In the past, extensive interest and research on health service delivery in PNG and elsewhere has been committed to understanding the provider side of health systems, including financing to make services accessible and available. As highlighted elsewhere in other sections of this thesis, there has been some attention on infrastructure, management arrangements and capacity of staff. While these are important to making health care delivery work better, certain aspects on the provider side have not been examined and analysed adequately. One of these is health service. Too often, this is emphasised and generalised without adequately identifying specifics, such as the type of health worker, section of the health facility and the specific services provided.
Peter Berman contended that when analysing provision of health services, two aspects on the supply side are crucial: the nature of health care services and the determinants of provider behaviour. He noted that there has been very little research on assessing the simple interactions between the provider and the user, where the health services are provided (1999:4-6). The HSB and health service utilisation studies have centred on the determinants influencing people’s use of services. Although human resources for health have been considered crucial (World Bank 2011), the focus has been on quality and quantity in service delivery. Although health worker–patient relationships have a direct impact on HSB, this aspect of health service usage and health outcomes are neglected areas of empirical studies. Exploring the determinants influencing the behaviour of health workers in the delivery of health services is as important as investigating the determinants influencing the HSB of health service users. As Phylis Noerager Stern pointed out, ‘health care is influenced by the beliefs of providers as well as consumers’ (1986a:123). Similarly, van den Broek and Graham saw the significance of understanding both sides and argued that ‘the use of services and maternal health outcomes are the result not only of the provision of care but also of women’s experience of that care …’ (2009:18). Health care comprises a diverse set of products, which may be produced in diverse settings by different individuals with different skills and educational levels. Services can
be a specific type or class of health care services, such as ambulatory illness treatment, or more narrowly focused on a specific intervention or procedure (Berman 1999:8).
A health care provider can be an individual or a recognised legal or administrative entity that organises and carries out the production of health care services. They can range from individual practitioners working out of their homes with minimal resources to large hospitals or facilities with many workers. The provider is normally referred to as the person treating the patient. However, an organisation is not the provider, as it merely provides a setting and the resources for workers to deliver services. Thus, there is a need to understand both the macro- and micro-structures of health care provision and look beyond the individual health worker or the organisation that is enabling the production of services. Distinguishing the levels of influence on the health care provider within the environment in which the services are delivered is useful for making improvements (Berman 1999:4, 6).
This study examined health care services provided at primary and secondary levels in urban and rural settings in PNG, including MCH. It adopted several frameworks for understanding the behaviour of health workers in the delivery of health services, both generally and in maternal health care specifically. These are shown in Figure 2.2. Berman’s framework was used for the internal and external environment of providers. A combination of Holmes and Goldstein’s conceptual framework for analysing the relationship between maternal health care providers (MHCPs) and patients was used (2012:12), as well as the conceptual framework for health worker motivation and demotivation by Thu et al. (2015:3).
Berman’s framework was adopted for understanding and analysing the determinants of provider behaviour within the macro-and micro-structures because the questions of ‘What are the underlying motivations driving the health care provider behaviour, and how are those related to different structures of provision?’ were closely aligned to the questions of this study. Berman’s framework describes the delivery of health services as being along a line, with the left side concerned with macro-structural issues and the right side concerned with micro-structural issues. The nation and market operating at the macro level account for higher level factors, such as policies, legislation, regulations and financing for the provision of health care. The size and composition of the provision of health care is at an aggregate level. The internal environment of the organisation and individual is described as the micro-structure of health care provision.
Holmes and Goldstein’s conceptual framework was developed specifically for analysing the attitudes and behaviours of MHCPs, owing to relatively low utilisation of health services and poor maternal health outcomes in developing countries such as SSA, Southern Asia, Southeast Asia, Latin America and the Middle East (2012:5,10).
The framework shows that the relationship between MHCPs and their patients affects the delivery of health care and maternal and newborn health outcomes. The quality of the interpersonal relationships affects other elements of quality of care and the satisfaction of MHCPs, influencing their self-esteem, motivation and confidence in their work. The factors influencing relationship between the MHCP and the patient exists on both sides. For instance, the factors influencing the attitudes and behaviours of the MHCPs may include their working conditions, workload, stress, lack of privacy, fear of infection, level of training and communication skills, norms in the workplace (including the influence of role models), personal characteristics (gender, culture, ethnicity and class) and personality attributes (self-confidence, caring, courtesy and charisma). The attitudes and behaviour of the patient may be influenced by their previous experiences with MHCPs, social, cultural or ethnic differences and personal characteristics (e.g., shyness, level of autonomy) and self- confidence.
A good relationship between a patient and health worker has been described as one in which there is mutual respect, openness and a balance in their respective roles (Govender & Penn-Kekana 2008). Negative attitudes from MHCPs, such as poor communication because of poor interpersonal relationship skills (Gilson et al. 1993), have the potential to dissuade a patient from seeking health care.
Thu and colleagues consider motivation as a key element affecting worker behaviour and performance. They describe motivation as a force energising the individual to make rational choices to take action. In the work context, motivation can be defined as ‘an individual’s degree of willingness to exert and maintain an effort towards attaining organisational goals’. Their framework was used to analyse health workers in rural districts of Vietnam who provide PHC services, including maternal health (see Figure 2.2). They argued that a health worker is motivated or demotivated by organisational and contextual factors. Organisational factors include the characteristics of the facility, working environment, training opportunities and working conditions. Contextual factors are characteristics of the population being served, including their perception of the service quality and their ethnicity. In the following figure, a distinction is made between intrinsic
and extrinsic motivation, with the former being based on the worker’s knowledge, skills, ability and individual values and the latter relating to organisational factors (2015:2-3).
Source: Thu et al. (2015:3)
Figure 2.2: Conceptual Framework for Health Worker Motivation and Demotivation
The frameworks that have been presented here have both similarities and differences. The factors in relation to motivating and demotivating health workers are similar. Gaining the respect of the community and good interpersonal relations are factors that motivate workers to perform better and thus, satisfy clients and encourage the use of health services. The factors demotivating workers include distrust by the users, lack of satisfaction at work, inability to provide good quality services, lack of supervision and heavy workload (Holmes & Goldstein 2012:12–14; Thu et al. 2015:3).