Study of Health Workers Occupational Challenges and Strategies for Empowering them in the Primary Health Care Systems in Iran
Introduction and Objectives: Health houses are one of the most important organs to provide health in society and also the first reference level and a patient facing with health personnel. So, their working forces, namely health workers, play an important role in conserving and promoting health of rural community and give service in the distant villages with the earliest facilities. Therefore health workers have confronted with challenges in their work that have to be identified and modified.
Methodology: This research is a qualitative study and of phenomenological type. Required data was gathered through semiconstructed interview with key experts, health workers and clients of health houses. Then to present strategies two specialized panels were implemented. Sampling method in this study was purposeful sampling. Then the concerned data was content analysed using Kelly’s method and findings were reported in the form of main and sub themes.
Findings: The most important job challenges of health workers are seven main themes including: quality of the presented services, financial dimension, and motivational dimension, quality of the presented services, human dimension, working relationships, and infrastructures. Training and retraining health workers, creating incentive to health workers, justice in promotion, equipment health houses, improvement of work relationships and matching work force with workload including were among the most important strategies suggested to empower health workers.
Conclusion: This study showed that over time many functions of health workers have confronted with problem. So, in order to increase their empowerment and efficiency, based on this study, providing a better public environment and culture among people in order to understand the status of health workers is recommended.
Health houses, Health worker, Challenge, Empowerment, Primary health cares
In today’s world, the ability, economic power and welfare of every country depend on its optimal utilization of resources, possibilities and human forces. Such that the more competent and efficient its work force, the country will be more developed in the economic and social area . So, in different organizations in order to empower work force, they present motivational measures and programs for training them . Among these organizations can refer to health and treatment centers and health houses that, providing more than 130 types of health activities, play an effective role in promoting the health level of community and health houses are the first reference level and the first place of patient facing with health personnel .
Forces working in the health houses, namely health workers, play an important role in conserving and promoting health of rural community. After over three decades from designing the health network system and given the change of burden and pattern of diseases and also change of needs and enhancement of rural community’s expectations, health workers have confronted with several challenges . Hence, the health and treatment environments and working circumstances of their staff is such that during the recent decades in order to enhance the work quality, protecting physical and mental health of their employees in order to more efficiency during the working years have been paid attention .
In the primary health care systems, the change of population construct and epidemiologic transition of diseases and also additional burden of infectious and incommunicable diseases, rising people literacy level, change of people opinions toward the quality of the provided services and transformation of the existing technologies has resulted in new challenges in the work situation of health workers and their serving way.
In a study it was shown that health worker class with a population of about 32000 people serve throughout the country and are trained by 1138 instructors in the primary health care section; that seems the system can be considered one of the largest service systems in the primary service care system of the country but yet they have serious difficulties in terms of salary payment and welfare possibilities and also in the education achievement and regarding the trainings being provided to them some health workers still haven’t reach to the level of awareness that diagnosis of the issue that service packages related to themselves what, where and when have to be made and don’t know the health services how are provided based on the defined services and also their priority . Nevertheless, crisis of human resources, insufficient skills and improper geographical distribution of health workers have created great challenges to achieve public health care [6,7].
Remaining health workers in the ranking of health working throughout the serving period and lack of job promotion and also necessity of staying in village throughout the serving period are two major problems for health working job . Also work stress is another major problem of health workers especially female health workers that this stress among women is more than men because they have responsibility of their family and children as well as their job tasks . So, physical fatigue and mental pressures have negative impact on the quality of providing services by health workers and, in turn, this result in decline of serving performance of health houses to rural people [8,9].
The main challenge that health systems providing services are confronted is reduction of human resources that the World Health Organization has announced the shortage of health workers across the world as 4.3 million; the shortage of health workers creates important challenges to achieve the development objectives of the century and meeting public health needs of societies and one way on which countries has to rely to access necessary health services has is employing local employees and using volunteer forces .
It can be stated that health work is one of the sensitive and stressful and yet important jobs of the society that studying their physical and mental health condition is especially important and attention to their problems will create motivate them . So, if the work issues confronted with health workers are identified and in the following proper strategies are provided to remove these problems, through investing on this class can utilize the most of the capacity of this great force. Hence, this study was conducted with the aim of study of work challenges of health workers and providing strategies to empower them in the health care system of Iran.
Materials and Methods
This study is a qualitative research on the area of health system studies and of phenomenological type that was conducted throughout the country. Statistical population includes policy makers and experts of the Ministry of Health and Medical Education and experts involved in the primary health care system in the country level and heads of medicine universities, health authorities and assistants in the provinces level and physicians, health worker instructors and clients of the health houses in the towns level. For sampling the purposeful method was used and in the following to achieve other informed people the snowball sampling method was used. Sampling was continued to achieve the gathered data saturation in interviews. To ensure the validity and reliability of the questions, the questions were first given to several experts and were approved by the experts, then used in the interview. Sampling criterion was having key information in the area of primary health care and particularly health houses and at least 5 years of administrative experience and activity in the health area. Qualitative data was gathered through interviews and holding panels with presence health authorities and assistants in the provinces level and physicians also Interviews were in semi-constructed and deep form that the number of interviewees was 24 of which 19 were men and 5 were women. The age mean of them was 45 years old and the average of their administrative experience was 20 years old. Each interview lasted about 35 minutes and the average of the interviewed health workers experience also is 15 years old and also a voice recorder was used to record and take note of the interviews. To analyze qualitative data (interviews) the clay’s content analysis method was used that is mostly for analysis of qualitative data of phenomenological studies. This method include seven steps of getting familiar with general concept, extracting important statements and determining main areas (themes) (Table 1), formulating concepts and main statements, layout and categorizing main concepts, interpretation and explaining themes, extracting main framework and validation of the study. All these steps was conducted by the authors manually and without using a specific software, also all ethical criteria such as the informed consent of the participants in the research, the confidentiality of information and the neutrality of the researchers in all stages of the study from collection to data analysis in this study were observed.
|Main themes||Sub themes||Challenges||Suggested strategies for empowerment|
|Quantity of providing services||1. Match of services volume with the number of health workers||1. Mismatch of services volume with the number of health workers||1. Using volunteer health forces to reduce the workload of health worker|
|2. Match of plans assigned to the system with work time of health workers||2. Mismatch of plans assigned to the system with work time of health workers||2. Eliminating useless services that aren’t in priority and reducing the national plans injected to the health houses|
|Financial dimension||1. Match of salary and income with workload of health workers||1. Mismatch of salary and income with workload of health workers||1. Increase of salary and also considering overtime and commission and per-case according the work hardship|
|2. Existing petty cash in the health houses||2. Not existing petty cash in the health houses||2. Allocating budget to health houses in order to do the works that can be made by themselves and need no corresponding and consuming time and money.|
|Motivational dimension||1. Being health workers multipurpose and encouragement||1. Not encouraging multipurpose health workers in the health houses||1. Providing possibilities for financial incentives for employees who work multi-purposefully|
|2. Considering university degrees||2. Not considering university degrees and job motivation||2. Providing a base to continue education in the related fields and considering their university degree and promoting them in the system|
|3. Welfare facilities||3. Lack of tourism-pilgrim facilities for health workers and lack of welfare facilities for their children in the village||3. Creating spaces in the village such as green space and access to sport facilities for their children and providing fun-pilgrim trips at the system cost to make diversity and change morale of health workers|
|Quality of the provided services||1. Match of services quality with the health worker’s education level||1. Mismatch of services quality with the health worker’s education level||1. Holding training classes to promote the health workers’ skills|
|2. Match of services quality with the health clients’ expectations level||2. Mismatch of services quality with the health clients’ expectations level||2. Enhancing the people awareness regarding getting familiar with the health workers’ task description and continuous monitoring on the middle rating and instructors of health houses|
|Human dimension||1. Status of health worker in society||1. Decline of acceptance and status of health worker in society||1. Enhancing people incrust in health worker and introducing their tasks|
|2. Performance||2. Increase of health workers age and reduction of their performance||2. Training and employing young and interested forces|
|3. Justice in job||3. Lack of justice in job promotion and acquiring particular advantages in the exemplary health worker of the country||3. Providing a base promotion and giving incentive and encouraging based on their performance during the service years|
|4. Immigration||4. Immigration from village to city||4. Providing the policy of population concentration|
|Infrastructures and facilities||1. Staying health worker in village||1. Lack of appropriate place and physical space in the health houses for health workers stay and work||1. Considering a completely separated place from health houses in the village for living of health worker|
|2. Technology and internet||2. Lack of access to internet and remote training||2. Setting up telecommunication networks for internet in the disadvantaged villages|
|3. Equipment of health house||3. Old and worn out equipment and lack of essential medicines, lack of vehicle for health worker to follow up and not paying fuel cost||3. Using health working council to communicate health workers problems to authorities and considering a budget for repairs and fuel of vehicles|
|Work relationships||1. Reference system||1. Weakness in the reference system and increase of reworking and increase of workload and wasting health worker time||1. Review of reference system and training personnel in the all three reference levels and holding retraining sessions for coordination|
|2. Weakness of planning and control in upstream||2. Lack of managed planning and required follow-up to solve the problems of health workers through upstream||2. Codified planning in order to hold sessions to solve problems of health workers by authorities or in-person refereeing to authorities to solve the problems of workplace of health workers|
|3. Inside and outside relationships of health workers||3. Weakness in relationships with village governors and not holding sessions by health workers with charitable people and officials of their region to solve the health problems of the village and inattention of authorities in the inter-sectional sessions||3. Introducing health workers as a full representative to departments by authorities and creating sensitivity and awareness in the authorities of other organs to cooperate with health section by top authorities|
Table 1: Themes, challenges and solutions
Quantity of providing services
Considering the growth of the population covered by each health house and lack of employing health workers according the population and injecting new unplanned programs that many of them aren’t necessary has resulted in increase of health workers work load that the main theme includes two sub themes:
1. Services volume has to be proportional to the number of health workers.
2. Plans and programs assigned to the system have to be proportional to the work time of health workers.
3. A number of interviewees stated:
“Quantitatively, the numbers of services that are provided in the health houses have increased but accordingly sufficient human resources hasn’t been defined” or another one said “in terms of human resources we have problem and forces that leave the system, in view of premature retirements and age retirements that certainly have to be substituted” (M3).
Considering that Health Ministry increasingly adds to its programs and plans in the health houses, accordingly it has to raise salary of health workers and also consider a budget for health houses as petty cash is needed to purchase means of health houses, health workers don’t waste their time for time consuming correspondence.
This main theme also includes two sub themes:
1. Proportionality of salary and income with workload.
2. Availability of petty cash in the health houses.
Interviewees said in this regard:
“Services are very different from the past, for example, less cares were provided in the past and also plans such as screening, mental health, follow-ups have been added but our salary hasn’t been raised proportional to the increase of workload” (M13).
Another one said “an amount has to be considered monthly for health houses until health worker him/ herself solve small problems. For example, if the light of the health house burns out; she/he wouldn’t wait the town health center and correspond with them until they come and change it” (M11).
Motivation is the driving engine of work power and health workers also are a hard-working class and considering that they work in remote villages without welfare facilities, so they need encouragement from top authorities. It can be stated that motivation has to be both financial and mental-spiritual; so top authorities have given priority to motivating employees. This theme includes three themes:
1. Multipurpose being of health workers and encouragement.
2. Considering university degree.
3. Welfare facilities.
“We have to be a wrench because we do environmental health work, family health, prevention, midwifery and injections or when other health houses haven’t force we have to go there as assistance force” said one interviewee or another one said: “neither the degree of health workers are considered nor their position is promoted. They remain in their place. This is a problem that results in dis-motivation and health worker’s morale is broken” (M5).
Quality of providing services
New plans of government in the health area and applied programs injected to the health system that enhance level of expectations regarding receiving high-quality services. This main theme also includes two sub themes:
1. Mismatching the quality of services with health worker’s education.
2. Mismatching the quality of services with expectation level of clients.
Some of interviewees said in this regard:
“The level of villages’ education has increased and they argue that health worker can’t answer to our health questions and people pay less attention to instructions” (M12).
“Health workers have to enhance education level and up to dated regarding the information about health houses”.
Considering the low budget of Health Ministry and reduction of employment of health working forces, we observe decline of the quality of services provided to people. Also rising the rural people literacy has resulted in difference of their literacy level with health worker’s that this issue has declined the status and acceptance of health worker in the rural community. This main theme also includes four sub themes:
1. Weak performance in view of ageing health working forces.
3. Injustice in the working.
4. Reduction of acceptance level and decline of health worker status in the society.
Some of the interviewees said in this regard:
“These health workers have committed to work for 30 years in that health house. So their children remain in the villages and health worker is compelled to remain in the village”, or another one said “our health workers became older. Their children have grown up and they have their problems and their performance has been weakened” (M22).
Infrastructure and facilities
In the issue of infrastructures despite that health houses are the first step of contact with people, unfortunately due attention hasn’t been paid and health houses of the country don’t have enough facilities and this has resulted in health worker can’t provide full and high-quality services to people. This main theme also includes three sub themes:
1. Technology and internet.
2. Residency and staying health worker.
3. Facilitates of health house.
For example, interviewees stated:
“Measuring devices hasn’t necessary quality and if we use them they will be destroyed even in shorter time”.
“In terms of technology our problem now is internet absence” (M20).
Cooperation inside and outside section as one of the principles of primary health care is very important in the success of health houses and health workers through attending in the provincial and village sessions can communicate the health problems of the village to authorities. This theme also includes three sub themes:
1. Poor planning and handling from upstream.
2. Weakness in the reference system.
3. Weak inter-sectional relationships.
For example, some interviewees argued that: “we go from a faraway place where authorities aren’t there or don’t have time for health worker’s issue and the affairs of health house also is delayed” (M17).
Another interviewee said: “outside section relationships is very weak. For example, we have some health houses that don’t form session with their council and village governor don’t cooperate with them” (M14) (Table 1).
One of the limitations of the study was the lack of access to some of the Experts due to the large extent of study in Iran.
Results of this study indicate the challenges and major problems of health workers in different dimensions. Major challenges are related to the quantity of the provided services; quality of the services provided to people, challenge related to human resources, challenges related to equipment, technology and financial resources, challenges related to work relations and finally motivational challenges that have the highest priority among the health workers challenges.
Quantity of services
According the findings obtained from interview with experts the mismatch of workload with the number of health workers and also new unplanned programs from Ministry to the health systems particularly health houses that are in the first level and operational line have been injected that resulted in exhaustion and also decline of health working quality. In the other hand, noncooperation of people in the follow-ups by health workers has doubled the follow-ups and workload. In a study performed by Saberi et al.  on “identifying challenges of health hoses of Iran and providing corrective strategies” it was shown that due to the large number of the population covered in some villages and shortage of health workers and even in some health houses that because of lack of employee they work as a single health worker, a lot of services have to be made by the health worker that certainly the most of them are left half-finished or some of clients receive incomplete service and some group don’t receive any service”.
Considering that health programs and plans increasingly are added to the system from Ministry and health workers job has been doubled, unfortunately the rate of salary increase has been zero or a minimally risen that has no proportionality with the workload of health workers and also the new country level plans that are applied on the system that their all burden is on the health worker and no payment is considered. In this regard, AliMehr et al.  performed a study on “the rate of clients’ satisfaction with health houses of Dezfool Medicine Sciences University” that showed that high quality services result in satisfaction of clients and considering financial payments in addition to salary to health workers including per-case and overtime and other financial assistances enhance morale and working power of health workers to provide high-quality services to clients .
Motivation is the driving engine of employees. So health workers considering that are serving in the remote villages and away from primary facilities in some places without water and electricity, they need special advantages to provide their services in the adverse conditions with a high quality and authorities considering financial and psychological arrangements help to these hardworking and sympathetic group and remove some of their problems. In a research by Daneshkohan et al.  on “effective factors on the job incentive among health workers: case study of Iran” it was found that reinforcing management capacities in the health services can increase and improve job motivation. Also the main motivational factors for health workers are: good management, support of supervisors and managers and in the other hand, weak management and lack of acknowledgment was the main destructive factor. In addition, 47.2 percent of health workers believed that the existing plans weren’t helpful for supervising on their performance improvement.
Quality of services
According to the findings from interview with experts’ issues such as promotion of literacy level and expectations of community has resulted in clients’ dissatisfaction with the quality of services provided in the health houses. As the reference load was high and the number of health workers also hasn’t been defined according the population, so high quality services can’t be expected from health workers and also with rising the level of literacy and education of rural people the expectations from health workers service provision has been enhanced that it can be argued that currently the quality of the provided services in some cases wouldn’t satisfy the expectations of clients. Nabilou et al.  in a study on “quality of family health in the health stations of the selected cities of West Azarbaijan province from reality through expectations of the service receivers” showed that the quality of the provided services is the first step in improving quality and creating value in the health system and identifying expectations of the services receivers is the first step to improve the services and a high performance. So through identification of the gap between high quality and poor quality services it can be removed to attract clients’ satisfaction.
Considering the low budget of Health Ministry and reduction of employing health workers we are witnessing decline of the services quality. In the issue of human resources one of the challenges mentioned by experts of this area is immigration. Currently, due to reasons such as lack of enough attractions in villages and poor welfare facilities in villages and also people desire to urbanization, the population of the most of villages migrates to cities. Hence authorities have to consider some measures to health workers remain in villages. Among the other problem of this section can refer to lack of justice in giving privileges for job promotion until hard working health workers have more incentive to improve indices.
In a study, Heidari et al. on “evaluation of human resources and physical situation of health houses and health and treatment centers in order to provide emergency services, a case study of Golestan province” found that in view of the poor level of human resources of health houses it is required that appropriate measures are made in order to improve the existing situation and an appropriate place are considered for stay of health workers to prevent immigration. For the end, Medicine Ministry has to plan for proper distribution of human force, solving employment problems, maintaining employees, encouraging charitable people and introducing the position of the hardworking class of health workers to society and allocating appropriate budget to health and treatment networks in order to employ human forces and supply necessary equipment .
Infrastructures and facilities
In the every organization the availability of accurate and latest possibilities and equipment play an important role to reach objectives of the organization and considering that health worker operate in the remote villages the availability of high quality equipment play an important role in providing high quality services. Also in the case of breakdown of the devices, access to health centers for repair or replacement is difficult because of distance. Another issue is internet for health houses because health workers require access to internet for training people and being up to date and also they need internet for their recordings in view of the networking of affairs that some health houses lack this possibility. So regarding infrastructures and facilities, major problems are in three areas of equipment, technology and physical space for health workers stating that according to the results of the interviews, investment on the health section is insufficient and this area hasn’t been paid attention so requires a particular attention and management.
In a study that Damari conducted on “challenges and strategies for development of the health area of the country, from viewpoints of assistants of medicine universities and heads of health centers of provinces” indicated that health area in terms of infrastructures requires an essential review and integration and the health budget is spent in a place that needs reconstruction also its facilities and equipment are worn out that require replacement . Also human forces of the health area confront with shortage that has a general review has to be made in the health section.
According the opinions of experts, unwillingness of health worker to hold session with village governor and council, weak reference system, lack of psychological support and enough support of top authorities and lack of sufficient feedback to health worker and also lack of timely cooperation of the related authorities and other organs with health worker and weakness in follow-up and performing the mentioned cases timely are among the most important challenges and problems related to the work relationship area. So authorities through retraining and holding sessions during year for health workers encourage them for more collaboration and communication with the organs associated with the health houses and also the authorities have to attend in the council sessions and introduce health worker as their representative to enhance the health worker’s status and strength it among the village people.
In a study by Malekafzali on “the primary health cares in the Islamic Republic of Iran” showed that inter-sectional health cooperation is performed in personal taste and in some of regions but lack a defined and sustainable structure and institution . Also more attempts have to be made for participation of people in the final decisions related to their region health and the relationship of the associated organs in the health sections become more purposeful.
Considering that health houses are the first step of providing services and the first contact of clients with health personnel, so play an important role in the clients’ view and satisfaction. Beside that health workers work in the remote villages and in some cases without water and electricity issues such as increase of programs and plans that just result in an additional burden on the health worker, severe shortage of human force to the extent that some health workers work simultaneously in three health house, prevalence of new diseases such as AIDS, demographic transition and the issue of ageing population, lack of justice in the job ranking and particular advantages for active and exemplary health workers, change of living pattern of societies and issues such as immigration and urbanization and also promotion of literacy level, awareness and expectations of societies, have faced health workers over time with challenges that make necessary need to improvement. Therefore, it is expected from authorities that consider special advantages in order to enhance their motivation and consider plans to celebrate exemplary health workers through which encourage other health workers to higher effectiveness and providing high quality services and also through holding retraining classes and managed plans, we witness enhancement of this great and effective class’s literacy level in the health section.
Conflict of Interest
The authors declare that there is no conflict of interest regarding the publication of this article.
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2Shoushtar Faculty of Medical Sciences, Department of Public Health, Shoushtar University of Medical Sciences, Shoushtar, Iran
3Health Services Management, Alborz University of Medical Sciences, Karaj, Iran
4Governmental Management, Dezful University of Medical Sciences, Dezful, Iran
5Faculty of Medicine, Department of Community Medicine, Ahvaz, Iran
6Health Services Management, Ahvaz, Iran
7Health Services Management, School of Health Management and Information Sciences, Tehran, Iran
Citation: Mostafa Alimehr, Ahmad Moradi, Ali Kord, Mehdi Zainivand, Mahin Salimi, Mohsen Jalili Tahmasebi, Hadi Kalantari, Study of health workers occupational challenges and strategies for empowering them in the primary health care systems in Iran, J Res Med Dent Sci, 2019, 7(2): 145-151.
Received: 13-Mar-2019 Accepted: 02-Apr-2019