Retention Strategy

for the
Health Workforce

September 1, 2010

Ministry of Health and Social Welfare

Government of Lesotho
 THL National Institute for Health and Welfare
International Affairs
Lintulahdenkuja 4, Helsinki
P.O.Box 30
FI-00271 Helsinki, Finland

HSS Technical Assistance office in Lesotho

Document MOHSW Retention Strategy Imperial Fleet Services Bldg
Version 1.0 Corner Kingsway and Moshoeshoe Rd
Date September 1, 2010 Maseru 100, Lesotho
Prepared HSS Project Office Tel/Fax (+266) 22325969
Executive Summary
According to the World Health Organization, it is now widely accepted that the dire shortage of
health workers in many places is among the most significant constraints to achieving the three
health-related MDGs1. The WHO has identified a threshold in workforce density below which
adequate coverage of essential interventions, including those necessary to meet the health-related
MDGs is unlikely.

This Strategy constitutes the response by the Ministry of Health and Social Welfare (MOHSW) to the
human resources crisis in Lesotho and is firmly embedded within broader government and sector
policies. The basis for this document is (a) the existing MOHSW Retention Strategy (Feb 23, 2010),
(b) broader government strategies, pertaining to retention, (c) recommendations made by the
PriceWaterhouseCoopers study (PWC, Nov 2009), and (d) existing sector-specific policies and
strategies that have a bearing on attraction and retention of health workers. Whereas previous
versions of this Retention Strategy focussed primarily on monetary incentives for health workers,
this edition takes a more holistic and comprehensive approach to defining country-specific priority
retention interventions.

In recent years, access to Health Care Services in Lesotho has been increasingly compromised. This
situation was exacerbated by shortages of skilled Human Resource within the health sector, to an
extent that during the Annual Joint Review of the health sector in 20042 the in-country World Health
Organization (WHO) and other health development partners decided to support the Government of
Lesotho (GoL) to re- strategise.

The GoL had to fully commit to the decade’s global declaration that focuses on Human Resource for
Health (HRH), by assigning a Senior Program Officer to support the HR Department to develop a
retention strategy proposal. This proposal was presented to Cabinet and had suggested improved
incentive packages. The Lesotho Health Development Partners also recommitted to support the GoL
to improve the quality of health delivery to the population, by strengthening systems with special
attention on HRH. One of the priority HR interventions designed by the MOHSW was the Retention
Strategy. The purpose of this Strategy is to establish mechanisms by which the health professionals
can be better managed, retained and motivated.

Staffing at all levels of health delivery does not meet the minimum requirements. Consequently this
situation has resulted in poor delivery of services at Health Centre level and at other higher levels of
the referral system. Poor service delivery has resulted in a distorted referral system where patients
refer themselves to the higher levels of Health Service including the National Referral Hospital i.e.
Queen Elizabeth II Hospital.

The escalating double burden of disease in Lesotho is worsened by the reported new cases of both
HIV and TB and the increasing rates of HIV and TB co-infection. This situation calls for strengthening
the HRH base to care for the increasing number of clientele. These emerging trends have brought
new challenges to Human Resources in Health, including: (i) In adequate and inappropriately trained

ii
Health Personnel, (ii) Low hiring rate of quality staff, (iii) Inadequate distribution of staff, (iv) Poor
working conditions, (v) Unattractive salary packages, (vi) High levels of burn out, and (vii) Poor career
management.

It is anticipated that this Strategy will contribute to mitigating some of these causal factors
associated with high rates of attrition of health workers. This Strategy seeks to establish the
mechanisms that control loss-abatement, brain drain and a largely de-motivated workforce, by
putting in place measures, such as salary improvements, better conditions of service and better
living conditions for health workers.

The approach taken by this Strategy is to first of all give due cognisance to existing and ongoing
interventions by government and by the health sector itself. Having done so, it then takes a more
holistic and comprehensive approach to indentifying additional financial and non-financial retention
interventions.

Chapter 1 of this Strategy gives the background and outlines the broader policy framework within
which it is located. The goals and objectives are in response to the acute problem of health worker
migration. Chapter 1 also gives details of the methodology followed for the development of this
Strategy. Chapter 2 gives a comprehensive overview of current retention interventions by
government and the health sector authorities.

The conceptual framework for the Strategy is developed in Chapter 3 and then used in Chapter 4 for
a systematic prioritisation of retention interventions. The Key Strategic Objectives, derived from this
prioritisation process, form the basis for Chapter 5. Chapter 6 outlines the monitoring and evaluation
procedure for the implementation of the Strategy. Chapter 7 covers the conclusions.

The added value of the process followed for the development of this Strategy is the systematic
approach to the prioritisation of the many possible retention interventions, both monetary and non-
monetary. The benefits of this effort are two-fold. In the first place, the resulting Strategy and Action
Plan are based on a generic framework of retention interventions, which will serve as a tool for
future revisions of this Strategy. Secondly, the recommendations made, in terms of prioritised
retention interventions and quick wins, are specific to the public health sector in Lesotho and are
thus more likely to have a tangible impact in the medium and long term.

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Acronyms
AJRR Annual Joint Review Report
CEIP Continuing Education Implementation Plan
CES Continuing Education Strategy
CHAL Christian Health Association of Lesotho
COLA Cost of Living Adjustment
DNS Director of Nursing Services
GoL Government of Lesotho
HIV/AIDS Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome
HMIS Health Management Information System
HRD Human Resource Development
HRH Human Resources for Health
HRIS Human Resources Information System
HRTWG Human Resources Technical Working Group
HSRS Health Sector Retention Strategy
LeBOHA Lesotho Boston Health Alliance
LMDPC Lesotho Medical, Dental & Pharmaceutical Council
LNC Lesotho Nursing Council
LRCS Lesotho Red Cross Society
M&E Monitoring and Evaluation
MCA Millennium Challenge Account
MDGs Millennium Development Goals
MOHSW Ministry of Health and Social Welfare
MOPS Ministry of Public Service
MOU Memorandum Of Understanding
NHTC National Health Training College
PHC Primary Health Care
PPPs Public Private Partnerships
PRSP Poverty Reduction Strategic Plan
PWC PriceWaterhouseCoopers
QE II Queen Elizabeth II Hospital
SADC Southern Africa Development Community
SAHCD Southern Africa Human Capacity Development
SWOT Strength Weaknesses Opportunities Threats
TB Tuberculosis
WB World Bank
WHO World Health Organization

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Table of Contents
1 INTRODUCTION ............................................................................................................................. 1

1.1 BACKGROUND ............................................................................................................................... 1

1.2 POLICY FRAMEWORK ..................................................................................................................... 2

1.2.1 Government Policies ....................................................................................................... 2
1.2.2 Sector Level Policies ........................................................................................................ 3
1.3 PROBLEM STATEMENT ................................................................................................................... 6

1.4 GOALS AND OBJECTIVES................................................................................................................ 8

1.5 GUIDING PRINCIPLES ..................................................................................................................... 8

1.6 STRATEGY DEVELOPMENT PROCESS............................................................................................ 10

1.7 METHODOLOGY APPLIED ............................................................................................................. 10

2 CURRENT RETENTION INITIATIVES ......................................................................................... 12

2.1 MINISTRY OF PUBLIC SERVICE ..................................................................................................... 12

2.1.1 Reward and Recognition Policy..................................................................................... 12
2.1.2 Remuneration and Job Evaluation Review ................................................................... 12
2.1.3 Strategy for Scarce and Critical Skills ............................................................................ 13
2.2 MINISTRY OF HEALTH AND SOCIAL W ELFARE ................................................................................ 14
2.2.1 Introduction .................................................................................................................. 14
2.2.2 Proposed Salary Increments ......................................................................................... 14
2.2.3 Allowances and Incentives ............................................................................................ 15
2.2.4 Strategic Partnerships ................................................................................................... 15
2.2.5 Decentralisation Deployment Framework .................................................................... 16
2.2.6 Infrastructure Development ......................................................................................... 16
2.2.7 Continuing Education .................................................................................................... 17
2.2.8 Strengthening Information Systems ............................................................................. 17
2.2.9 Improving Procurement Management ......................................................................... 18
2.2.10 Work Place Wellness Programme ................................................................................. 18
3 RETENTION THEORIES AND MODELS ..................................................................................... 19

3.1 INTRODUCTION ............................................................................................................................ 19

3.2 THE BROADER CONTEXT ............................................................................................................. 19

3.3 PUSH AND PULL FACTORS ........................................................................................................... 19

3.4 BEHAVIOURAL THEORIES ............................................................................................................. 20

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 3.5 CONTINUUM OF CARE .................................................................................................................. 21

3.6 INTERVENTION FRAMEWORK ........................................................................................................ 21

3.7 ATTRACTION AND RETENTION MODEL ........................................................................................... 22

4 PRIORITISATION OF INTERVENTIONS ..................................................................................... 23

4.1 THE PRIORITISATION PROCESS .................................................................................................... 23

4.2 RANKING OF INTERVENTIONS ....................................................................................................... 23

4.2.1 Introduction .................................................................................................................. 23
4.2.2 Recruitment-related...................................................................................................... 24
4.2.3 Financial incentives ....................................................................................................... 25
4.2.4 Working environment ................................................................................................... 26
4.2.5 Living conditions ........................................................................................................... 27
4.2.6 Personal development .................................................................................................. 27
4.2.7 Overall priorities ........................................................................................................... 28
4.3 HIGH PRIORITY INTERVENTIONS ................................................................................................... 29
4.3.1 Working environment ................................................................................................... 29
4.3.2 Financial incentives ....................................................................................................... 32
4.3.3 Living conditions ........................................................................................................... 34
4.3.4 Personal development .................................................................................................. 34
4.3.5 Recruitment-related...................................................................................................... 35
4.4 INTERVENTIONS FOR SPECIFIC CADRES ........................................................................................ 36
4.4.1 Medical doctors ............................................................................................................ 36
4.4.2 Nursing Cadre................................................................................................................ 38
4.4.3 Other Health Professionals ........................................................................................... 39
4.4.4 CHAL Employees ........................................................................................................... 39
5 THE STRATEGY .......................................................................................................................... 40

5.1 KEY STRATEGIC OBJECTIVES ....................................................................................................... 40

5.2 FRAMEWORK FOR IMPLEMENTATION ............................................................................................. 40

5.2.1 Ongoing Retention Initiatives ....................................................................................... 40
5.2.2 Working Environment ................................................................................................... 41
5.2.3 Financial Incentives ....................................................................................................... 42
5.2.4 Living Conditions ........................................................................................................... 43
5.2.5 Personal Development .................................................................................................. 44
5.2.6 Recruitment-related...................................................................................................... 45
5.3 QUICK W INS ................................................................................................................................ 45

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 5.4 PRIORITY ACTIONS ...................................................................................................................... 46

6 MONITORING & EVALUATION ................................................................................................... 49

6.1 KEY INDICATORS ......................................................................................................................... 49

6.2 PERIODIC REVISION OF THE STRATEGY ........................................................................................ 50

7 CONCLUSIONS ............................................................................................................................ 51

ANNEX 1 RETENTION INTERVENTIONS: GENERIC FRAMEWORK ............................................. 52

ANNEX 2 RETENTION INTERVENTIONS: PRIORITISED ................................................................ 54

ANNEX 3 LOGICAL FRAMEWORK: ACTION PLAN ........................................................................ 56

ANNEX 4 TIMEFRAME (GANTT CHART).......................................................................................... 56

ANNEX 5 SURVEY INSTRUMENTS ................................................................................................... 57

REFERENCES ...................................................................................................................................... 58

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1 Introduction
1.1 Background
Lesotho’s Vision 2020 Document presents a broad perspective framework of how Basotho would like
to see their country by the year 2020. Inter-alia, they would like Lesotho to be a healthy nation with
a well-developed human resource base. The country will have a good quality health system with
facilities and infrastructure accessible and affordable to all Basotho, irrespective of income,
disabilities, geographical location and wealth; health personnel will provide quality health service
and patient care. All Basotho will be conscious of healthy lifestyles and will engage in sporting and
recreational activities. Needless to mention, Basotho recognize the value of attracting and retaining
a cadre of human resources in the health sector and other sectors if ever the Vision 2020 is to be
realized. However, recent trends have shown that Health Care Services in Lesotho have been
increasingly compromised by shortages of skilled Human Resource. According to the 2009 Facility
Accreditation Survey, staffing at every level of healthcare delivery does not meet the minimum
staffing requirements. The effect of the crisis is to an extent that provision of even the minimum of
the services required of the MOHSW has become compromised.

The current human resources crisis in the Lesotho health sector is partly due to an inability to
produce adequate numbers of professional health workers, i.e. recruitment-related, and partly due
to an inability to retain these professionals, once trained and deployed, i.e. retention-related.
Presently there is an urgent need to recruit and retain health workers, especially at the district level.
Of equal importance is the development of capacities of the existing staff throughout the health care
system.

The MOHSW has long recognized the potential negative impact that the pervasive shortage of
human resources has on its ability to deliver the services required. To that end, the state of human
resources in the sector, and the need to review and tackle the problems associated with human
resources in the sector was put on the health sector reform agenda. The MOHSW defined the
human resource crisis as one of the eight areas of reform under the MOHSW Health Sector Reform
Programme. Within the context of the Health Sector Reform Programme, the MOHSW
commissioned a Human Resources Consultancy that was tasked with undertaking a Health Sector
Human Resources Needs Assessment in preparation for the formulation of a Human Resources
Development Plan and an accompanying Human Resources Strategic Plan. Within the context of the
Health Sector Reform Programme, the MOHSW commissioned a Human Resources Consultancy that
was tasked with undertaking a Health Sector Human Resources Needs Assessment (HSHRNA) in
preparation for the formulation of a Human Resources Development Plan and an accompanying
Human Resources Strategic Plan.

A SWOT analysis undertaken during the formulation of the Human Resources Strategic Plan
concluded that the principal constraints to the realization of the Strategic Plan defined for Human
Resources for the Health and Social Welfare sector was the ability of the MOHSW to address the
career management issues to the satisfaction of the MOPS and the ability of the sector to produce
the requisite personnel and retain them in the service.

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It is against this background that the MOHSW produced this Health Sector Retention Strategy
(HSRS), which caters for both Government of Lesotho (GoL) and Christian Health Association of
Lesotho (CHAL) health workers.

1.2 Policy Framework

1.2.1 Government Policies
The development agenda of GoL is governed by long term Vision 2020, the objectives of which have
clearly articulated a strong human resources base as one of its corner-stones. The GoL’s Poverty
Reduction Strategy Paper (PRSP) was developed to realise this vision. Within this strategy, GoL
defined a three pronged Public Service Improvement Reform Programme (PSIRP), namely the Public
Financial Management (PFM), the Public Service Reform (PSR) and the Decentralization Reform. All
these components are directly or indirectly linked to the Strategy herein defined.

The Public Service Regulations (GOL Gazette, 2008) determine the framework for public sector
salaries, benefits and allowances. The Table below summarises the financial incentives covered by
these regulations:

Table 1 Index of Public Service Financial Incentives

Remuneration Benefits Allowances

Remuneration policy
Job evaluation and grading
Salary entitlements
Incremental credit
Salary on promotion
Salary during absence
Car loan scheme Acting allowance
Housing loans Local subsistence allowance
Medical Aid Entertainment allowance
Pension Fund Hardship allowance
Government housing International subsistence
Government vehicles Training allowance
Benefit management Dependents’ allowance
Excess baggage allowance
Sitting allowance
Motor mileage allowance
Equine allowance
Hospitality allowance
Retention allowance

The Ministry of Public Service (MOPS) is, through job evaluation and salary survey processes,
committed to offer competitive remuneration for public sector workers, in an effort to enhance
workers’ motivation and thus reduce the high staff turnover. As integral part of this effort, the
MOPS has developed a Training and Development Policy in 2006. This policy was intended to provide
general guidelines in the management and administration of Training and Development of public
officers to ensure cost-effectiveness in the development, utilization and retention of human
resources in the public sector in accordance with national priorities’ (Human Resource Policy
Manuals, 2006).

2
The MOPS has also put in place a Performance Management Policy. The policy is based on national
strategic principles provided by the GoL’s Mission, Vision and Values. The policy provides the basis
for Performance and Development Management in the Public Service and is complemented by the
need to promote efficiency and effectiveness. The policy defines the process as managing the
performance and development of each individual through planning, recognition, assessing and
rewarding outputs (Human Resource Policy Manual; 2006). These objectives are directly linked to
staff motivation and retention.

1.2.2 Sector Level Policies

Strategies aimed at addressing health worker retention, apply to both Government of Lesotho (GoL)
and Christian Health Association of Lesotho (CHAL) employees. Currently the government has 81
health centres (including 4 filter clinics), 9 district hospitals and 3 tertiary hospitals, while CHAL has 8
hospitals and 71 health centres. Both GoL and CHAL are critical partners in health care service
delivery. They draw their human resources supply from the same pool.

Key sector-specific documents having a bearing on the development of this Retention Strategy
include:

 National Health and Social Welfare Policy, 2004

 Human Resources Development & Strategic Plan, 2005-2025
 Health Sector Human Resources Needs Assessment, 2004
 Health Services Decentralization Strategy, 2009
 Continuing Education Strategy, 2010
 Continuing Education Implementation Plan, 2010
 HIV and AIDS Workplace Policy, 2010
 Posting Policy for the MOHSW (draft, August 2010)
 Recruitment Strategy for the MOHSW (draft, August 2010)

The overarching National Health & Social Welfare Policy (2004) gives due recognition to the need
for professional development of individual health workers. The Policy focuses on the following policy
measures:

 To ensure that HRH are properly trained to provide health service delivery;
 To strengthen and expand training/development capacity in the country;
 to ensure employment and career progression; and
 To subject all professionals to periodic assessment during employment.

While these provisions were made in the National Health & Social Welfare Policy, the review of the
current Policies and the study which was done recently on maximizing Human Resources capacity
have revealed weaknesses in the system5. A recent study funded by the Trinity College in Dublin
(Maximising Human Resource Capacity in Rural District Health Systems in Lesotho, August 2008)
came to the following conclusions:

3
  There is an opportunity to improve Human Resources Management using some modest
interventions, i.e. quick wins
 Despite progress in the development of strategies and policies to address Lesotho‘s Human
Resources crisis, progress at the district level is slow, partly because of lack of staff or
resources to implement these policies
 The MOHSW needs to work together with the district management in developing and
implementing these policies
 The MOHSW needs to monitor the impact of the policies on the health workers and their
motivation
 Improved Human Resource Management (career progression, performance appraisal,
supervision, training, deployment and transfer) should be a priority of the Ministry
 The issue of the inequity between workers employed by the MOHSW and CHAL facilities is
one that needs to be addressed

Moreover, the current disease burden in particular, the HIV and AIDS pandemic is impacting
negatively on the HRH in as far as provision of services is concerned. This calls for more aggressive
efforts in maintaining the desired skill mix in numbers and levels, hence the need for a
comprehensive Retention Strategy.

The National Health and Social Welfare Policy and the Human Resource Strategic Plan have been
developed in cognisance of the prevailing resources and thus inform a long term plan which can be
operationalised into shorter term prioritized plans. Past developments, which had resulted in
substantial gains in Health Service Delivery within the Health-Sector, included:
 Adoption of Primary Health Care Strategy in 1979 which sought to improve the provision of
health service in Lesotho by demarcating the delivery around the 18 Hospital catchments
into Health Service Areas;
 Decentralization of Health Services to 18 Health Service Areas which were then recognised
as the core of the Lesotho health care system and the level in which the full range of
management activities such as planning, leading, supervision and monitoring would take
place;
 Creation of a Nurse Clinician Cadre as a Specialist area that would serve as heads of the
health facilities in the rural areas where there were no doctors;
 The introduction of Community Health Worker Programme to work directly with clinics at
community level; and
 The introduction of Filter Clinics which are used to serve the peri-urban areas and thus
relieve the main hospitals in highly populated towns.

The National Health Policy has also informed the District Health Package which elaborates the
services to be provided at the different levels of the referral system. This has the potential to make
more efficient use of scarce resources.
The key guiding document for the development of this Strategy is the Human Resources
Development and Strategic Plan (HRDSP, 2005-2025). The HRDSP combines recruitment and
development of the workforce. The HRDSP outlines five strategic objectives, being:

4
 1.Improve the efficiency of the labour supply
a. Restructure career ladders
b. Strengthen supervisory procedures
c. Re-grade selected job cadres
d. Introduce a career management system
2. Improve equity of coverage of the labour supply
a. Prioritise PHC and Social Welfare workers
b. Institute an equitable posting policy
3. Institute loss abatement strategies
a. Improve career management
b. Minimise attrition
 Conduct a benefits review to address inequities
 Conduct a formal job grading/re-grading exercise
 Invest in improvements to the working environments
 Create opportunities for experts to engage in consulting assignments
 Extend the mandatory retirement age for high skilled jobs
 Hire well qualified retirees
 Introduce systems to curb the brain drain
4. Strengthen training capacity
a. Revitalise the MOHSW Training Committee
b. Establish a Quality Assurance Programme
c. Restructure and strengthen NHTC
d. Review status and role of CHAL training institutions
e. Establish a HR Information System
f. Refurbish and enhance training institutions
g. Establish and/or revitalise a Health and Social Welfare Desk
5. Enhance national training capacity and performance
a. Develop a National Continuing Education Program
b. Establish dedicated CE infrastructure
c. Strengthen HRD capacity, including CHAL
d. Create a National Resource Centre

The development of this Retention Strategy has taken due cognisance of the strategic action points
pertaining to the institution of loss-abatement strategies and minimising attrition among health
workers.

The draft Posting Policy for the Ministry of Health and Social Welfare (draft: August 2010) is meant
to assist the MOHSW with developing policy guidelines for posting of health workforce. The
objective is to create a conducive environment to enable movement of the workforce in order for
them to develop and to meet organizational needs. The main purposes of the Posting Policy are to (i)
close the supply gap at the Primary health level and ensure rotation of staff in remote areas who
have served for a given period of time to less remote areas, and (ii) ensure that all staff members in
the Ministry of Health and Social Welfare are fully informed of the main elements of the Posting
Policy and to secure their co-operation in its implementation.

5
It is proposed that the recommendation made by the Posting Policy will be duly considered in
subsequent revisions of this Retention Strategy and Action Plan, once that Policy has been finalised
and approved.

The objective of the Recruitment Strategy for the Ministry of Health and Social Welfare (draft:
August 2010) is to support the Human Resource Directorate of the MOHSW with the development of
a Strategy aimed at aligning the MOHSW requirements and the Government of Lesotho (GOL)
recruitment policy. It is expected that the MOHSW Recruitment Strategy will provide useful insight
into specific recruitment-related actions that may have a bearing on staff retention. It is therefore
proposed that the recommendations made by the Recruitment Strategy are duly considered for
future revisions of the Retention Strategy and Action Plan.

Lesotho Nurses Strike Over

1.3 Problem Statement
Low Wages, Poor Working
The key problem addressed by this Strategy is the high rate of Conditions
attrition of public sector health workers in Lesotho. The
statistics are alarming: Lesotho Times
May 5, 2010
1. From 1994 to 2004 the number of employed nurses fell
by 15%; MASERU — Nurses and nursing
assistants at Queen Elizabeth II
2. 54% of professional nursing posts at health centres are
Hospital, on Tuesday downed tools in
vacant (2007); protest against their poor working
3. Only 6 of 171 health centres in the country have the conditions and wages. Their placards
minimum staffing required (2007); and indicated that their complaints
included meagre salaries, working
4. More than half of the health workers are actively
overtime without night shift
seeking other employment. allowances, lack of resources such as
medication, heaters and hot water,
It is generally recognized that Africa’s health workforce is especially during winter.
insufficient and will be a major constraint in attaining the
“We are nurses not slaves,” said one
Millennium Development Goals (MDGs) for reducing poverty
of the placards.
and disease. The majority of health workers migrate from the “We need money not peanuts,” said
rural areas to the cities; and more and more leave poor another.
countries for more attractive jobs abroad3. A major factor, “How are we expected to work when
there is no equipment and
contributing to the resource drain is the increasing level of
medication.”
migration of health workers and the absence of strategies to
attract and retain adequate supplies of professional health The strikers said they would seek
workers. This problem is particularly acute at the district and support from their colleagues in the
community level. ten districts of Lesotho, triggering
fears that by next week the strike
could cover the entire country.
Existing studies consistently report that many African health
professionals are dissatisfied with their current situation. The

6
common reasons for dissatisfaction are delayed salaries, delayed promotions, lack of recognition,
and an inability to afford the basic necessities of life. Consequently, health professionals often
migrate to seek more profitable situations.

The health workforce crisis is crippling health service delivery in many low-income countries4. High-
income countries with high salaries and attractive living conditions are drawing qualified doctors and
nurses, to fill the gaps in their own human resources pool.

Lesotho health workers are no exception to this trend. When asked if they would recommend their
jobs to a friend or family member, only 20% of health workers say ‘yes’ without reservation5. More
than half of health workers interviewed admit that they are actively seeking employment elsewhere.
Managers in the districts indicated that the level of attrition is not the same for all cadres; doctors
and nurses are leaving at a higher rate than other professions, except for social workers who are
leaving at a higher rate in the past few months.

There has been a marked decrease in doctors and professional nurses because of migration.
According to Schwabe et al, there were 89 doctors countrywide, and 80% of these were foreigners
from other African countries, most of whom were awaiting certification in South Africa where they
can get higher paying jobs (Schwabe et al, 2004). Nurses are also in short supply: from 1994 to 2004
the number of employed nurses fell by 15%.

Focus group discussions with health workers revealed that health workers in the districts are not
adequately motivated in their jobs5. Their motivation to remain in their present job is based on the
desire to render assistance both to the country and to their local community. Health workers
interviewed mentioned that they are not properly managed as continuous education and career
progression strategies are not adequate.

The health authorities in Lesotho have established that Human Resources for Health (HRH) have
reached critically low levels. Two consecutive quality assurance accreditation assessments found
that the ministry has not reached the required standard.1 These HR shortages could also be
exacerbated by the high mortality and morbidity from HIV and AIDS. Ratios of health workers to
population are some of the lowest in the region, while the disease profile is worsening due to the
double burden of infectious and non communicable diseases. An inter-country comparison of
nursing and medical doctors’ coverage is given in the Table below.

1
At health centre level the minimum staff requirements should be. 1 Nurse Clinician, 1 to 3 General Nurses, 1 Nurse Assistant. Their core responsibilities are
illustrated in the human resources strategic plan page 5-44 table 50.

7
 Table 2 Health Workforce Statistics (WHO, 20106)
Density per 10,000 population, 2000-2009

Country Doctors Nursing & Dentistry Pharmaceutical

Midwifery Personnel Personnel
Personnel
Swaziland 2 63 <0.5 1
South Africa 8 41 1 3
Namibia 3 31 1 1
Botswana 4 26 <0.5 2
Uganda 1 13 <0.5 <0.5
Kenya 1 12 <0.5 1
Zambia 1 7 <0.5 <0.5
Zimbabwe 2 7 <0.5 1
Lesotho 1 6 <0.5 <0.5
Malawi <0.5 3 <0.5 <0.5

USA 27 98 16 9
Japan 21 95 7 19
Netherlands 39 151 5 2

Note: The WHO recommendation is a minimum of 2 doctors per 10,000 population.

1.4 Goals and Objectives

The goal, or broader objective of this Strategy, is to contribute towards attaining a full staff
complement at the health institutions in Lesotho. The specific purpose of this Strategy is to reduce
the number of health professionals leaving the service, by way of improving motivation and job
satisfaction among those workers. The key strategic objectives to achieve this are outlined in
Chapter 5.

1.5 Guiding Principles

The guiding principles for the development of this Strategy are based on the broader principles
stipulated in the Health and Social Welfare Policy (2003), in particular:

Equity
Providing fairly distributed interventions, available to all health workers in all localities.

Affordability
Giving priority to interventions that are within financial means, taking cognisance of external
funding opportunities.

Accessibility
Make retention interventions equally available to all health workers.

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Evidence based
Choice of preferred interventions will be based on the best evidence available, in
consultation with all stakeholders, to decide upon the options which suits the target group
best.

Sustainability
Refers to the continuation of benefits from the interventions, the probability of long-term
continuation of interventions and the resilience to risk of the net benefit flows over time.

Collaboration and partnership

Revising the Retention Strategy requires a wide consultation and coordination effort. All
relevant stakeholders participate in the process of selecting the most appropriate strategies
and interventions.

Efficiency of resources
As much as possible, resources will be used only where the greatest benefit to the largest
number of health workers is envisaged.

In addition to these general principles, the development of this Strategy has paid particular attention
to the following considerations:

A holistic approach
This Strategy is based on a holistic and comprehensive approach to the problem of health
worker migration. The methodology takes cognisance of past experiences and of lessons
learned from other countries and other continents. In contrast to taking a haphazard and ad-
hoc approach to choosing retention interventions, this Strategy considers all available
options and prioritises those interventions that are relevant to Lesotho. Both monetary and
non-monetary initiatives are considered.

Understanding the broader context

National and health sector initiatives, addressing retention, take place within an
international and indeed global environment. The global socio-economic environment has a
bearing on the decision-making process of health workers.

Understanding migration
Mobility and movement are a natural expression of people’s desire to choose how and
where to lead their lives. This Strategy is based on a good understanding of the causal
factors that make health workers migrate, expressed as ‘push and pull factors’.

Understanding the individual health worker

It is imperative that, in order to develop a sound Strategy, the underlying reasons for health
workers intending to migrate need to be well-understood. An in-depth analysis of issues
pertaining to staff motivation and job satisfaction needs to take place prior to drafting
Strategy.

9
1.6 Strategy Development Process
For the development of the Retention Strategy, the following process was followed:

1) Study of documentation
Broader Literature
International experiences
Lesotho studies
MOHSW policy & strategy documents
2) One-to-one meetings with key informants
3) Draft conceptual framework for development of the Strategy
4) Stakeholder meeting: HR Technical Working Group
5) Drafting the Intervention Framework
6) Technical Consultative Meeting
7) Draft priority interventions
8) Draft Strategy and Action Plan
9) Dissemination of draft Strategy
10) Stakeholder meeting: HR Technical Working Group
11) Further consultations with key informants
12) Submission of the final product

1.7 Methodology Applied

The approach taken by this Strategy is to first of all give due cognisance to existing and ongoing
interventions by government and by the health sector itself. Having done so, it then takes a more
holistic and comprehensive approach to indentifying additional financial and non-financial retention
interventions. Inevitably, there will be some overlap in the detail between existing and ongoing
retention interventions and recommended additional interventions. In summary, the methodology
comprises of the following stages:

1) Identify existing and ongoing retention interventions

2) Develop a comprehensive and inclusive ‘Framework of Interventions’
3) Agree on Lesotho-specific interventions that are relevant, feasible and affordable
4) Develop Key Strategic Objectives based on identified priority interventions
5) Develop an Action Plan guided by the Key Strategic Objectives
6) Define ‘Key Indicators’ to measure impact
7) Adjust the Strategy periodically, based on impact evaluation

The methodology used to develop this Retention Strategy has generalized all identified health cadre
positions. This approach implies that any analysis and assumptions made will apply to all types of
health workers, including managers, doctors, nurses, midwives, pharmacists, dentists, lab
technicians, community health workers, support workers, trainers and students. The Strategy,
however, gives special attention to the cadre of doctors and nurses since they are front line workers
and therefore are the mainstay for the Lesotho health services. This approach is in step with

10
government intentions, that seek to take care of highly qualified staff and establish a scarce and
critical skills policy as recommended in the PriceWaterhouseCoopers (PWC) Consultancy report (see
Chapter 2). It is noted, however, that generalising all health sector workers carries with it a potential
concern, as certain recommended interventions may not motivate certain senior staff categories,
who are generalised together with lower qualified staff.

The methodology adopted for developing this Strategy is based on a systematic approach to
selecting Lesotho-specific interventions from a comprehensive and generic ‘framework of
interventions’. The reasoning behind this framework is outlined in Chapter 3. In order to arrive at a
manageable number of priority retention interventions for the Lesotho health sector, as the basis for
this Strategy, a Technical Consultative Meeting was convened. The participants to the meeting
constituted a diverse group of key informants from the MOHSW, CHAL, Training Institutions, DHMTs
and Health Development Partners. In order to enable the group of experts to undertake the task of
prioritisation, a plenary discussion took place during which the pros and cons of all possible
retention interventions were debated and considered. Having thus acquired an expert opinion of
each option, individuals were then asked to ‘score’ each intervention according to these criteria:
importance, feasibility, affordability, external support and sustainability. An explanation of the tool
used for this exercise is given in Annex 5. Finally, all interventions were ranked according to their
cumulative score. The results are given in the following Section. It is recommended that, for future
updates of this Strategy, a similar prioritisation process will be undertaken, using the same, or an
improved version of the Intervention Framework developed for this purpose.

11
2 Current Retention Initiatives
2.1 Ministry of Public Service
2.1.1 Reward and Recognition Policy
The Lesotho Public Service (LPS) seeks to introduce reward and recognition incentives for all its
employees and aims to achieve this through the development of appropriate incentive mechanisms
and frameworks7. An important element of this policy is performance-related pay. Performance-
related pay is pay that varies according to the level of performance of the individual, the team, or
the ministry as a whole. Performance-related pay for individuals is typically based on performance
ratings. The ratings determine the nature and level of the increase that is awarded to the individual
employee.

2.1.2 Remuneration and Job Evaluation Review

In addition to the introduction of policies and manuals, the Ministry of Public Service (MOPS) has
engaged PriceWaterhouseCoopers (PWC) to conduct a Remuneration and Job Evaluation Review
Project8. The review included:

 Review of the public service salary and grading structures

 Review of the current Job Evaluation System
 Development of a remuneration and benefits framework
 Development of a Strategy on the retention of scarce skills
 Provision of inputs on the ‘Performance Based Pay’ principle

The PWC study refers to scarce skills as occupations in which there is a scarcity of qualified and
experienced people, currently or anticipated in the future, either because such skilled people are not
available, or they are available but do not meet employment criteria. Critical skills refer to specific
key or generic skills, as well as ‘top up’ skills within an occupation. Within the Lesotho context, both
scarce and critical skills are observed within the health and allied professions, in particular: dentists,
doctors and specialised physicians, epidemiologists, laboratory technicians, nurses and specialised
nurses, obstetricians and gynaecologists, occupational therapists, pharmacists, radiologist and
radiographers. In a formal presentation of their findings, in 2009, the PWC proposed a number of
interventions impacting directly on scarce and critical skill occupations:

12
 Table 3 PWC: Findings related to scarce and critical skill occupations (2009)

Theme Findings
Training and University training programs not geared towards scarce skills
development Training within public service not well coordinated
Stakeholders do not have the relevant information regarding
scarce skills
Vacancies High vacancy rates
Slow filling of vacancies
Perceived lack of synergies between PSC and MOPS
Job-person misfits
Retention Lack of structured retention strategy
High turn-over rates of staff
Non-competitive salaries
Working conditions Organisation environment not conducive to growth
Staff does not get rewarded
Staff not recognised for good performance
Management is not motivational
Lack of proper and modern equipment

In their report, PWC makes broad recommendations to combat the shortcomings identified. The
report also makes the case for a holistic and inclusive approach, taking into account attraction,
development and retention aspects.

The MOPS, as the custodian of remuneration and benefits across the civil service, continues to offer
benefit schemes for staff, including health professionals, such as car loans, pension fund, loan
mortgages, etc. The MOHSW has the opportunity to explore how to maximise utilisation of this
scheme for retention purposes, i.e. partnerships with property developers for staff housing and
possible donor support for housing schemes.

2.1.3 Strategy for Scarce and Critical Skills

The MOPS is in the process of drafting a Retention Strategy for Scarce and Critical Skills. The purpose
of the proposed MOPS Retention Strategy is to provide a framework within which the MOPS can
operate to meet the national government agenda with regard to scarce and critical skills. The
proposed Strategy is expected to be largely based on the recommendations made by PWC (refer to
previous section). The Strategy is targeted at the attraction, development and retention of staff
within the identified scarce and critical skills within the Lesotho Public Service, while it applies to
occupations and not to individuals. Note: For reasons that the Retention Strategy for Scarce and
Critical Skills of the MOPS is still in draft form and has thus not been formally approved, no extracts
from that proposal have been included in the text of this Strategy.

13
2.2 Ministry of Health and Social Welfare
2.2.1 Introduction
The MOHSW is in the process of implementing various programmes and initiatives that are expected
to have a direct positive impact on attraction and retention of health workers. In an attempt to
control the HR crisis, the MOHSW already introduced a retention Strategy in 2006. The 2006
Strategy sought to establish retention mechanisms to control the high attrition rates, the brain drain
and the symptoms of a generally de-motivated workforce. The 2006 Strategy focused primarily on
visible control measures, in particular salary improvements, incentives, allowances and better
conditions of services. In February 2010, an update was prepared of the 2006 Strategy, prompted by
a Global Fund requirement (explained hereafter). The focus of the update remained on monetary
incentives. This revised Retention Strategy is based on the February 2010 version and takes it a step
further by including non-monetary initiatives.

2.2.2 Proposed Salary Increments

Negotiations between the MOHSW, MOPS and the Global Fund, to elicit structured salary top-ups
for a period of three to five years (Global Fund, Round 8), have now been completed. This initiative
will affect the salaries of most health workers and constitutes an increase of around 16% and 14% on
average (MOHSW and CHAL respectively). The condition set by the Global Fund is that the MOHSW
will prepare a comprehensive Retention Strategy that will address both financial and non-financial
incentives for health professionals.

In terms of an ‘exit strategy’ for the Global Fund support, the GoL intends to finance the incremental
recurrent costs of the posts that are technically justified and can be filled with adequately trained
personnel. Currently there are no guidelines in place for skills transfer and succession plans geared
towards staff retention within the civil service, but the MOHSW ensures that there is close
collaboration within departments in order to sustain the scarce and critical skills in the long run. The
GoL has also forged agreements with other countries to stop importing the health professional from
Lesotho as it hampers health improvement efforts within the country. The MOPS, through the job
evaluation and salary survey processes, is also committed to offer competitive remuneration as form
of motivation to reduce the high staff turnover for personnel with limited and on-demand skills. The
MOHSW anticipates that when the support for salary top-ups has been withdrawn after a period of
three to five years, remuneration of all affected position would be on par with what would then be
offered under the MOPS salary structure.

The trend has shown that the annually cost of living adjusted (COLA) factored towards the salaries of
the public officers will be maintained and this is likely to place public servants salaries even at the
higher level than the amounts proposed in the retention strategy before the intended period is
reached therefore the assurance for sustainability of the proposed salaries will not be a challenge to
the ministry.

14
2.2.3 Allowances and Incentives
For MOHSW employed health workers, there are currently two types of allowances in place. The
hardship allowance of M275 is given to everyone who works in locations that have been declared
hardship areas. The call allowance applies to Consultants, Specialists, Registrars, Senior Housemen
and Interns and ranges from M850 to M2,000. An important effort supported by Health
Development Partners is the ongoing allocation of monthly incentives and hardship allowance
offered to the health professionals based within both MOHSW (GoL) and CHAL facilities. It is
assumed that this intervention will taper the number of health workforce leaving the health centres
especially in remote and hardship areas. For the first time the government of Lesotho is awarding
monetary incentives to Community Health Workers of M300 per month.

2.2.4 Strategic Partnerships

The MOHSW has a long history of forging partnerships with development partners. These
collaborations are in the areas of infrastructure, training and development, strengthening and
streamlining support services, such as the Health Management Information System, the
procurement systems and the allocation of direct financial and non financial incentives for health
workers.

There is a strong coordination with CHAL, who supplements skills within the health sector. CHAL is a
voluntary organization of six member churches, namely; Anglican Church, Assemblies of God, Bible
Covenant, Lesotho Evangelical Church, Roman Catholic, and the Seventh Day Adventist Church of
Southern Africa. The Association was registered in Lesotho in 1974 under the Societies Act following
some historical developments briefly discussed below. CHAL currently provides about half of health
care services in Lesotho and is a key partner of the GoL in the health sector. An MOU exists between
the MOHSW and CHAL that explicitly prevents migration of staff from one employer to the other.
This is done by means of identical remuneration structures for health care professionals2. The
MOHSW will explore whether this MOU can be extended to other partners in Lesotho, such as LRCS.

The partnership between the Government of Lesotho, Irish Aid and the Clinton Foundation is also
focused on addressing the human resources crisis. Activities include mentorship programmes, the
recruitment of additional nurses, the provision of support (through Partners in Health) to remote
rural clinics and health stations. The Lesotho-Boston Health Alliance (LeBoHA) represents Boston
University's Public Health and Family Medicine programs in Lesotho. LeBoHA is working with the
MOHSW for the implementation of a program for the sustainable strengthening of district hospitals
and their associated health centers.

Internationally, the MOHSW has engaged in bilateral partnerships with the Southern Africa
Development Community and East African Counterparts, in an effort to supplement the current skills
shortage. Partnerships have also been established with Cuba and China2.

2
Annual Joint Review Report, 2009/10FY, Health Planning and Statistics Department, MOHSW, May 2010

15
2.2.5 Decentralisation Deployment Framework
The MOHSW is currently in the process of devolving health service delivery to local authorities,
having started with three pilot districts and subsequently bringing it to scale in compliance with the
Local Government Act 1997. The overall purpose of the health services decentralisation reform is to
increase access to quality promotive, curative, preventive, and rehabilitative health and social
welfare services on the basis of equity and social justice and to promote the governance of health
service interventions in Lesotho.

The devolution and de-concentration of some of the essential public health and clinical functions will
require certain categories of human resources to be deployed to local authorities. In order to
accomplish this, there are different methodologies that can be adopted to deploy personnel from
the Public Service to local authorities or to the Local Government Service commission. The options
are (i) Appointment, (ii) Transfer, and (iii) Secondment. Simply put, ‘Appointment’ refers to the
process whereby a competent authority engages a person as an employee, ‘Transfer’ in this context
refers to a permanent involuntary assignment on the same terms and conditions, while in the same
context ‘Secondment’ refers to a temporary involuntary assignment until such time that the local
authority is ready to appoint.

From a point-of-view of attraction and retention of health workers, there are advantages and
disadvantages to these options for human resources deployment. Careful consideration should be
given to the pros and cons of each option. Preference should be given to a methodology whereby
health workers gain maximum job security with long term prospects for continuity and career
development opportunities.

2.2.6 Infrastructure Development

Health infrastructure throughout the country has been inadequately maintained, largely due to
other financial priorities. Much of the health infrastructure has been in constant use for more than
30 years without renovation or upgrading. Hospital OPDs have been overloaded for more than a
decade with new case loads from HIV and AIDS and TB patients. Many health facilities lack
appropriate water, sanitation, power and medical waste disposal infrastructure. Some health
centres lack any means of communications, including landline telephone, mobile phone, or a
working two-way communications system needed for referrals and data transmission. Staff housing
is in need of upgrading or rehabilitation, or deemed inadequate to entice trained professionals to
stay in health posts.

The Ministry of Health and Social Welfare through support of various development partners have
engaged in a number of infrastructure improvement activities, in order to attain the Millennium
Development Goals. The national referral hospital is currently under construction, and three filter
clinics have been rehabilitated and expanded as well as the nine Lesotho Flying Doctors Service
health facilities. Processes are underway to construct the new national referral laboratory, the blood
bank facility, and to refurbish OPDS for 14 hospitals and majority of COL, CHAL and the LRCS health
centres throughout the country, to enhance provision of HIV services with support of the
Millennium Challenge Account (MCA). The MCA (USA) has committed over USD90m, with an

16
additional estimated USD50 from the GoL, to improve physical infrastructure at health facilities. It is
estimated that 600 additional health care workers will be needed to staff these new and
rehabilitated health structures.

2.2.7 Continuing Education

Health workers generally express concern about the lack of opportunities for continuous education
within the Lesotho public health service. Although having some opportunities for in-service training,
few professionals have opportunities for long term training. This aspect impacts on morale and
motivation and contributes to some professionals leaving their jobs. Lack of continuing education
also affects choices made by potential new recruits.

In view of this, the MOHSW, in close collaboration with their development partner, the Health
Systems Strengthening Project (HSS), has developed a Continuing Education Strategy and
accompanying Continuing Education Plan (finalised in March 2010 and June 2010 respectively). The
National Continuing Education Strategy for Lesotho Health Sector (2010-2015) sets out the broader
goals and objectives to achieving continuing education for all. The CE Implementation Plan focuses
on the practicalities of training, in particular on resources, methodologies, training providers and
implementing partners. As such, the CE Implementation Plan complements The National Continuing
Education Strategy for Lesotho Health Sector and is informed by it.

The National Continuing Education Strategy for Lesotho Health Sector (2010-2015) stipulates that
the mobilization of funding for CE shall be streamlined within the existing financing coordination
arrangements for the MOHSW under the Planning & Statistics Department, including General Budget
Support. The financing from Development Partners shall be governed by the Code of Conduct
between the MOHSW and the Partners.

2.2.8 Strengthening Information Systems

Health workers are motivated by well-functioning information systems. The Ministry, in close
collaboration with their development partner, the HSS Project, has embarked on a comprehensive
programme to upgrade information systems in order to ensure proper management of health
information. There is a general lack of usage of data for decision making, policy making and planning.
Health and Management Information Systems need to be responsive to current health issues in
order to adequately inform planning and resource allocation. Lagging analysis of health system data
means that healthcare providers are unable to utilize data to manage performance.

In addition, the Ministry is putting an effective HR Information System (HRIS) in place. There is a
need for a more mature and responsive system. The HR Directorate and CHAL are in the process of
undertaking a data validation exercise, in preparation for a system, named iHRIS; an open source
software to be provided and supported by development partners. The iHRIS system will
accommodate key functions for the registration and monitoring of employees.

17
2.2.9 Improving Procurement Management
The GoL has undertaken to overhaul Financial and Procurement Management systems. To this effect
the MOFDP has awarded line ministries with newly established Procurement Units (2009) that are
meant to improve procurement of goods and services respectively in line ministries. The MOHSW
has therefore, with the support of development partners, been able to strengthen the Procurement
Unit by engaging competent officials to execute the function, whilst efforts are also underway to
substantively fill the positions within the Ministry. This reform has come at an opportune time, as
the MOHSW has been experiencing difficulties in procuring the necessary health commodities,
stocks and services; hence contributing to the disillusionment of health workers.

2.2.10 Work Place Wellness Programme

Lesotho has the third highest adult HIV prevalence in the world, at 23.2%1. This sobering statistic has
a direct impact on the health workforce. The MOHSW Workplace Wellness Programme is aimed at
the wellbeing of staff, by means of increasing access for them to HIV/AIDS services. This initiative
was led by the Director HR with technical support from SAHDC. To date, many wellness program
champions have been trained in different health facilities across the country. The HIV and AIDS
Work Place Policy (March 2009, “Care of carers”) is being implemented to improve the plight of
health care workers in the Health and Social Welfare Sector. The International Labour Organization
(ILO) and National AIDS Commission (NAC) are collaborating with the Ministry of Public Service in
integrating Labour Code Amendment Act (2006) and the ILO Code of Practice into a Public Service
HIV and AIDS policy. The HIV and AIDS Work Place Policy has been developed in line with the draft
Public Service Policy.

18
3 Retention Theories and Models
3.1 Introduction
This Chapter outlines some theories and models pertaining to the issue of health worker retention,
leading to the development of a comprehensive framework for attraction and retention
interventions. Theories and models indicate possible courses of action, that have a bearing on the
choice of approach to determining key strategic objectives and a subsequent actions. The reason
behind developing a holistic intervention framework is that policy proposals towards improving
attraction and retention generally seem rather haphazard and not rooted in a sound understanding
of the nature and source of HR-related problems.

3.2 The Broader Context

The discussion pertaining to the individual health worker and teams of health workers, in terms of
their motivation and job satisfaction, is located within the broader context of the public health
sector. The health sector is situated in a national context, which in turn is positioned within the
global environment. The broader environment has a bearing on the decision-making process of the
health worker and includes (i) the global economy, (ii) global health initiatives, (iii) regional
interventions (e.g. standardisation of remuneration packages) and many other factors. The national
context includes, among others: (i) political stability, (ii) socio-economic climate, (iii) infrastructure,
communication, and (iv) rural development programs. This Strategy focuses predominantly on the
individual health worker and to his/her immediate working and living environment.

3.3 Push and Pull Factors

Migration of health workers is commonly interpreted as being from national to international and
from rural to urban. Migration, however, also takes place when professionals move from the public
to the private sector, from primary to tertiary care levels, from government to NGOS and from the
health sector to other sectors. In the recent literature on health workforce mobility, the concepts
‘push and pull factors’ are increasingly used to describe the conditions that motivate people to
migrate. Pull factors are those that attract individuals to new destinations. Push factors are those
that repel the individual from a location and drive them to leave their homes and jobs9.

19
 Table 4 Examples of push and pull factors

PULL FACTORS PUSH FACTORS

(Attract individuals to other (Repel individuals from a location)
destinations)
Professional work environment Lack of promotion opportunities
Better remuneration Low salaries
Able to save money Lack of training opportunities
Skills development Poor retirement benefits
Training opportunities Heavy workload
Proper infrastructure Burnout
Modern equipment Lack of motivation
Better social benefits Lack of supervision
Recognition of good performance Lack of proper equipment
Opportunities for research Poor facilities and equipment
Gain experience Poor housing conditions
Better living conditions Lack of appreciation by managers
Upgrading of qualifications No professional future
Good schools and teachers Poor management
Quality health care Poor health care
Travel opportunities Poor roads and transport
Job satisfaction Poor access to information

The pattern of migration is characterised by both internal and external movements. With regard to
external migration, the following destinations are frequently cited: UK, Australia, Republic of South
Africa and the Middle East. Internally, migration is characterized by movement from rural to urban,
CHAL to MOHSW (GoL) institutions and from government to private and donor agencies5.

3.4 Behavioural Theories

Having a bearing on the decision-making process of ‘ambivalent’ health workers, are so-called
behavioural theories, starting with those of Abraham Maslow and Frederick Herzberg10, which put at
the centre of a more complex decision-making process the satisfaction that workers get out of their
job. Psychologist Abraham Maslow first introduced his concept of a hierarchy of needs in his 1943
paper "A Theory of Human Motivation"1 and his subsequent book, Motivation and Personality.2 This
hierarchy suggests that people are motivated to fulfil basic needs before moving on to other needs.
Maslow set up a hierarchy of five levels of basic needs. Beyond these needs, higher levels of needs
exist. These include needs for understanding, aesthetic appreciation and purely spiritual needs. In
the levels of the five basic needs, the person does not feel the second need until the demands of the
first have been satisfied, nor the third until the second has been satisfied, and so on. Maslow's basic
needs definition consisted of (i) Physiological Needs, (ii) Safety Needs, (iii) Needs of Love, Affection
and Belongingness, (iv) Needs for Esteem, and (v) Needs for Self-Actualization.

During the 50's and 60's, Frederick Herzberg decided to carefully study and research the key factors
affecting a worker's performance. He found that certain factors tended to cause a worker to feel

20
unsatisfied with his job. These factors seemed to directly relate to the employee's environment,
such as the physical surroundings, supervisors and even the organisation itself. Herzberg carried out
research into the sources of job-related satisfaction and dissatisfaction and proposed, that for
workers to be motivated, the content of the job itself must be motivating. Simply removing the
sources of discontent will not cause a person to be motivated or produce better results.

3.5 Continuum of Care

The so-called ‘Continuum of Care’ concept is often applied to the human life-cycle, for example by
UNICEF, to emphasise the need for a continual care for children, as they grow into adolescents and
adults. Another example is the continuum of care in terms of creating a supportive environment for
maternal and newborn health, based on the respect for women’s rights and the elimination of
discrimination suffered by girls and women and fostering an atmosphere where there is a demand
for quality services through health education.

The Continuum of Care concept can equally be applied to the monitoring of and caring for health
workers, as visualised in the diagram below.

Figure 1 Monitoring and caring for health employees

The concept is based on caring for health workers throughout their individual ‘cycles of
employment’; from beginning to end, from recruitment to retirement. This approach also allows for
the identification of critical drop-out points during the life-cycle. A key element of this approach is to
develop a database of health workers and build up a knowledge base for each individual.

3.6 Intervention Framework

The term ‘push factors’ has been defined as the reasons why health workers migrate and seek
greener pastures. These push factors can be counteracted with specific interventions, in an attempt
to halt the outflow. Following an exploration of the abundant literature on the subject of health
worker attraction and retention, both from inside and outside Lesotho, it follows that these
interventions can be categorised in five distinct categories. The Intervention Framework that will be
used henceforth, for the development of this Strategy and subsequent Action Plan, is structured as
follows:

21
 A. Recruitment-related
B. Financial incentives
C. Working environment
D. Living conditions
E. Personal development

Each category contains a comprehensive ‘bundle of possible interventions’, from which one can
make a country- or region-specific choice.

3.7 Attraction and Retention Model

Based on the above theories and intervention framework, the model adhered to for determining
health worker attraction and retention factors within the Lesotho health sector is visualised in the
diagram below.

Figure 2 Lesotho Health Workforce: Attraction and Retention Model

OBJECTIVE INTERVENTIONS OUTCOME

MOHSW attracts and retains a motivated health workforce

Priority Interventions to attract and retain health workers

Recruitment-related
Full Staff Complement at the Health Institutions

Fulfil basic needs

Attraction
of health workers
Financial incentives

Working environment

Living conditions
Continual Care for
Retention
health workers

Personal development

The objective of this Strategy is realised by the implementation of selected prioritised interventions.
The expected outcome of the implementation of the Strategy is that the MOHSW attracts and
retains a competent and motivated workforce.

22
4 Prioritisation of Interventions
4.1 The Prioritisation Process
This Strategy argues that, rather than focusing on monetary incentives alone, there is a need for ‘a
package’ or ‘bundle’ of interventions. No single intervention is likely to produce a sustainable
solution to all workforce challenges facing an organisation11. The elements of this bundle of
interventions need to be diverse and respond to current prevailing causal factors for health worker
attrition. The process of determining priority retention interventions has been described in the
Methodology section of this document (Chapter 1). This Chapter presents the results of this process.

As a result of the literature study and broad consultation, a total of 64 possible interventions were
identified and grouped into 5 categories (intervention framework – see previous Chapter). The
complete generic intervention framework is given in Annex 1, which forms the basis for the
prioritisation exercise documented in this Chapter. It is recommended that, for any future revisions
of this Retention Strategy, reference is made to this comprehensive framework or an adaptation
thereof.

4.2 Ranking of Interventions

4.2.1 Introduction
Prioritisation was done within each category of the Intervention Framework. The results are given in
this section. The cumulative results of the ‘scoring exercise’ that formed the basis of the
prioritisation process, reveals priorities as perceived by the assembly of key informants and are
presented according to the categories of the framework.

23
4.2.2 Recruitment-related
The results from the prioritisation process, for recruitment-related interventions, are given in the
following Table. Note: Detailed descriptions of these interventions are given in Annex 1.
Table 5 Priority recruitment-related interventions
SCORE INTERVENTION
HIGH Establish statutory body for
HRH
Establish ‘rural pipeline’
Fixed term rural posting
Targeted local recruitment
Attract Diaspora
Task shifting, skilled
substitution
Expert Patients
Rotational locum system
MOPS/MOHSW special
contracting arrangements
Targeted recruitment drives
Re-employment of retired
professionals
Retention of foreign doctors
Compulsory rural service
Bonding
Employment of international
volunteers
Prohibit poaching by donors
Age-specific deployment to
rural areas
LOW Retention of academic
certificates and transcripts
Create a body responsible for all health workers, keeping track of
recruitment trends, retention, career advancement, etc.
Establish and nurture linkages between health department and rural
schools and colleges; then follow through with recruitment drive
Agree on a fixed term contract in rural areas
Recruit trainees from remote areas results and assign them
placements close to their original locality
Put in place measures to ‘attract back’ health professionals who
have migrated out of the country
Train certain cadres of health workers to provide additional services;
delegate tasks to less specialised health workers
Train patients to assist at clinic level, with tasks like filing, taking vital
signs and counselling patients
Allow staff to work additional shifts with pay within their duty
station
Introduce an innovative contracting system, with yearly quota of
health worker positions for which candidates apply
Recruit individuals from specific locations
Attract retired health workers from inside or outside the country
Put in place measures to halt the out-migration of foreign doctors
Obligate health workers to serve in a rural location, for a period of
time
Obligate health workers to work for government, after initial
training has been completed
Recruit doctors, nurses and other professionals through
international voluntary organisations
Combat poaching practices of professionals by donor agencies
Sent older health workers, with less need for diverse social life, to
the rural areas
Withhold qualification certificates, to ensure graduates working for
government for a period of time
24
4.2.3 Financial incentives
The results from the prioritisation process, for interventions related to financial incentives, are as
follows:
Table 6 Priority financial interventions
SCORE INTERVENTION
HIGH Review and increase
allowances
Equalise benefits
Review and increase
incentives
Equalise salaries
Salary based on scarce and
critical skills
Incentives for new recruits
Eliminate discriminatory
financial incentives
Higher salaries
End-of-service payments
Review and increase
insurances
Performance-based pay
LOW Allow dual practice/income
Update allowances, e.g. hardship allowance, transport allowance,
study allowance, etc.
Equalise benefits between government and non-government
healthcare providers
Update incentives in an effort to retain health workers, e.g. house
loans, car purchase loans, etc.
Equalise salaries between government and non-government
healthcare providers
Reward scarce skills, i.e. occupations for which there is a scarcity of
qualified and experienced people
Introduce a special package of incentives for students after they
graduate and enter into service
Do away with incentives which only apply to certain health worker
categories
Increase basic salary level
Issue generous payouts at end of service
Provide insurances, e.g. life insurance, medical cover, accident
cover, etc
Supplement basic salary by a performance-based top-up, e.g.
bonuses
Improve income levels of health workers by allowing them to take
on second jobs, e.g. running a private practice
25
4.2.4 Working environment
The results from the prioritisation process, for working environment-related interventions, are as
follows:

Table 7 Priority working environment-related interventions

SCORE INTERVENTION
HIGH Supportive supervision Ensure regular supervision with the aim of increasing motivation and
job satisfaction of health workers
Strengthen information Provide timely feedback to suppliers of data on health statistical
systems information, based on routine data provided
Management support Give attention to individual health workers, by management
Communication and Issue relevant information to health workers that affects them
information personally, e.g. changes in policy, conditions of service, etc.
Career paths and promotion Stimulate career progression of individual health workers
opportunities
Provision of equipment and Ensure adequate, safe and well-maintained equipment; ensure
drugs timely supply of pharmaceuticals
Improve procurement Ensure effective procedures are in place for the procurement of
management goods and services
HIV/AIDS workplace Increase access for health workers to HIV and AIDS services
strategies
Decentralisation of HR Delegate decision related to staff matters to district and facility level
management
Clean and orderly work Ensure a healthy, clean and well-organised place of work
environment
Stress management Ensure that tasks given to health workers are in line with their
qualifications, so as to avoid stress
Nurture positive working Improve staff morale and retention through dedicated training in
relationships people skills and other measures
Appropriate infrastructure Ensure adequate, safe and appropriate infrastructure
Performance management Establish and maintain a holistic approach to people management,
system which is developmental, rather than punitive in nature
Workload management Put measures in place to avoid excessive workload for individual
health workers
LOW Special leave/career break Allow leave with or without pay, to encourage workers to return to
service after a break

26
4.2.5 Living conditions
The results from the prioritisation process, for living conditions-related interventions, are as follows:

Table 8 Priority living conditions-related interventions

SCORE INTERVENTION
HIGH Means of communication Install and maintain radio communication systems at selected
facilities to reduce time lost to travel
Security Ensure safety and security for health workers, both on- and off-duty
Housing for staff Ensure an acceptable quality of living for health workers, which is
safe, secure and comfortable
Home heating Provide heating systems for staff houses
Transport for staff Provide or subsidise duty and private transport
Amenities (water, electricity) Provide subsidised utilities (water, electricity, telephone)
Childcare Pre-schooling and care for children
LOW Entertainment Provide entertainment systems, including TV/Video, Internet, Sport
facilities in areas that are under-served

4.2.6 Personal development

The results from the prioritisation process, for personal-development-related interventions, are as
follows:

Table 9 Priority personal development-related interventions

SCORE INTERVENTION
HIGH Education and training Ensure career progression opportunities
opportunities
Competency-based training Encourage the provision of training which is of direct relevance to
the job
Study leave Allow study while on leave with continued pay
Research Allow health workers to carry out research on topics of interest
Access to information Facilitate the availability of computers, internet and traditional
libraries
Distance education Facilitate learning programmes that are provided remotely, either
programmes through internet or using traditional postal services
Local/rural training Provide training on-location, in rural under-served areas
availability
Subsidised studies Provide or subsidise study fees
Free learning materials Supply staff who wish to progress with learning tools and materials
LOW Educational opportunities for Make provision to study for dependent spouse and children
family members

27
4.2.7 Overall priorities
The overall outcome of the prioritisation process, for all categories combines, is given in Annex 2,
which is the result of category-independent priority-ranking. The Table below is an extract from
Annex 2 and gives the ‘top 20’ priority interventions, as perceived by the group of key informants.

Table 10 ‘Top 20’ Priority Interventions

SCORE RANK INTERVENTION CATEGORY

HIGH 1 Supportive supervision Working environment
2 Strengthen information systems Working environment
3 Management support Working environment
4 Communication and information Working environment
5 Review and increase allowances Financial incentives
6 Career paths and promotion opportunities Working environment
7 Equalise benefits Financial incentives
8 Means of communication Living conditions
9 Review and increase incentives Financial incentives
10 Security Living conditions
11 Provision of equipment and drugs Working environment
12 Education and training opportunities Personal development
13 Housing for staff Living conditions
14 Improve procurement management Working environment
15 Home heating Living conditions
16 Establish statutory body for HRH Recruitment related
17 HIV/AIDS workplace strategies Working environment
18 Equalise salaries Financial incentives
19 Decentralisation of HR management Working environment
20 Competency-based training Personal development
… … …
… … …
LOW 64 … …

In observing these results, it is clear that ‘Working Environment’-related factors are of paramount
importance to health workers. This is evidenced by the fact that the ‘top 4’ interventions are all
associated with working conditions. Financial issues are also important, but priority issues around
financial matters are mainly to do with allowances and incentives and the fair allocation of these.
Interestingly, the salary itself only features later in the order of priorities. Living conditions focus
primarily around issues of personal security, taking priority over home comfort.

These prioritised interventions, which are in step with the broader recommendations made in the
PWC study mentioned in Chapter 2, form the basis for the key strategic objectives stipulated in
Chapter 5.

28
4.3 High Priority Interventions
In addition to the broader ongoing initiatives, outlined in Chapter 2, this Strategy promotes the
implementation of more specific actions that are mostly directed at the individual employee, as they
aim to improve their motivation and job satisfaction.

The action points recommended in this Chapter are listed according to the structure of the
Intervention Framework defined in Chapter 3 and summarised in the Logical Framework in Annex 3.
The sequence of the intervention categories is according to perceived priority categories, being:

1) Working environment
2) Financial incentives
3) Living conditions
4) Personal development
5) Recruitment-related

An arbitrary3 ‘top 20’ priority interventions have been selected from a total list of 64 possible
interventions. These shortlisted interventions are elaborated upon henceforth and form the basis for
the Priority Action Plan.

4.3.1 Working environment

SUPPORTIVE SUPERVISION
The quality of the supervision an employee receives is critical to employee retention. People leave
managers and supervisors more often than they leave companies or jobs. Supportive supervision is
closely associated with performance management. Effective supervision reinforces the concept that
management is getting things done through people. Traditionally, supervision is associated with
‘inspection’ and ‘control’. More recently supervision is viewed as a mechanism for bringing about
change and improvement. Direct supervision leads to improved motivation, work satisfaction,
performance improvement and better quality of care in remote settings12,13 Trust, concern and
support from the manager and/or supervisor is a key driver of stay-or-leave decisions by health
workers. Making supervision systems more effective holds potential for increasing health workers
productivity. Supportive supervision reinforces communication and counselling, reflection and
learning, especially among inexperienced health workers, helping them to improve their
communication skills.

Recent studies show that in Lesotho many health workers feel that they are inadequately supervised
with no feedback on performance. Supervision is usually in the form of irregular visits by supervisors
who seldom or never visit outreach/hardship areas. Many supervisors lack the knowledge, skills and
tools for effective supervision. Supervision received by staff is perceived to be inadequate since
managers have limited time because of the heavy workloads. There is lack of clarity on the scope of
supervision. The supervision system is currently not standardised.

3
As an alternative, one could focus on a more limited or more extensive set of priorities; at this point 20 top priorities were
selected

29
Retention strategies are closely linked to the application of a Performance Management System
(PMS). The current Public Service Regulations stipulates criteria for assessment of individual
performance and promotional prerequisites. There is an existing performance management system
in place cutting across all ministries in the civil service. In order to maintain consistency affected
holders of cadres included in the retention strategy will be subjected to this PMS, through an annual
appraisal assessment. The standard tool kit has been designed by the MOPS to ensure efficiency,
quality service delivery and planning within all levels of public servants. The current PMS requires
the respective subordinate and supervisor to develop a work plan and register quarterly progress
based on the agreed objectives and targets framework. At the end of every fiscal year the
assessment will be made with ratings indicated in order to determine how the individual officer has
performed.

Currently there is no performance-related pay and staff members are not even required to sign a
performance agreement that enforces termination of service for underperforming workers. The
Public Service Regulation of 2008 Chapter five (5) on Performance Management System, section 88
assets that the Minister of Public Service in consultation with the Minister responsible for finance
shall determine performance related pay to be rewarded to public officers each year and this will
replace the automatic annual increment however the government gazette effecting this new
condition has not yet been issued.

STRENGTHENING OF INFORMATION SYSTEMS

A well functioning Health (Management) Information System (HMIS/HIS) constitutes one of the
essential building blocks of the WHO HSS Framework. WHO defines a ‘well functioning HIS’ as being
one that ensures the production, analysis, dissemination and use of reliable and timely health
information by decision-makers at different levels of the health system, both on a regular basis and
in emergencies. It involves three domains of health information namely health determinants, health
systems performance and health status. This means that an information system must provide the
policy maker, manager, doctor, nurse and field worker with the right information in the right place at
the right time, in order to assist them with policy making and decision taking.

Health workers are motivated by timely feedback on health statistical information, based on routine
data provided by them to a higher level. Typically, routine data is submitted from the facility to the
district. Often, however, no routine feedback is given to the facility which is a de-motivator for staff.
Of equal importance is that a poor information system results in ‘lagging analysis’ of health system
data.

The MOHSW is currently in the process of developing a comprehensive HR Information System,

named iHRIS. The iHRIS system envisaged by the Ministry intends to accommodate functions related
to the registration and monitoring of staff.

MANAGEMENT SUPPORT
This concept is closely related to supportive supervision and performance management, but broader
in scope and primarily focused at the level of the individual health worker. Attention given by
management to individuals demonstrates good management and has the potential to improve

30
quality of care14 as it plays an important role as a motivational force among workers. Studies
consistently quote health workers, by stating that their supervisor's management and leadership
skills are inadequate, leading to a de-motivation of the workforce. Skilled managers have the ability
to motivate their employees. However, often in resource-poor institutions, management roles are
assigned to staff who are not adequately trained. Effective managers are also responsible for
lobbying on behalf of health workers and without their commitment factors affecting health worker
motivation will not be identified or addressed.17

Therefore, greater importance must be given to the development of inter-personal and leadership
skills of managers. Personal recognition and appreciation either from managers, colleagues or the
community are highly influential in health worker motivation. Allowing workers to make
recommendations towards HR polices that can be implemented to improve their motivation, is one
example of involving lower level staff in management.

COMMUNICATION AND INFORMATION

Health workers are motivated by receiving timely information and communications that affect them
personally, such as changes in government policy, conditions of service, new circulars, etc. Health
workers in Lesotho often complain that they don’t receive important notifications related to their
employment condition. Timely provision of relevant information is directly linked to good
management and supportive supervision, as it can reinforce communication and counselling,
reflection and learning, especially among inexperienced health workers, helping them to improve
their communication skills.

CAREER PATH AND INFORMATION

Well-defined career paths and promotion opportunities are key to health worker motivation.
Conversely, the lack of these lead to health workers feeling trapped in their positions, which makes
them more susceptible to the ‘pull factors’ of migration. Health workers in Lesotho indicate that,
although there is a promotion system in place, career opportunities are limited. This is attributed to
the absence of a systematic performance appraisal system. Health workers serve in the same
position for years without any promotion or increment. Considering current trends and priorities,
the main focus of interventions will be on health workers at district and community level, who are
affected by the process of decentralisation.

Promotion will be linked explicitly to performance appraisal. This is supported by the public service
regulations which stipulates that promotion be based on merit and not just seniority. The MOHSW
will discourage the practice whereby staff members are promoted for reasons other than good
performance. Performance management of health workers will be aligned with the Performance
Management Policy of the Ministry of Public Service which aims to promote efficiency and
effectiveness.

PROVISION OF EQUIPMENT AND DRUGS

Health sector resource constraints is a common theme in international studies. The lack of
equipment and drugs are seen as an important de-motivators for health workers and are closely
associated with emotional exhaustion. Efforts need to be made to ensure that health workers are
able to do their jobs and utilise their knowledge to the fullest and this should be an intrinsic

31
component of any plan to increase retention. Hospital infrastructure, equipment and drugs should
be a principal consideration, as patient care cannot be effective without these key resources. Poor
quality infrastructure and equipment does not inspire confidence from health workers, nor from
patients17. Measures are to be put in place to reduce the incidences ‘one month stock-out’ in any of
the drugs in the essential drug list in the health facilities.

IMPROVE PROCUREMENT MANAGEMENT

Poor practices and procedures for the procurement of goods, works and services contributes to
dissatisfaction among health workers. The ministerial procurement reform process (refer to Chapter
2) comes at an opportune time.

HIV/AIDS WORKPLACE STRATEGIES

The focus of the MOHSW Workplace Wellness Programme is on HIV and AIDS and is aimed at the
wellbeing of staff, by means of increasing access for them to HIV and AIDS services (refer to Chapter
2 for details). The MOHSW HIV and AIDS Workplace Policy and the accompanying programmes are a
direct response to the needs of Lesotho health care workers.

DECENTRALISATION OF HR MANAGEMENT
Decentralisation leads to better health workforce recruitment, performance and retention in rural
areas through the creation of additional revenue for the health sector and better use of existing
financial resources15. Studies show that health workers are generally more motivated in
‘decentralised districts’ where more decisions are taken at district and facility level. Presently, in the
Lesotho public health sector, promotion, career progress, transfers, etc. are all done at central level.
There is a need for greater autonomy by the districts. Recently, managers interviewed in
government hospitals mentioned the lack of autonomy they have in relation to staff recruitment,
continuous education and training, salaries/benefits, supervision and termination of employment.
CHAL appears to have more autonomy than government in most management policies.

Recent studies show that stress and burnout of health workers is less of a problem in decentralized
districts with staff employed in these districts scoring significantly higher on personal
accomplishment, lower on emotional exhaustion and lower on depersonalization scales than those
in the non-decentralised districts.

4.3.2 Financial incentives

REVIEW AND INCREASE ALLOWANCES
In the Lesotho public health sector, certain categories of health workers are eligible for allowances,
in particular the on-call duty allowance for doctors and the mountain allowance for health workers
in remote mountainous areas. Studies conducted in a number of countries in Africa, however, do not
reveal a strong correlation between payment of allowances and staff retention. In Zambia, for
example, the rural hardship allowance of 30% of the salary was found not to have a significant
impact in terms of improved retention and the same was found true for Ghana16. In South Africa,
Cameroon and Zimbabwe rural allowances also proved to have a limited effect on retaining health
workers. These findings confirm that monetary incentives alone will not deter Lesotho health
workers from migrating.

32
EQUALISE BENEFITS
The equalisation of benefits among health workers between government and non-government
healthcare providers reduces migration of workers between employers. A recent study5 revealed
that the inequitable treatment received by employees in terms of salaries, pension funds,
government scholarship loan refunds and gratuity is counter-productive to efforts in trying to halt
staff migration. Perceptions amongst staff interviewed in the decentralised districts supports this
finding.

REVIEW AND INCREASE INCENTIVES

In some countries financial incentives are applied to specific cadres of health workers. While
financial initiatives are thought to slow down the migration of the cadres, it may lead to enhanced
loss of health staff cadres not covered by the scheme, due to strong feelings of unfairness.
Interestingly, doctors and dentists are significantly more likely than other health workers to cite
income and incentives as a reason to migrate.

Among the Lesotho health workforce, discriminatory incentives are generally regarded as de-
motivating by those who do not qualify for the incentives. A major concern cited by managers are
the discriminatory monetary incentives given by donor agencies to nurses caring for HIV/AIDS
patients. This de-motivates nurses who are not dealing with HIV/AIDS patients.

EQUALISE SALARIES
Equalisation of salaries between government and non-government healthcare providers reduces the
migration of workers between employers. Lesotho health workers generally state that their salaries
are insufficient to meet their individual and family needs. Increase in basic salary, i.e. higher salary
grade is generally believed to be important, but research shows a modest impact. A research
exercise in 18 countries in Africa and Asia17 revealed that around 90% of retention-related studies
mentioned the importance of health worker salaries on motivation. However, it was noted that
financial incentives can only have an impact when combined with other incentives. Poor salary
packages were found to be particularly de-motivating as health workers felt that their skills were not
valued.

Countries such as Kenya, South Africa, Zambia, Malawi, Tanzania and Mozambique have increased
salaries of various cadres of health workers in an effort to retain them. In some countries this
enhanced salary is applied to particular grades of health workers. However, doing so tends to cause
strong feelings of unfairness among other health cadres.

In Lesotho, the salary discrepancies between the CHAL and MOHSW employees and the Global Fund
recipients lead to an uneven distribution of health workers in the country, as well as serving to de-
motivate staff in the public sector.

33
4.3.3 Living conditions
MEANS OF COMMUNICATION
For health workers in rural and remote areas, information and communication are of paramount
importance. The permanent availability of means of communication is essential for the emotional
well-being of health workers.

SECURITY
Providing security to health workers is of paramount importance and has a direct positive impact on
attraction and retention of health workers. Protection from risk, mainly in terms of bodily harm, is
quoted as a major consideration for health workers in rural and remote areas, in particular for
women.

HOUSING FOR STAFF

There is a strong correlation between quality of living conditions and willingness of health workers to
move or stay in a particular location. In particular in remote areas of Lesotho, there is a serious
residential accommodation shortage. On some occasions, staff posted to remote areas of the district
have to live elsewhere other than at the place of posting, due to no accommodation being available
there to rent.

HOME HEATING
In mountainous areas in particular, heating of staff worker homes is an issue that cannot be ignored.
The cold weather during the winter months requires measures to be taken to secure the well-being
and comfort of health workers when off-duty.

4.3.4 Personal development

EDUCATION AND TRAINING OPPORTUNITIES
Health workers generally express concern about the lack of opportunities for continuous education
within the Lesotho public health service. Although having some opportunities for in-service training,
fewer have opportunities for long term training. This concern impacts on morale and motivation of
health workers and contributes to some professionals leaving their jobs. Career development is
generally identified as very important. Health workers are often reluctant to work in remote areas,
where opportunities for personal development are typically less than in urban areas. Health workers
are more motivated when they feel they have the opportunity to progress17. Education and training
opportunities have strong motivating effects. Training enables workers to take on more demanding
duties and to achieve personal goals of professional advancement. It also allows them to cope better
with the requirements of their job. This is especially important for young health professionals.

In Lesotho, district managers generally are of the opinion that training does indeed lead to improved
job performance of health workers. However, most of the HR management and planning is done at
the central level, leaving the districts with little or no autonomy to implement changes. Some health
workers complain that those who complete training do not receive any reward for it. They also
perceive training to increase their workload, as more duties are assigned to them, because of the
new skills they acquire during the training.

34
The Ministry of Health and Social Services has recently finalised the Continuing Education Strategy
(CES) and Implementation Plan (CEIP). The purpose of the CEIP is to act as a ‘Master Plan’ for all
public health sector Continuing Education and serve as a point of reference for all stakeholders and
beneficiaries. Potential funding agencies will refer to the plan, so as to determine for which priority
areas and for which target groups funding may be identified. The CEIP is subject to annual review,
based on a periodic assessment of training needs.

COMPETENCY-BASED TRAINING
A competency is defined as the blend of skills, abilities, and knowledge needed to perform a specific
task4. Worldwide, the traditional approach to education in the health sector has been for trainers to
determine what content needs to be learned, teaching it, and then testing to see if the content was
learned. This approach however, though long established, does not guarantee that trainers use
content reflecting the needs of the workplace and often relies on passive memorization from
lectures as the dominant learning method for students.

Recent reforms support the application of competency-based education – defining, teaching, and
assessing competencies and then assessing student performance in relation to these, thus focusing
on the outcome of the training, rather than on the process (applying knowledge and skills rather
than merely gaining knowledge).

A competency-based education model starts by asking the question: What must the trainee be able
to do on the job, after the training? Then, appropriate training and assessment methods are
developed that will ensure reaching the objectives. Finally, evaluation is conducted to ensure that
students have mastered the desired competencies.

4.3.5 Recruitment-related
ESTABLISH STATUTORY BODY FOR HRH
Some of the challenges in attraction and retention of health workers are due to perceived disparities
between the terms and conditions of service in the MOHSW and MOPS by the health workers. For
this and other reasons, there is a need for an independent statutory body, responsible for all health
workers in the country.

The functions of this body will include:

1) Keeping track of the trends, both nationally and internationally, in health worker
recruitment, retention and deployment; and devise proactive strategies to protect Lesotho
from shortage of health workers,
2) Responsibility for all public health workers in Lesotho regardless of where they are
deployed,
3) Determine the terms and conditions of service of the health workforce,

4
Source: Human Resources for Health, 2010, http://www.human-resources-health.com/

35
 4) Responsibility to attract, recruit, deploy and retain health workers throughout the Lesotho
Public Health sector, and
5) Responsibility for devising sound career advancement strategies – including continuing
professional development programmes, in collaboration with the relevant professional
structures, promotion procedures/processes and feedback mechanisms.

Benefits of and lessons learnt from established HRH statutory bodies in countries such as UK,
Uganda, Malawi, and Zimbabwe could be examined and adapted for the Lesotho Public Health
system.

4.4 Interventions for Specific Cadres

A key component of this Strategy is the improvement of existing salary scales within the different
cadres of health professionals. The salary increments have now been approved by the Ministry of
Public Service (MOPS). The approval was influenced by the fact that these revised salaries are in line
with the results of the recent job evaluation project undertaken within the Public Services.

To date the revised salary scales for the nursing cadre has normalised the overlap between the
Principal Nurse and Senior Nurse levels, and has also established the nursing Directorate. The next
step is to work on the proposal for Medical Doctors and other remaining cadres. With the Medical
Doctors over and above the incentives that are already issued (i.e. call allowance, housing)
considerations include offering them remuneration at a higher notch at first appointment. The
revised salary structure was also informed by regional comparison.

The strategies and action points recommended in this document pertain, in principle, to all
categories of health workers. Issues around remuneration, motivation and migration are
crosscutting, as they affect both managerial, clinical, technical and administrative staff. It is
recognised, however, that certain cadres of health professionals are best targeted with additional
specific interventions.

4.4.1 Medical doctors

It is general knowledge that there is a serious shortage of Medical Doctors in the country. To address
this challenge innovative efforts to train Medical Students have been introduced by the MOHSW
with the support of development partners. Currently the numbers of Basotho medical students
studying at various levels of Medical Schools has increased. Moreover, the ministry has adopted an
approach of sending student to African countries and constantly supports and follows them up to
encourage their return to Lesotho. The number of Basotho medical students studying at various
levels of training in Medical Schools in RSA and elsewhere, has increased from 2009. It is projected
that, by the end of 2012, about 10-15 qualified doctors could return to the country annually. Formal
arrangements are also in place for in-country internships to indicate commitment. The government
through in-service training has policy that requires officials to enter into a bonding agreement to
ensure their return to Lesotho after completion of studies. It is anticipated that this would afford the
country a fair distribution of Basotho doctors to serve either MOHSW or CHAL institutions.

36
Currently, the country is heavily dependent on non-national Medical Doctors, amongst which there
is also high attrition rate because they are using Lesotho as a stepping stone to South Africa. This
situation hinders long term planning and sustainability of health services and programmes intended
to improve the skilled Human Resource base. The Table below gives an illustration of the distribution
of Doctors across the country for MOHSW and CHAL hospitals and Filter Clinics.

Table 11 Distribution of Doctors across MOHSW and CHAL institutions

(Source: Retention Strategy, MOHSW, February 23, 2010, QEII excluded)

MOHSW Number of CHAL Number of

Doctors Doctors
Mohale Filter Clinic 3 Seboche 7
Qoaling Filter Clinic 3 Maluti Hospital 7
Likotsi Filter Clinic 2 Mamohau 3
Mabote Filter Clinic 1 St Joseph 7
Lesotho Flying Doctors Services 1 St James 4
Berea 4 Scott 7
Leribe 9 Tebellong 4
Maputsoe Filter Clinic 1 Paray 7
Butha Buthe 4 St Joseph 7
Mafeteng 5 -
Mohales’ hoek 5 -
Quthing 4 -
Thaba Tseka 0 -
Katse Clinic 1 -
Qacha’snek 5 -
Mokhotlong 4 -
Senkatana 6 -
Mental Hospital (Mohlomi) 6 -
-
TOTALS 64 46

The 2004 HR Assessment indicated that the prevailing labour supply of medical doctors was around
106 (including Specialists), whereas the Table above shows that the number of medical doctors has
increased. This could be attributed to multiple reasons, such as donor-funded HIV and AIDS
interventions. The MOHSW has currently proposed a two pronged approach to retaining medical
doctors; career structure and salaries.

The following medical career structure is proposed:

(a) Houseman/Intern: This level has been proposed as an entry level and does not appear
in the current staff establishment list. This entails a twelve to fifteen months post
qualification programme of training in preparation for registration by an appropriate
medical council or body, as a general medical practitioner;

(b) Senior Houseman: A post registration position qualifying one to practice independently
as a general practitioner;

(c) Registrar: A position senior to that of senior houseman usually attained after two years
as senior houseman in the case of Ministry of Health and Social Welfare;

37
 (d) Senior Registrar: A position to allow upward mobility for a doctor who did not have an
opportunity for further training three years after attaining the position of Registrar and
yet has shown high quality of work and dedication. The position of senior registrar is a
new proposal in the medical officers’ career structure;

(e) Specialist: A position designated to a medical practitioner registered with an appropriate

registering council or body, with a diploma/degree in one of the medical specialities; and

(f) Consultant: A specialist who through good conduct and professional competence has
been recommended for promotion to Consultant, by the MOHSW to the Public Service
Commission, who endorses the recommendation for promotion.

(g) Managerial Positions: Senior staff will have the opportunity to progress further into
managerial positions. These include Medical Superintendants and District Medical
Officers.

Proposed salary increases for doctors are within the existing salary structure and grading applicable
in the public sector. The submission to Global Fund therefore (see Chapter 2) does not change the
overall grading of medical officers but suggests that the notch at which a medical officer enters into
a particular grade.

4.4.2 Nursing Cadre

There is a serious shortage of Nurses in the country. According to the Needs Assessment study done
in 2004, the country then had a shortfall of six hundred Nurses. The coverage of the existing staff is
steadily declining for reasons similar to those that affect doctors. This is despite a vigorous training
effort by several local nursing colleges. Nurses emigrate in large numbers, while they still remain in
great demand locally. Nursing services play an important role in the overall care and treatment of
patients and their importance cannot be over-emphasized. The MOHSW thus proposes a remedial
initiative which will effectively cover career structure and salaries.

The structure indicates entry into the Nursing Profession to be a single qualified diploma. Officials
will therefore acquire a second diploma, which enables them to progress along the ladder through
experience. Further training and acquisition of higher diplomas/degrees shortens the period of
progression, in recognition of these acquired skills. The career ladder shows the position of Director
of Nursing service as the head of the Nursing profession. Two positions of Chief Nursing Officers are
proposed. They are accountable to the Director of Nursing Services (DNS). They will be in charge of
Northern and Southern regions of the country, while Principal Nursing Officers will be in charge of
individual hospitals and some programmes.

The current career ladder and structure has some challenges, hence the need for the proposed
structure to deal with nurses’ specialisation and careers in the future. The following career structure
for nurses is presented with different entry levels, while all the appointments and promotions will be
guided by the Public Service Regulations:

38
 1. a) A Nursing Assistant enters at Grade E
b) A single qualified nurse enters at Grade F
c) A double qualified nurse enters at Grade G as Senior Nursing Sister and after two (2)
years experience can qualify to progress to the level of Nursing Officer, Grade H.
After five (5) years one qualifies into the level of Senior Nursing Officer and can
become the Principal Nursing Officer after another ten (10) years. All these
promotions are not automatic and will be determined by available vacancies.

2. A double qualified Nurse with another diploma will enter at Nursing Officer level, Grade
H and after three (3) years can then qualify into the level of Senior Nursing Officer and
Principal Nursing Officer after five (5) years and can become Chief Nursing Officer after
ten (10) years.
3. A double qualified nurse with a degree enters at Nursing Officer level, Grade H and can
be promoted to the level of Senior Nursing Officer after two (2) years. After three (3)
years one can then qualify to the level of Principal Nursing Officer and Chief Nursing
Officer after eight (8) years. All these promotions are not automatic and will be
determined by the available vacancies.
4. A nurse who acquires a Master Degree enters at Principal Nursing Officer level, Grade J
and after five (5) years one can be promoted to Chief Nursing Officer. This Nurse shall
have practical experience before studying for Masters Degree. All these promotions are
not automatic and will be determined by the available vacancies.

4.4.3 Other Health Professionals

The quality of Health Care Services is greatly enhanced by clinical support programmes of high
quality and efficiency. These attributes have been seriously compromised by inadequate and
inappropriately trained support staff. The turn-over of highly qualified and efficient staff contributes
to the disruption of service provision and consequent unsatisfactory attention to the public.

The Health Sector Reform Programme has emphasized Decentralization for efficient health Services
Delivery. It has also drawn attention to provision of adequate clinical support staff for enhanced
quality of care. Eight (8) clinical support programmes are currently reviewed; salary increments are
based on the existing salary structure. Attention is paid to a shorter period and to avoid overlaps.
Attention will also be given to allowances, which are regarded as essential to alleviate hardships and
to compensate for unusual working hours. They should be reviewed in the wider context of the
Public Service. The MOHSW thus present a remedial initiative for these clinical support workers.

4.4.4 CHAL Employees

As per the 1995 MOU between GoL and CHAL it is expected that all salaries be benchmarked and
certain provisions be applicable in both sectors. Similarly CHAL has been experiencing problems of
insufficient health force and high staff turnover of health professions for different cadres hence why
it is necessary to extend this Retention Strategy to CHAL human resources.

39
5 The Strategy
5.1 Key Strategic Objectives
The key strategic objectives are derived from the findings from the prioritisation process outlined in
the previous Chapter. In addition to ongoing actions and initiatives, described in Chapter 2, this
Strategy focuses to a large extent on non-financial interventions.

Strategic Objective #1
Support ongoing efforts by the Ministry of Public Service and the Ministry of Health and
Social Welfare, in order to ensure improved financial incentives for health workers.

Strategic Objective #2
Improve the working environment and working condition of health workers, in order to
improve job satisfaction and staff morale.

Strategic Objective #3
Support efforts to promote equity and fairness among health workers, in terms of salary,
allowances and incentives, in order to improve staff motivation and satisfaction.

Strategic Objective #4
Maintain minimum standards for living conditions of health workers, with special emphasis
on physical comfort, security and means of communication.

Strategic Objective #5
Increase access for health workers to personal development opportunities, including skill
building and in-service training.

Strategic Objective #6
Improve recruitment procedures, in order to reduce the propulsion to migrate of health
workers deployed to rural areas.

5.2 Framework for Implementation

5.2.1 Ongoing Retention Initiatives
Strategic Objective #1
Support ongoing efforts by the Ministry of Public Service and the Ministry of Health and Social
Welfare, in order to ensure improved financial incentives for health workers.

This Strategy endorses the existing and ongoing broader national and sector-specific interventions
and efforts towards improving attraction and retention of public sector workers. Reference is made
to Chapter 2 for an overview of existing and ongoing actions at government and sector level. These

40
ongoing projects and actions by MOHSW and MOPS are fully supported by this Strategy and have
been included in the Logical Framework (Action Plan) in Annex 3.

5.2.2 Working Environment

Strategic Objective #2
Improve the working environment and working condition of health workers, in order to improve job
satisfaction and staff morale.

SUPPORTIVE SUPERVISION
A key element of supportive supervision is the existence of an operational Performance
Management System (PMS).

Introduce a Performance Management System (PMS) approach, by ensuring that three Human
Resources Management rules are in place:
1) Staff know and understand what performance is expected from them
2) Staff have the competencies to perform as expected
3) Staff received continuous positive feedback about their performance

To implement PMS interventions, the following steps will be taken:

1) Foster agreement and commitments among stakeholders
2) Determine the expected performance of local health teams
3) Assist local health teams to carry out performance improvement
4) Manage change and performance support efforts
5) Celebrate progress made (success stories, pilots, etc.)

STRENGTHENING OF INFORMATION SYSTEMS

a. HMIS System
1) Implement the National HIS Policy/Strategy
2) Establish Leadership and Task Teams
3) Carry out an Information Audit
4) Define Key Indicators and Minimum Data Sets
5) Define a Data Flow Policy
6) Ensure Quality Control
7) Implement Training Programmes
b. HR Information System
1) Establish the iHRIS system
2) Provide user training at all levels

MANAGEMENT SUPPORT
1) Provide training to management at all levels on relational and inter-personal skills, e.g.
leadership, conflict management, communication skills
2) Provide awareness training for health workers at all levels, related to health services
organisation and the role of management

41
COMMUNICATION AND INFORMATION
1) Provide training to managerial staff at all levels, on subjects related to communication and
information sharing
2) Strengthen the system to provide timely and relevant information to health workers, such as
information on job opportunities, recent developments in the health sector, opportunities
for research and elective training courses
3) Establish a periodic news bulletin for health workers

CAREER PATH AND PROMOTION OPPORTUNITIES

1) Carry out a situation assessment related to existing career development paths
2) Ensure that promotion is explicitly linked to performance appraisal procedures
3) Develop or update DHMT staff and community health workers career path plans
4) Develop implementation mechanism for updated career path structures

PROVISION OF EQUIPMENT AND DRUGS

1) Carry out a national situation assessment related to the status of medical equipment
2) Assess the technical support systems for equipment maintenance
3) Assess and improve procurement procedures (refer to next section)
4) Ensure adequate budgets in place for the procurement, replacement and maintenance of
equipment, adhering to international standards for minimum budgets
5) Improve the procurement and distribution system for drugs and other pharmaceuticals
6) Put in place measures to reduce the percentage of health facilities reporting ‘one month
stock-out’ in any of the drugs in the essential drug list

IMPROVE PROCUREMENT MANAGEMENT

1) Strengthen the Procurement Unit within the Ministry, by filling vacancies with competent
officials
2) Provide training to procurement staff at all levels

HIV/AIDS WORKPLACE STRATEGIES

1) Disseminate the HIV and AIDS Work Place Policy to all health workers
2) Identify wellness program champions and disseminate success stories
3) Carry out a policy impact assessment at periodic intervals
4) Expand the scope of the Workplace Wellness Programme beyond HIV and AIDS

DECENTRALISATION OF HR MANAGEMENT
1) Implement the GoL and MOHSW decentralisation policy
2) Implement district-specific initiatives towards the retention of health workers, according to
this policy

5.2.3 Financial Incentives

Strategic Objective #3
Support efforts to promote equity and fairness among health workers, in terms of salary, allowances
and incentives, in order to improve staff motivation and satisfaction.

42
REVIEW AND INCREASE ALLOWANCES
1) Review existing allowances, with special emphasis on equality among health workers
2) Extend the on-duty call allowance to all health workers who take calls
3) Extend the mountain allowance to all health workers in hardship areas
4) Consider alternative or additional allowances, e.g.: transport allowance, special duty
allowance, security allowance and cell phone allowance (for doctors on call)

EQUALISE BENEFITS
1) Investigate discrepancies in benefits between government and non-government health
workers
2) Put measures in place to standardise benefits between government and non-government
employers
3) Standardise repayment rate of the National Manpower development Secretariats (NMDS)
bursary schemes for government and non-government employees

REVIEW AND INCREASE INCENTIVES

1) Review existing incentives, with special emphasis on equality among health workers
2) Consider alternative or additional allowances, e.g.: paid leave, house loans, car purchase
loans and other personal loans

EQUALISE SALARIES
1) Address the discrepancies between the CHAL, and government employees and the Global
Fund recipients
2) Carry our an in-depth assessment, as to the impact of salary on staff migration in Lesotho

5.2.4 Living Conditions

Strategic Objective #4
Maintain minimum standards for living conditions of health workers, with special emphasis on
physical comfort, security and means of communication.

MEANS OF COMMUNICATION
1) Explore the feasibility of two-way radios and/or other means of communication, at health
facilities where neither landlines nor mobile connections are available
2) Ensure the maintenance of existing radio communication systems
3) MOHSW to negotiate the extension of public services, such as banking (for instance through
mobile banking services) and communication (through improved cell phone networks,
internet services, satellite technology, etc) to remote areas; these services should be
advocated as part of the service providers’ social responsibility
4) Explore the feasibility of setting up access to the internet in designation rural locations
5) Explore the feasibility of traditional book libraries for clusters of health workers

43
SECURITY
1) Put security measures in place to minimise risk and protect health workers from potential
bodily harm, both on- and off-duty
2) Provide or subsidise secure housing
3) Ensure means of communication for health workers at all times (see above)
4) Provide duty-transport to health workers, especially for staff working late and at odd hours

HOUSING FOR STAFF

1) Explore concepts around house owning schemes for district-level health workers
2) Explore ways of ensuring maintenance and renovation of staff houses
3) Explore the designation of housing by local authorities

HOME HEATING
1) Explore provision of heating systems for staff housing
2) Explore the feasibility of subsidizing utilities (water, electricity)
3) Explore the provision of solar water collectors
4) Explore the free distribution of warm clothing and blankets

5.2.5 Personal Development

Strategic Objective #5
Increase access for health workers to personal development opportunities, including skill building
and in-service training.

EDUCATION AND TRAINING OPPORTUNITIES

1) Implement the MOHSW Continuing Education Implementation Plan (CEIP)
2) Ensure buy-in and concurrence to the CEIP by all Health Partners and Training Providers
3) Carry out a Training Needs Assessment to inform the periodic revision of the CEIP
4) Give greater autonomy to districts in determining training needs for health workers
5) Explore ways of conducting training at district and facility level

COMPETENCY-BASED TRAINING
1) Develop training programmes for health workers that are competency-based and thus of
direct relevance to their jobs
2) Apply evaluation methods that ensure that training objectives are reached

44
5.2.6 Recruitment-related
Strategic Objective #6
Improve recruitment procedures, in order to reduce the propulsion to migrate of health workers
deployed to rural areas.

ESTABLISH STATUTORY BODY FOR HRH

1) Assess the feasibility of establishing a MOHSW-managed Health Services Commission (HSC),
responsible for all matters related to HRH
2) Develop Terms of Reference for the HSC, in the event that such an initiative proves
beneficial to the recruitment process and retention of health workers
3) Depending on the outcome of the feasibility study, establish the HSC

5.3 Quick Wins

There are opportunities for quick gains, in terms of impacting on attraction and retention with low-
cost interventions in the short term. These include:

Training in Supportive Supervision and Management Support

Supportive supervision and management support have been identified as having top priority,
in terms of retaining health workers in remote places. It is recommended that training
programmes, wherever, whenever and whoever by, put supportive supervision and
management support on top of the agenda. The HSS Project and other Development
Partners are advised to give priority to training in these specific areas.

IT Refresher Courses
IT/ICT plays a crucial role at all levels of the organisation; mastery of basic IT and computer
skills is a requirement for most, if not all, cadres of health workers. It is recommended that
all health workers receive refresher training in IT basics. The way this can be done is by
developing a purpose-written training/reference manual that focuses on IT essentials
(suggestion: HSS Project to assist). This manual will be circulated among all health workers,
as a learning tool and reference guide to keep. Subsequently, certain categories of health
workers will undergo a formal test, so as to ensure that the manuals have been read and its
content assimilated.

Training related to Information Systems

Health workers’ motivation and job satisfaction are directly associated with the efficient and
effective flow of information within the organisation. The MOHSW is advised to give priority
to all aspects of information systems development. It is recommended that in-service
training programmes give priority to topics related to communication and information.

News Bulletin
Given the perceived importance of information and communication, the MOHSW should
consider the issuance of a monthly or quarterly general newsletter, for distribution among
all health workers. It is understood that such a newsletter did exist in the past. Renewed

45
 management support will be required. The newsletter will cover a variety of topics, such as:
key events, performance statistics, staff matters, training opportunities, success stories, fun-
page, etc. The newsletter will encourage individual health workers to respond to issues and
communicate their experiences, as potential input for subsequent editions. The newsletter
will be made available as hard copy, posted on the ministerial website and distributed by
email.

Conduct Exit Interviews

The reasons why health workers resign and leave the service should be routinely
documented to assist policy makers to address the causes of internal and external migration.
Health information management systems should be used to track the flows of health
workers and inform the planning and distribution of health workers. Health worker profiles
are necessary to be able to monitor implementation of interventions and assess impact.

Lessons Learned in Decentralisation

A recent study funded by the Trinity College in Dublin (Maximising Human Resource Capacity
in Rural District Health Systems in Lesotho, August 2008), suggested that ‘decentralisation’
and in particular the decentralisation of HR management, has a positive impact on staff
retention. The evidence for this, however, is merely anecdotal. It is recommended that
lessons learned from Berea, Thaba-Tseka and Mohale’s Hoek districts are replicated to other
districts. It may be necessary to carry out a rapid study in those pilot districts whereby
health workers are interviewed around issues of motivation and job satisfaction.

It is recommended that the MOHSW and their Development Partners endeavour to incorporate
these quick-win strategies into their current projects and programmes, wherever applicable.

5.4 Practical Actions

This section takes a closer look at the more practical and tangible priority interventions (see Annex
2) and gives specific details of feasible options and sub-activities, based on the Action Plan (see
Annex 3). The reasons for doing this is to provide the Ministry with practical ideas and suggestions
that can be explored for rapid implementation of high-impact interventions. This section
complements the previous section on ‘quick wins’. The practical actions and suggestions are listed in
the Table below.

46
Table 12 Suggested Practical Actions
# Interventions
1 Improve security
for health workers
in isolated areas
2 Improve staff
housing
3 Improve home
heating for workers
5
For a complete range of self-defence products: http://hubpages.com/hub/Self-Defense-Gadgets-Every-Woman-Should-Carry
Key Activities
1) Put security measures in place to
protect health workers from bodily
harm
2) Provide or subsidise secure housing
3) Ensure means of communication for
health workers at all times (also see
above)
4) Provide duty-transport to health
workers, especially for staff working
late and at odd hours
1) Explore concepts around house
owning schemes for district-level
health workers
2) Explore ways of ensuring
maintenance and renovation of
staff houses
3) Explore the designation of housing
by local authorities
1) Explore provision of heating
systems for staff housing
2) Explore the feasibility of subsidizing
Suggested Practical Initiatives Seek Donor/NGO Support
1) Issue self-defence gadgets to female workers, e.g. pepper 1) Yes
spray, taser, personal alarm key chain, screecher5. 2) Yes
Combined with flash light (torch). Train essential self- 3) Yes
defence tactics to female workers. 4) No
2) Set minimum standards for home alarm for staff housing
and install practical security measures, e.g. burglar bars,
locks, movement detectors, outdoor security lights with
motion detection (when electricity is available)
3) Issue one-off free cell phones to selected categories of
health workers
4) Institute sponsored taxi-service for selected health
workers, e.g. transport at set times to and from fixed
locations
1) Set minimum standards for staff housing; negotiate with 1) Yes
potential donor agencies to fund a national housing 2) Yes
project for rural health workers; explore home owning 3) No
schemes for rural health workers
2) Set minimum standards for maintenance; extend health
facility maintenance services to staff housing; donor-
assisted renovation of staff housing
3) MOHSW negotiates with local authorities to acquire
housing for health workers
1) Provide 3-month supply of charcoal or firewood to 1) Yes
selected health workers 2) No
2) Water and electricity for staff partially paid for by health 3) Yes
47
# Interventions Key Activities
utilities (water, electricity)
3) Explore the provision of solar water
collectors
4) Explore the free distribution of
warm clothing and blankets
Suggested Practical Initiatives Seek Donor/NGO Support
facility concerned 4) Yes
3) Install solar water heaters in selected staff houses; donor
funded pilot project to assess feasibility
4) Distribute free blankets and clothing to selected health
workers at the beginning of winter

4 Improve means of 1) Explore the feasibility of two-way 1) Survey of radio systems; link all health facilities with 1) Yes
communication for radios at selected facilities district offices 2) Yes
health workers in 2) Maintain existing radio 2) Maintenance project 3) No
remote areas communication systems 3) Negotiations with private sector; refer to Social 4) No
3) Negotiate the extension of public Responsibility 5) Yes
communication services to remote 4) MOHSW negotiates with ISPs
areas (banking, cell phone) 5) Book libraries in designated locations
4) Improve access to the internet in
rural areas
5) Explore the feasibility of traditional
book libraries

5 Transport for staff 1) Provide or subsidise duty and 1) Sponsored taxi-service for selected health workers (see 1) No
private transport above) including weekly shopping trip; subsidised
transport for taking children to local schools

It is recommended that several pilot locations in diverse remote locations are identified, where a broad selection of the above practical interventions are put into
practice. Funding for such an initiative could be negotiated with a donor agency/ health development partner. The evaluation of the pilots will lead to broader
implementation of successful initiatives that have a positive impact on staff retention.

48
6 Monitoring & Evaluation
6.1 Key Indicators
Once the Plan of Action is implemented, close monitoring and evaluation of impact will be required.
This will generate empirical evidence which can be used by the MOHSW to inform a more accurate,
comprehensive, relevant and realistic retention strategy for health professionals. The MOHSW will
adopt key indicators to measure impact of the Strategy.

The following key indicators, both quantitative and qualitative, are proposed:

Key Indicator 1: Rate of vacant posts6

Rate of vacant posts, for all cadres. Vacancy rate is the extent to which the health department has
unfilled positions18.

Key Indicator 2: Turnover rates

Turnover Rates, which is the percentage of health workers who have left the service over a certain
period of time.

Key Indicator 3: Annual rate of retention

Annual rate of retention of health care workers at the health institutions. This is an indicator
commonly used by the Global Fund.

Key Indicator 4: Reason for leaving

It is recommended that exit interviews are conducted, whereby reasons for leaving are given and
documented for periodic analysis. The most common reasons for leaving are:

1) Mandatory retirement
2) Early retirement
3) Retrenchment
4) Further studies
5) Job opportunities outside the country
6) Joining private practice
7) Dismissal on disciplinary grounds
8) Desertion of duty
9) Medical grounds
10) Transfer of services
11) Death of staff member

6
There are currently about 3,241 established positions in the establishment register. Of these 2,532
positions are filled. 709 positions are vacant, 76 staff are on long term training (Source: Draft Posting
Policy, MOHSW, August 2010 – Figures to be confirmed).

49
6.2 Periodic Revision of the Strategy
Based on the findings from the periodic impact analysis, it is recommended that the Strategy will be
updated periodically, preferably at 3-5 year intervals, with an initial mid-term evaluation after two
years. The mid-term evaluation will give guidance to the interim adjustment of the Strategy and
corresponding Action Plan. It is further recommended that the same survey instrument is applied,
which was used for the prioritisation process described in Chapter 4. The survey tool is given in
Annex 5.

50
7 Conclusions
Human resources for health, as an important element of the health system, must be given a more
dominant place in the ongoing reform process. The GoL must ensure that working conditions and
living standards of health workers in Lesotho are maintained at acceptable standards, especially in
rural areas. The political commitment toward ongoing health reform, including this Retention
Strategy, must be strengthened and serious steps need to be taken to ensure sustainability.

A concern has been raised that past and present initiatives in Lesotho, to alleviate the problem of
high attrition, have thus far not resulted in reversing the trend in migration of health professionals.
Research suggests, however, that health workers are more likely to remain in their jobs when
offered a combination of benefits to boost job satisfaction and morale. For this reason there is a
need for this comprehensive Retention Strategy, which goes beyond purely financial incentives for
health workers. This Strategy gives ample attention to non-financial interventions, as they offer
feasible and affordable complementary measures to stem the outflow of trained professionals. It is
crucial that both financial and non-financial interventions are pursued by the Ministry as a package
of interventions.

As much as the Ministry of Public Service takes leadership in the overall retention of public servants,
this MOHSW Retention Strategy constitutes an important complementary measure to address the
human resources crisis. It is crucial that all Health Development Partners work together, under the
leadership of the Ministry, to address the key strategic priorities addressed by this Strategy.

Finally, it is recommended that the methodology used for the development of this Strategy, i.e.
determining priority retention interventions for health workers in Lesotho, will be applied at periodic
intervals, so as to evaluate and adjust the appropriate package of interventions for health workers. it
is recommended that the Ministry reviews and refines this Strategy at 3-5 year intervals, with a mid-
term evaluation after 2 years from the start of implementation. The Action Plan needs to be updated
annually, while implementation is monitored throughout the year.

51
Annex 1 Retention Interventions: Generic Framework
Intervention
A. Recruitment-related
Compulsory rural service
Bonding
Fixed term rural posting
Retention of academic certificates
and transcripts
Targeted local recruitment
Targeted recruitment drives
Establish ‘rural pipeline’
Attract Diaspora
Retention of foreign doctors
Task shifting, skilled substitution
Rotational locum system
MOPS/MOHSW special contracting
initiative
Establish statutory body for HRH
Expert Patients
Prohibit poaching by donors
Age-specific deployment to rural
areas
Re-employment of retired
professionals
Employment of international
volunteers
B. Financial Incentives
Higher salaries
Equalise salaries
Performance-based pay
Salary based on scarce and critical
skills
Review and increase allowances
Review and increase incentives
Incentives for new recruits
Review and increase insurances
Equalise benefits
Eliminate discriminatory financial
incentives
End-of-service payments
Allow dual practice/income
Description
Obligate health workers to serve in a rural location, for a period of time
Obligate health workers to work for government, after initial training has
been completed
Agree on a fixed term contract in rural areas
Withhold qualification certificates, to ensure graduates working for
government for a period of time
Recruit trainees from remote areas results and assign them placements
close to their original locality
Recruit individuals from specific locations
Establish and nurture linkages between health department and rural
schools and colleges; then follow through with recruitment drive
Put in place measures to ‘attract back’ health professionals who have
migrated out of the country
Put in place measures to halt the out-migration of foreign doctors
Train certain cadres of health workers to provide additional services;
delegate tasks to less specialised health workers
Allow staff to work additional shifts with pay within their duty station
Introduce an innovative contracting system, with yearly quota of health
worker positions for which candidates apply
Create a body responsible for all health workers, keeping track of
recruitment trends, retention, career advancement, etc.
Train patients to assist at clinic level, with tasks like filing, taking vital
signs and counselling patients
Combat poaching practices of professionals by donor agencies
Sent older health workers, with less need for diverse social life, to the
rural areas
Attract retired health workers from inside or outside the country
Recruit doctors, nurses and other professionals through international
voluntary organisations
Increase basic salary level
Equalise salaries between government and non-government healthcare
providers
Supplement basic salary by a performance-based top-up, e.g. bonuses
Reward scarce skills, i.e. occupations for which there is a scarcity of
qualified and experienced people
Update allowances, e.g. hardship allowance, transport allowance, study
allowance, etc.
Update incentives in an effort to retain health workers, e.g. house loans,
car purchase loans, etc.
Introduce a special package of incentives for students after they graduate
and enter into service
Provide insurances, e.g. life insurance, medical cover, accident cover, etc.
Equalise benefits between government and non-government healthcare
providers
Do away with incentives which only apply to certain health worker
categories
Issue generous payouts at end of service
Improve income levels of health workers by allowing them to take on
second jobs, e.g. running a private practice
52
Intervention
C. Working environment
Management support
Supportive supervision
Strengthen information systems
Communication and information
Performance management system
Career paths and promotion
opportunities
Decentralisation of HR management
Workload management
Stress management
HIV/AIDS workplace strategies
Special leave/career break
Nurture positive working
relationships
Appropriate infrastructure
Provision of equipment and drugs
Improve procurement management
Clean & orderly work environment
D. Living conditions
Housing for staff
Amenities (water, electricity)
Home heating
Transport for staff
Means of communication
Childcare
Security
Entertainment
E. Personal development
Education & training opportunities
Subsidised studies
Free learning materials
Local/rural training availability
Competency-based training
Distance education programmes
Educational opportunities for family
members
Study leave
Access to information
Research
Description
Give attention to individual health workers, by management
Ensure regular supervision with the aim of increasing motivation and job
satisfaction of health workers
Provide timely feedback to suppliers of data on health statistical
information, based on routine data provided
Issue relevant information to health workers that affects them personally,
e.g. changes in policy, conditions of service, etc.
Establish and maintain a holistic approach to people management, which
is developmental, rather than punitive in nature
Stimulate career progression of individual health workers
Delegate decision related to staff matters to district and facility level
Put measures in place to avoid excessive workload for individual health
workers
Ensure that tasks given to health workers are in line with their
qualifications, so as to avoid stress
Increase access for health workers to HIV and AIDS services
Allow leave with or without pay, to encourage workers to return to
service after a break
Improve staff morale and retention through dedicated training in people
skills and other measures
Ensure adequate, safe and appropriate infrastructure
Ensure adequate, safe and well-maintained equipment; ensure timely
supply of pharmaceuticals
Ensure effective procedures are in place for the procurement of goods
and services
Ensure a healthy, clean and well-organised place of work
Ensure an acceptable quality of living for health workers, which is safe,
secure and comfortable
Provide subsidised utilities (water, electricity, telephone)
Provide heating systems for staff houses
Provide or subsidise duty and private transport
Install and maintain radio communication systems and/or other means of
communication, at health facilities where neither landlines nor mobile
connections are available
Pre-schooling and care for children
Ensure safety and security for health workers, both on- and off-duty
Provide entertainment systems, including TV/Video, Internet, Sport
facilities in areas that are under-served
Ensure career progression opportunities
Provide or subsidise study fees
Supply staff who wish to progress with learning tools and materials
Provide training on-location, in rural under-served areas
Encourage the provision of training which is of direct relevance to the job
Facilitate learning programmes that are provided remotely, either
through internet or using traditional postal services
Make provision to study for dependent spouse and children
Allow study while on leave with continued pay
Facilitate the availability of computers, internet and traditional libraries
Allow health workers to carry out research on topics of interest
53
Annex 2 Retention Interventions: Prioritised

SCORE RANK INTERVENTION CATEGORY

HIGH 1 Supportive supervision Working environment
2 Strengthen information systems Working environment
3 Management support Working environment
4 Communication and information Working environment
5 Review and increase allowances Financial incentives
6 Career paths and promotion opportunities Working environment
7 Equalise benefits Financial incentives
8 Means of communication Living conditions
9 Review and increase incentives Financial incentives
10 Security Living conditions
11 Provision of equipment and drugs Working environment
12 Education and training opportunities Personal development
13 Housing for staff Living conditions
14 Improve procurement management Working environment
15 Home heating Living conditions
16 Establish statutory body for HRH Recruitment related
17 HIV/AIDS workplace strategies Working environment
18 Equalise salaries Financial incentives
19 Decentralisation of HR management Working environment
20 Competency-based training Personal development
21 Salary based on scarce and critical skills Financial incentives
22 Clean and orderly work environment Working environment
23 Establish ‘rural pipeline’ Recruitment related
24 Fixed term rural posting Recruitment related
25 Transport for staff Living conditions
26 Targeted local recruitment Recruitment related
27 Incentives for new recruits Financial incentives
28 Stress management Working environment
29 Amenities (water, electricity) Living conditions
30 Eliminate discriminatory financial incentives Financial incentives
31 Higher salaries Financial incentives
32 Nurture positive working relationships Working environment
33 Attract Diaspora Recruitment related
34 Appropriate infrastructure Working environment
35 Task shifting, skilled substitution Recruitment related
36 Expert Patients Recruitment related
37 Encourage Research Personal development
38 Performance management system Working environment
39 Access to information Personal development
40 Study leave Personal development
41 Rotational locum system Recruitment related
42 End-of-service payments Financial incentives
43 Workload management Working environment
44 Subsidised studies Personal development
45 Distance education programmes Personal development

Continued on next page...

54
Annex 2 Retention Interventions: Prioritised (cont’d)

SCORE RANK INTERVENTION CATEGORY

46 MOPS/MOHSW special contracting initiative Recruitment related
47 Review and increase insurances Financial incentives
48 Local/rural training availability Personal development
49 Targeted recruitment drives Recruitment related
50 Re-employment of retired professionals Recruitment related
51 Childcare Living conditions
52 Retention of foreign doctors Recruitment related
53 Free learning materials Personal development
54 Compulsory rural service Recruitment related
55 Bonding Recruitment related
56 Performance-based pay Financial incentives
57 Educational opportunities for family members Personal development
58 Special leave/career break Working environment
59 Employment of international volunteers Recruitment related
60 Entertainment Living conditions
61 Prohibit poaching by donors Recruitment related
62 Allow dual practice/income Financial incentives
63 Age-specific deployment to rural areas Recruitment related
LOW 64 Retention of academic certificates and transcripts Recruitment related

55
Annex 3 Logical Framework: Action Plan

The Logical Framework with detailed Action Plan is available as a separate document.

Annex 4 Timeframe (Gantt Chart)

The timeframe for the implementation of the Action Plan is available as a separate document.

56
Annex 5 Survey Instruments

The survey tool is tailored to the methodology, outlined in Chapter 1. A key element of the survey
tool is a scoring sheet, whereby each intervention from a generic Intervention Framework is
evaluated according to its (i) importance, (ii) feasibility, (iii) affordability, (iv) external support, and
(v) sustainability.

This exercise can be carried out with a group of experts, who are representative for the health
worker cadres under investigation. After a period of discussion on each intervention topic,
individuals are asked to complete the score sheet, based on their own personal interpretation and
opinion of each intervention.

The scoring sheet has the following format:

This exercise can be carried out with a specific group or sub-group of health workers. Should a more
comprehensive study be required, then the same methodology can be used as the basis for a
stratified, random sampling survey among health workers of sub-groups of health workers, so as to
identify priority interventions that are likely to lead to improved staff retention. Such a study should
be carried out at periodic intervals, preferably once every two years.

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