Improving Patient Care, One Employee at a Time

Recently, my fellow GHC cohorts in Malawi launched the #health2me photo campaign to promote global health and GHC in Malawi, and to encourage people to think beyond traditional understandings of health. As I considered what health meant to me – well-being, happiness, self-sufficiency, peace of mind, and so on – I settled on the idea of a “happy, productive workforce committed to making big changes in the world.” There are a number of reasons behind this. I work with four others in a tiny office in Zomba, as the Organizational Development Fellow at the Art & Global Health Center Africa (AGHC). One might ask, what can five people do to address the challenges Malawi faces? The answer: more than you think. At the heart of our productivity is an organizational structure that acknowledges the dedication and work put in by the staff. The pay-off we receive is both personal and tangible; while our personal values and interest in public service motivated our initial interest in the work, the benefits we receive – competitive salaries, health insurance, training opportunities, etc. – help keep us there.

In the past few years, healthcare has started to embrace patient-centered care, and rightfully so. To provide a guideline for improving the U.S. healthcare system, the Institute for Healthcare Improvement developed a framework with three equally important dimensions: improving patient care experience, improving population health, and reducing per capita costs (i.e. the Triple Aim). The same guidelines can be used to improve patient care in Malawi. I believe that at the core of developing a patient-centered culture in health organizations is an engaged workforce. Studies have shown that satisfied employees mean productive employees: “Staff that have their needs met can focus on the needs of the patient.” A qualitative study of healthcare organizations across the U.S. noted that two key factors in successfully making care more patient-centered include sustained focus on staff satisfaction and staff capacity building. Interestingly, there is a cyclical nature between employee satisfaction and patient-centered care. Nurses who perceived their work as more patient-centered reported higher levels of job satisfaction than those who viewed their work as less patient-centered.

Since beginning my fellowship, I’ve had interesting conversations about the Malawian work culture. I repeatedly hear that employees don’t personally invest in the outcome of their work – as if the lack of motivation is a problem only Malawi faces. On the contrary, I find that there are amazing individuals eager to use their skills and experiences to positively impact their communities, but there are few avenues to do so. As social goods, the health of the public and the work that goes into maintaining that health are often undervalued. As a result, these fields attract fewer applicants than their more “respected” counterparts. Rather than assume that these individuals are collectively lazy and unproductive – as poor work ethic can be found in all parts of the world – employers need to cultivate work environments that focus on the growth and development of their workers. While the passion is there, many professionals face seemingly endless challenges to fully investing in their work, because of either limited development opportunities or a general lack of interest in their well-being. The Students With Dreams (SWD) program at AGHC is a prime example of the positive impact investing in Malawi’s untapped drive can have. The program provides local college students with trainings and mentorship to implement social projects they themselves design. Investing in the students’ success directly influences their interest in achieving their desired outcomes. As one Dreamer notes, the “positive message that each project brings [touches] multitudes across the nation, and slowly the mindset of Malawians is changing. People are changing and wanting to do better for our country.” These students are the bright spots of Malawi’s emerging workforce.

Malawi faces many challenges to overcoming the workforce dilemma. Some examples:

1. A visiting doctor volunteering at the local hospital remarked that the nurses he worked with displayed little interest in their work. The burnout from being underpaid, under-appreciated, and overworked had significant negative consequences on the hospital. They neglected patient charts, overlooked medication schedules, and showed little regard for their patients. As a result, doctors lost hours searching for patient records, patients did not receive their regimented medication, and this routinely caused patient neglect and preventable deaths as the result of withholding vital meds and services.
2. Several months ago, medical students completing a global health rotation in rural Malawi were given tutorials on protocols for dealing with Ebola if it were to hit Malawi. None of the safety hazard equipment, suits or masks shown in the lesson were available at their facility. One student jokingly commented, “If Ebola does hit, I’m booking the first ticket out of here!”
3. Rural health facilities experience high rates of absenteeism. Workers sent to the field for meetings or trainings will often find that expert patients or HCT counselors haven’t shown up for work that day, despite having the meeting in their schedules. Because they’re not paid enough and overworked, they take their own time off. As a result of these self-assigned holidays, there aren’t enough HCT counselors available to handle the patient load and a significant number of patients aren’t tested.
4. Local physicians and nurses ask patients who aren’t required to pay for services for “informal payments” – i.e. bribes – to be seen that day because the compensation they receive is disproportional to their qualifications and workload. While this can be seen as corruption, when the occurrences are as prevalent as they are, the issue becomes less about morality and ethics and more indicative of a systemic issue.
5. Workers have no promotional opportunities. Within their current workplace, they have no opportunities to rise through the ranks, and there aren’t enough positions in Malawi that are a step up based on their current experiences.
6. Qualified professionals seek opportunities abroad, which provide better pay and benefits, resulting in significant brain drain. Visiting healthcare professionals acknowledge that their skills are very much needed – often times they are the only trained professionals in the facility – but that they couldn’t stay for long because the work “doesn’t pay enough.”
7. Individual workers who attempt to make changes to provide better care to their patients quickly become apathetic due to the overwhelming, widespread problems in their work environment. While employee buy-in is necessary for creating cultural shifts in the workplace, without effective leadership to guide and encourage the progress, a single employee will be unable to affect change.

So what can be done about these issues? Without a doubt, Malawian health facilities need greater funding to strengthen infrastructures and to ensure that vital resources are available to effectively diagnose and treat patients. In the meantime, alternative solutions to improving the outlook for workers – reducing the possibility of burnout, increasing employee buy-in, improving general satisfaction, reducing employee turnover – can emphasize non-monetary factors. Such factors include: the quality of supervision, support from coworkers, social supports, supporting and empowering work environments, clarity of job roles, recognition, and participative decision-making. Creating a supportive environment will likely involve a significant investment of time and resources by leaders. However, the resulting benefits the employees and organizations receive significantly outweigh the costs of increased administrative overhead, workplace disruption, and reduced productivity. Ultimately, happy employees lead to happier, safer and healthier patients.