Supervision methods and obstetric care worker motivation: Multilevel analysis of the HSSE study in Malawi, Tanzania, and Mozambique Michael Daly & Eilish McAuliffe Centre for Global Health, Trinity College Dublin & the HSSE Team Maynooth, November 30th 2010

Background to study High levels of maternal and infant mortality in sub-Saharan Africa - proportion of global maternal deaths in sub-Saharan Africa increased from 23% (18–27) in 1980 to 52% (45–59) in 2008 Lack of human resources for healthcare plays a key role - Malawi vacancy rates - 77% for specialist doctors, 45% for medical officers, 80% for nursing officers, 44% for nursing sisters. Evidence for clinical efficacy, economic value of mid-level cadres - Fenton et al. (2003), N = 7622 caesarean sections - Clinical officers vs Qualified doctors in Malawi - emergency caesarean section maternal death rate and perinatal deaths - non sig difference 2

Mid-level providers: an essential human resource Hongoro & Price (2004): Main conclusions: -The “… expansion of the numbers and roles of auxiliaries whose qualifications are not internationally recognised seems to be a quiet success story, providing large numbers of health workers who keep the system running in a number of countries. Much more needs to be documented about the parts played by these workers and their safety in different areas.” -“…the human resource management function needs to be substantially upgraded in the public sector as a whole, and specifically the health sector.” 3

The supervision issue: qualitative study Bradley, S., & McAuliffe, E. (2009). Mid-level providers in emergency obstetric and newborn health care: factors affecting their performance and retention within the Malawian health system. Human Resources for Health, 7, “Most staff members reported receiving support from senior colleagues when necessary, but supervision was reported to be extremely limited and almost exclusively negative or corrective in nature. A Matron suggested that this is due to staff shortages, as high nurse-patient ratios lead to mistakes, while there is lack of officer-grade staff with adequate training to carry out the supervisory role. This has a major impact on staff appraisal, with the majority of staff members reporting the absence of any such mechanisms in their institution.” 4

Study sample 5 VariableMalawi (N = 577) M (SD) Tanzania (N = 594) M (SD) Mozambique (N = 441) M (SD) Age Female 33.8 (10.5) 64.8% (9.37) 75.6% (7.83) 79.7%

Breakdown of sample by cadre 6 * Includes those who classified themselves as ‘Agent Medicine’, ‘Medical Technician’, & ‘Surgical Technician’ CadreMalawiTanzaniaMozambique Enrolled nurses Registered nurses Medical attendants / Medical assistants* & Clinical officers Doctors Nurses Midwives Other Missing 357 (61.9%) 52 (9%) 151 (26.2%) Medical assistants* & 10 (1.7% 7 (1.2%) 210 (35.4%) 136 (22.9%) 236 (39.7%) Medical assistants* & 7 (1.2%) 5 (0.8%) - 79 (17.9%) Medical assistants* & (62.6%) 66 (15%) 15 (3.4%) 5 (1%) Total sample

Supervision methods Which of the following methods of supervision are in place in your facility? Please tick the one that applies:  Formal supervision process with regular pre- arranged supervision meetings.  Supervision is available if I request it from my line manager.  Supervision consists of negative feedback when performance is poor.  I never receive any supervision or feedback on my performance.  Other (please explain ______________________________________ __________ 7

Supervision methods: Descriptives for Malawi 8

Supervision methods: Descriptives for Tanzania 9

Supervision methods: Descriptives for Mozambique 10

Job satisfaction With regard to your job, please indicate the extent to which you agree or disagree with the following statements (1 – 5 scale) (Dmour & Awamleh, 2002) In general, I am satisfied with this job I find that my opinions are respected at work. Most people in this job are very satisfied with it I am satisfied with the recognition I get for the work that I do. I am satisfied with the way my pay compares with that for similar jobs in other I am satisfied with the personal relationship between my manager and his/her staff I am satisfied with the way my manager handles staff 11

Intention to leave With regard to your job, please indicate the extent to which you agree or disagree with the following statements (1 – 5 scale) (Dmour & Awamleh, 2002) I would consider working for another hospital/clinic I have seriously thought about leaving this hospital/clinic I am actively seeking other employment 3 questions so min = 3, max = 15 12

Supervision methods and adequacy of supervision 13

Hierarchical nested nature of the data DistrictFacility Healthcare worker Facility Healthcare worker 14

Supervision methods and outcome variables 15 Supervision methods by country Job SatisfactionIntentions to Leave Malawi a On request Negative only No supervision Other Tanzania a On request Negative only No supervision Other Mozambique a On request Negative only No supervision Other b (SE) t (df) -.49 (.62) -.78 (489.5) -.98 (.41) -2.38* (492) -.85 (.37) -2.3* (494).32 (.78).42 (494) -.79 (.75) (488.3) -.88 (.41) -2.13* (501) (.42) -4.01** (499.6) (1.61) -.9 (481.1) -.51 (.81) -.62 b (386) -.75 (.46) b (386) -.53 (.57) -.93 b (386) -.1 (.77) -.13 b (386) b (SE) t (df) (.18) -.41 (499.4).28 (.12) 2.43* (500.8).36 (.1) 3.45** (500.7) -.03 (.21) -.15 (407.5).01 (.18).08 (449.9).17 (.1) 1.69† (467.5).27 (.1) 2.65** (468.1).41 (.37) 1.09 (443.8).73 (.57) 1.3 (370.5).91 (.33) 2.77** (378.1) 1.15 (.42) 2.77** (374) -.27 (.54) -.51 (379.6) a Base category for comparison in analyses is ‘Formal supervision’, b Model failed to converge

Supervision method and intention to leave in three countries 16 Malawi

17 Tanzania Supervision method and intention to leave in three countries

18 Mozambique Supervision method and intention to leave in three countries

Results: Formal supervision vs. other methods 19

Proposed mediation 20

Mediation results: Supervision and job satisfaction 21 Malawi Tanzania Mozambique Sobel test for mediation significant in all countries: Malawi (Z = 4.38, p <.01), Tanzania (Z = 7.32, p <.01), Mozambique (Z = 3.33, p <.01) Note. Sobel test: Where a = regression coefficient of the relationship between the independent variable and the mediator, s a is the standard error of a. And where b = the regression coefficient of the link between the mediator and the dependent variable adjusting for the independent variable, and s b is the standard error of b. The formula for the calculation of a given Z-value = a*b/√ (b 2 *s a 2 + a 2 *s b 2 )) (Preacher & Leonardelli, 2003).

Mediation results: Supervision and job satisfaction 22 Malawi Tanzania Mozambique Sobel test for mediation significant in all countries: Malawi (Z = 4.38, p <.01), Tanzania (Z = 7.32, p <.01), Mozambique (Z = 3.33, p <.01) Note. Sobel test: Where a = regression coefficient of the relationship between the independent variable and the mediator, s a is the standard error of a. And where b = the regression coefficient of the link between the mediator and the dependent variable adjusting for the independent variable, and s b is the standard error of b. The formula for the calculation of a given Z-value = a*b/√ (b 2 *s a 2 + a 2 *s b 2 )) (Preacher & Leonardelli, 2003).

Mediation results: Supervision and intention to leave 23 Malawi Tanzania Mozambique Sobel test for mediation significant in all countries: Malawi (Z = 5.7, p <.01), Tanzania (Z = 4.55, p <.01), Mozambique (Z = 2.79, p <.01) Note. Sobel test: Where a = regression coefficient of the relationship between the independent variable and the mediator, s a is the standard error of a. And where b = the regression coefficient of the link between the mediator and the dependent variable adjusting for the independent variable, and s b is the standard error of b. The formula for the calculation of a given Z-value = a*b/√ (b 2 *s a 2 + a 2 *s b 2 )) (Preacher & Leonardelli, 2003).

Mediation results: Supervision and intention to leave 24 Malawi Tanzania Mozambique Sobel test for mediation significant in all countries: Malawi (Z = 5.7, p <.01), Tanzania (Z = 4.55, p <.01), Mozambique (Z = 2.79, p <.01) Note. Sobel test: Where a = regression coefficient of the relationship between the independent variable and the mediator, s a is the standard error of a. And where b = the regression coefficient of the link between the mediator and the dependent variable adjusting for the independent variable, and s b is the standard error of b. The formula for the calculation of a given Z-value = a*b/√ (b 2 *s a 2 + a 2 *s b 2 )) (Preacher & Leonardelli, 2003).

Conclusions This large-scale three country study showed that when healthcare workers are not supported their motivation suffers A lack of supervision, or a supervision system characterized solely by negative feedback, was closely linked to intentions to leave and low job satisfaction Strengthening the human resources for health in African healthcare services requires an enhancement of the systems in place for planning, developing and supporting the workforce We interpret the evidence from this study as strongly supporting the need for systematic training programs to develop more supportive human resources policies and improve the human resource management function in Malawi, Tanzania, and Mozambique 25