In health facilities across Kenya, many workers are struggling to do their jobs in less-than-ideal conditions. Work climate issues such as poor working environments, unfriendly colleagues, disorganized facility functions and ineffective supervision have been hindering workers’ performance and productivity—and contributing to low retention. At Hola District Hospital, for example, morale was low. “Work schedules weren’t well organized,” says Dr. Muriuki Meme, district medical services officer, and “the management was not friendly towards the staff.” As Capacity Project consultant Dr. Betty Chirchir phrases the issue, “Many times people have come in and improved the facilities and the supply of goods, but what about the health workers themselves?”

A recent study on retention of health workers in Kenya identified workplace climate among the nonfinancial factors affecting morale and motivation. Other studies also show that where motivation is low, the resulting poor practices may contribute to low service use. George Okore, former deputy director of human resource development at the Ministry of Medical Services, points to the bottom line: “If the environment is not conducive, then the productivity of the workers is lowered.”

Over 18 months, the Capacity Project collaborated with the Ministry of Health to pilot the Work Climate Improvement Initiative in ten rural facilities. The initiative focuses on four key areas: the patient/health worker relationship; the health worker/supervisor relationship; workplace environment; and worker wellness. Findings from the initial survey illustrated very low morale, and a vast majority of the health workers were unhappy about their working environment. Facility-based teams assessed their own work climates and generated activity plans to test low-cost approaches for improvement.

“Where there were no signs [giving directions to service points],” Dr. Chirchir explains, “signs were put in place. Where there were no job descriptions, they would write their own. Where there was no shared vision and mission, they would put up signs to let them know who we are and what we want to achieve.” Other accomplishments include departmental workplans, more equitable shifts, managed inventories, safe waste disposal, cleaner yards and facilities, organized patient flow, infection prevention protocols, staff lounges with free tea, new resource centers, community outreach days, painted and refurbished facilities, new equipment and more frequent team meetings and sharing of information.

At St. Luke’s Mission Hospital in Kilifi, for example, the unkempt grounds were distressing to both staff and patients. “There were tall grasses which even snakes could hide in,” recalls Nurse Morris Kai. “The workers were not comfortable.” Furthermore, “When patients came here, they were not interested [in entering] because this hospital is like they have come to the bush. [Now] we have so many flowers; they say the compound is neat.” The physical environment instills patients’ confidence and helps them find their way around. “There is no need to ask for directions,” says Shadrack Tsuma, who visited the hospital recently, “because with all the signage you can now know where to go for assistance.”

At Hola District Hospital, Nurse Faith Gilliago shares an improvement. “We made arrangements for our staff to get tea [at the hospital]. Because if I am alone in the department and I go out for a break and an emergency comes, people do not realize that you have gone home for a few minutes to increase your blood sugar! If you have that tea there and an emergency comes, people do not have to waste time looking for you. So it has improved our services.”

“I want to add a point about the trainings [for continuing medical education],” Nurse Habia Joyce interjects. “Now we are doing them weekly, so it’s really motivating staff. Even when people are off they come for the sessions!”

In a follow-up survey, nearly all staff in the ten sites expressed high satisfaction with their environments and had no intention of leaving. All sites reported increases in service use. The Capacity Project and the Ministry of Health have planned a second phase targeting the same facilities, and the Project is evaluating the program’s results.

“What is really unique,” notes Dr. Chirchir, “is that it involves everybody at the health facility, from the reception and administration to the technical. Before, there was no team working together in terms of everybody understanding their role.” Adds Dr. Mohamed Sheikh, district medical officer at Ijara District Hospital, “Even the community sees a big improvement.”