PERFORMANCE MANAGEMENT AND PRODUCTIVITY IN PUBLIC HEALTH INSTITUTIONS IN THE SOUTH- EAST OF NIGERIA

ABSTRACT

This study explored performance management and productivity in public health institutions in the South- East of Nigeria with particular reference to three selected public health institutions in the area. The problem of the poor quality of health services rendered to the Nigerian population, even though the National Health Policy advocates for improved quality of services was the motivating factor for this research. The objectives of this study were basically to find out what factors influence employee productivity in the hospitals understudy, and how and to what extent motivation and reward systems are related to the performance management system in public health institutions.  The study followed a quantitative research approach using a survey research design. The target population included all employees of the public health institutions understudy, which was 4,834. A sample of 369 was drawn from the population using Taro Yamane’s formula. The reaction to the study was positive as a response rate of 81.30% (300) was obtained.

The X2   (chi-square) test statistic at 0.05 level of significance was used in testing the hypotheses. The study revealed that the performance management factors in the selected organizations had positive influence on employee productivity. The study also revealed that there was a positive relationship between training and developmental efforts in the selected institutions  and  productivity.  However,  it  was  observed  that  public hospitals currently have deficiencies in some training and developmental

aspects (i.e. incompetent healthcare employees are not always identified and provided with the necessary support, and that good leadership and management training are not always available). The study further revealed among others that the management of the public health institutions were more   committed   to   a   membership-based   reward   system   than   a performance-based system; that hospital managers in the selected organizations were equipped to facilitate good performance of their subordinates. Based  on  the  results,  some  recommendations were  made which include; that public health institutions should make their work environment safe and free from hazards and also to purchase modern and new equipments; hospital managements are also advised to acknowledge job  responsibility/  effort  and  the  recognition  of  hardwork  in  their motivation and reward system. Consequently, a management framework was   proposed.   The   framework   consists   of   strategies/activities   for enhancing the productivity of healthcare personnel; strengthening knowledge and expertise, and improvement of communication processes.

CHAPTER ONE INTRODUCTION

1.1     BACKGROUND OF THE STUDY

Worldwide health   care systems, whether public   or private, are facing pressures to reduce costs, be more productive, innovative and improve the quality  of  care  (Alves,  2003:19-38,  D’Aunno,  Fottler  and  O’Connor,

2000:64-105). Thus, if health care systems are to improve their efficiency they must be interested in developing and deploying effective performance measurement and performance management systems, since it is only through such systems that they can become and remain high performance organizations. That  is,  they  must  be  able  to  manage  and  improve  the performance of their employees since human resource remains the most valuable resource of any organization including the health care system. In other words, in recent years it has been increasingly recognized that managing and improving the performance of health personnel should be at the core of any sustainable solution to health system performance.

In this regard, African countries including Nigeria are trying to improve the functioning of health care delivery systems to ensure that the populations they serve  receive timely quality care.  Health care  is  labour-intensive, making human resources one of the most important inputs in health care delivery (WHO 2003a:3).

Health care in Africa including Nigeria faces difficult challenges such as shortage of health workers, increased case loads for health workers due to migration of skilled health personnel, and the double burden of disease and the HIV/AIDS scourge that affect both the general population and health personnel (Dielem,  Coung,  Anh,  and  Martineau,  2003:1).  It  is  widely acknowledged that health workers are not producing the desired output of health interventions. Many have echoed this concern. An example, is the Africa’s Ministers of Health Meeting during the fifty-second session of the WHO Regional Committee for Africa (WHO, 2002a:2) and other organizations’ policy-and decision-makers at the high-level forum on the Millennium development goals (High-level Forum, 2004:1). During this African Conference on the MDGs, it was stated that insufficient health personnel, in terms of numbers and level of performance, is one major constraint in achieving the  millennium development goals  (MDGs) for reducing poverty and diseases. Some of the actions proposed to rectify this situation  include  improving  the  motivation,  retention,  productivity and performance of health workers (High-level forum, 2004:7; Stilwell, 2001:

2). Thus, a prerequisite for a well-functioning health system is a well- motivated staff that carries out their work according to standards set by the organisation (Dielem, et al, 2003; Awases, Gbary, Nyoni, and Chatora,

2004:53-57). This implies that human input in terms of work by well- motivated and productive human beings will yield the required result.

The Federal Ministry of Health in Nigeria has the same concern as other African countries which is to ensure that a well functioning health system is available to promote the health and social well-being of all Nigerians (Modebe, Adinma, Nwabueze, Ohia, and Nwofor, 2007: 48). In view of this, the historical view of managing the performance of employees has been through the traditional performance appraisal system. Events have overtaken this model, as increased competition, cost, information technology and greater customer focus on quality care have all raised the stakes in managing the performance of employees for organizational success. The  move  is  away from the  traditional performance appraisal system to a more modern performance management system. In addition, the widespread sentiment on the part of both professional employees and management in most organisation’s, that the traditional annual performance review form and process were no longer meeting their needs, gave rise to the need for a new performance evaluation system; the performance management approach. Performance management is therefore a more developmental performance process for employees (Coopee, Marchesani, Marshall, Woo, Arsenault, Perkins, and Wise, 2001:1).

Therefore, the manager’s job is to achieve results through the coordination of people’s activities in an organization. This is achieved in the main by properly managing the performance of organization’s employees. The performance  management system(PMS) is  thus  an  integral part  of  the career development process and it helps managers decide who should be paid more based on contribution (Gomez-Mejia and Balkin, 2002: 274). It is one of the key processes that, when effectively carried out, helps employees know that their contributions are recognized and acknowledged. In otherwords, without the PMS being linked to the reward and motivation system, the PMS is incomplete and based on a short-term approach. An alignment between them, helps reduce potential dysfunctional behaviour. It is thus a motivating device for employees. This agrees with the views of Gibson, Ivancevich and Donnelly (1982:442) that the two broadly stated purposes of performance management and evaluation system are to reach an evaluative or judgemental conclusion about job performance (i.e, improving performance by changing behaviour through reward and motivation system) and to develop employees through the programme.

According to Gore (1997:4) leading-edge organizations, whether public or private,  use  performance  management  to  gain  insight  into,  and  make

judgements about, the effectiveness and efficiency of their programmes, processes and people. These best-in-class organizations decide on what indicators they will use to measure their progress in meeting strategic goals and objectives, gather and analyse performance data, and then use these data to drive improvements in their organisation and successfully translate strategy into action. Thus, put simply, performance management involves performance  appraisal,  continuous  monitoring  of  performance, performance measurement and evaluation, and performance improvements programmes.

Thus, performance management is one of the most important and critical functions  of  human  resource  management.  It  is  seen  as  a  way  of establishing  mechanisms  for  reviewing  the  performance  of  staff,  and helping them to effectively contribute towards the achievement of organisational objectives (Price, 2000: 181; Martineau, 2005:7). Authors differ as to the understanding of performance management. Katz and Green (1997:7) define performance management as “… a system composed of an orderly series of programmes designed to define, measure, and improve organizational performance”. The PSMPC (2000:1) defines performance management as “… helping people to work more effectively by improving

individual and team performance, increasing the overall productivity of an agency” in the context of staff management.

Performance management is a shared process between managers, the individual and the teams they are supervising; it is designed to improve the performance of an organization and the people working within it (Armstrong 1994:1; Torrington & Hall 1998:317).    Performance management is based on agreed objectives, competencies required to undertake the work and development plans for achieving the objectives. Performance management focuses on strategically increasing the effectiveness of an organisation through improving the productivity of its people.

According to Price (2000:181), Armstrong (1994:1), Amaratunga and Baldry (2002:218), Van Der Bij and Vissers (1999: 214) and De Bruijn (2002:579), performance management systems incorporates performance assessment or appraisal systems which are specifically developed to appraise the performance of individuals or teams. Armstrong (1994:25) says that the aims of performance management and human resources management are similar, namely, to achieve sustained improved performance of organizations and employees to ensure that people develop

and achieve their fullest capacity and potential for their own benefit and that of the organisation.

However, it is important to understand that performance management is only a means to achieve an end and not a panacea. Performance management is based on an assumption that there is a link between organizational and individual performance (Armstrong 1994:26, Hornby and Forte 2002:3). This assumption is disputable because an organisation’s contextual factors are not always in place before the performance management system is considered. Nevertheless, despite the absence of fully integrated performance management systems, most health systems in developing countries attempt a design that focuses mainly on the enhancement of staff performance through staff or performance appraisal reviews (Martinez, 2003:221).

In the same vein, Adams and Ferrinho (2003 : 424) are of the view that it is naïve to regard performance management systems as a magic solution. There is very modest evidence that formal performance management systems actually have an  influence on  the  quality of  care  or  patients’ outcomes and none has shown that the returns in efficiency outweigh the cost of setting up the system. However, there is also no evidence to the contrary.

Moreover, it should be noted that besides a well functioning performance management system that proper recruitment, selection and placement of employees on jobs are also predictors of job performance.

It is against this background that this study on performance management is proposed. This study therefore assays or rather analyses performance management and productivity in public sector organizations with particular reference to three public health institutions in South East Nigeria.

1.2     STATEMENT OF THE PROBLEM

There  is  a  growing concern about  the  poor  quality of  health services rendered to  the  Nigerian population, even  though  the  National Health Policy advocates for improved quality of services to be provided at health facilities in the country. Thus, there is a decline in the quality of health services available in the country, that most Nigerians prefer to be treated abroad, coupled with the long queues of clients and patients in most of our hospitals whether public or private.

This assertion is supported by events that occurred in the recent past in our country Nigeria. On January, 2009, the ex- Governor of Yobe state, Alhaji Mamman Ali, died in the United States of America where he had gone to

receive medical attention. Similarly, on February 21, 2009, when the Shehu of Borno, Alhaji Mustapha Umar El Kanemi, collapsed in his palace he was  flown  to  a  Cairo  hospital  in  Egypt  where  he  eventually  died (Kolawole, 2009: 19).   Lately, our late president, Umar Musa Yar’Adua was treated for acute pericarditis and chronic kidney problems, firstly in a German hospital and later on, in a Saudia Arabia hospital. All these are sad commentaries on Nigeria’s healthcare system.

Moreover, the quality, efficiency and equity of services of health personnel are all dependent on the availability of skilled and competent health professionals when and where they are needed. Thus, insufficient health personnel, in terms of numbers (due to migration of skilled health personnel) and level of performance, is one major constraint in achieving the millennium development goals (MDGs) for reducing poverty and diseases in Africa/South-East Nigeria (High-Level Forum on MDG’S,2004:2). To the UNDP( Dada, 2009:46), there is a shortage of more than one million health workers in sub- saharan Africa, while Nigeria has approximately 0.3 physicians per 1,000 people. All these point to the fact that a study on performance management is not only necessary but compelling in Nigerian public health institutions.

1.3     OBJECTIVES OF THE STUDY

Given the  statement of the  problem,  this  research seeks  the  following objectives:

1.       To   determine   what   factors   influence   employee   productivity positively in the hospitals under study.

2.       To evaluate the extent to which performance management in public health institutions is a training and developmental mechanism that affects productivity.

3.       To determine how and to what extent the motivation and reward systems are related to the performance management system in the public health institutions under study.

4.       To ascertain the skills and competence levels of hospital managers in the selected public health institutions in order to determine    how they facilitate improved productivity by their subordinates.

5.       To  determine  the  extent  to  which  the  public  health  institutions establish clear performance standards rather than vague   ones.

6.       To  identify  the  challenges  faced  by  public  health  institutions  in carrying out the performance management process.

7.       To examine if there is a relationship between communication process strategies and health care employee productivity.

1.4     RESEARCH QUESTIONS

Given the objectives of the study, the following research questions guided the conduct of the study:

1.       What  elements  or  factors  influence  employees’  productivity positively in the case study hospitals?

2.       Is   the   performance   management   system   in   the   selected organizations  a  training  and  developmental  mechanism  that affects productivity?

3.       How and to what extent are the motivation and reward systems related  to  the  performance  management  system  in  the  public health institutions under study?

4.       Do the skills and competence levels of hospital managers in the selected institutions facilitate the improved productivity of their subordinates?

5.       Do hospital managers in the selected organizations establish clear performance standards rather than vague ones?

6.       What    are    the    major   challenges   faced   by   performance management in public health institutions?

7.       Is   there   any   relationship   between   communication   process strategies and health care employees’ productivity?

1.5     RESEARCH HYPOTHESES

In this study, the following research hypotheses will serve as aids jointly in finding answers to the research questions and in fulfilling the objectives of the study.

Hypothesis One:

The  performance  management  factors   in  the  selected  organizations influence employees’ productivity positively.

Hypothesis Two:

There is a positive relationship between training and developmental efforts in the selected institutions and productivity of Healthcare Employees. Hypothesis Three:

The management of the selected public health institutions are more committed to  a  membership-based reward  system than a  performance- based system.

Hypothesis Four:

The  skills  and competence levels of  hospital managers  in the  selected public health institutions enhance the productivity of their subordinates.

Hypothesis Five:

The management of the selected public health institutions are more committed to the establishment of clear performance standards than vague performance standards.

Hypothesis Six:

The challenges faced by performance management in the selected public health institutions are different from one institution to the other.

Hypothesis Seven:

There  is  a  relationship  between communication process  strategies  and healthcare employees’ productivity.

1.6     SCOPE OF THE STUDY

A study of this nature ought to be carried out with a larger number of public health institutions in the South-East Area of Nigeria. However, the study scope  is  limited to  three public  health institutions in South-East Nigeria.    These  public  health  institutions  include:  The  University  of Nigeria Teaching Hospital (UNTH), Enugu, Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, and Imo State University Teaching Hospital, Orlu, Imo State.

1.7     SIGNIFICANCE OF THE STUDY

According to Homedes and Ugalde (2004:1), human resources or the health workforce are the most important assets of health systems. There are many complex reasons for the deterioration of  health systems in the  African region including South-East Nigeria; however the main cause is the neglect or rather the improper performance management of the health workforce (High-Level Forum on MDGs, 2004:2). Hospital employees are important component of the health care delivery system. This study is  important because the data so generated will serve as a base and framework for future researchers to expand further the field of knowledge under study.

In addition, the Federal, State and Local Government Ministries of Health, which are the employers of all public health personnel in Nigeria and overseers  of  the  health  sector  in  the  country,  and  are  tasked  with developing  performance  management/appraisal systems  in  Nigeria  will benefit from the study. This is because they will learn how to improve and revise the performance management system in the public service titled “Service Compact with all Nigerians (SERVICOM)”; hence, the health workforce will be left with an improved formal system of assessing performance, acknowledging efforts or constructing measures to redress performance gaps.

Thus, in view of the       current demands on health care personnel at health facilities in our country to provide timely and quality health services, a supportive performance system which could contribute to the enhancement and improvement of the performance of health care employees would be of great value.

1.8     LIMITATIONS OF THE STUDY

The quality of research work is heavily dependent on the quality of data used  and  this  in  turn depends  on  the  methods  used  in  collecting and analyzing the  data.  In  Nigeria,  the  main  limitation  facing  majority of research  institutions/studies  is  non-availability  of,  at  times  very  poor quality data and that not all questions are clear and relevant. Caution was taken during the construction of the questionnaire to ensure that the questionnaire items are clear, unambiguous and elicit the intended data. According to Polit and Hungler (1989:22), Babbie (2005:254), virtually all research studies contain some flaws. Another limitation to this study was time constraints and the several absences of some respondents in keeping to the scheduled time for the interviews resulted in some sort of delay to the researcher in submitting the report on time. Moreover, the limited funds to execute the study impeded the movement to and from the case study hospitals.

1.9     PROFILE    OF     THE     SELECTED    PUBLIC     HEALTH INSTITUTIONS

1.9.1  University of Nigeria Teaching Hospital, UNTH, Enugu

1.9.1.1Historical Background

The University of Nigeria Teaching Hospital (UNTH) began early in the

20th century as a standard general hospital for Africans built by the colonial administrators. It later metamorphosed into a general hospital on the attainment of Nigeria’s independence in the 1960s.However, at the end of the Nigerian civil war in 1970, the then government of East central  State transformed it into a specialist hospital with effect from July 1, 1970. At this time, the hospital had a total of 50 doctors, 10 wards f 300 beds and a chest bay of 60 beds. There were also 350 nurses working in the hospital.

By Decree 23  of 1974,  the  federal military government took over the hospital but left the management in the hands of the council of the University of Nigeria, Nsukka. The University of Nigeria Hospital became independent in July 1976 with the appointment of an autonomous management board.

1.9.1.2 Objectives and functions of UNTH, Enugu

(a)     Objective:  University  of  Nigeria  Teaching  Hospital,  Enugu  has broad objectives of service, teaching and research.

(b)     Functions: The hospital aims to achieve the objective above through the following functions:

1.       Provision of in- patient and out patients services to its clients through the high trained staff;

2.       Provision of adequate clinical materials for service and training as well as for equipment for research;

3.       Provision of teaching facilities for the training of medical students, resident doctors, student nurses, pupil pharmacists, laboratory technology students, physiotherapist and radiographers, as well as other persons in the health delivery team;

4.       Conduct and  promotion of  research on  all  matters  pertaining  to health.

1.9.2  Nnamdi Azikiwe University Teaching Hospital  (NAUTH) Nnewi.

1.9.2.1 Historical Background of the Hospital

The  Nnamdi Azikiwe University Teaching Hospital, Nnewi, was established by the Anambra State of Nigeria (ASN) Edict No.10 of 1988 as Anambra State University of Technology (ASUTECH) Teaching Hospital and situated at the former General Hospital, Nnewi. The General Hospital, Nnewi, which was then under the State Health Management Board, was officially handed over to the Teaching Hospital Management Board on the

6th  of June 1990. Following the handover, a great number of abandoned

hospital equipment  were  refurbished  and  the  buildings  renovated.  The hospital was officially commissioned on Friday 19th July, 1991 by the then Anambra State Military Governor, Col. Robert Akonobi. The Teaching Hospital was, however, taken over by the Federal Government of Nigeria through Decree No. 68 of 1992 and renamed Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi.

In order to meet the demands of the National policy on Medical Education which stipulates that each Teaching Hospital shall be associated with a community Medicare centre, a centre for community and primary health care, Neni, Anaocha Local Government Area, was designated as an annex

of the Teaching Hospital in October, 1989 and commissioned on the 27th of

December, 1991.

Another annex of the Teaching Hospital is the Guinness Eye Hospital, Onitsha, Onitsha North Local Government Area. This Eye hospital was handed over to the Teaching Hospital Management Board on the 26th  of June, 1991 for the treatment of eye disorders.

Other annexes of the hospital include:

a.       The centre for community/ primary health care, Ukpo, Dunukofia

Local Government Area, which was commissioned on 10th   April

1997.

b.       The Trauma Centre, Oba, Idemili South Local Government Area, which started offering services to the community on 28th  February,

2005.

c.       The Centre for community / primary health care, Umunya, Oyi Local

Government Area, which was commissioned on 17th June, 2005.

The  present  location of  the  main  teaching  hospital at  Nnewi  is temporary. It is hoped that in future, the hospital will move over to its permanent site of over 54 hectares landmass at the confluence of Nnewi, Oraifite, and Ozubulu towns, which is currently being developed.

1.9.2.2 Mission and Vision

Mission: To deliver specialized health services in a timely, effective and efficient manner that will make our clients healthy, as well as provide training, research.

Vision: By 2011, NAUTH would have achieved 70% movement to its permanent site by developing necessary infrastructure for in-patient, out patient, and diagnostic services.

The hospital would also have embarked on full computerization of services as well as development of human resources, subspecialties in endoscopy, neurosurgery, and renal medicine with improved quality of services.

1.9.3  Imo State University Teaching Hospital (IMSUTH), Orlu

1.9.3.1 Background of IMSUTH

The Imo State University Teaching Hospital, Orlu started operations in May 2004. However, the commissioning of the hospital, albeit belated was done  by  the  then president of  the  Federal Republic of  Nigeria,  Chief Olusegun Obasanjo on November 30th, 2004.

1.9.3.2 Activities / Objectives

Though, IMSUTH was primarily established to attend to the following objectives.

(1)     To provide a training ground for medical students of Imo State

University (i.e future doctors).

(2)     To provide advance tertiary health care services; as a result of the need to establish a health institution that can act/serve as a referral centre.

(3)     To involve in training, research and health care services within the state and beyond.

(4)     Advanced Health Care

However, they specialized in advanced health care such as:

(a)     Dialysis: This is a form of kidney treatment carried out with the help of the state government and dialysis machines. The hospital started this dialysis on October 30th, 2006 and till date they has recorded over 40 dialysis patients.

(b)     Again, they carried out ‘Endoscopic Surgery.’ Thus they are fully equipped for the treatment of people with prostrate complications.

(c)     The third advanced health care services rendered by IMSUTH is the “Emergency Medical Response (EMR) Services: This  is  a state wide emergency treatment to save accident victims. This as implemented by IMSUTH involves the use of ambulances, and radio communication    equipments.    However,    information    here    is

communicated between one base station to another, and between one ambulance to another. Other specialist advanced healthcare services provided by IMSUTH include:

(i)      Intensive care (IC) Services;

(ii)     Radiology/Radiography service (this includes the use of mamagram equipment in the early dictation of breast cancer in women) etc;

(iii)    Child and maternal care services

1.10 DEFINITION OF TERMS

The following terms are relevant to this study.

Competency: This refers to the skill, knowledge and attitude acquired through training, education and experience, and performed to specific standards under specific conditions (Hornby, 2001: 228).

Human Resources for Health: Human resources for health (HRH) or health workers are defined as “All persons working in health service delivery including: Private practices and health-related institutions, plus personnel working in units that supply medical or related aids for people with disabilities, staff in the administration of a health sector, health information system, health ministry staff and the respective staff

developing and producing health products like drugs, aids, spectacles, and supplies,  or  equipment  for  health  care  units  like  beds  and  technical

equipment, as well as teaching staff, students, catering and maintenance staff (WHO, 2000:1).

Human Resources Management (HRM): This  refers to  mobilization, motivation, development, and fulfillment of human beings in and through work and covers all matters related to the employment, use, deployment and motivation of all categories of health workers, and largely determines the productivity, and therefore the coverage, of the health services system and its capacity to retain staff (Hendry, 1995).

Outcome Measurement: This is any measurement system used to uncover or identify the health outcome of treatment of a patient, or at a systems level,  for  example,  outcome  of  a  set  performance  standard  (WHO

2000:47).

Performance: Perform means “to carry out, accomplish or fulfill an action or task”. It also means “work, function or to do something to a specific standard”. Performance is “an action or process of performing a task or function” (Oxford Concise Dictionary 1999: 1060). Important variables to be  kept in  mind are  function, work,  action, task,  process and specific standard. Performance is the actual conducting of activities to meet responsibilities according to standards. It is an indication of what is done

and how well its is done (Winch, Bhattacharyya, Debay, Sarriot, Bertoli & Morrow 2003:2)

Productivity:  This  refers  to  a  state  of  yielding  or  furnishing  results, benefits or profits. It is an organization’s outputs divided by its inputs, and group cohesiveness. It implies the quantity or volume of the major product or service that an organization provides. It includes capital investments, innovation, learning, and an employee’s motivation (Decenzo and Robbins

2000: 360).  Employees are  performing  well when they are  productive (Decenzo  and  Robbins,  2000:  360).    Productivity  itself  implies  both concern for effectiveness and efficiency.

Performance Appraisal:  This means the Observation and assessment of employee performance against  pre-agreed and  pre-established activities and standard.

Performance Management: Leading edge organizations use performance management to gain insight into and make judgements about, the effectiveness and efficiency of their programmes, processes and people (Gore,1997:4).

Performance Measurement: Measurement and  evaluation are  used  to strengthen  and  improve  performance  practices.  According  to  WCPS

(2001:47), measures “… are the yardsticks used to determine how well work units and employees produced or provided products or services”. Performance  Improvement:  Katz  and  Green  (1997:28)  and  WCPS (2001:25) stress the importance of having a performance improvement plan as part of performance management. The performance improvement plan should address the question of how to improve the level of performance. Performance  improvement  is  thus  a  response  to  make  services  of  an organisation better, affordable and faster. It seeks to rectify any problems that exist and build upon those performance levels that are already good (Katz and Green 1997:28).

Skill: This refers to the ability to perform a task or a group of tasks which often requires the use of motor functions but also specific knowledge and skills.

Standards of Quality: This refers to authoritative statements of the minimum levels of acceptable performance or results and excellence levels of results, or the range of acceptable performance results. Standards can be based on scientific knowledge and professional consensus. Standards of conduct  and  ethical  standards  are  based  on  social  consensus  (WHO

2000:47).

Work Environment: Characteristics of the environment in which a person is expected to work, includes physical and social environment, employment conditions and benefits.

Workforce: People who work in the various professions of health care, that is doctors, nurses, midwives, pharmacists, dentists, allied health workers, community health workers, paramedics, whose goal is to improve the health of the populations they serve.

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