Implementing private-public hospital models in South Africa for improved health outcomes

Despite high health expenditure and a myriad of health policies in South Africa (which is regarded as a middle-income country in terms of its economy), our health outcomes are worse than those in many lower income countries.

This seems to suggest that improved health outcomes are less to do with funding and policies and more to do with the inefficient and ineffective use of available resources and an inadequate focus on staffing issues and job descriptions by the South African health system.

The adverse health outcomes currently facing South Africa are even more pronounced in a rural province such as the Eastern Cape Province. Consequently, the Eastern Cape Department of Health (ECDOH), some five years ago, turned to Private Public Partnerships (PPP) with the hope of mitigating some of the challenges beleaguering the health system in the province.

The impact of implementing PPP models

This study evaluated the impact of the implementation of one of the PPP models at an Eastern Cape Hospital (referred to as ‘Bright Hospital’ for the purposes of this study) on key employee job outcomes.

Prior to the implementation of the PPP model, the hospital was a 219 bed, 100% government owned hospital. In line with the definition of a PPP, the private partner refurbished some existing structures and built numerous new structures including, but not limited to, Accident and Emergency (A&E), radiology and theatre units (referred to as “shared service areas”). While changes occurred in many areas of the hospital as a result of the implementation of the PPP, the greatest changes occurred at these three shared service areas – in the design and management of the jobs, as well as the environment in which the jobs are performed.

In the process of implementing the PPP, the existing public sector employees were retained, additional staff were employed by the private sector entity and new roles were created, while existing jobs were redesigned at all three of the shared service areas.

Additionally, the private partner is responsible for the management of the staff and operations in all three shared service areas. In the case of the radiology department, the private partner further outsourced its management and operations to a private radiology practice.

The motivation to perform their jobs well

Theoretical guidance for the study was provided by the Job Characteristics Theory (JCT) of Oldham and Hackman (1975), which predicts that changes in five core characteristics of a job will affect critical psychological states of employees, which will, in turn, impact on employee job outcomes and their motivation to perform their jobs well.

The five core characteristics (Oldham and Hackman, 2010: 464) are:

• Task identity (the extent to which the job involves completing a task from start to finish);
• Skills variety (the extent to which the performance of the job requires different skills and talents from the employee);
• Task significance (the extent to which the job has substantial impact on the lives of others, both within and beyond the organisation);
• Autonomy (the degree of exercisable independence and freedom that employees have in determining the work schedules and procedures for performing the job); and
• Job based feedback (the extent of feedback to the employee about his/her effectiveness in performing the job).
These five job characteristics impact on the psychological states of experienced meaningfulness, experienced responsibility and knowledge of results.
Experienced meaningfulness refers to the perception of the employee that the work is important, worth performing and of value.

Experienced responsibility pertains to the employee feeling that s/he is personally responsible and accountable for the outcome of the work performed.

Knowledge of results refers to the regular feedback from the employer on how effectively the employee is performing the job.

The three psychological states in turn affect employee job satisfaction, intention to stay or leave and internal job motivation.

Summary of some of the key findings of the study

Poor change management at the initial stages of the implementation of the PPP evoked unnecessary anxiety and apprehension in the staff members. This led to a perception of a “breach of their psychological contract” with their employer the Eastern Cape Department of Health.

The perception of a breach in psychological contract results in a negative impact on employees’ attitudes, wellbeing and organisational commitment. This, and a sense of inequity are unintended consequence of poor management of the change that followed the PPP implementation and that continue to remain a challenge.

Key findings:

• The changes in the nature and management of the job affect the JCT core job characteristics to various extents at this hospital. Task significance (and skills variety to a slightly lesser degree) was more affected by changes in the nature of the job, while job-based feedback and autonomy was very sensitive to changes in job management.
• Skills variety appears to be the single JCT core job characteristic of greatest importance to the health care workers studied.
• Importantly, the findings of the study could not support the predictions of the JCT w.r.t the relationship of job characteristics to the (JCT) psychological states. For instance, among the health care workers studied, experienced meaningfulness was not affected by changes in skills variety, task significance and identity as predicted by the JCT, but was casino online rather reported to be immune to job characteristics changes. On the contrary, skills variety and task identity (and even contextual factors) affect experienced responsibility.
• Contextual factors (such as staff shortages, quality of supervision, adequacy of equipment and work physical environment, availability of senior clinical support/opinion) were more important than currently recognised by the JCT, Herzberg’s two-factor theory and other extant job enrichment theories.
• Unmitigated job enlargement (i.e. a mere increase in the quantity and scale [not scope] of same job tasks) occurred more at a particular shared service area (the accident and emergency unit) and incidentally, this area has, comparatively, incurred the worst employee job outcome (greatest staff turnover, lower satisfaction and motivation levels).
• A lot of positive changes have also been brought to life by virtue of the PPP. More important ones include the opportunity to work with specialists, the significantly improved work physical environment; availability of state of the art equipment; the acquisition of non-clinical skills such as computer literacy/administrative skills/ customer care skills; better maintenance services.

Employee feedback

Employees working at the newly built PPP Accident & Emergency (A&E) and Theatre units voiced frustration at the increased clerical duties and seeming lack of access to their bona fide employing organisation, the Eastern Cape Department of Health.

Two nurses from the A&E unit explained that that the PPP brought about a massive decrease in the domain of task identity with respect to their job as emergency room nurses.

One of the nurses said: “With the PPP, we can no longer dispense drugs. Even if you suture a little wound, you have to wait for a doctor to discharge. You cannot do even the little things you have been trained to do…we have been trained to do these things”.

The A&E unit has had the highest staff turnover rate post-PPP.

Positive about the changes

Employees interviewed described some positive changes.

Nurses in the theatre unit explained that with the PPP implementation, tasks are now broken down into smaller more manageable chunks between the three nurses on duty with a resultant increase in their individual ability to own and complete tasks from start to finish. One of the nurses said: “Previously, when we used to be only two on duty, I had to run all around… and be all over the place but now, I can focus on the job I had to do and finish it”.

The sole DoH radiographer in the third shared services area, the new Radiology unit, was positive about the changes brought about by the PPP.

The private partner built a completely new radiography unit. In addition to the installation of modern, computerised digital X-ray machines, there was a reportedly significant improvement in the overall office environment, with the inclusion of such amenities as a kitchenette within the Radiology unit.

Acquired computer literacy skills

The DoH radiographer interviewed said the skill variety of her job was enhanced, including acquiring computer literacy skills to operate the new facility, which she found stimulating and a great personal achievement, as she “did not even know how to use a computer mouse before the PPP was implemented”.

She also commented on the unit’s greater use of “softer skills like communication skills and patience” post-PPP. This was because there has been an upsurge in the number of private patients accessing radiography services through the unit post-PPP and these private patients were described as “being more demanding of attention”.

Interestingly, the radiographer was emphatic that the PPP implementation had brought about significantly increased autonomy in her job. She found it easier to relate to her new manager who had insight into what the job of a radiologist entailed and allowed her some flexibility in the way she discharged her duties. She mentioned flexitime as an example of an arrangement, which was easier to arrange with the new manager.

Improved work environment

She reported increased job satisfaction related to the improved work environment, and that she had every reason to stay in her job: “I find my work more satisfying now. This is because of the new equipment that I now work with and the facility where I work in… It may sound silly but now I have a kitchen, a rest room and a decent place. I like it that I now have these things at work. And like I said, there’s this awesome interaction with the new private radiology management. All these make the job more satisfying.”

Recommendations for management

Several management recommendations emerged from the study:

• When significant changes in the work context accompany job (re)design, no one job enrichment theory should, singularly, guide job design study in such a situation.
• The need for proper change management should be anticipated and prepared for when introducing a PPP model on an existing health facility. The capacity of management (both public and private) to deliver on this on an ongoing basis should be one of the key priorities.
• Where it is inevitable that some core job characteristics will be decreased (for example job autonomy), job (re)design practitioners should, at the very onset of job redesign, explore innovative ways to mitigate this by enhancing some other job characteristic(s) (for example skills variety).
There is clearly a need for Bright Hospital’s management to assist employees to delineate their written employment contract (which has not been breached) from the perceived psychological contract.

Greater interaction and engagement with employees is needed to unearth the root causes of the perception of inequity and breach of psychological contract that is pervasive among the staff at the shared service areas.

There is also evidence that there may be poor communication and poor change management at the hospital.

Furthermore, management has been found deficient in giving feedback to the employees on how they are performing their jobs.

Customer care skills have become a key competence required for effective discharge of duties at the hospital post-PPP, and customer care re-training of staff is required.

The DoH Management should benchmark from the management style of the private radiology practice operating in the radiology unit, as there may be lessons to be learnt.

It is also recommended that a follow-up quantitative study be commissioned to further explore the main themes that emerged from this study.

In conclusion, the PPP has huge benefits and potential for success but better change management and greater staff education, engagement and ownership of the PPP project is critical.

This above is a synopsis of the MBA research mini-thesis, entitled, The impact of job redesign on employee job outcomes: the case of the implementation of a private-public partnership model at a hospital, submitted by Dr Chukwuka Onaga who graduates with distinction from the Rhodes Business School in 2015. He was supervised by Professor Noel Pearse, whom he thanked in his acknowledgement “for being so knowledgeable and yet providing acres of space for me to freely express myself”.

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