system as good or very good. Supporting responses

within the open questions included statements such as “Submitted documents get lost most

of the time and have to be resubmitted”, and “I've had MANY documents lost or

mismanaged”.

It is clear that there is a link between the salary issues and the submission of

documentation. Failure to submit documents was often cited as the reason for unpaid

salaries with one medical officer stating, “We are often threatened with salary delays if we

do not do this”. At first glance this may seem like a failure on the side of the doctor to

submit forms on time but the results from the survey refuted this. Both the quantitative and

qualitative data combines to show a fundamental lack in documentation management.

Figure 5: Performance Rating of Document Management

84%

15% 0% 0%0%

20%

40%

60%

80%

100%


Performance Rating of the Statement "An adequate document collection, filing and storage system

"

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One individual when arriving at the complex for Community Service cited, “I had to

submit some forms twice, as people misplaced my forms. The eventual excuse that I was

given was that my papers were in the desk of someone who had gone on maternity leave.”

The incidents of documents being lost or mismanaged did not stop there, with one

individual finding his documents on the floor of the HR department and another being

unable to trace the original copy of her IRP5 form.

What is also of concern is the need to repeatedly resubmit documents. The underlying

reason for this is unclear but whatever the case may be, the reality is that, “You have to

resubmit ALL your documents again and again. I think I�have done that 3 times already;

surely they should have a file with my name on and keep referring to that instead of asking

for new documents each time?” (Registrar)

The effects of this inadequate document management extend beyond salary influences and

frustrating resubmissions. It has disastrous effects for new applicants that apply to work

within the hospital complex. A consultant within a department leadership role claimed that,

“[My department] has had about 50% of applications lost over the last few years”. Another

doctor highlighted that; “The doctors do not feel welcome here and become easily

despondent about the constant failure of HR to process their applications. Documents

are�regularly lost, misplaced or even put aside by incompetent staff to such an�extent

that many jobs remain unfilled and the junior applicants find better avenues.” The effect of

this is devastating for staff morel and the attempts being made to curtail the threat of the

HR crisis in the public health sector.

As said eloquently by a medical officer, “Adequate documentation management is

fundamental for a system to run smoothly”. She was supported in her suggestion by a

consultant that identified that, “Good administrative support and effective processing of

paperwork goes a long way in�keeping an employee happy.”

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4.4.3 Communication

Communication forms a fundamental part of the relationship between doctors and the HR

department. HOD interviews revealed the importance of this practice and its direct

implications on the retention of staff. The heads of departments also highlighted that

communication is a multifaceted practice that requires a great deal of attention.

In the survey, communication was ranked as the third most important item when it came to

dealings with HR (Table 5). Many responses found communication to in fact be central to

many of the issues relating to HR practices. One doctor explained that his salary had not

been paid because HR had not notified him that they needed documents resubmitted.

Another senior doctor attributed the poor communication and the time taken to process

applications as the main reason that leads to many doctors taking posts elsewhere. This

doctor noted that, “This results in staff shortages and often drags the name of our complex

even further through the mud.”

Communication also played a key role regarding the solving of doctor’s problems and the

rectification of HR related errors. “They never update you on how far the status is of your

query/problem” and “No one updates me on the progress and each time I enquire no

progress has been made” were just two of the statements made regarding this. The latter

statement refers to an issue that the doctor has been trying to resolve for the preceding five

years.

It is clearly evident that the communication between HR staff and the doctors in the

Complex appears poor. A medical officer illustrated one of the effects of this poor

communication in her statement saying; “Part of the reason I have decided to leave the

ELHC was the failure of communication especially regarding the application for registrar

posts.”

Within the suggestions put forward by respondents, the centrality of communication is also

apparent. “I think that many of the core issues surrounding HR / staff relations could be

resolved with improving communication between HR and staff”, “If there were a good

communication system in place a lot of the other issues would be fixed.”

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Figure 6: Performance Rating of HR communication Efforts

Unfortunately this solution through improved communication is not likely to be occurring

as the overwhelming majority of doctors declared the HR efforts as unacceptable (Figure

6). Only 16% of respondents decided otherwise and rated the communication efforts as

acceptable (15%) or good (1%). There was however not one doctor that perceived this

crucial issue as very good.

4.4.4 Value and Respect This item describes the nature of the interaction of doctors with HR staff. It enquired into

the importance of being valued and respected and whether helpful friendly service was of a

high priority to doctors. This question was developed out of the literature surrounding

knowledge workers in the private sector and seemingly had a reduced importance in this

setting being ranked fourth behind communication (Table 5).

Although lower down on the importance ranking, this statement was rated by 64% of

doctors as being unacceptably performed with only 4% rating it “good” (Figure 7). The

statements made in the open questions seemed to validate this poor performance and

included remarks such as, “If we were valued they would not treat us with such disrespect

and would care more” and “The staff are generally unfriendly and are not aware of what’s

going on.”

84%

15% 1% 0%0%

20%

40%

60%

80%

100%


Performance Rating of the Statement "Good communication e.g. Post availability, status of

requests made the department, and the whereabouts of submitted documents"

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Figure 7: Performance Rating of HR Interaction Quality

Other responses were more emotional as evidenced by reports such as, “Helpful service is

non-existent despite the best lip service”, and “I have had NO helpful interaction, EVER,

with ANYBODY (apart from one in HR and one person from the frontline office) in ALL

my dealings�with our HR department over the last 8 and a bit years. Neither has my wife

[also a doctor]. The HR department is staffed with people that are not qualified or able to

do the most basic of tasks. I know that being negative is of no help, but I put this as

euphemistically as I could.”

It was however very apparent that the issue of being valued and respected was more than

just courteous service. A medical officer remarked, “My biggest problem with HR is their

total lack of respect for you as a colleague. There is such a hostile atmosphere and you are

made to feel like�a nag for just checking if you have all necessary documentation or

checking�leave or salary problems. NO ONE is friendly and willing to help.” This topic of

collegial respect is one that is mentioned repeatedly and said to be a “common courtesy”

that has been unacceptably neglected.

Other doctors feel a lack of respect and value not from what HR do, but rather what they

do not do. They feel that if respected and valued their concerns would be looked after

timeously and they would strive to be more efficient. A statement corroborating this is, “If

we were valued as staff then our requests would be seen to ASAP”.

64%

32%

4% 0%0%

20%

40%

60%

80%

100%


Performance Rating of the Statement "To be respected and valued by HR staff and receive

friendly and helpful service "

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4.4.5 Re-imbursement for Courses and Conferences Continued education and training was a topic that was founded in the literature

surrounding both the motivation of healthcare workers and the retention of knowledge

workers. It was not mentioned in the interviews with the HOD’s but did receive multiple

mentions in the open responses in the survey.

When it came to ranking the statement, it was labelled by doctors as the least important HR

practice in relation to the former factors that have been highlighted (Table 5). What is

noteworthy is that despite being on average the lowest ranked factor, course and

conference reimbursement was ranked first and second by 16% of respondents. Its

importance can thus not be overlooked and may have more bearing on certain age and

professional groups than others.

This can be seen in two statements. The first of these was made by a consultant who wrote,

“10 years at the ELHC, only once succeeded to get reimbursed for expenses incurred to

attend the annual [specialty] congress.” The other comment was made by a registrar and

reads, “It took more than 12 months to be reimbursed for the College exam fees”. To these

individuals, this factor was noticeably important and thus an influential retention factor.

Figure 8: Performance Rating of Continued Education Facilitation

When it came to rating the performance of “Re-imbursement for courses/conferences

attended, and processing of special leave requests", 43% of doctors rated it good or

acceptable with 55% feeling that it needed substantial improvement and put it in the

unacceptable category (Figure 8).

55%

39%

4% 0%0%

20%

40%

60%

80%

100%


Performance Rating of the Statement "Re-imbursement for courses/conferences attended, and

processing of special leave requests"

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4.5 Survey Findings Theme 2: Human Resource Characteristics This theme of human resource characteristics incorporates five qualities or characteristics

that the department demonstrates. These characteristics were developed from the HOD

interviews and were made up of the availability of staff, HR task competence, salary level

adjustment efficiency, accountability and general process efficiency.

This component of the survey began similarly to section one, with respondents requested to

rank these five HR characteristics according to their perceived importance to the individual.

Table 6 below expresses the outcomes of this ranking question.

Table 6: Importance Ranking of Human Resource Characteristics

The characteristic that doctors felt most important was the task competence of the HR staff.

This was followed by the accountability of staff for queries made or documents submitted

and then general process efficiency. OSD and PMDS specific efficiency was ranked fourth

with the availability of staff during tea and lunch times being perceived as the least

important HR characteristic.

Each of these factors is individually reviewed below with each description incorporating a

rating of the doctors’ perception of how well this specific HR department is exhibiting the

various characteristics. Relevant extracts from the open responses are incorporated into the

analysis in order to support the quantitative data and provide specific clarifying examples.

1st The task competence of HR staff

2nd The accountability of HR staff for queries made or documents submitted

3rd General HR process efficiency

4th OSD* Salary level adjustments and PMDS** efficiency

5th The availability of HR staff during tea and lunch times

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4.5.1 Task Competence The characteristic that received the highest ranking in this section was that of task

competence of HR staff (Table 6). This means that the majority of doctors felt that it was

most important to them for the HR staff to be competent in the tasks required for effective

HRM. Both the HOD interviews and the survey results revealed evidence that these tasks

incorporate a wide variety of functions from the paying of salaries to the resolution of

problems.

Examples of this, included statements such as, “It is annoying not to be paid on time,

because this reflects administrative incompetence” and “I find it difficult to get HR staff to

explain the various packages or options in a coherent and simple way”. Another doctor

mentioned that, “There is nothing as�frustrating as going to HR the third or fourth time to

find out that nothing has been done in regards to certain requests.”

Other respondents were less specific and remarked that there was a widespread and distinct

lack of required skills with the “general competency of the average HR staff member

[being] poor”. The responses identified that this lack of competence and knowledge of

fundamentals, “makes everything difficult and prolongs all requests”.

This topic of task competence seemed to generate a significant amount of emotion with

one senior doctor remarking, “They are inefficient, corrupt and incompetent and have no

idea what is expected of them. They do not care and they are the main reason, together

with� Bisho, that I hear my doctors say; ‘We will never come back to this place’.” This

was followed by another respondent stating that, “They're also not of any help because NO

ONE KNOWS WHAT I AM SUPPOSED TO DO!!!”

It appears that the lack of competence of the HR staff manifests in inefficient and

ineffective visits by doctors to the department. Comments included, “I feel so

frustrated�when they cannot answer my questions and then send me from pillar to post”,

and “They usually refer you to someone else, even though you’d expect them to know

certain things”. One more unique case involved a doctor that had acquired drug resistant

Tuberculosis and needed to apply for special leave. This doctor revealed that, “You have to

walk everywhere, from one point to the next attempting to sort out the issue. Despite

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feeling ill I still did this as I didn't trust anyone with my documents as I know it would take

ages to reach its destination or it could possibly get lost in translation”.

This lack of competence may be contributing to a fundamental collapse of trust between

the doctors and the HR department. A medical officer remarked that, “Overall, it appears

that I cannot trust HR for doing the job correctly. Several times I have been asked to re-

document my personal details since it has�been lost. This is at a point now, where I

provisionally, make copies of all my�dealings with HR just so that I have a "back-up" in

case they lose it.”

Figure 9: Rating of Task Competence of HR Staff

The doctors proposed, “Our HR needs training in basic tasks”. They feel that “Competent

HR staff [are] very important… They are there to make the administrative part of our jobs

easier”. What is clear is that this opinion regarding task competence does not only belong

to a select few. Figure 9 illustrates that 77% of doctors felt the same way and believed the

task competence was “unacceptable”

Sadly, results like this can paint all HR staff with the same brush but it must be noted that

this is not always true. This is supported by a doctor replying, “Unfortunately their

reputation of incompetence clouds the occasional individual [doing a] good job.”

77%

19% 3% 0% 1%0%

10%20%30%40%50%60%70%80%90%

100%

Unacceptable Acceptable Good Very Good N/A

Rating of the task competence of HR Staff

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4.5.2 Accountability This characteristic measures the accountability of HR staff for queries made or documents

submitted. When asked to rank the importance of this factor, doctors at the ELHC placed

this second behind that of task competence (Table 6).

Statements in support of this ranking read, “They are not held accountable for anything, if

a salary is not paid they aren't willing to find out why” and “Unfortunately they are not

held accountable for their inefficiency”. One doctor even remarked, “I have no faith in

HR's accountability”. This link between document loss and accountability featured

numerous times in the responses with observations such as, “HR is constantly asking you

to resubmit documents. No one is held accountable for losing documents.”

Another of the junior doctors identified that this lack of accountability possibly has an

origin in departmental structure. She stated, “There is a lack of titles in the HR i.e. Who is

in charge of community service doctors and interns and someone else who is in charge of

medical officers�etc. Together with that there is no one senior in the HR department

who�oversees everyone and no one senior to speak to if there are problems and salaries

that haven't been paid”. Another doctor replied, “HR always passes the buck, and there is

always another signature or stamp that must be done by another person, or by Bisho and it

is NEVER the fault� of the person sitting in front of you that your request is not

completed”. This frustration with accountability appeared to be generalisable with 81% of

doctors rating the accountability of HR staff as unacceptable (Figure 9).

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Figure 10: Rating of HR Staff Accountability

Accountability was at the core of some recommendations put forward by doctors. One

doctor suggested, “This�communication should be between the staff member and an

individual, �named HR provider - which would encourage greater staff participation and

assist with HR accountability’. Another senior doctor explained a situation where one

individual “took responsibility for the issue and personally saw it to completion.” He

concluded saying, “It was fantastic knowing that the 'buck stopped' with them, and that

they were on my side and willing to keep me up to date with where things stood.”

81%

16% 1% 0% 0%0%

10%20%30%40%50%60%70%80%90%

100%


Rating of the Accountability of HR staff for queries made or documents submitted

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4.5.3 General Process Efficiency The characteristic of general process efficiency was rated by 87% of responding doctors as

unacceptable with not one individual perceiving this characteristic as very good (Figure

11). This view was despite being recognised as the third most important amongst the five

characteristics offered to respondents (Table 6).

Figure 11: Rating of General Process Efficiency of HR Staff

Indications as to why doctors felt this way could be found scattered throughout the

responses. A medical officer reported that, “Most of my dealings with HR seem to involve

multiple visits and a huge amount of effort on my part to accomplish fairly simple matters”.

Another registrar felt that, “HR is in general just non-efficient”; while two other doctors

concurred that system inefficiency was crippling process efficiency. A head of department

exemplified this by reporting, “The mechanism in place to complete tasks is so

cumbersome that it is often self-defeating. I have examples of doctors who applied to work

in my�department who, when finally offered a post, had already been working in

an�alternative post elsewhere for over 6 months.”

Numerous doctors recognised efficiency as playing a pivotal role in HR management.

“Efficiency is ultimately the most important for saving employees time and rendering

adequate services”, remarked a junior doctor. Another response echoed this argument; “A

HR department needs to provide a friendly and efficient service to the employees of a

business. It is the link between the employers and employees in organisations especially

where there is minimal communication between management to employees”.

87%

12% 1% 0% 0%0%

10%20%30%40%50%60%70%80%90%

100%


Rating of the General Process Efficiency

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4.5.4 Salary Adjustment Efficiency OSD and PMDS are two financial incentivising tools used in the public sector to attract,

motivate and retain staff. Their role in retention capability of the hospital complex is thus

paramount, however the efficient management of these two processes was ranked by

responding doctors as the fourth most important characteristic of HR (Table 6). 17% of

respondents did however feel that this was the most important function and rated it number

one.

One of the doctors pointed out the fact that “The OSD system has been fully implemented

in much of the country with exception to the Eastern Cape Province” with another stating

that “Salary progression in the Eastern Cape does not happen and as a result [medical]

employees of the Eastern Cape are unsatisfied”.

Figure 12: Rating of HR Staff Efficiency toward OSD and PMDS

Not being placed on the correct level or not being promoted when appropriate, causes a

significant amount of unhappiness. 51% of respondents perceived this service to be

unacceptable but when the results were filtered to medical officers, registrars and

consultants, due to their greater involvement with OSD and PMDS, this “unacceptable”

figure rose to 71% with no one rating this HR practice as very good (Figure 12).

51%

27%12% 1% 9%

0%

20%

40%

60%

80%

100%


Rating of the OSD* Salary level adjustments and PMDS** efficiency

(*Occupation Specific Dispensation)(**Performance Management and Development System)

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4.5.5 Availability

Availability refers to the doctors’ ability to access HR staff during specific times of the day.

This characteristic was initially not included in the survey; however three of the

respondents in the pilot study commented on its absence and suggested that it should be

incorporated. In the open responses, multiple doctors alluded to the necessity of physically

visiting the HR department on numerous occasions. This however causes much distress, as

doctors need to take time out of their working day to attend to HR matters. One of the key

issues with regard to this necessity is that the Cecilia Makiwane Hospital is situated 20km

away and does not have a compliment of staff to deal with HR related queries. This means

that doctors need to ask for special permission to leave early or come in late in order to

visit the HR department situated on the Frere Hospital grounds.

From this concern arose the issue of HR staff availability during tea and lunch times when

doctors could visit HR and avoid losing clinical practicing time. One doctor remarked,

“We can only go to the office during certain hours and then they are on tea or lunch”,

while another stated, “It’s not always easy to do admin during certain hours”.

One of the registrars that responded perceived this issue differently and concluded, “I can

still try and make time to see them (would prefer if our lunch times didn't overlap, though),

if only they would do their tasks well!!! Then we wouldn’t have to take time to go there

over and over”.

Figure 13: Rating of HR Availability

65%

28%

3% 0% 4%0%

20%

40%

60%

80%

100%


Rating of the availability of HR staff during tea and lunch times

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When it came to rating the complex’s availability of HR staff (Figure 13) during lunch and

tea, 65% reported that this was unacceptable with a further 28% terming it just acceptable.

4.6 Conclusion The results to this survey have revealed a number of pertinent issues with regard to the HR

management of doctors in the EL Hospital Complex. What must be kept in mind is that

HRM plays a critical role in the retention of employees and attention must be paid to the

consequences of poor service. Although not specific to the effects of HRM, 45% of doctors

surveyed confirmed that they were not willing to stay in the complex (Table 3). Add this

figure to the 23% who were unsure about their willingness and one can see that 68% of

ELHC doctors are not prepared to commit to remain working at the two hospitals.

Table 7: Doctors Willingness to Stay at the Complex

Willing to stay at the Complex %

Yes

32

No 45

Unsure 23

In conclusion, this chapter has endeavoured to present and analyse all findings from phase

one, two and three of the data collection process. The next chapter continues from this

point to discuss these results and relate them to the literature that exists in this area.

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5. Discussion

5.1 Introduction The focus of this study was primarily to understand what Human Resource management

practices strengthen and erode doctor retention capabilities in the South African Public

Health Sector. As the research process has unfolded, HR interaction with doctors has been

categorised into management practices and into department characteristics. Both these

facets play a substantial role in HRM and as a result influence retention capabilities. This

categorisation has also enabled a more thorough exploration of the various practices and

characteristics and their perceived importance to the workforce in question.

The research has also allowed for the opportunity to not only understand the importance of

the various practices and characteristics but also to quantify how well they are being

performed in a South African setting that is currently facing significant retention

challenges. It is the researcher’s contention that a better understanding of this Hospital

Complex’s HRM might allow extrapolation of this data to a national level to facilitate the

retention of doctors in South Africa and more specifically the public sector of South Africa.

Below is a discussion of the findings of the research and various practices and

characteristics.

5.2 Demographic Characteristics of Respondents

Lyons (2004) generational classification was used when selecting age categories for

respondents to choose from in the survey. This was done intentionally so as to determine if

there were generational variations in the responses to the survey. Generation Y or

individuals from 25 to 32 years of age formed the largest group of respondents making up

almost 70% of responses. This is interesting for a number of reasons. The first is that if the

sample population is representative of the whole, then a significant portion of the ELHC

medical workforce is made up of a generation that is proving difficult to manage (Eisner,

2005).

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The literature surrounding the management of Gen Y is extensive and the resounding

agreement points towards a growing challenge. In a news article, intergenerational

management authority Bruce Tulgan explained the resulting challenges of managing Gen

Y workers in this way: "Gen Y'ers are like X'ers on steroids . . . They are the most high-

maintenance generation to ever enter the work force" (Breaux, 2003, p. 2).

Francis-Smith, (2004) highlights that Gen Y tends to favour an inclusive style of

management. They also dislike slowness, and desire immediate feedback about

performance. Eisner (2005) adds that Gen Y’ers place a high importance on respect and are

willing to earn it. This therefore poses a significant challenge to health managers. As soon

in this study the workforce is being significantly infiltrated with Generation Y doctors and

thus management styles and in particular HRM needs to be revised to cater for changing

needs.

In the next section of demographical data, respondents were asked to state their current

position in the hospital. This question revealed that the most number of responses came

from the medical officer group. This group is particularly important as is forms the bulk of

the doctor compliment. They therefore form the most vital target for retention strategies.

Community service doctors and interns are also of extreme importance both from a clinical

capacity and retention target point of view. These individuals are mandated by the state to

complete two years of internship and one year of community service. They thus are

unlikely to leave the complex during this time; however they are under no obligation to

stay once their three years are complete. Often these doctors are undecided as to their next

step after community service and therefore form a crucial target for the complex to retain.

They generally move into medical officer posts and, if treated well, may stay for an

extended period of time. This aids in expanding the workforce, which is critical for the

delivery of quality service.

The contrary to this is also true. Treat these doctors poorly and they will move off to other

towns and cities with virtually no chance of returning at a later stage. Reid (2001) in fact

suggests that these community service doctors who express an interest in long-term service

should be encouraged to do so through contractual agreements with provincial health

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departments. He suggests that these agreements should include incentives, as the long-term

benefit for the public health system is immense. It is thus vital to firstly understand this

Gen Y dominated group of doctors and the context they find themselves in and then tailor

HRM practices to suit them.

This argument is supported by the fact that 74% of doctors have been working at the

complex for 5 years or less. This means that only 26% of staff remain for longer than 5

years. From this alarming statistic the question needs to be asked, “What is causing doctors

to leave?”

The reason for this high rate of staff turnover in the public sector is described by Kotzee

and Couper (2006) as multidimensional; however judging by the substantial amount of

frustration and antagonism expressed toward HRM in this research, the role that HR plays

in this challenge cannot be discounted. Thus while retention deficiencies cannot be entirely

attributed to poor HRM, this deficiency can be said to be contributing to this struggle.

5.3 Human Resource Practices

5.3.1 Salary Remuneration plays an important role in the retention and motivation of healthcare

workers (Willis-Shattuck et al., 2008). The findings from this research corroborate this

importance by revealing that timely salary payment is the practice that most doctors feel is

of utmost importance. King and McInerney (2006) support this sentiment by stating that if

this aspect of motivation and retention is ignored, it tends to make HCWs feel undervalued

and demotivated. This can be witnessed repeatedly in the qualitative responses that link

these remuneration issues with a perceived lack of respect and doctors feeling undervalued.

Although financial incentives were found to be insufficient on their own to facilitate

motivation (Kotzee & Cooper, 2006; Mathauer & Imhoff, 2006), it can be said that

individuals require financial security in order to remain in an institution (Pfeffer, 1998).

Elsner (2005) echoes this sentiment when referring to Generation Y and states that this

generation find making a lot of money to be less important than contributing to society.

Pfeffer (1998) also continues to say that it is employment security that is the most

important aspect of retention. This importance is understandable as Maslow (1943), in his

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research into basic human needs, placed employment security on a primary level with other

issues of safety.

With this importance noted, the researcher opines that an institution such as the ELHC

should be striving for a rating regarding remuneration accuracy of nothing less than very

good. If doctors experience or are under the impression that the institution does not place a

high value on this fundamental HRM practice, there will be a substantial erosion of

organisational retention capacity, as noted in the recent ELHC staffing difficulties.

5.3.2 Document Filing and Storage System

Document submission is an unfortunate necessity for HR department functioning and

something with which all employed personnel are familiar. From the findings of this

research, it is clear that it is not the need to submit documents that frustrates doctors but the

manner in which the submitted documentation is handled. As can be seen in the qualitative

data, documents are often lost and mismanaged. This situation results in HR staff requiring

repeated submissions of specific documents which causes the doctors a great deal of

frustration.

Document mismanagement seems to have two effects on doctors. The first is that it causes

substantial irritation and the second is that it erodes the trust that needs to be in place for

employment security to exist. This was demonstrated in the qualitative responses and by

the fact that doctors ranked this practice as the second most important issue.

Document management in an HR setting should be bound by strict protocols to safeguard

not only the physical documentation but also the information that these documents carry.

This information is extremely sensitive, and its protection is of paramount importance

(Hazen, 2010). In the latter half of 2011, the ELHC was plagued by more than fifty cases

of identity theft in which doctors’ identities were used to fraudulently open credit cards and

insurance policies (see appendix 6). Hazen (2010) remarks that reclaiming a lost identity is

exhausting, time consuming and expensive. This was apparent amongst the identity theft

victims and caused a significant amount of anger to be directed towards the HR department

who had failed in the task of safeguarding their information. Hazen (2010, p2) advises that,

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“An ounce of prevention is worth a pound of cure with issues of sensitive information and

identity theft.”

5.3.3 Communication

Kotzee and Cooper (2006), in their study on rural doctors, found that HR departments were

a particular problem area with regard to promotion issues and communication. This

problem was highlighted by the findings of this research, in which 84% of doctors

surveyed rated the ELHC communication efforts as unacceptable. With such a poor

demonstration of a fundamental HR practice, multiple areas of the ELHC HRM have been

affected. These areas include both internal and external post advertisements, remuneration

related failures and neglecting to communicate with doctors regarding the status of

requests and grievance resolutions.

In both the interviews and the survey responses, poor communication is cited as a

quintessential contributor to staff shortages for of a number of reasons. Firstly, new

applicants are not informed about the status of their applications and as a result seek

alternate employment. Secondly, doctors employed by the complex who are willing to stay,

are often not informed about post vacancies and leave without applying. Lastly, the poor

communication offered by the HR department contributes to the administrative frustration

that is experienced by doctors, making the decision to leave the complex easier.

Padarath et al. (2003) in their meta-analysis on HCW migration, state that a lack of

employment opportunities in host countries often precipitates immigration. In relation to

South Africa and particularly the ELHC, this begs the question of whether there are

insufficient opportunities or whether there is a fundamental failure of the public sector to

recruit and retain doctors. An organisation that has emerged in order to assist with this

failure is a not-for-profit company called African Health Placements (AHP). This company

is attempting to recruit and assist doctors for public sector posts. Below is an excerpt from

their 2011-2012 organisational profile.

“When AHD first came into being, it was driven by the insight that we needed to

fight fire with entrepreneurial fire. If developed nations were capitalising on our

brain drain by attracting our local professionals with the promos of money and

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security, we needed to counter this trend by finding ways to market our region to

local and international talent. With little research, we discovered that the region

offered,

1. Far greater scope for gaining relevant experience

2. The satisfaction of making a difference

3. Unparalleled lifestyle experience, especially in rural areas

The challenge however, was that getting people to South Africa involved a

laborious and inefficient administrative process. Our response: gather a team of top

notch recruiters and administrators, build a high performance culture, then work

with local and national government to streamline the relevant systems and process.

Our work has reduced the average lag time to placement from 2 years to as little as

3-6 months. Since our inception in 2006, we have helped hundreds of health

facilities to render better service to their communities by placing over 2500

healthcare workers” (AHP Organisational Profile 2011-2012).

As can be seen, AHP recognised the communicative and administrative failure of the

public health HR system and have developed an entire company to assist with its

shortcomings.

5.3.4 Value and Respect Generation Y are said to place a high value on respect (Eisner, 2005), yet 55% of Gen Yers

ranked this as the fourth or fifth most important HR practice. This incongruity may be the

result of doctors placing more priority on the basic HR functions ahead of softer practices

such as value and respect. In the interviews, the HOD’s remarked that doctors in the public

sector, in particular the ELHC, have had to get used to being treated badly. Young doctors

coming straight out of university are also unaware of what reasonable HR management

entails. It is only when these individuals are contacted by the developed countries that they

experience what it is to be truly valued (Padarath et al., 2003).

What is of note is that the doctors that did rank this statement fairly high, highlighted that

if the staff of HR respected and valued them, then this would be seen through on-time

payment, improved document safeguarding, more effective communication and the

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prioritising of continued education. This was reiterated by a doctor who stated that all five

of the practices are vitally important and should be ranked evenly.

What is important with these findings is that the reader must not be misled into thinking

that valuing and respecting doctors is not important. It is the researcher’s opinion that these

findings occur in an incredibly strained context and that if the basic HR functions are

improved then a respectful and friendly service will take a higher priority. If this occurs, it

can only aid in the ELHC and the public sector retaining doctors.

5.3.5 Re-imbursement for Courses and Conferences Career development is important in 85% of studies regarding HCW motivation yet this

research has indicated that continued education is the least important practice for HR to

facilitate (Padarath et al., 2003). While it is clearly apparent from the literature that HCWs

thrive off the opportunity to progress (Reid, 2004; Kotzee & Couper, 2006; Manongi,

Marchant, & Bygbjerg, 2006), the case of the ELHC may be more convoluted than other

institutions that have managed to perform the basic HR functions well. Similarly to value

and respect, doctors seem to want the basic practices performed consistently well before

“extras” are added.

Continued education is not only important to the doctor but also to the hospital in which

they work. Mathauer and Imhoff (2006) state that training and development enables

HCW’s to assume greater levels of responsibilities. Continued education expands the

doctor’s clinical ability and this together with this increase responsibility allows for

improved healthcare delivery. The costs of continued education are far outweighed by

these benefits provided that the doctor remains in the hospital complex or state sector. This

retention is thus paramount and all efforts must be made to value these doctors because

after all it is they who hold the ability to add value to the community as a whole.

Kock and Burke (2008) suggest that for maximum dual benefit, integrating these

educational efforts with the individual’s career growth can ensure that the individual’s

development plans reflect their department or hospital's future development needs. In this

way the ELHC can safeguard against both staff and skills shortages.

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5.4 Ranking Human Resource Characteristics

5.4.1 Task Competence The task competence of HR staff involves all basic practices that were highlighted in the

first section of this research. It is thus understandable that 80% of doctors surveyed felt that

this was the first or second most important characteristic of HR. If one assumes that the

rating of this characteristic is indicative of an average rating of the five practices in theme

one, then 77% of doctors feel that this is unacceptable.

This therefore means that there are a significant number of doctors that are disgruntled and

frustrated with the ELHC HR department.

It was clear from the survey responses that many doctors felt that the staff of the HR

department needed basic training in tasks required to perform personnel management.

This may possibly be the case as Buchan (2004) indicates, that HRM in the health sector is

inherently a challenge as the workforce is large, diverse, and comprises separate

occupations. Be this as it may, HR staff should carry the ability to adequately address all

employee needs no matter how complex they may be. One example of this is PMDS,

where the nature of the system implementation for doctors is complicated and difficult.

Here HR staff should be sufficiently trained to handle this procedural complexity in order

to avoid frustrating confrontations with doctors.

This was clearly not the case in the ELHC as depicted by the both the qualitative and

quantitative data. It was in fact clear that this lack in staff competence had resulted in a

complete erosion of trust, where doctors fundamentally believed that the HR staff did not

hold the ability to resolve their grievances. Multiple doctors mentioned the need to take

problems into their own hands and drive to Bisho (Headquarters of EC Health) to

personally deal with matters and ensure their resolution. This is an inefficient and

ineffective means to overcome the incompetence found in the local HR department. One

of the doctors depicted this picture well by saying, “You wouldn’t go back to a doctor who

shrugged [his/her] shoulders and said that they couldn’t help you because they didn’t know

how to write a script for medicine”

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What was clear in a number of responses was how well doctors responded to competent

individuals. They were both appreciative and impressed at how well their concern had been

dealt with. Unfortunately all these comments were followed by remarks mentioning that

there were only a handful of individuals who held these capabilities and that as a result

these individuals were inundated with requests for assistance.

5.4.2 Accountability This characteristic received a significant number of emotive responses in the qualitative

findings. Doctors were noticeably angered at the lack of accountability of HR staff for any

tasks that they were given. This sentiment carried through into the quantitative data that

revealed an alarming 81% of doctors rating this characteristic as unacceptable.

This characteristic however seems intimately linked to the issue of task competence.

Doctors perceived that because skills levels were so low, HR would not take responsibility

and instead “always pass the buck”. There were also many mentions made of doctors not

being able to trace who was responsible for carrying out specific processes. Possible

reasons for this lack of accountability are the bureaucratic nature of the department and the

resultant multistep processes. Doctors described that this was the most commonly used

excuse for delays and documentation losses.

Some insight shared from the older more experienced doctors was that a complete

dissociation has developed between the HR department and the clinical staff. They

explained that HR staff were unaware of the pressures of day-to-day clinical work and

therefore did not realise how difficult it is for doctors to visit the HR department. They also

stated that this dissociation did not allow HR staff to understand the importance of their job

when it came to recruitment and retention of staff. The doctors felt that there was a need

for HR staff to witness the pressures of staff shortages and understand the desperate need

for accurate new application processing. They concluded that they felt like HR staff were

not on the same team as the medical professionals and thus were not striving for the

common goal of quality healthcare delivery.

Doctors suggested that a solution to the HR problem plaguing the ELHC lay in the

designation of a small number of doctors to one HR member. They proposed that this

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individual would be entirely responsible for all issues relating to the particular group of

doctors and that this person would be the first point of call if they needed something. This

way doctors would know that someone was looking out for them and striving to ensure

their occupational wellbeing.

5.4.3 General Process Efficiency This characteristic received the lowest rating of the entire survey with an alarming 87% of

doctors rating it as unacceptable. The effects of this inefficiency are far-reaching with

doctors attributing this directly to staff shortages. This characteristic was repeatedly

mentioned as a fundamental failure of not only the ELHC HR department but also the

broader Eastern Cape Department of Health.

Bureaucracy and institutional geographic distribution were the most common reasons cited

for this failure. With the ELHC being comprised of two hospitals separated by 20km, HR

staff seem to struggle extensively with the timely processing of tasks. There is also only a

skeleton of staff that manage a small HR department at CMH who are often rendered

helpless when documents need to be signed or submitted. All tasks thus need to flow

through the Frere HR department; however this department is required to work intimately

with the main HR function that is situated in Bisho more than 60km from East London.

This sheer distance, combined with a paper dependent bureaucracy, facilitates the poor

accountability and opens the ELHC department up to complete process efficiency failure.

Doctors felt that the only way to overcome this problem was to move towards an electronic

system with status monitoring and automatic feedback capability. This feedback is

important for both the doctors and the HR staff because “productivity must be measured so

that performance feedback can occur” (Grobler & Warnich, 2011, p. 153).

5.4.4 Salary Adjustment Efficiency (PMDS and OSD) PMDS combines two integral human resource management (HRM) processes namely, pay

progression and performance bonus (PSA Union, 2010). These two processes come

together to play an incredibly important role in the attraction, motivation and retention

capability of staff within the public sector. With this importance understood, one can

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understand the need for the system’s success as its failure can potentially have long-lasting

effects that could cripple the hospital system.

Working conditions in the public system are often challenging and doctors and nurses

working in these institutions need to be carefully looked after and valued. National

government thus proposed and implemented these PMDS and OSD systems. From the

qualitative and quantitative findings of this research, doctors do not feel that this system is

being implemented effectively. Cases of not being paid OSD increases are numerous and

the interviews with the HOD’s exposed that PMDS has been a categorical failure with not

one doctor receiving PMDS payment since the systems’ inception more than four years

ago.

Some doctors have postulated that the PMDS and OSD system failures have been as a

result of HR staff not holding the capability of correctly interpreting the policies mandated

from national administration. An example of this has occurred with intern doctors who,

despite been allocated a salary increase in their second year of service, have not received it

since the system’s implementation in 2008.

Although the PMDS and OSD systems were designed to improve the retention and

motivation through pay progression and incentive bonuses, the ELHC appears to have

failed in the delivery of these with the result that these potential retention tools have been

transformed into a frustrating fantasy for many doctors. This claim is underpinned by the

fact that an immense 71% of medical officers, registrars and consultants rated OSD and

PMDS efficiency as “unacceptable”.

This problem does not seem to be unique to the ELHC, with a large majority of the 14000

public sector doctors being affected in some way (Batemen, 2010). The link between OSD

failure and retention is apparent with a senior doctor admitting this; “With 10years’

experience I now earn very little more than comserves (Community Service Doctors)�– I

must say it makes you feel a bit undervalued” (Batemen, 2010, p. 272).

5.4.5 Availability

As previously mentioned, the geographic separation of the two hospitals in the ELHC complex

poses a multitude of problems. As seen with this research, availability of staff is one of them.

Doctors’ attempts to complete administrative tasks during tea and lunch are often met with

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resistance and apathy. This is proven by the quantitative statistic that 65% of doctors feel that HR

can improve on this characteristic.

Although in the ranking of HR characteristics, this was categorised as the fifth most important

practice, remedying this issue may require virtually no effort and may have a substantial impact on

the doctors’ ability to sort out day–to-day problems.

5.5 Conclusion

From the alarming performance ratings of all ten facets of HRM, the findings to this

research leave little doubt that HRM in the ELHC with regard to doctors is far less than

optimal. The consequences of this poor performance are far reaching and appear to have a

direct impact on the complex’s retention capacity. This impact is enunciated in the last

demographic question, which although not specific to the effects of HRM, revealed that

68% of ELHC doctors are not prepared to commit to remain working at the two hospitals.

It is clear that doctors in this sample simply want the basic HR functions performed

consistently well.

In conclusion this discussion has attempted to overlay the results of this study onto the

existing literature in this field. The next chapter summarises the entire research process in

order to draw conclusions and make recommendations.

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6. Conclusion Human resources, in the form of doctors, are an expensive commodity that all countries

cannot do without. Understanding how to prevent immigration and movement away from

the host country’s public sector is thus something that all developing countries should be

trying to master (Padarath et al., 2003). South Africa is no exception with the number of

doctors leaving the South African public sector reaching dangerous proportions (Grant,

2006; Hagopian et al., 2004).

Between 2002 and 2010 the retention gap for doctors broke 62% (HRH Strategy, 2011).

This retention gap is driven by doctors leaving the public sector to take up posts in the

private sector or to immigrate, usually to one of the developed nations. The forces

responsible for this movement are complex and include a multitude of so-called push and

pull factors (Mejia, Pizurki & Royston, 1979). These factors have over the years been

rigorously studied across the globe however this rigor has not gravitated through into

specifically trying to understand doctor retention in the South African public sector. This

has therefore left a void of knowledge that, if not filled, will bear witness to the downfall

of South Africa’s health system (Grant, 2006).

An institution and province that has been particularly affected by staffing shortages is the

East London Hospital Complex (ELHC), which can be found in the Eastern Cape. During

2012, this complex and province have experienced severe staffing difficulties with

“delayed or non-payment of critical healthcare workers” being cited as one of the reasons

causing doctors and other staff to abandon their public healthcare posts (Eager, 2012).

This situation as a result exposes the relationship between human resource management

and retention and highlights the need to assess and understand the impact of their

correlation.

It is has been suggested that this facet of the public health system holds the ability play an

active part in fighting the exodus of doctors and the crippling “brain drain” (Buchan, 2004).

With this potential in mind, this research has therefore attempted to explore the

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relationship between HRM and retention and in doing so, add to the body of knowledge

concerning the retention of doctors in the South African public health sector. While

attempting this investigation, the research has facilitated the exploration of not only the

role and impact of HRM on doctor retention but also the evaluation of how well these

practices are being performed in the South African context.

6.1 Important HRM Practices that Influence Doctor Retention at the ELHC

To answer the main research question, the ELHC with its current staffing difficulties was

identified as a potential organisation in which to perform the research. The research design

consisted of a mixed methods approach, which combined both qualitative and quantitative

strategies. Bryman and Bell (2007) consider this a valid approach that allows for the

triangulation of data (Jick, 1979). This facilitated the exploratory and descriptive study to

be conducted within in the doctor complement.

The way this was done was through a three-stage process. The first stage consisted of a

vigorous review of the literature and revealed a paucity of studies surrounding HRM

practices and their impacts on retention of HCW’s in the public health sector. Studies

regarding the forces underpinning HCW migration (Padarath et al., 2003) and surrounding

HCW motivation (Kotzee & Couper, 2006; Willis-Shattuck et al., 2008) were therefore

drawn on to begin the research process. With the ultimate goal of a multiple doctor survey,

the researcher embarked on a semi-structured interview process of four of the complexes

clinical heads of department. These interviews were undertaken to shed light onto the

understanding of the role of HR and the impact of their practices.

With this information, and the findings from the literature, the third and final part of the

research, a survey questionnaire, was built. Following a small pilot study, the survey was

administered anonymously via an electronic platform following an email and SMS request

to all approximately 300 doctors in the complex. Responses to the survey trickled in over

a two-week period. During this time, the full doctor complement was reminded repeatedly

via email and SMS to complete the survey. At the time of closing 93 responses were

entered, however only 75 of these were complete. This thus yielded a 25% response rate

from an estimated sample population of 300.

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6.2 Measuring the Performance of the ELHC HRM Practices

This questionnaire separated HRM into two distinct parts, the first being HR practices and

the second being HR characteristics. Following a short section on demographics,

respondents were asked to rank five identified HR practices in order of importance. This

was then followed by an open question enquiring about their highest ranked practice, with

a Likert Scale question, thereafter requesting doctors to rate the performance of the ELHC

HR department in the five practices. This template was repeated once more for the second

theme, that being the five HR characteristics.

Due to the focused nature of the research design employed, the results are unlikely to be

generalisable; however following the advice of Leedy and Ormrod (2005), the context of

the study was clearly identified in order assist readers to make conclusions as to whether or

not the results could be applicable to the broader South African public health sector.

6.3 The Most Important HR Practices

Most doctors felt that being paid on time and being paid correctly was the most important

HR practice. Much emotion surrounding remuneration inconsistencies and financial

security was conveyed with doctors feeling that it is simply not acceptable to fail to pay

salaries timeously. Documentation management and communication, both essential HR

components, were ranked by responding doctors as second and third respectively. Like

salary errors, documentation loss and failing communication was detested and resulted is

extreme amounts of frustration by doctors.

Ranking fourth, being respected and valued by HR staff, was something that doctors felt

was less important than fulfilling the basic HR functions well. One doctor in fact ranked

this practice as first and stated, “If the staff of HR respected and valued us then they would

pay us on time, keep our documents safe, strive to communicate effectively and place

priority on our continued education.” This last practice, that is, continued education,

although playing a critical role in both the doctors’ development and the clinical

functioning of the hospital complex, was ranked by doctors as the least important practice.

This, like value and respect, was trumped by the importance of the basics: salary payment,

documentation management and communication.

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6.4 Rating of the ELHC HR Practice Performance

Judging from both the quantitative and qualitative data collected, the ELHC’s performance

in all five HR practices is lacklustre to say the least. Salary payment accuracy, with its

critical role in employee security, was mentioned as a problem 45 times in the open

responses. Multiple doctors had fallen victim to some form of late or inaccurate payment

and numerous others feared non-payment on a monthly basis. Quantitative data revealed a

spread of responses for a practice that in the private sector is a complete non-negotiable. It

is thus clear that the poor execution of this practice still provides doctors at the ELHC with

a substantial amount of frustration.

With both practices being rated by 84% of doctors as unacceptable, document management

and communication efforts by the ELHC HR staff are dismal. Doctors felt that the efforts

made by the HR department to fulfil these practices were completely insufficient and this

opinion was supported by numerous cases of repeated document loss, identity fraud and

communicative failure.

For the practice ranked as the fourth most important practice, 64% of doctors felt that they

were not respected and valued by HR staff. This was corroborated by the qualitative

findings in both the interview and survey responses. As mentioned above, the crucial

nature of continued education and career development, although ranked least important

still received an alarming vote of unacceptable by 55% of responding doctors.

In summary, all HR practices in the ELHC require substantial improvement. From

correlating the qualitative responses with the performance rating, doctors in the ELHC are

clearly frustrated by the poor levels of HRM execution. It is this frustration that is

unfortunately bound to have negative effects on the institution’s retention capacity.

6.5 The Most Important HR Characteristics The second research theme of HR characteristics was categorically dominated by doctors

ranking task competence of HR staff, as the most important factor. It was clear that doctors

were annoyed by and frustrated when HR staff could not exhibit a high degree of

competence when dealing with their concerns. This characteristic was followed in the

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importance ranking by accountability. This was a characteristic that doctors perceived to

be a driver of excellence and quality.

The third ranked characteristic that doctors felt was important for HR staff to exhibit was

general process efficiency. It was emphatically emphasised that process efficiency allows

for timeous handling of critical activities such as application processing, problem

identification and failure resolution. This importance was confirmed by the fourth ranked

characteristic, salary adjustment efficiency relating to OSD and PMDS. Here doctors

experienced a significant amount of valuing and affirmation when salary adjustment was

correctly carried out.

In relation to the other five characteristics, HR staff availability was ranked the lowest. As

a result of a substantial clinical load, interview findings showed that doctors struggled to

visit the HR department at times outside of their tea and lunch times. These tea and lunch

visits were however only possible if staff were available during these times.

6.6 Rating the ELHC HR Characteristic Exhibition

With 77% of doctors rating the task competence of HR staff as unacceptable, it was

apparent that there was a deficiency in this characteristic. Many doctors felt that this was

the greatest failure of the HR department and believed the solution to the problems of poor

HRM lay in the training of HR staff. This failure was noticeably the most frustrating for

doctors as it impacted them on a daily basis.

The second and third ranked characteristics, these being accountability and general process

efficiency, were very poorly rated by the responding doctors. Both of these characteristics

were alarmingly perceived to be unacceptable by 81% and 87% of doctors respectively.

There were multiple examples of doctors being affected by these failures however the most

distressing comments was made by a senior doctor who stated, “I have examples of doctors

who applied to work in my�department who, when finally offered a post, had already been

working in an�alternative post elsewhere for over 6 months.”

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OSD and PMDS performance, although lower down on the importance ranking, was also

rated by 51% of doctors as unacceptable. From the responses, this crucial tool for

incentivising doctors is now noted to in fact, be more of a frustration and dreamlike fantasy

for doctors. Lastly the availability of HR staff during tea and lunch times, received a vote

of unacceptable by 65% of respondents.

It is clear from these findings that the identified characteristics are all being performed

unacceptably despite the relative importance rankings. As with the first theme, doctors

were overwhelmingly pessimistic towards the exhibition of characteristics by the ELHC

HR staff with virtually all written responses being negative.

6.7 HRM at the ELHC and its Impact on the Retention of Doctors

In light of the human resource crisis that is occurring in the ELHC and the Eastern Cape,

this research has revealed that the HR function of the ELHC is doing insufficient to curb

the flow of doctors leaving. The study has in fact shown that the HR department and its

fundamental failings have caused a substantial degree of frustration to and devaluing of

doctors. This seemingly has had a direct impact on doctors’ willingness to remain at the

complex with only 32% of the surveyed doctors willing to commit to continue working at

the ELHC. This influence can thus only be perpetuating the staffing problems that plague

the institution.

HRM in the health sector is known to be an enormous challenge (Buchan, 2004), and

although many of the problems in this research have been attributed to the staff within the

department, the influence of the cumbersome system inefficiencies that have been

implemented cannot be discounted. Staff within the ELHC HR may in fact be hamstrung

in their ability to enhance their productivity and may be as frustrated in their limited

capability as are the doctors who they attend to. An investigation into this aspect of HR

may be a sound follow-on to this research, the results of which would augment our

understanding of public health HRM significantly.

This said however, if HR is going to play an active part in retaining doctors at the ELHC,

then substantial improvement, in all areas, needs to occur as a matter of urgency. As the

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workforce of doctors changes to predominating that of members of Generation Y,

managing, motivating and most importantly retaining these individuals is set to become

more and more challenging. HRM improvement is thus not only critical to alleviate the

immediate staffing concerns but also to prepare for the diverse generational blend of

HCW’s that is set to pose a distinct management challenge in the future (De Meuse &

Mlodzik, 2010).

6.8 HRM in the Public Health Sector and its Impact on the Retention of Doctors

In conclusion, this research has revealed that the ELHC HR department through

unacceptable HRM appears to be perpetuating the doctor shortage and not assisting with its

mitigation. The link between sound HRM and doctor retention is thus clearly evident and

the importance of this relationship must be acknowledged and addressed.

South African public hospitals need to strive to become “magnet hospitals” (Buchan, 2004),

ones where doctors from all over the world jostle with our locally qualified doctors for the

opportunity to experience our impressive clinical practice. This however will never happen

unless these doctors together with our locally qualified professionals can work knowing

that all administration has been taken care of by highly trained and passionate HR staff

members.

6.9 Limitations of the Study This research was conducted on a single public hospital complex in South Africa. The

results of this research may thus not be generalisable to the broader public health sector.

The context that the research exists in is also very particular in terms of timing and the

current nature of the staffing crisis. Responses thus may be jaded by current circumstances

that the doctors find themselves in. Lastly this research has been primarily focused on

understanding the relationship between HRM and retention of doctors. As a result an

improvement strategy cannot be recommended in order to resolve the problems identified.

Further analysis and interpretation would need to be conducted to generate this type of

intervention.

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6.10 Future research This research lends itself to multiple areas for future investigation. First and foremost the

researcher opines that an investigation into the perspectives held by the HR staff is

paramount in further understanding the problem at hand. Both local and national HR staff

opinions would assist with isolating the cause for the problems and highlight the areas that

would need attention.

Secondly the generational complexity of the workforce is increasing and the public sector

especially the public health sector, must fully comprehend and plan for this progression. It

would be naïve to assume that management of these institutions can continue as is. It is

therefore suggested that a study be undertaken to investigate this change in composition of

the public health workforce in order to understand how best to manage these new HCW’s.

Lastly, it would be very pertinent to overcome the poor generalisability of this study by

investigating the perspectives of doctors from multiple institutions and provinces. This

would aid in not only determining the extent of the problem but, if a site of excellence is

found, may also facilitate an enquiry into what is driving this superior functioning.

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8. Appendices

Appendix 1: Authorisation from The Chief Executive Officer at the ELHC

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Appendix 2: UCT Ethical Clearance Form

21 September 2012

To whom it may concern, Re: Ethical clearance for research proposed by Bruce Longmore This is to certify that the GSB Ethics in Research Committee has considered the subject and the methodology of the research proposed by Bruce Longmore, for the project titled, “Human resource management practices in the South African public health sector: Assessing their impact on the retention of South African doctors,” and has given ethical clearance on the basis of guidelines and rules provided by the UCT Faculty of Commerce. Please let us know if you have any comments or queries.

Kind regards,

Ralph Hamann

Chair of the GSB Ethics in Research Committee

Ralph Hamann

Associate Professor & Research Director

T: +27 (0)21 406 1503

E: [email protected]

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Appendix 3: Head of Department Questionnaire

Head of Department Questionnaire

1. With regard to the management of doctors:

a. What management practices do the HR department utilise that you feel

positively influence doctors to stay at the complex?

i. Of these mentioned which ones have the greatest impact?

b. What management practices do the HR department perform that you feel

reduce the potential for doctors to stay at the complex?

i. Of these mentioned which ones have the greatest impact?

2. With regard to the way the HR functions as a department:

a. What inherent HR activities encourage positive interaction between Doctor

and HR?

b. What inherent HR activities frustrate doctors and negatively affect the

Doctor/HR relationship?

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Appendix 4: Survey Page 1

Page 1

Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)Human Resource Practices at the East London Hospital Complex (ELHC)

Please note responses are FULLY ANONYMOUS.

5. If South African, what is your province of origin?5. If South African, what is your province of origin?5. If South African, what is your province of origin?5. If South African, what is your province of origin?

6. Curent Position6. Curent Position6. Curent Position6. Curent Position

Section 1 of 3 : Demographic Information

1. What is your gender?1. What is your gender?1. What is your gender?1. What is your gender?*

2. Age Group2. Age Group2. Age Group2. Age Group*

3. Race (As per the Employment Equity Act, 3. Race (As per the Employment Equity Act, 3. Race (As per the Employment Equity Act, 3. Race (As per the Employment Equity Act, 1998) OPTIONAL1998) OPTIONAL1998) OPTIONAL1998) OPTIONAL

4. Nationality4. Nationality4. Nationality4. Nationality*

*

7. How long have you been working at the ELHC?7. How long have you been working at the ELHC?7. How long have you been working at the ELHC?7. How long have you been working at the ELHC?*

8. Do you intend staying at the 8. Do you intend staying at the 8. Do you intend staying at the 8. Do you intend staying at the ELHC?ELHC?ELHC?ELHC?

*

Female Male

25-32 33-50 51-66 +67

African Coloured Indian White

Other (please specify)

South African

Other

Intern Community Service

Medical Officer

Registrar Consultant

0 to 2 yrs 2 to 5 yrs 5 to 10 yrs More than 10yrs

Yes No Unsure

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9. Please RANK the following HR practices in order of their importance to 9. Please RANK the following HR practices in order of their importance to 9. Please RANK the following HR practices in order of their importance to 9. Please RANK the following HR practices in order of their importance to you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)

10. With reference to your most important practice above, please provide a 10. With reference to your most important practice above, please provide a 10. With reference to your most important practice above, please provide a 10. With reference to your most important practice above, please provide a brief description of why you feel this way.brief description of why you feel this way.brief description of why you feel this way.brief description of why you feel this way.

11. On a scale of 111. On a scale of 111. On a scale of 111. On a scale of 1----4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex HR department performs these tasks.HR department performs these tasks.HR department performs these tasks.HR department performs these tasks.

12. Any other comments or factors not raised above?12. Any other comments or factors not raised above?12. Any other comments or factors not raised above?12. Any other comments or factors not raised above?

Section 2 of 3 : HR Practice Importance

*

1. To be respected and valued by HR staff and receive friendly and helpful service

2. Monthly salary paid on time

3. An adequate document collection, filing and storage system

4. Good communication E.g. Post availability, status of requests made the department, and the whereabouts of submitted documents.

5. Re-imbursment for courses/conferences attended, and processing of special leave requests.

*

*

UnacceptableAcceptable GoodVery Good

To be respected and valued by HR staff and receivefriendly and helpful service

An adequate document collection, filing and storage system

Re-imbursment for courses/conferences attended, and processing of special leave requests.

Monthly salary paid on time

Good communication E.g. Post availability, status of requests made the department, and the whereabouts of submitted documents.

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13. Please RANK the following HR practices in order of their importance to 13. Please RANK the following HR practices in order of their importance to 13. Please RANK the following HR practices in order of their importance to 13. Please RANK the following HR practices in order of their importance to you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)you (i.e. In your dealings/ interactions with HR)

14. With reference to your most important practice above, please provide a 14. With reference to your most important practice above, please provide a 14. With reference to your most important practice above, please provide a 14. With reference to your most important practice above, please provide a brief description of any situation that has contributed to you feeling this way.brief description of any situation that has contributed to you feeling this way.brief description of any situation that has contributed to you feeling this way.brief description of any situation that has contributed to you feeling this way.

15. On a scale of 115. On a scale of 115. On a scale of 115. On a scale of 1----4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex 4 please rate how well the East London Hospital Complex HR department performs these tasks.HR department performs these tasks.HR department performs these tasks.HR department performs these tasks.

16. Any other Comments or factors that this survey has failed to raise16. Any other Comments or factors that this survey has failed to raise16. Any other Comments or factors that this survey has failed to raise16. Any other Comments or factors that this survey has failed to raise

Section 3 of 3 : HR Practice Importance

* 1. The task competence of HR staff

2. The accountability of HR staff for queries made or documents submitted

3. General HR process efficiency

4. The availability of HR staff during tea and lunch times

5. OSD* Salary level adjustments and PMDS** efficiency (*Occupation Specific Dispensation, **Performance Management and Development System)

*

UnacceptableAcceptableGoodVery Good

N/A

The accountability of HR staff for queries made ordocuments submitted

The task competence of HR staff

The availability of HR staff during tea and lunch times

General HR process efficiency

OSD* Salary level adjustments and PMDS** efficiency (*Occupation Specific Dispensation, **Performance Management and Development System)

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Appendix 6: Daily Dispatch Newspaper Article