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Factors Influencing the Performance of Health Workers: A Case Study of HIV/AIDS Programs in Msambweni Sub-County, Kwale County, Kenya

Kenya is challenged with an inability to attract and retain health workers especially in the public sector as well as with performance management issues, unequal distribution of staff, and diminishing productivity among the health workforce. Many studies have been carried out to determine the performance of health workers in Kenya however little information is available on factors affecting the performance of health workers in HIV/AIDS programs in Kenya. The overall aim of the study was to determine the factors influencing the performance of health workers, a case study of HIV/AIDS Programs in Msambweni sub county, Kwale County. The study was guided by the following research objectives; to determine the effects of leadership style, organizational culture, and job security on the performance of health workers in HIV/AIDS programs in Msambweni, Kwale County. The study design used was mixed research design involving both descriptive and analytical methods which enable generalization of the findings to a larger population. The study targeted population of health workers working in HIV/AIDS programs in Msambweni subcounty which comprised of; the project managers, nurses, lab technicians, nutritionist, clinical officers, pharmacists and public health officers working in both private and public sector. Purposive sampling method was used in which only health workers formed the target population. The study used both qualitative and quantitative methods which involved the use of questionnaires for collecting data. The data was analyzed using Statistical Package for Social Sciences (SPSS) version 16.0 and Regression models. Correlation was used to test the strength of the association and estimate the relation between variables that contribute to the performance of health workers in HIV/AIDS programs in Msambweni, Kwale County. The results of the study, leadership style (r= 0.878,p<0.05), organization culture (r= 0.639,p<0.05) and job security(r= 0.584,p<0.05) indicated a significant and positive effect of the independent variables on performance thus leading to the conclusion that leadership style, organization culture and job security affect the performance of health workers. It is therefore recommended that organizations should adopt democratic leadership style, make jobs more secure and formulate organizational visions, values, beliefs and habits that are acceptable, relevant and sustainable so as to improve the performance of health workers.


Background to the Study Problem
Health management and support workers, (HRH, 2006) constitute one of the key components of any national health system. They provide the invisible backbone for health systems; if they are not present in sufficient numbers and with appropriate skills, the system cannot function well, (WHO, 2006). Many developing countries face serious human resources for health (HRH) constraints. Since the start of the Joint Learning Initiative (JLI), in 2003, the human resources crisis in low-income countries (LICs) has received global attention, particularly the crisis in sub-Saharan Africa. In some countries less than 50% of the required staff is available to serve rural populations; while at times care is provided by non-qualified staff (WHO, 2006;Hongoro & Normand, 2006). This situation seriously compromises the health status of the communities, particularly the poor. The overall shortage of health workers in developing countries has several dimensions. Not only is there an absolute shortage of staff, the available workforce is often illdistributed within the system and attrition rates are high as a result of brain drain and HIV/AIDS. Therefore, human resource for health staff is quite a significant asset of health systems. Performance of health care organizations depends on the knowledge, skills and motivation of individual employees. Employers should provide working conditions which support the performance of employees since the quality; efficiency and equity of services depend on the availability of sufficient and skilled providers, competent health professionals when and where they are needed (Awases et al, 2013 & TI, 2011). Additionally, there is a wide range of reasons why health workers leave their jobs, and financial reasons are often not the only (or the main) reasons. Staff motivation and morale is also reported to be low. Factors are also likely to be interrelated and their influence on health providers depends on the political, socioeconomic and cultural environment. Staff motivation and morale is reported to be low. Ministry of health in different countries have proposed remedial actions towards improving motivation, retention, productivity and the performance of health care workers, and mobilizing unemployed trained staff, or those working in other areas, to return to the health sector (High Level Forum 2004:7; Stilwell 2001:2).
The production or supply of health sector workers does not even come close to keeping pace with the rate of population growth (The World Bank, 2004). In addition, health care workers are not producing the desired output in terms of health interventions which has remained a big concern for the World Health Organization (WHO) as well as policy and The HIV pandemic has placed additional strain on health service provision through the extra burden of increased testing and counseling, treating opportunistic infections and providing antiretroviral treatment (ART). Health workers, too, have been affected and infected by HIV adding further stress to the provision of health services. In fragile health systems, as is the case in most resource-constrained countries, the human resource crisis is the result of many macroeconomic and governance factors. The crisis is further compounded by the impacts of the HIV/AIDS pandemic, which lead to excessive workload and burnout, high worker attrition rates with no replacement and limited entry into the workforce. Factors are Intrinsic Factors that will increase employees" job satisfaction; while Hygiene Factors are Extrinsic Factors to prevent any employees" dissatisfaction. Herzberg furthered that full supply of Hygiene Factors will not necessary result in employees" job satisfaction. In order to increase employees" performance or productivity, Motivation factors must be addressed.

Research Objectives
Two-Factor Theory is closely related to Maslow's hierarchy of needs but it introduced more factors to measure how individuals are motivated in the workplace. This theory argued that meeting the lower-level needs (extrinsic or hygiene factors) of individuals would not motivate them to exert effort, but would only prevent them from being dissatisfied. In order to motivate employees, higher-level needs (intrinsic or motivation factors) must be supplied. The implication for organizations to use this theory is that meeting employees" extrinsic or hygiene factors will only prevent employees from becoming actively dissatisfied but will not motivate them to contribute additional effort toward better performance. To motivate employees, organizations should focus on supplying intrinsic or motivation factors (Robbins, 2009).
According to the setting of theory, Extrinsic Factors are less to contribute to employees" motivation need. The presences of these factors were just to prevent any dissatisfaction to arise in their workplaces. Extrinsic Factors are also well known as job context factors; are extrinsic satisfactions granted by other people for employees (Robbins, 2009). These factors serve as guidance for employers in creating a favourable working environment where employees feel comfortable working inside. When all these external factors were achieved, employees will be free from unpleasant external working conditions that will banish their feelings of dissatisfactions, but remains themselves neutral in neither satisfied nor motivated; however, when employers fail to supply employees" Extrinsic Factors needs, employees" job dissatisfaction will arise.

ISSN (Online
Intrinsic Factors are the actually factors that contribute to employees" level of job satisfactions. It is widely known as job content factors which aim to provide employees meaningful works that are able to intrinsically satisfy themselves by their works outcomes, responsibilities, delegated experience learned, and achievements harvested (Robbins, 2009). Intrinsic Factors are very effective in creating and maintaining more durable positive effects on employees" performance towards their jobs as these factors are human basic needs for psychological growth. Intrinsic Factors will propel employees to insert additional interest into their job. When employees are well satisfied by motivational needs, their productivity and efficiency will improve.

Critical review of Two Factors Theory
The groundwork of Two-Factors Theory is built on the factors for employees" job satisfactions. Job satisfaction is defined as "the extent to which people like (satisfaction) or dislike (dissatisfaction) their jobs" (Spector, 2001). It has been recognized to have its positive impact on organizational performance and employees" commitments (Levy, 2003).Following the definitions provided, it may assume that if individuals place high preferences on Extrinsic Factors such as Working Environment or Supervision, then the Extrinsic Factors will have positive effects towards their job satisfactions, rather than only prevent their dissatisfactions and keep them in a neutral feeling.
In order to support such assumption, several research finding have been introduced. Schroer, a researcher found contradictions with Herzberg"s findings. The researcher used the Two-Factor Theory to study the impact of demographical factors on job satisfaction. Findings derived from the study has concluded that overall job satisfaction was related to age and educational level, and that levels of Intrinsic and Extrinsic Motivation factors vary among occupational groups of people. Besides, another case study that covered two Universities in Kuala Lumpur, Malaysia to understand their job satisfaction factors was also found in support to the idea of criticism. Ten major factors corresponding to job satisfaction using Herzberg Two Factor theory were utilized to determine how these selected factors are related to job satisfaction of Malaysia faculty members. Interestingly, presence of Extrinsic Motivation Factors have positively contributed to respondents" job satisfactions; while absent of Intrinsic Motivation Factors don"t really neutralize their feeling, but have de-motivated them.

Mc Gregor's Theory X and Y
According to this theory, type X individuals are considered to be inherently lazy and not fond of their jobs. As a result, an authoritarian management style is required to ensure that individuals fulfill their objectives. Workers managed this way need to be closely supervised under comprehensive systems of control. A hierarchical structure is needed with narrow span of control at each and every level. According to this theory, employees will show little ambition without an enticing incentive program and will avoid responsibility when they can. As a result, if the organizational goals are to be met, Theory X managers must rely heavily on the threat of punishment to gain compliance of employees. When practiced, this theory can lead to mistrust, highly restrictive supervision and a punitive atmosphere. The Theory X manager tends to believe that all actions can be traced back and the individual responsible for them needs to be directly rewarded or reprimanded depending on the action's results. This managerial style is more effective when used to motivate a workforce that is not inherently motivated to perform. It is usually exercised in professions where promotion is infrequent, unlikely or even impossible and where workers tend to perform repetitive tasks in their jobs.
One major flaw of this management style is that it limits employee potential and discourages creativity.
In this theory, management assumes employees can be ambitious, self-motivated and exercise self-control. It is believed that employees enjoy their mental and physical work duties. According to them, work is as natural as play. They possess the ability for creative problem solving, but their talents are underused in most organizations. Theory Y managers believe that given the proper conditions, employees will learn to seek out and accept responsibility, exercise self-control and self-direction in accomplishing objectives to which they are committed. A Theory Y manager believes that, given the right conditions, most people will want to do well at work. They believe that the satisfaction of doing a good job is a strong motivation. Many people interpret Theory Y as a positive set of beliefs about workers. A close reading of The Human Side of Enterprise reveals that McGregor simply argues for managers to be open to a more positive view of workers and the possibilities that this creates. He thinks that Theory Y managers are more likely than Theory X managers to develop a climate of trust with employees required for employee development. This would include managers communicating openly with subordinates, minimizing the difference between superior-subordinate relationships, creating a comfortable environment in which subordinates can develop and use their abilities. This environment would include sharing of decision-making so that subordinates have a say in decisions that influence them.

Leadership Style
Improved performance does not result from the number of HR practices alone, but also from effective implementation, which requires management skills (Caulkin, 2001 Leadership style is a key determinant of the success or failure of any organization. A leader is a person who influences, directs, and motivates others to perform specific tasks and also inspire his subordinates for efficient performance towards the accomplishment of the stated corporate objectives. Leadership style is the manner and approach of providing direction, implementing plans, and motivating people.

Charismatic leadership
By far the most successful trait-driven leadership style is charismatic. Charismatic leaders have a vision, as well as a personality that motivates followers to execute that vision. As a result, this leadership type has traditionally been one of the most valued. Charismatic leadership provides fertile ground for creativity and innovation, and is often highly motivational. With charismatic leaders at the helm, the organization"s members simply want to follow. It sounds like a best case scenario. There is however, one significant problem that potentially undercuts the value of charismatic leaders: they can leave. Once gone, an organization can appear rudderless and without direction. The floundering can last for years, because charismatic leaders rarely develop replacements. Their leadership is based upon strength of personality. As a result, charismatic leadership usually eliminates other competing, strong personalities. The result of weeding out the competition is a legion of happy followers, but few future leaders .

Transactional leadership
The wheeler-dealers of leadership styles, transactional leaders are always willing to give you something in return for following them. It can be any number of things including a good performance review, a raise, a promotion, new responsibilities or a desired change in duties. The problem with transactional leaders is expectations. Transactional leadership style is defined as the exchange of reward (Howell & Avolio, 2003). Transactional leaders fulfill employee needs of rewards when targets are met. Pounder (2002) defines this style as the transaction of needs fulfillment from both sides of the organization and employees.

Autocratic leadership
Autocratic leaders are classic "do as I say" types. Typically, these leaders are inexperienced with leadership thrust upon them in the form of a new position or assignment that involves people management. Autocratic leaders retain for themselves the decision-making rights. They can damage an organization irreparably as they force their "followers" to execute strategies and services in a very narrow way, based upon a subjective idea of what success looks like. There is no shared vision and little motivation beyond coercion. Commitment, creativity and innovation are typically eliminated by autocratic leadership. In fact, most followers of autocratic leaders can be described as biding their time, waiting for the inevitable failure this leadership produces and the removal of the leader that follows (Bougourlet , 2011)

Bureaucratic leadership
Bureaucratic leaders create, and rely on, policy to meet organizational goals. Policies drive execution, strategy, objectives and outcomes. Bureaucratic leaders are most comfortable relying on a stated policy in order to convince followers to get on board. In doing so they send a very direct message that policy dictates direction. Bureaucratic leaders are usually strongly committed to procedures and processes instead of people, and as a result they may appear aloof and highly change adverse. The specific problem or problems associated with using policies to lead are not always obvious until the damage is done. The danger here is that leadership"s greatest benefits, motivating and developing people, are ignored by bureaucratic leaders ( Bougourlet, 2011).

Democratic leadership
Democratic leadership is a leadership style in which decision-making is decentralized and shared by subordinates. The potential for poor decision-making and weak execution is, however, significant here. The biggest problem with democratic leadership is its underlying assumption that everyone has an equal stake in an outcome as well as shared levels of expertise with regard to decisions. That is rarely the case. While democratic leadership sounds good in theory, it often is bogged down in its own slow process, and workable results usually require an enormous amount of effort.

Leadership Style and Organizational Performance
Relationship between leadership style and organizational performance has been discussed often. Most research showed that leadership style has a significant relation with organizational performance, and different leadership styles  ,2000) report that there is significant relationship between leadership styles and organizational performance. Effective leadership style is seen as a potent source of management development and sustained competitive advantage, leadership style helps organization to achieve their current objectives more efficiently by linking job performance to valued rewards and by ensuring that employees have the resources needed to get the job done. (Sun ,2002) compares leadership style with the leadership performance in schools and enterprises, and found that leadership style had a significantly positive correlation with the organizational performance in both schools and enterprises.
Broadly speaking, leadership performance is identical with organizational performance. Business management attributes their successes to leadership efficiency, that is, the leadership style of administrative supervisors has a considerable effect on the organizational performance (Sun, 2002). ( Fujin,2010) opine that when executives use their leadership style to demonstrate concern, care and respect for employees, it would increase interest of employees in their work and enable them to put up better performance, thereby affecting their job satisfaction positively Figure 1 shows the relationship between the variables i.e. Independent variable and dependent variable. Independent variable is what is varied during the experiment; it is what the investigator thinks will affect the dependent variable. Independent variable influences and determines the effect of another variable. Independent variables in this study are leadership style, organization culture and job security.

Conceptual Frame Work
Dependent variable is what will be measured; it's what the investigator thinks will be affected during the experiment (Zechmeister & Zechmeister, 2000).Dependent variable in this study is performance of health care workers in HIV/AIDS programs.

Research Methodology
The study adopted a descriptive research design. This approach combines elements of qualitative and quantitative research approaches (e.g., use of qualitative and quantitative viewpoints, data collection, analysis, inference techniques) for the purposes of breadth and depth of understanding and corroboration (Harwell, 2011). A descriptive research design was used to describe persons, organizations, settings or phenomena (Creswell, 2003). The design also has enough provision for protection of bias and maximized reliability (Kothari, 2008). The descriptive research design was used to assess the effects of leadership style, organizational culture, and job security on the performance of health workers in HIV/AIDS Programs in Msambweni Sub County, Kwale County. Descriptive research design was chosen because it enabled generalization of the findings to a larger population (Creswell, 2003). According to Mugenda (2013), descriptive research determines and reports the way things are and it helps in establishing the current status of the population.
The study population constituted the health workers working in HIV/AIDS programs in Msambweni sub-county. The target population for the study comprised of; the project managers, nurses, lab technicians, nutritionist, clinical officers, pharmacists, public health officers and other health related workers both in the private and public sectors.
The sampling frame for the study comprised health workers from all cadres working in HIV/AIDS programs in Msambweni Sub County of Kwale County. The list of the health workers will be obtained from the office of Msambweni Sub County Medical Officer of Health.
The sampling technique used in this study was purposive. In this sampling technique, the researcher chooses the sample based on who they think would be appropriate for the study and is used primarily when there is a limited number of people that have expertise in the area being researched on. In this study, the focus will be on professionals in the health sector only.
The sample size for the study is calculated as follows: In the study 95% confidence interval will be applied and sampling error is 0.05 Therefore n=484/ (1+484(0.05)²) =218 n=218 Sample size of each category of health workers (%) to be used== 45% Questionnaires will be used to collect data in this study. A questionnaire consists of a set of questions presented to a respondent for answers. The respondents read the questions, interpret what is expected and then write down the answers themselves. Questionnaires are commonly used because they are simple to use, large amounts of information can be collected from a large number of people in a short period of time and is relatively cost effective.
The self-administered questionnaires were delivered to the departmental heads of HIV/AIDS programs in all the health facilities in Msambweni Sub County who distributed the copies to the other health workers.
Pilot study enabled researcher to obtain assessment of validity of questionnaire as well (Saunders et al., 2011). According to Cooper and Schindler (2003), research instrument should be pilot tested to detect weaknesses or errors in the instrument. The pilot test should be conducted with the subjects from the target population and simulate the procedures and protocols that have been designated for data collection (Cooper and Schindler, 2003). The objective of the pilot test is to pre-test the questionnaire with the respondents and ensure that there is no ambiguity in the questionnaire.
Processing and analysis of the data collected was done using Statistical Package for Social Sciences (SPSS). The data has been presented in descriptive statistics which involved the use of visual aids such as graphs and charts to aid in understanding the data distribution. Data analysis was done using SPSS version 16.0 through correlation and regression analysis to measure the strength and direction of relationship between the dependent variable and the independent variables.

Correlation analysis
Correlation analysis was incorporated to describe the strength and direction of the linear relationship between the independent variables and the dependent variable. The results are shown in table 3. The results of the correlation analysis shown in the table above leadership style (r= 0.878,p<0.05), organization culture (r= 0.639,p<0.05) and job security(r= 0.584,p<0.05) indicate a strong and positive effect of the independent variables on performance.

Regression Analysis
Linear regression analysis was conducted to examine the extent to which the independent variables; leadership style, organization culture and job security influence the dependent variable (performance). The result of regression analysis is shown in table 4.  The results of ANOVA as presented in the table above= 15.16, p < 0.05. The results imply that least one of the three independent variables; leadership style, organization culture and job security can be used to explain performance of the health workers. Table 6: Entrepreneurship on investment in mining The results indicate that the model is highly significant (p < 0.05) thus based on the above correlation and regression analysis results, this study rejects the null hypothesis (H0) and accepts the alternative hypothesis (HA) of all measured independent variables (H1, H2 and H3) that there is a highly significant and positive relationship between the independent variables; leadership style, organization culture ,job security and performance (the dependent variable) Based on the results of the study, it is clear that there is a positive and significant relationship between leadership style, organization culture and job security with the performance of health workers working in HIV/AIDS Programs in Msambweni sub county, Kwale County. Organizations should therefore strive to adopt acceptable and effective systems that can enhance the three mentioned factors so as to improve the performance of its employees.
In order to improve the performance of health workers, the following recommendations are proposed; Leaders of HIV/AIDS programs should adopt effective leadership style that ensures cordial working relationship, staff involvement in decision making and builds the confidence and self esteem of health workers, the leadership and management of HIV/AIDS programs should undergo training on leadership to increase their effectiveness in running programs, organizations should adopt sound vision, values, beliefs and habits that are acceptable, relevant and sustainable, health workers on short term contracts should be adequately remunerated and compensated and employees performance review should be conducted regularly and exemplary performance rewarded. In addition, policy should be formulated to put a cap on the minimum number of years that employees should be engaged in employment to protect health workers working on contracts.
Further research should be conducted on the perceived positive influence of job insecurity on the performance of health workers as well as the influence of health workers individual characteristics on the leadership style adopted in running organizations. Additionally, other factors like incentives, working conditions, training and individual characteristics that could have influence on performance should be included in order to obtain more comprehensive understanding of other factors that influence performance of health workers and which needs to be carried out on a larger population and sample size to increase the generalizability of the findings.