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CHALLENGES FACING THE IMPLEMENTATION OF CITIZEN’S CHARTER
A CASE STUDY OF KISII LEVEL 5 HOSPITAL - KENYA
Josiah Obegi Mang’era
(MBA – Strategic Management, Bachelor of Education Arts, Diploma in Computer
Application)
Senior Teacher , St. Joseph Lietego Secondary, P.O. Box 52255 – 00100,
Nairobi, Kenya,
Dr. Walter Okibo Bichanga (Ph.D., MBA, Bcom., Dip. Computer Science, Dip. Personnel Management) Senior Lecturer - Jomo Kenyatta University of Agriculture and Technology
P.O. Box 52255 – 00100, Nairobi, Kenya,
Abstract
Citizen‟s charters are intended to empower citizens by mentioning their rights, privileges
and duties; to make the administrative less bureaucratic-dominated and more citizen-led.
One of the highlights of the sweeping global reforms in public service delivery is the
concept of the citizen‟s charter adopted by many countries around the globe as an
initiative. While several governments have employed similar efforts, it is only in 2003
that Kenya rolled-out the citizen‟s charter as a nation-wide program both to enhance the
delivery of government services and to tap its potential as a tool for good governance.
Despite the fact that Citizen‟s Charters are of such great importance, in the recent years
there has been doubts among professionals on whether employees are achieving the
desired service delivery standards contained in them. This study examined the challenges
of implementing Citizen‟s Charter initiative in the health sector on service delivery. The
study specifically focused on disposition of the implementers, competence of the hospital
staff and the management structure of the hospital. This study was carried out at the
Level 5 Hospital in Kisii county and the target population was two administrators, twelve
Doctors, twenty seven Clinical Officers and two hundred and thirty eight Nurses all of
whom are permanently employed by public service in the hospital (KL5H staff register).
Stratification and simple random sampling were used to attain the required sample size of
84 respondents. Questionnaire and observation were used as tools for data collection.
Quantitative and qualitative analyses were followed. Findings showed that although
many players in the implementation team were aware of the existence and importance of
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the Citizen‟s charter, still the charter program suffered greatly. Standards and time frames
set in the Citizen‟s charter were considered not to be realistic.
Keywords: Citizen’s Charter, Implementation, Kisii Level 5, Government services and
Challenges
List of Acronyms: CC – Citizen‟s Charter, CO – Clinical Officer, KL5H – Kisii Level 5
Hospital, MOPHS – Ministry of Public Health and Sanitation, NPM – New Public
Management, PSRP – Public Service Reform Programme, SS – Support Staff, TQM –
Total Quality Management, UNDP – United Nations Development Programme, SPSS -
Statistical Package for Social Sciences
1. Background of the Study
Prof Savitch, H.V (1998) in his presentation on institutional capacity, compares public
service delivery with policy implementation which he regards as the accomplishment of
policy objectives through the planning and programming of operations and projects so
that agreed upon outcomes and desired impacts are achieved. Public service for many
years has been blamed for poor service delivery which some scholars like Obsorne and
Plastnik; (1997) refer to ineffective, insensitive and inefficient and often hostile to the
very people they are supposed to serve. Many countries world over have tried to come up
with new ways of delivering services to citizens effectively and efficiently by shifting the
focus from the service providers to service receivers. One of the tools which has yielded
positive results in this shift is the citizen charter. A citizen charter can be defined as a
written statement prepared by a public institution which outlines the nature, quality and
quantity of service that citizens should expect from the institution. It should outline; what
the institution does, the standards of the services to be provided, what service users can
expect, the responsibilities of the service users and how users may seek redress if they are
dissatisfied with the services or in the event the institution does not live up to the
commitments in the charter (Ministry of Health-Kenya 2010).
Citizen charters were first articulated and implemented in the United Kingdom by the
Conservative Government of John Major in 1991 as a National Programme with a simple
aim, to continuously improve the quality of public services for the people of the country
so that these services respond to the needs and wishes of the users. Several countries
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around the world have implemented similar programmes such as the UK‟s while others
chart new ground by leaning on the service quality paradigm of the Total Quality
Management (TQM), examples Australia (service charter, 1997) Belgium (public service
users‟ charter 1992) Canada (service standards initiative 1995), France (service charter
1992), India (citizen‟s charter 1997) and Malaysia (client charter 1993) (Centre For Good
Governance 2008).
Public Service Reforms in Kenya started immediately after independence. The reforms
were aimed at addressing three challenges facing the government at the time namely
disease, poverty and illiteracy. The main focus was on Africanization of public service,
land reforms among others with the objective of improving service delivery and
performance. Noting that Public Service efficiency sets standards for other sectors, the
Kenyan government launched the Civil Service Reform Programme in 1993 to enhance
Public Service efficiency and productivity. The reforms were expected to facilitate
equitable wealth distribution necessary for poverty alleviation and create an enabling
environment for investment and enhanced private sector growth.
Since 2003 the government of Kenya has adopted different reform strategies to improve
service delivery, notably; Rapid Results Approach, Performance Contracting,
Transformative Leadership Values & Ethics, Institutional Capacity Building and
Citizen‟s Charter. All service-based government institutions are required to develop and
implement citizen‟s charter in Kenya. The ministry of health launched its service charter
in December 2006 for health service delivery. Despite the fact that these reforms have
taken place in the country and service provision improved greatly we still find service
provision from government sector being below their own set standards in their citizen‟s
charter. This study seeks to find out challenges of implementing citizen‟s charter in the
health sector.
2. Purpose of the Study
The purpose of this study was to find out challenges of implementing citizen‟s charter on
service delivery in Kisii Level 5 Hospital in Kisii county-Kenya.
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3. Statement of the Problem
According to MOPHS (2008-2012) Service delivery in government health facilities in
Kenya still faces multiple challenges. These challenges can still be identified six years
down the line since the introduction of citizen charter. The Citizen‟s Charter initiative
introduced in the ministry of health in 2006 intended to improve the old bureaucratic
service delivery mechanism in the hospitals by enhancing transparency, accountability
and responsiveness to the citizens. Kisii Level 5 Hospital adopted the Citizen‟s Charter as
a tool for good governance and improved service delivery yet still clients complained of
the quality of services they received as not meeting the standards specified in the charter.
4. Objectives of the Study
1) This study tries to evaluate challenges facing the implementation of citizen’s charter in
the health sector.
2) To establish how the disposition of implementers of citizen’s charter influence in
implementation of citizen’s charter.
3) To find out how the competence of the hospital staff affect the implementation of the
citizen’s charter.
4) To explore how the hospital management structure influence the citizen’s charter
implementation.
5. Justification of the Study
All public institutions in Kenya are funded by the government to subsidize the running
costs so that citizens can be given better services. Citizens expect to receive effective,
efficient and prompt services whenever they visit any public health facility, given that the
facilities are subsidized by their own tax. Even after the introduction of Citizen‟s Charter
in public institutions, still clients of public hospitals raised eye brows as to whether the
hospitals are meeting the very standards set in their citizen charters. The study sought to
find out challenges facing the implementation of the citizen‟s charter as a tool of
improving the effectiveness, efficiency and promptness of service delivery in this public
institution.
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6. Scope of the Study
The research was conducted in Kisii Level 5 Hospital within Kisii County between
November 2012 to January 2013. The research was a case study and a sample of eight-
four respondents were sampled randomly from a stratification of four levels of employees
( administrators, doctors, nurses and clinical officers ) drawn from the target population
of all two hundred and seventy eight employees of the hospital. Data were collected using
questionnaires and observation methods.
7. Significance of the Study
It is expected that the study will shade light to employees of the health sector on citizen‟s
charter. The study also intended to come up with new knowledge for the health sector
which would be used by the hospital management to deliver prompt efficient and
effective services. Besides, the findings of this study were expected to add value to the
existing literature on service delivery in Kenya and in general all other organizations
which might be serious enough to accommodate the citizen charter.
8. Limitations
Some respondents declined to answer a questionnaire due to fear of hospital secrets
leaking while some senior management officers declined to share some information,
which they considered vital to the hospital. This prompted some parts of the study to rely
on secondary data which was found in the hospital library and human resource
department.
LITERATURE REVIEW
9. Theoretical Framework
Due to rapid technological, political and social changes that have taken place in the last
few years, governments have been forced to take fundamental administrative changes to
embrace development. Traditionally governments dominated in decision making and
citizens were treated as service receivers with less regard of their interests. These,
according to Osborne and Gaebler (1992), caused irritation to citizens in dealing with the
arrogance of the government bureaucracy where he further argues that even skilled
people get lost in the bureaucratic wilderness in government operations. Since the
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inception of the NPM policy different governments have shifted paradigm of
management to good governance which tends to move the conventionally provider-
dominated, especially in public service provision such as health care and education where
powerful autonomous professions defended vested interests and could not be held to
account (Pollitt, 1994), into one that is bottom-up and citizen driven. The study will focus
on the theory of good governance and policy implementation theory as reviewed by
different scholars as a basis for CC.
Theory of Good Governance
According to UNDP (2000), good governance means managing public in a manner that is
transparent, accountable, and participatory based on rule of law consensus. Citizens who
are service users have had problems while dealing with service providers; they have
encountered poor governance as opposed to good governance. United Nations
Development Program (2000) spells out eight characteristics of good governance;
Accountability, Transparency, Responsiveness, Equity and Inclusiveness, Effectiveness
and Efficiency, Rule of law, Participation, and Consensus building. The European
commission in 2001, published a white paper on governance that presented five
principles of good governance; openness, participation, accountability, effectiveness, and
coherence (European commission 2001).
Implementation Theory
Implementation is the process of turning policy into practice. However, it is common to
observe a gap between what was planned and what actually occurred as a result of a
policy. According to Buse (2005), there are three major theoretical models of policy
implementation. Top-down approach: This approach sees policy formation and policy
execution as distinct activities. Policies are set at higher levels in a political process and
are then communicated to subordinate levels that are then charged with the technical,
managerial, and administrative tasks of putting policy into practice. Bottom-up
approach: This approach recognizes that individuals at subordinate levels are likely to
play an active part in implementation and may have some discretion to reshape objectives
of the policy and change the way it is implemented. Principal-agent theory: In each
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situation there will be a relationship between principals (those who define policy) and
agents (those who implement policy), which may include contracts or agreements that
enable the principal to specify what is provided and check that this has been
accomplished. According to Pressman and Wildavsky (1973), Implementation, is the
ability to forge subsequent links in the causal chain so as to obtain the desired result. Van
Meter and Van Horn (1975) describe Policy implementation as encompassing “those
actions by public or private individuals (or groups) that are directed at the achievement of
objectives set forth in prior policy decisions."
10. Conceptual Framework
11. Knowledge Gap
Kenya‟s PSRP was introduced in 1993 and it aimed at improving service provision under
which the CC was launched as one of the tools to enhance transparency, accountability
and responsiveness of the service providers. Though this initiative of CC has been widely
adopted by many ministries and government institutions, there are no legal and social
mechanism put in place to monitor and give information on the implementation of the
CC. This study sought to find out the challenges of implementing the CC in KL5H and
come up with information that leads to enhanced and better utilization of this vital tool of
good governance.
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RESEARCH METHODOLOGY
12. Research Design
The study adopted a descriptive study design. This study design would help capture the
cognition, direction of response, the intensity of response, training of staff, response to
citizen and the management structure.
13. Target Population
This study was conducted in Kisii Level 5 Hospital. The target population were all the
two (2) administrators, twelve (12) doctors, all the twenty seven (27) clinical officers and
all the two hundred and thirty eight (238) nurses who were, employed permanent as
contained in the staff register. This population was chosen because they were the most,
immediate implementers of the Citizen‟s Charter. Also, the hospital is the largest health
provider in the region and was the only Level 5 hospital within Kisii, Nyamira, Migori
and Narok counties.
14. Sampling Procedure
Employees were stratified into four levels- Administrators, Doctors, clinical officers and
nurses. One administrator, representing 50%, and an equal percentage of 30% from the
number of doctors, clinical officers and nurses were calculated as tabulated bellow;
Table 1 Sampling Procedure
15. Data Processing and Analyis
The data collected were both quantitative and qualitative nature. Qualitative and
quantitative analysis were followed to analyse the data. Quantitative data collected was
coded, organized and analyzed according to research objectives using descriptive
Level Number Percentage % Total
Administrators 2 50 1
Doctors 12 30 4
C.O 27 30 4
Nurses 238 30 71
279 84
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statistics. The mean was used to determine the levels of agreement within variables.
SPSS computer package was used to present the analyzed data into tables. Qualitative
data was analyzed in narration form through coding and organizing it into themes and
concepts.
RESEARCH FINDINGS AND DISCUSSION
The main objective of this section was to use qualitative data in a process of inductive
reasoning within the context of hospital setting in order to generate ideas, as opposed to
hypothesis testing. Much of the qualitative analysis was focused on the strategies
hospitals are using to implement the charter so that they would realize the full value of
the charter.
16. Composition of Respondents
The data obtained came from four categories of respondents. The constitution of
respondents were tabulated as depicted in table 2 below.
Table 2 Categories of Respondents
Category No of Respondents % rate
Nurses 71 84
Administrator 1 1
Doctors 4 5
Clinical Officers 8 10
84 100
It was evident that out of eight-four respondents, seventy-one were nurses who
represented 84% of the total sample whereas the number of administrators who
responded to the questionnaire was one which represented 1%. Doctors, who responded
to the interviewing questionnaires, were four who represented 5% of the respondents and
clinical officers constituted 10%.
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17. Years of Work Experience
It is worthwhile to take into consideration the years of experience that the respondents
have. This will somehow reflect knowledge and implementation of the CC among the
respondents.
Table 3 Years of Work Experience
Years Practiced No of Respondents % Rate
Less than 5 years 40 48
5 ≥ years ≤ 15 8 9
Over 15 years 36 43
84 100
Most of the respondents have a work experience for less than 5 years. This is represented
by 48%, followed by those with over 15 years experience represented by 43 % and lastly
those with work experience between 5 years and 15 years. It is therefore presumably safe
to say that implementation of CC has been greatly affected due to lack of many years of
work experience.
18. Findings on Implementer’s disposition
The citizens‟ charter being a new policy in the medical field in Kenya drew various
reactions on how the public responded to its implementation. The reactions were based
on the employees‟ awareness, its usefulness, whether it has made the services in public
hospitals improve, its facilitating nature of dealing with citizens and whether it could
transform a dream into reality.
The „likert‟ scale guided the respondents in giving their opinion about the perception on
the implementation of the charter and was recorded according to the level of agreement.
An open question seeking a general opinion of respondents about what they feel should
be done to improve on implementation of CC was of great benefit to this variable.
According to Saunders (2007), the „likert‟ scale is the level of agreement (strongly agree,
agree undecided, disagree and strongly disagree). From these likert scale, the respondents
have a preference. The fact is that the „likert‟ scale has the advantages, as it presents a
load of data for conducting the research in a limited time and is able to analyze very
simply and effectively. The respondents gave information in order to ascertain their
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views on challenges faced by hospitals in implementing citizens‟ charter, as well as to
gain an approximate picture of how their characteristics and views were similar or
different, on dimensions of relevance to the study.
Table 4 Implementer‟s disposition about the citizens‟ charter
Level of Agreement
Aspects about Citizen’s Charter 5 4 3 2 1
Awareness of employees on existence of
CC
52 24 4 4 0
Usefulness of CC in provision of service 40 28 4 12 0
Improved service 28 36 12 8 0
Improved inquiry by clients 24 44 8 8 0
Positive feedback from citizens 16 40 16 8 4
Level of realities in the CC 12 32 20 12 8
Analysis of Implementer’s disposition
Mean value of general perception of the citizens‟ charter is given by;
Mean (µ) = Where Fi is the number of respondents in each slot. Wi is the weight
that represents the level of agreement.
Table 5 Calculation of Mean
Level of Agreement
Aspects about Citizen’s Charter 5 4 3 2 1
Weighted
Mean
Awareness of employees on existence of
CC
52 24 4 4 0 84 376 4.48
Usefulness of CC in provision of service 40 28 4 12 0 84 348 4.14
Improved service 28 36 12 8 0 84 336 4.00
Improved inquiry by clients 24 44 8 8 0 84 336 4.00
Positive feedback from citizens 16 40 16 8 4 84 308 3.67
Level of realities in the CC 12 32 20 12 8 84 280 3.33
Mean 4.01
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The mean value level of agreement in favour of the implementer‟s disposition about the
citizens‟ charter is 4.01. The study obtained the mean through engagement of weights on
the level of agreement that was 1 – 5. The table shows that the weighted mean on
employee awareness of the CC is high. Employees also agreed that service provisions
have since improved and that CC is useful on the daily provision of service. Majority of
the respondents agreed that the CC helped to facilitate in dealing with citizens and that
citizens make more inquiries since the introduction of CC. However many of the
respondents were undecided whether the standards and time frames in the CC were
realistic, also a good number of respondents were undecided whether CCs have helped
improve on feedback from Citizens.
19. Staff Competence
Korossy (1997), defines competence as skills or abilities that enable persons to solve a
problem, and cannot be observed directly. Of course, competence, demands and
performance are related. However, competences are properties of persons, while demands
are properties of problems. While a demand requires a competence to fulfil it, the
relationship is not a one to one relation. It is worthwhile to note that when a performance
of a person is observed, it is not obvious what underlying competences have contributed
to the solution.
Table 6 Level of Staff Competence
Level of Agreement
Competence Aspects 5 4 3 2 1
Conversant with the citizens' charter 12 4 8 36 24
Inadequacy of training on new technology 8 8 16 36 16
Citizen‟s awareness of the existence of CC 28 24 8 16 8
Level of publicity 24 32 12 8 8
High level of communication about service
charter among staff
8 24 8 32 12
Awareness of local language 8 44 0 20 12
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Analysis of Staff Competence
The mean was reached through the weights assigned to the level of agreement of the
competence aspect in the likert scale.
Mean (µ) =
Where Fi is the number of respondents in each slot
Wi is the weight that represents the level of agreement
Table 7 Calculation of Mean
Level of Agreement
Aspects about Citizen’s Charter 5 4 3 2 1
Weighted
Mean
Conversant with the citizens' charter 12 4 8 36 24 84 196 2.33
Inadequacy of training on new
technology
8 8 16 36 16 84 208 2.48
Citizen‟s awareness of the existence of
CC
28 24 8 16 8 84 300 3.57
Level of publicity 24 32 12 8 8 84 308 3.67
High level of communication about
service charter among staff
8 24 8 32 12 84 236 2.81
Awareness of local language 8 44 0 20 12 84 268 3.19
Mean
3.01
The mean value was 3.01. It exceeded the figure three (3) which represented the
undecided level in the „likert‟ scale. It was worthwhile to conclude that the respondents
had confidence in the competence of staff to embrace the spirit of citizens‟ charter.
However, data from the table above indicate that employees were not given enough
training on CC and that the training on the new technology recently introduced in the
hospital was inadequate. Also, the data show that communication amongst staff about the
CC was not adequate.
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20. Management Structure
Choosing the correct management structure ensures an organization‟s continued growth,
content, employees and profitable returns for the shareholders. Choosing the wrong
structure creates tension between employees and managers, allows inefficient work
practices to flourish and reduces company profitability. In the worst case, an incorrect
management structure can lead to company closure. A number of key components that
underpin a management structure in the organization and should be considered when
implementing a new structure. They include; task definition, communication style,
formalization, type of influence, centralization, complexity and coordination.
Table 8 Management Structure and Responses
Management View on Citizens' charter
Level of Agreement
5 4 3 2 1
Adequacy of information to citizens 8 36 4 28 8
Constant supervision by the seniors 20 36 4 20 4
Adequacy of staff to implement charter 0 16 4 36 28
Teamwork is embraced 20 40 4 12 8
Decision remains the management's role 20 28 0 28 8
Barriers by rules and regulations 4 32 12 28 8
Priorities are adhered to 20 36 12 8 8
Sensible and knowledgeable seniors 8 40 12 12 12
There exists free downward communication 12 40 8 12 12
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Analysis of Management Structure
Table 9 Views about Management
Management View on Citizens'
charter
Level of Agreement
Weighted
Mean 5 4 3 2 1
Adequacy of information to citizens 8 36 4 28 8 84 260
3.10
Constant supervision by the seniors 20 36 4 20 4 84 300
3.57
Adequacy of staff to implement charter 0 16 4 36 28 84 176
2.10
Teamwork is embraced 20 40 4 12 8 84 304
3.62
Decision remains the management's
role 20 28 0 28 8 84 276
3.29
Barriers by rules and regulations 4 32 12 28 8 84 248 2.95
priorities are adhered to 20 36 12 8 8 84 304
3.62
Sensible and knowledgeable seniors 8 40 12 12 12 84 272
3.24
there exists free downward
communication 12 40 8 12 12 84 280
3.33
Mean
3.20
The mean value was 3.2. It exceeded the figure three (3) which represented the undecided
level in the „likert‟ scale. It was worthwhile to conclude that the respondents had
confidence in the management structure to embrace the spirit of citizens‟ charter. The
data showed there was inadequate staff in the hospital which has resulted to low
implementation of CC, and that some rules and regulations in the hospital hinder the
smooth implementation of CC.
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SUMMARY, CONCLUSSIONS AND RECOMMENDATIONS
21. Summary of the Findings
It was evident from the findings that the mean exceeded three (3) mark. This meant that
the majority of the respondents agreed, that the charter implementation benefitted from
both the implementers‟ disposition, competence of the staff and the management
structure was conducive. However, some were of the opinion that little input was in place
to make the charter popular among the beneficiaries. Owing to the numerous challenges
that hinder the implementation of the citizen‟s charter, the study established that a lot was
required. The implementers needed a thorough training on the strategies to implement the
charter. Many players were conversant with the existence and importance of the charter.
However, what was on the ground did not portray the same. This was evident from the
findings that established that patients could stay in ques for long hours more than
stipulated in the CC and they only complained to hospital management when there was a
problem but kept quiet when not aggrieved. It was found that some rules and regulations
in the hospital hindered CC implementation also communication among staff was
inadequate. Many employees were undecided whether standards and time frames in CC
were realistic.
22. Conclusion
Citizen‟s charter is an important strategic process that seeks to address the challenges that
affect service delivery in hospitals. It is worthwhile to note that its implementation suffers
a lot since various players have received less support, both materially and non-materially.
The research attained its basic objectives; to evaluate the challenges that face the
implementation of citizen‟s charter. A lot was required to ensure service delivery became
so efficient in hospitals across the country and even beyond. They included; training,
publicity through advertisement, recruitment of more staff and embraced modern
technology. Besides, for the service charter to realize better implementation exercise the
ministry needed to employ enough and qualified personnel to undertake the exercise of
citizen‟s charter implementation. Lack of enough and qualified staff, stagnated the
process of effectiveness in service delivery as provided in the charter. It is imperative to
note that adequate training on new technologies eased the challenge of implementation of
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the charter. This would go along with staff motivation and even translation of citizen‟s
charter to local languages which the intended beneficiary would understand.
23. Recommendations
The ministry should recruit field officers ought to synthesize the citizens about the
existence of the charter that ensured efficient service delivery in hospitals. The exercise
would reduce the incidences of manipulation of the citizens by hospital staff. The staff
required intensive training about the strategies towards implementation of the charter and
consequently, on how to maximize the utilization of the existing staff. The ministry
should employ some resources to train its workers and even encourage the employees to
go and pursue courses on their own, which would be beneficial to the implementation of
the charter.
Motivated workers efficiently increased output. The ministry should motivate workers,
both psychologically and economically. It is worth to note that the ministry did very little
to make the profession in medical, administration and management fields seen lucrative.
Regular workshops and trips are necessary to psychological satisfaction whereas salary
increment is necessary to economic satisfaction.
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