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JHOM
30,8
Understanding human resource
management practices in
Botswana’s public health sector
1284
Received 22 May 2015
Revised 27 May 2016
30 September 2016
Accepted 2 October 2016
Onalenna Stannie Seitio-Kgokgwe
Department of Health Policy Development,
Monitoring and Evaluation, Ministry of Health, Gaborone, Botswana
Robin Gauld and Philip C. Hill
Department of Preventive and Social Medicine,
University of Otago, Dunedin, New Zealand, and
Pauline Barnett
School of Health Sciences at Canterbury University of Canterbury,
Christchurch, New Zealand
Abstract
Purpose – The purpose of this paper is to assess the management of the public sector health
workforce in Botswana. Using institutional frameworks it aims to document and analyse human
resource management (HRM) practices, and make recommendations to improve employee and health
system outcomes.
Design/methodology/approach – The paper draws from a large study that used a mixed methods
approach to assess performance of Botswana’s Ministry of Health (MOH). It uses data collected
through document analysis and in-depth interviews of 54 key informants comprising policy makers,
senior staff of the MOH and its stakeholder organizations.
Findings – Public health sector HRM in Botswana has experienced inadequate planning, poor
deployment and underutilization of staff. Lack of comprehensive retention strategies and poor working
conditions contributed to the failure to attract and retain skilled personnel. Relationships with both
formal and informal environments affected HRM performance.
Research limitations/implications – While document review was a major source of data for this
paper, the weaknesses in the human resource information system limited availability of data.
Practical implications – This paper presents an argument for the need for consideration of formal
and informal environments in developing effective HRM strategies.
Originality/value – This research provides a rare system-wide approach to health HRM in a
Sub-Saharan African country. It contributes to the literature and evidence needed to guide HRM policy
decisions and practices
Keywords Botswana, Human resource management, Institutional theory, Public health sector
Paper type Research paper
Introduction
This paper seeks to understand the human resource management (HRM) practices in
the public health sector in Botswana. As other Sub-Saharan African countries,
Botswana experiences numerous human resource (HR) challenges (Awases et al., 2010;
WHO, 2006). Chronic staff shortages, limited skills, and poor motivation and retention,
Journal of Health Organization and
Management
Vol. 30 No. 8, 2016
pp. 1284-1300
© Emerald Group Publishing Limited
1477-7266
DOI 10.1108/JHOM-05-2015-0076
Conflict of interest: The authors have no competing interests.
The authors would like to thank the Botswana MOH management and staff for the support,
and participants for their willingness to participate in this study. The research reported in this
paper was funded by a University of Otago Scholarship, for which the first author is grateful.
are some of the major threats to delivery of services and overall performance of the
health system (MOH, 2001, 2009; Seitio-Kgokgwe, 2012). Nationally, the density of
health personnel per 10,000 population has been persistently low by international
standards (WHO, 2010, 2014). The World Health Organization (WHO) views personnel
as the most critical of all health system resources. Countries with fewer health workers
are unable to deliver services effectively or scale up interventions essential for
achieving health goals (WHO, 2006).
While significant emphasis has been placed on strategies to address continuing
threats to HR availability in poorer countries, limited attention has been paid to HRM in
their health systems overall (Dovlo, 2005; Kabene et al., 2006). HRM systems comprise
the policies, strategies, processes, procedures and practices used in the management of
people in the workplace (Armstrong, 2006). There is extensive evidence that HRM
practices have an impact on organizational and employee performance in many sectors
(Bowen and Ostroff, 2004; Guest, 1997). However, the focus on HRM and its potential to
contribute to improved performance of health systems, health care organizations,
patient and employee outcomes is just emerging (Adano, 2008; Bartram and Dowling,
2013; Campbell et al., 2013; Vermeeren et al., 2014). In Botswana, there is dearth of
studies in the area of HRM in the health sector. A few available HR studies focussed on
quantifying existing HRs (Nkomazana et al., 2014), and evaluating strategies
addressing HR challenges (Ledikwe et al., 2013). Drawing from a large study assessing
performance of the Botswana’s Ministry of Health (MOH) this paper explores how the
health workforce is managed in the public health sector, specifically aiming to: analyse
and document the HRM practices; and make recommendations that can enhance HRM
in the public health sector.
There is a growing realization that HRM systems exist within organizations which
are social entities (Meyer and Rowan, 1983). These organizations and their external
environments influence the structure and functioning of the HRM systems (Boon et al.,
2009; Meyer and Rowan, 1983). In view of this reality, this paper uses institutional
theory as a lens to understand HRM in Botswana’s public health sector. Based on this
theory, it is presumed that HRM practices in the public health sector to a large extent
reflects the values, norms and beliefs of the public sector and Botswana as a larger
context (Meyer and Rowan, 1983; Scott, 1983b).
Institutional theory, HRM and health
Institutional theory has been applied to HRM for over a decade (Mohamed and
Terpstra, 1999; Najeeb, 2014). This theory permits a more expansive, system-wide view
of HRM within health. Organizations in institutional theory are viewed as social entities
that constantly adapt to their environments in order to gain social acceptance
(legitimacy) (Meyer and Rowan, 1983). The environments are described as comprising
rules, norms, standards and requirements that exert pressure on organizations
influencing their structures, processes and practices (Fadare, 2013; Meyer and Rowan,
1983). These authors identified three categories of institutional pressure: regulatory
(such as legal and government requirements which tend to be considered “coercive”);
cognitive which are “common knowledge” and expectations of a group of professionals
in the organization; and “normative”, which reflect the values, beliefs and norms of
the wider society (Meyer and Rowan, 1983; Scott, 1983b). Scott (1983b) argues that the
value and belief systems in the organization’s external environment are myths in the sense
that they depend for their efficacy and reality on the fact that they are widely shared by
individuals or groups that have been given the right to determine such matters.
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The normative and cognitive pressures can be summarized as “informal” institutions that
“attend to the deeper and more resilient aspects of social structure” (Scott, 2004 cited in
Amadi and Ekekwe, 2014, p. 170) while regulatory pressures can be characterized more as
“formal” institutions.
In the field of HRM, institutional theory argues that organizations adopt HR
practices that fit their environment’s rules, values, norms and beliefs (Boon et al., 2009;
Meyer and Rowan, 1983; Paauwe and Boselie, 2003; Scott, 1983b). The public health
sector in Botswana exists within the public service which provides its immediate
external environment. The Directorate of Public Service Management (DPSM), which is
a body under the Ministry of State President established through the Public Service Act
of 1998 (GoB, 1998a) has the statutory responsibility for the management of the public
service. The DPSM responsibility entails provision of policy framework and developing
and enhancing strategies to improve public service performance (GoB, 1998a). In view
of this relatedness, it can be concluded that HRM practices in the public health sector
are to a large extent a reflection of the broader public service (Paauwe and Boselie,
2003). Similarly, the public service exists within the nation-state or society (Scott, 2014)
which presents the broader socio-economic and political context which may also
influence HRM practices (Paauwe and Boselie, 2003). The state as an entity has power
and authority over other organizations. Its inherent legitimate coercive power can play
a significant role in shaping the public service structure and behaviour (Scott, 2014)
which consequently influence HRM systems in the health sector.
While there are limited HRM studies using institutional theory in the public health
sector in developing countries, in Sub-Saharan Africa, research into commercial and
development organizations suggest that there are two broad institutional pressures in
the region. One is the formal regulatory environment necessary for decision making
and implementation of policy. This can be undermined by poor democratic process,
lack of accountability and acceptance of “grand” corruption (Amadi and Ekekwe, 2014).
The second comprises the informal institutional characteristics of the community
including the functioning of an informal economy ( Jackson, 2012), the tolerance of petty
corruption, not necessarily involving pecuniary gain but prioritizing the interests of
family or local community over the requirements of the workplace.
Of importance for this research is that Botswana is regarded as one of only two
states in Sub-Saharan Africa that has maintained robust democratic processes since
independence (Young, 2000) and is the least corrupt country in the region, ranking 28th
in the world in 2015 (Transparency International, 2016). There are a variety of reasons
for this, including the minimizing of the impact of colonialism on existing institutions,
and a political culture that encourages consensus and dialogue (Gapa, 2013).
This places Botswana in a favourable situation for the implementation and
management of effective HRM policies. This paper elucidates the role of the public
service and the state in shaping the HRM practices in the public health sector.
Methods
Setting
The public health sector in Botswana comprises a variety of health facilities such as
clinics, hospitals, medical laboratories, pharmacies and health training institutions.
Prior to 2010, responsibility for provision of public sector health services was shared by
the MOH, which was accountable for all public hospitals, and the Ministry of Local
Government, which was responsible for primary health care (PHC) services in clinics
and health posts. PHC services have since been transferred to the MOH. The public
sector is the major employer of health workers accounting for over 80 per cent of the
health workforce (MOH, 2001, 2009). HRM in the public health sector is a shared
responsibility of the MOH and DPSM. The MOH’s responsibility for HRM occurs at two
levels. First, it has statutory responsibility for development and oversight of HRs for
health. This entails determining the needs, providing standards and guidelines for the
training and distribution of health workers, and ensuring effectiveness of accreditation
mechanisms (GoB, 2002). Second, through its role in service provision, the MOH is
directly responsible for HRM in public health facilities under its supervision. This latter
function is the focus of this paper.
Evaluation domains and indicators. This paper draws from a large mixed-method
study designed to assess the performance of the Botswana’s MOH (Seitio-Kgokgwe,
2012). As a conceptual framework the study used the WHO health systems functions of
leadership and governance, health service delivery, health financing and resource
generation which includes HRs (Seitio-Kgokgwe, 2012). Performance indicators for
system-level HRM were developed from the general literature on HRs and/or adapted
from existing works, particularly, from WHO and USAID’s works on health systems
(Islam, 2007; WHO, 2008). These indicators were categorized under the following areas:
HRM structures and policies, HR planning, HR recruitment and deployment and HR
attraction and retention (Table I). Although training and development is an important
aspect of HRM, it is not addressed in this paper.
A well-defined structure that delineates roles, responsibilities and accountability
facilitates coordinated planning, management and monitoring of HR activities
(Nyoni et al., 2006; WHO, 2002). HR policy identifies the HR needs of the country,
establishes priorities and identifies ways to mobilize and retain HRs (Dussault and
Dubios, 2003; Nyoni et al., 2006).
A HR plan facilitates implementation of the policy by translating it into specific
activities necessary to achieve identified goals (Islam, 2007; Martineau, 2008; Nyoni
et al., 2006; WHO, 2002). It defines the targets to be attained within set time periods,
identifies resources and assigns responsibility and accountability for achieving results.
It should be supported by a robust HR information system that provides data on the
availability, attributes and characteristics of the workforce (Islam, 2007; Nyoni et al.,
2006; WHO, 2006).
Appropriate recruitment strategies and processes ensure that the appropriate skills
are available in a timely manner (WHO, 2006, 2008). Effective deployment strategies
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Assessment domain
Indicator
Human resource management
structures and policies
Availability of a structure for handling the human resource
function of the MOH
Availability of functional human resource policies
Availability of a functional human resource plan
Effectiveness of the human resource planning process
Availability of an efficient and effective human resource
information system
Table I.
Effectiveness of recruitment strategies and processes
Assessment domains
Effectiveness of deployment/utilization strategies
and performance
Availability and effectiveness of retention strategies
indicators for HRM
in health
Human resource planning
Human resource recruitment and
deployment
Human resource attraction and
retention
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enhance full utilization of health worker competencies (WHO, 2006). Maintaining a
skilled and motivated health workforce requires comprehensive retention strategies
(Islam, 2007; WHO, 2006).
Data collection
Two sources of data were used for this study: document analysis and key informant
interviews.
Document analysis. A data abstraction sheet based on the indicators in Table I was
developed and used to collect data from published and unpublished documents. These
included National Development Plans (NDPs), MOH strategic and annual performance
plans and various forms of reports, government and MOH policies, and related reports
from other agencies such as the WHO. We searched electronic databases including
PubMed, Science Direct, Ovid, Scopus, Web of Knowledge, ProQuest and Google
Scholar for published articles.
Key informant interviews. In total, 54 key informants were purposively selected and
interviewed (Seitio-Kgokgwe, 2012). These comprised policy makers, senior
management and staff of the MOH (n ¼ 40), including nine retired employees
identified through a snowballing technique, and 14 (n ¼ 14) senior officers from various
stakeholder organizations such as the Ministry of Local Government, mission
hospitals, regulatory bodies, professional organizations and international agencies
working in Botswana (Seitio-Kgokgwe, 2012). An interview guide using assessment
areas and indicators identified in Table I was used in the data collection. Interviews
were tape recorded and transcribed.
Data analysis
Data from documents and transcripts were analysed using directed content analysis
(Hsieh and Shannon, 2005) and thematic analysis, both guided by Miles and Huberman’s
(1994) approach which consists of data reduction, data display and conclusion drawing/
verification. The study indicators acted as the organizing framework (Seitio-Kgokgwe,
2012). The key informants were categorized into two main groups coded as “M” for MOH
employees (MR for retired officers) and “S” for participants from stakeholder
organizations. This study was approved by the University of Otago Ethics Committee
and the Health Research and Development Committee of the Botswana MOH.
Findings
HRM structures and policies
Structure for handling the HR function in the MOH. The Department of Health
Manpower was established in 1984 and charged with the responsibility of coordinating
all HR activities in the Ministry (Directorate of Personnel, 1983). This department was
headed by a Director who reported to the Permanent Secretary. In spite of the existence
of the Department of Health Manpower, individual departments created their own HR
units making coordination and accountability in HRM difficult. Some of the problems
observed included unfair promotions and inequitable professional development
opportunities, leading to staff disgruntlement:
Promotions were going very well in hospital services because they had vacancies.
In primary hospitals there was stagnation […] There were disgruntlements after every
promotion […] (M31).
A reorganization in 2002 dissolved the Department of Health Manpower and placed the
HRM function under the Department of Corporate Services as a division with several
units which included recruitment, deployment, training and development (MOH, 2002,
2005). Although this structure might be seen to have downgraded the HR function by
moving it from a department to a division, informants reported enhanced coordination
and better management.
HR policy. The need for a comprehensive HR policy was identified during the 1983
organizational review, with responsibility for its development assigned to the
Department of Health Manpower (Directorate of Personnel, 1983). The intention was to
identify health sector HR needs, establish priorities, identify approaches to HR
development and address issues of retention and utilization (Directorate of Personnel,
1983). Before 2012 the MOH did not have HR policies or guidelines specific to the health
sector but relied on general policies at a national level developed by the DPSM.
The main policy documents were the Public Service Act of 1998 (which has since been
reviewed), Public Service Regulations of 1998, General Orders, directives and
savingrams passed from time to time by DPSM to address specific HR issues.
HR planning
A functional HR plan. The MOH made significant efforts to develop HR plans. The first
plan was developed in 1987 and the second in 1992 (MOH, 2001). These plans were,
however, criticized for failure to address adequately the HR needs of the country, the
staffing needs of upgraded facilities and to link with health sector development plans
(MOH, 2001). Despite this critique, the 1992 plan showed some success, with 75 per cent
of the training target achieved and a number of new training programmes established
(MFDP, 1997).
The third HR plan was developed in 2001 with the technical assistance of the
Norwegian Agency for Development and WHO. While this plan purported to have used
better approaches and to link better with the health sector infrastructure and service
plans during NDP8 (1997-2003) (MOH, 2001), it was reported as the least productive in
terms of HR development (MFDP, 2003). It is important though to note that this plan
was developed and implemented during the last part of the NDP8 which might have
limited its full impact.
The latest plan was developed in 2007 with the assistance of a group of consultants
(MOH, n.d.). It proposed staff establishments for the different functions, established norms,
identified training needs and proposed training strategies (MOH, 2001, 2007). The plan
was, however, not implemented. Although it was available at the MOH headquarters,
some of the managers with HR development responsibilities in the Ministry were not
aware of its existence. Other informants expressed some of its limitations:
There is a document about human resources although it is very doubtful whether it is
implemented. The document was developed by consultants. It made some recommendations
that do not address the needs of departments, for example, it recommended cuts in staff, while
on the ground there are gaps related to inadequate numbers of personnel (M28).
The NDP health sector plans included some aspect of HR plans with training targets set
for the each plan period. In the absence of a functional strategic HR plan, some form of
HR planning occurs annually as part of the annual budgetary process. Different
departments usually submit their training and HR needs as part of their budget guided
by targets set in the NDPs. These are consolidated and prioritized at headquarters level
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based on availability of financial resources (MOH, 2009). The requests for additional
positions are negotiated with DPSM.
Effectiveness of the HR planning process. One of the major challenges of HR planning
is to link HR plans with infrastructure development or service delivery plans.
Participants indicated that on a number of occasions structures were completed but the
HR establishment was not yet determined:
Maybe we do have a deficiency in there. But the ideal thing was that for every new facility, let
say we build a new hospital, we should be able to say that it is going to be a 200 bed hospital,
in this we will need so many doctors and so many x-ray technicians […] and so many
specialists. Ideally we are aware that this ought to be the case. It doesn’t always work out that
way. But it is an area that I acknowledge is not adequately addressed. We do have projects
that get completed and we don’t have the human resources to immediately take over that
facility and utilize it to its optimum potential (MR35).
These participants questioned the MOH’s ability to forecast HR needs and plan
strategically:
We are incapable of strategic planning because if you were going to build a hospital, you
knew it will take 3-4 years to train staff. You will start training staff before you start building,
right! […] Not here. You do everything after […] (M27).
Also of concern in the planning process, cited by a number of informants, was inadequate
consultation with the various stakeholders such as the University of Botswana, Ministry
of Education and Skills Development, Ministry of Local Government, Institutes of Health
Sciences and the mission schools. The MOH was reported to have no forum for
discussing HR issues with its stakeholders, including the government owned training
institutions who were not adequately involved in the HR planning process:
The institutions get to know the needs of the country through National Development Plans
[…] I wouldn’t say there is a forum. Training needs may also be communicated through the
coordinating office and the director […] (M20).
Positive efforts in collaborative planning were reported in the area of midwifery
training and services, but training institutions were generally limited in their
knowledge of the Ministry’s HR needs.
A HR information system. The lack of robust and efficient health information
systems that can provide data to facilitate planning and decision making is a
continuing problem (MOH, 2007, 2009). The MOH depends on the government
computerized personnel management system, introduced in the late 1990s under the
auspices of the DPSM (MFDP, 1997, 2000, 2003). Although, in the absence of a health
HR information, this system could have been helpful, the quality of data is reported to
be unsatisfactory due to failure of regular updating and the lack of system ownership
by ministries (MFDP, 2003; MOH, 2009). This system’s limitations have led government
to explore more effective alternatives (MFDP, 2009).
HR recruitment and deployment
Effectiveness of recruitment strategies and processes. Shortage of HRs has long been a
feature of the health system in Botswana (MFDP, 1991, 1997, 2003). Recruitment of
health workers is guided by the Public Service Act (Section 6), and the Public Service
Regulations (Sections 5 and 6) (GoB, 1998a, b). While DPSM has the statutory
responsibility for appointing officers, varying levels of authority and responsibility
have been delegated to ministries over the years to recruit certain levels of staff
(MFDP, 2003). As with other ministries, the MOH has a recruitment board chaired by
the Permanent Secretary that coordinates and undertakes recruitment of health
personnel. A representative of DPMS sits in the board to provide support and guidance
in terms of national HR policies.
Deficiencies in the recruitment process both at DPSM and ministries have been cited as
one of the contributing factors to high vacancy rates (MFDP, 2003). During NDP7, the
vacancy rate in the MOH was above 15 per cent (national target 5 per cent, national
average 9 per cent). By the beginning of NDP8, the vacancy rate was reported to have risen
to 20 per cent (MOH, 2001). In 2007/2008 a total of 840 (9 per cent) MOH positions were not
filled (MOH, 2007). These were reported to be mainly for professional staff such as medical
doctors and other specialists for whom training was not locally available. Notwithstanding
this, vacant positions have been reported to take an unduly long time to fill:
Understanding
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Recruiting-it can take ages to fill the vacancies. You struggle to get staff. You have to struggle
to try to do whatever you can to get the work done. That is, see what you can do to produce
results […] (M22).
DPSM and the MOH have periodically engaged external and local recruitment agencies
to facilitate recruitment or travelled outside the country to recruit staff where the local
skill pool is limited. Some participants, however, regarded these efforts as poorly
planned and uncoordinated:
We just do recruitment haphazardly. Whenever we feel we need to recruit at such and such a
place we go there. Whenever we hear of a certain recruitment agency we engage it […] (M28).
The Ministry comes up with things they have not budgeted for. For example, recruitment
expenses-the Ministry decided to hire somebody to recruit on its behalf while this was not
budgeted for […] (M18).
There was a notable reduction in vacancies for nursing, medical, pharmaceutical and
laboratory personnel from 2004 (Figure 1). This reduction was related to both increased
625
2008
2007
497
2006
498
448
2005
405
2004
231
2003
186
2002
136
2001
104
2000
1999
1998
49
132
Source: Infinium Database, MOH accessed 2009
Figure 1.
Trends in
recruitment of
nursing, medical,
pharmaceutical and
laboratory personnel
1998-2008
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internal supply and to external recruitment efforts, both of which were supported at a
national level. The target vacancy rate at a national level was set at 2 per cent for NDP8
(MFDP, 2003) and ministries were denied any additional positions while they still had
vacancies within their establishments.
Effectiveness of deployment/utilization strategies. Appropriate deployment and
effective utilization of staff was reported as another area of concern. Deployment did
not always take into account staff preparation on initial posting and transfer (MOH,
2009). This was observed particularly for specialist nurses, with many examples cited
of inappropriate placement of specialist staff:
But there is also a challenge where specialists are not placed in their area of expertise. This
happens often because of promotion. For example, theatre nurses may be promoted to
psychiatric hospital […] (M29).
Underutilization of nurse specialists such as Family Nurse Practitioners and
Psychiatric Nurses has also been reported (MOH, 2009). Concerns have also been
raised on the loss of doctors to management positions in hospitals and at the Ministry
level, a situation seen to deny the country the opportunity to benefit from the expertise
of these highly skilled health workers:
What we find now is a lot of young doctors, young specialists, who have spent a lot of time
and a lot of government money being trained, and are doing a good job, and after a year or
two they find themselves superintendents of hospitals […] (M17).
We take doctors who are such a scarce commodity in this world, we take them away from
looking after patients and we put them behind very big desks and try and make them
engineers, electricians, cleaning specialists, laundry specialists. They are doctors! Their job is
treating people. They shouldn’t be administrators […] (M27).
On the issue of doctors (most of whom are specialists) assuming leadership role in the
MOH headquarters while there is acute shortage in health facilities, this participant
went further to say:
In this building, we have 6 or 7 or 8 doctors, and we have 6 or 7, or 8 doctors short at Scottish
Livingstone Hospital, at Marina and at every hospital. We are 6 or 7 or 8 doctors short and yet
we have 6 or 7, or 8 doctors in this building not doing any clinical work whatsoever […] 90%
of their work is not involved in deciding clinical work. It’s on what salary scales should
accountants be paid? What’s the Ministry establishment going to be? On budgeting! On stores
buying! They are not qualified to do that. That is wrong […] (M27).
Concerns regarding loss of clinical competencies faced by medical specialists working
in management roles were also raised:
What is very unfortunate is when they (specialists) remain in limbo. Basically they are
employed as specialists, but they work as administrators. They trained as specialists, but the
longer they stay out of it, they lose touch […] (M17).
HR attraction and retention
Availability and effectiveness of HR retention strategies. The public health sector
benefits from attraction and retention strategies introduced from time to time by the
Government. Examples include the parallel progression and scarce skill schemes.
Parallel progression was introduced in 1993 (MFDP, 1997). The overall goal was to
improve career prospects for workers by allowing professional staff opportunities to
reach the highest grade within the civil service without necessarily leaving their
professional cadre to join management (MFDP, 1997). The parallel progression
scheme was evaluated during NDP8 and continues to be implemented with
modifications (MFDP, 2003).
The scarce skill scheme was initiated in 1998 (MFDP, 2003). Through this
government hoped to attract local personnel with critical skills and retain them in the
public service (MFDP, 2003). It was, however, soon realised that the implementation
had failed to discriminate cadres qualifying for scarce skill from those not qualifying
(MFDP, 2003). This created dissatisfaction among the workforce and the programme
was abolished. The government instead introduced a scarcity allowance that is paid to
selected cadres (MFDP, 2003).
While these initiatives might have brought some gains in terms of better retention
and improved productivity, some participants observed that they were not fairly
implemented. Incentives were seen to be focussed on one cadre and hence brought
dissatisfaction to and increased attrition in others:
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HRM practices
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If nurses are not recognized, they cannot be retained. They have to go somewhere where they
could be recognized better. Things are much better on the side of doctors. A lot of
improvements have occurred but the same cannot be said for other disciplines, in particular,
for nursing […] (M29).
Our system is leaking really. We are losing many locals. Young ones just come to register with
council and join the private sector or go back to countries where they trained. One of the
concerns is that salary scale entry levels are very low and there are a lot of disparities between
cadres in the system […] (M13).
Review of available records validates concerns raised by participants about attrition.
Between 2004 and 2007, a total of 1882 employees left the MOH (Figure 2). Of these 949
(50 per cent) terminated through resignation, transfer to other ministries, termination of
contracts and voluntary retirement. In 2007 those who voluntarily left employment
constituted 57 per cent of all terminations.
600
500
400
300
200
100
0
Total
Resignation/TC/ER/T
2004
441
213
2005
485
207
2006
469
253
2007
487
276
Notes: TC, Termination of contract; ER, early retirement; T, transfer to
other ministries
Source: Infinium Database accessed 2009
Figure 2.
Number of health
workers who left
MOH employment
2004-2007
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The view that various forms of incentives including training opportunities were not
fairly distributed among the workforce came out strongly in this analysis:
Scholarships are not well distributed. The Ministry prioritises. May be in its priorities the
training of specialist medical doctors comes first. The number of doctors is not adequate, but
if you send 5-6 of them and one, one for other disciplines-it is a challenge (M13).
1294
Explaining why the Ministry may seem biased towards certain cadres, one of the
participants said:
Maybe it’s because the Ministry is mainly run by people of certain cadres. They are the ones
holding the very influential positions of the Ministry […] (M17).
Participants emphasized the need for retention strategy to be comprehensive,
addressing the needs of all health workers:
[…] we need to do that with not just doctors though. We have to look at our other health
professionals and make sure we are doing the same for them because otherwise we will be
brewing a very toxic brew for ourselves. So even the others they need to be well looked after
and we need to ensure that we develop them both in numbers and skills […] (MR34).
Participants indicated what, from their perspective, should be considered in the HR
retention strategy. This included better salaries, improved conditions of service, more
educational opportunities, better work environment with appropriate equipment,
recognition and accommodation.
Discussion
HRM research in health in Sub-Saharan Africa has concentrated on service
organization level practices (Marchal et al., 2010) or specific occupational groups
(Abubakar et al., 2015). Such research is only just emerging in Botswana (Mkubwa,
2010) but as it develops it will provide important insights into technical aspects of
HRM. For local HRM practices to achieve full impact, there also needs to be a strongly
functioning national system comprising appropriate structures, policies, plans and
systems for recruitment, retention and deployment as examined in this paper.
National HRM structures and policies
The Department of Health Manpower was established in 1983 in recognition of the
important role played by HRs in delivery of health services and the observation that
the HR function was underplayed (Directorate of Personnel, 1983; MOH, 2002). While the
structure delineated positions, roles and responsibilities, co-ordination and accountability
were observed to be poor undermining performance of the department. Although this
under performance could be attributed to inadequate HR capacity, the mythical nature of
formal organizational structures (Meyer and Rowan, 1983) should not be undermined in
creating the discrepancy between the structure and day to day activities of the
department ( Jackson and Schuler, 1995; Meyer and Rowan, 1983, 1991). Meyer and
Rowan (1991) argue that the different elements of the structure may be poorly linked to
each other and to activities (loosely coupled) consequently affecting the overall
functioning of the department.
Effective HRM requires its strategic placement within health structures
(Adano et al., 2008), accompanied by strong leadership for policy and coordination
(Awases et al., 2010). The presence of the Department of Health Manpower ensured
a strong representation of HR issues at the policy level during the 1980s and 1990s.
The dissolution of this department and the integration of the HRM function in the
Department of Corporate Services in 2002 reduced HR visibility in the MOH. There is
limited evidence to suggest that the decision to dissolve the department was driven by
rationality (Meyer and Rowan, 1991; Wright and McMahan, 1992) but rather a result of
what DiMaggio and Powell (1991) would term coercive isomorphism a form of pressure
that forces-related organizations to resemble each other. The creation of the
Departments of Corporate Services which incorporated HR units was a common
practice in the public sector that emerged during the NDPs 8 and 9 as many
government ministries were reviewed (MFDP, 1997, 2003). The MOH was, therefore,
under pressure to become similar to other government ministries (DiMaggio and
Powell, 1991; Jackson and Schuler, 1995; Scott, 2014) with limited consideration for the
efficiency this change may produce (DiMaggio and Powell, 1991). The dissolution of
this department gives further credence to Meyer and Rowan’s (1983, 1991) argument
that formal structures adopted by many organizations reflect the myths of their
institutional environments rather than the demands of their work activities.
In Botswana, HRM in the public health sector is regulated by national HR policies
and legislation from the DPSM which act as coercive pressures (Fadare, 2013; Meyer
and Rowan, 1983; Paauwe and Boselie, 2003) limiting the MOH’s ability to define
national HR priorities and strategies. In the absence of specific health-related HR
policies, the MOH could not adequately guide its stakeholders including the training
institutions. The situation in which HRM lies beyond the MOH is not unique to
Botswana. In many African countries, responsibility for HRM has been fragmented
across ministries or government departments, creating inefficiencies in HRM processes
(Adano et al., 2008).
Planning for HRs in health
The literature emphasizes the need to establish stronger links between HR plans and
overall health sector plans and policies (Martineau, 2008; WHO, 2002). This is critical in
ensuring timely availability of a skilled workforce to deliver health services to meet
health system goals. For example, effective HRM strategies were associated with
increased health service coverage and improved health outcomes in Brazil, Ghana,
Mexico and Thailand (Campbell et al., 2013). Despite efforts to plan for HRs in the
public health sector in Botswana, the planning process had limitations such as
inadequate consultation and weak stakeholder engagement, which contributed to lack
of ownership and inadequate implementation of the plans. Lack of vision or strategic
focus in the planning process undermined the alignment of HR plans with broader
health sector plans, as shown by the gap between the assessed need for personnel and
their ultimate availability for new projects. The lack of investment in an efficient and
effective information system for health HRs further compounds the challenge of HR
planning and monitoring (Adano et al., 2008; WHO, 2006).
Recruitment, attraction and retention
In countries with effective recruitment and retention strategies, positive patient and
employee outcomes were reported (Darwish et al., 2013). Inadequate recruitment
processes, however, were observed in this analysis, a feature that Botswana shares
with many African countries (Adano et al., 2008; WHO, 2006). Although the challenges
in filling vacant positions could be attributed to inefficient recruitment processes, in
fact the Botswana health system has found it difficult to respond to the external
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institutional environment, including the labour market and education and training
sector. Jackson and Schuler (1995) observed that when labour markets are tight,
organizations use more expansive and intensive recruiting methods. Outsourcing
recruitment activities to the private sector proved beneficial in some countries
(Adano et al., 2008), including Botswana, although this strategy could not be sustained.
While improving wages, benefits, and working conditions in order to attract and retain
employees are some of the responses to tight labour supply ( Jackson and Schuler,
1995), the Botswana MOH had limited flexibility in this area because salaries and
conditions of service were externally controlled by the DPSM.
WHO argues that strong HRM system and effective leadership are necessary to
manage the different kinds of retention strategies (WHO, 2006). These have not been
significantly present in Botswana, with retention strategies poorly implemented
through the MOH. Professional biases creating unfair differences in the implementation
of retention strategies were perceived, underscoring the relevance of informal
institutional pressures. Scott (2014) noted challenges in designing and implementing
HR policies or strategies in organizations employing groups of professionals whose
strongly embedded norms and values may limit management control. Paauwe and
Boselie (2003) observed that professional norms, values and expectations play an
important role when new HR policies and practices, such as new incentives are
introduced. The MOH might have been under pressure to meet the expectations of
certain professional groups creating perceptions of unfairness.
Personnel deployment
Botswana’s health sector suffers from lack of skilled personnel. Nevertheless, poor
deployment and underutilization of specialist staff were reported. Concerns were raised
over the assignment of medical specialists to administrative responsibilities despite
acute shortages in clinical areas. This practice is common in African countries
(Dovlo, 2005; WHO, 2006) and needs to be understood from an institutional theory
perspective where normative pressures from professional and societal norms and
values legitimizes the leadership role of medical specialist in health care organizations.
Paauwe and Boselie (2003) emphasized the need to consider the relevance of normative
mechanisms in organizations employing professionals where education, training and
professional bodies determine norms and values which may often be taken for granted.
Similarly, Scott (1983a) observed that some practices in health care organizations may
be the result of a social construction process that has come to attain mythical sense of
legitimacy. Using highly skilled health professionals in areas not requiring their
expertise creates inefficiencies and reduces productivity. This practice is a form of HR
wastage that denies the country the ability to realize the full potential of its workforce
(Dovlo, 2005) and optimize the benefits of earlier investment in HR development.
Implications
Implications for theory
This study used institutional theory to understand the HRM practices in the MOH in
Botswana. The study demonstrated the importance and applicability of institutional
theory in unravelling intricate challenges facing HRM in an emerging economy such as
Botswana. In line with existing literature, the institutional environment played a major
role in determining the HR practices in the public health sector in Botswana. The DPSM
which has overall responsibility for HRM in the public sector sets the rules. The MOH
has limited flexibility in the application these rules. Consequently, the structure and
functioning of the public health sector HRM system reflects pressures and demands of
the external environment.
Implications for practice
Health system managers and practitioners seeking to strengthen HRM systems need to
be cognizant of the many institutional pressures that influence HRM practices and their
potential impact on health systems outcomes. HRM practices and strategies such as
recruitment, retention and rewards are controlled at a national level which may
undermine performance of the HRM system. This paper also highlights the impact of
the labour market in emerging economies. Despite availability of positions and
financial provisions, the public health sector suffered from inadequate personnel.
Timely and effective planning for recruitment is needed to mitigate the impact of the
labour market on delivery of services. In addition, emerging economies should put more
efforts in developing HRs internally to meet their needs. Of significance also in this
paper is the role of the formal structure in influencing performance of the HR function.
While the need for strategic placement of the HR function is highly recommended, the
formal structure alone may not determine performance. The Department of Health
Manpower experienced performance challenges despite its strategic position.
Conclusion
Despite the problems facing HRM in Botswana, there was no indication in any of the
interviews that the health sector was subject to political manipulation. This is in
contrast with some other African countries where the manipulation of senior roles on
the basis of patronage may discourage a strategic approach to HRM (Lem, 2011).
This confirms that the formal institutional arrangements for HRM are relatively stable
and robust in Botswana and, despite current informal pressures and inefficiencies, can
form the basis for improvement (Rowe et al., 2005).
While the WHO framework HRM indicators provided the structure for
understanding the HRM system in Botswana, the use of institutional theory in the
analysis provided deeper insights into the contextual factors that shape HRM practices
in the public health sector. Considering the centrality of HRM to the workforce and
health system performance, health systems researchers need to undertake more
research in this area to inform HRM policy and decision making. In view of the role
played by institutional theory in this analysis, we argue for the integration of
appropriate theory with mechanistic frameworks often used in studying HR matters in
the health sector.
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