Monetary Resource Factors Influencing Strikes among Healthcare Workers in Public Hospitals in

Healthcare workers play a pivotal role in the delivery of essential medical services, and their commitment is critical for the overall functionality of public hospitals. However, persistent strikes among healthcare workers in public hospitals in Nairobi County, Kenya, pose a significant threat to the stability and effectiveness of the healthcare system. The consequences of these strikes are far-reaching, affecting the quality and accessibility of healthcare services, patient outcomes, and the overall reputation of the healthcare system. This research sought to evaluate the Monetary resource factors influencing strikes among healthcare workers in public hospitals in Nairobi County, Kenya. The research was conducted at Kenyatta National Teaching and Referral Hospital, Mbagathi Hospital, Mama Lucy Kibaki Hospital, Ngara Health Center, and Pumwani Maternity Hospital all located in Nairobi County, Kenya. The study employed a descriptive research design and the sampling frame involved 400 Healthcare workers. The study used semi-structured questionnaires with closed-ended items for data collection. The data processed using SPSS, version 26.0, software, and the level of significance was set at 0.05. Both descriptive and inferential statistics were employed in data analysis. From the responses, most of the respondents as shown by 55.2% (191) were female. In terms of the age of the respondents in years, more than half of the respondents as shown by 55.8% (193) were aged 31-40 years. The study found that some of the significant monetary factors that influence strikes by HCWs comprise: salary status ( 𝒳 2 (3, 𝑁 = 346) = 39.248 , p-value<0.001; OR = 3.610; CI = (2.072, 6.289)), status of allowances ( 𝒳 2 (3, 𝑁 = 346) = 63.457 , p-value<0.001; OR = 2.835; CI = (1.692, 4.749)), status of extra work pay ( 𝒳 2 (3, 𝑁 = 346) = 10.183 , p-value=0.017; OR = 1.472; CI = (0.892, 1.764)), and status of bonuses ( 𝒳 2 (3, 𝑁 = 346) = 59.382 , p-values <0.001; OR = 1.708 and CI = (1.435, 2.155)). This study recommends that more resources should be set aside by the government to cater for salary increments, better allowances, and competitive bonuses.


Introduction
Healthcare workers play a pivotal role in the delivery of essential medical services, and their commitment is critical for the overall functionality of public hospitals.However, persistent strikes among healthcare workers in public hospitals in Nairobi County, Kenya, pose a significant threat to the stability and effectiveness of the healthcare system.For example; during the Coronavirus pandemic especially the beginning of December 2020, there were various rumors and threats by the Health care workers to down their tools (Xinhua, 2021).On 10th September 2021, Pumwani Maternity Hospital was closed indefinitely after employees boycotted duties in solidarity with the ongoing strike by Nairobi County Government workers.
One of the key factors contributing to these strikes is the influence of monetary resource factors on the working conditions and welfare of healthcare professionals.These Frequent strikes by the HCWs lead to the closure of public hospitals thus preventing Kenyans from accessing health services of high quality.The strikes also lead to deaths and complications that could be avoidable and also cause increased medical tourism where citizens seek treatment abroad.While the drawn-out strikes finish, it usually gives the idea that a few issues remain unsettled leading to more future strikes.
Monetary resource factors comprise many components that are associated with the pay received by the healthcare workers such as basic salary, bonuses, extra work pay, commissions, benefits, and incentives (Oladeji et al., 2024).Further, monetary resource factors are associated with the pay HCWs get after they fulfill their duties.According to Siddiqui & Vishwakarma (2023), monetary rewards relate to merit and base pay, health allowances among other bonuses in the line of service provision.According to Al-Mohammad et al. (2023), monetary factors are one of the extrinsic factors that play a key role in service delivery through their influence on issues such as job satisfaction and motivation.
For instance, in Nigeria, Eruaga et al. (2023) found that nurses normally embark on unrest via strikes due to inequality and agreements that are unfulfilled in mechanisms of payments in comparison with other health professionals.Sarpong et al. ( 2022) evaluated actions of strikes in Ghana's health sector and found monetary factors associated with delays in increasing salaries to trigger strikes in Ghana.In Bangladesh, high incidences of unrest by HCWs have been associated with non-payment of dues owed to the HCWs (Haque, 2020).Through a regression analysis, Vincent and Gichinga (2017) showed that monetary rewards positively affect industrial unrestat Coast Provincial General Hospital in Kenya.
In the USA, growth in gross domestic product (GDP) and widening differences in wages among healthcare professionals have been shown to lead to strikes.Disputes in wages are informed by workers comparing their salaries and wages with those in the private sector or similar comparable levels (Russo et al., 2019).In a study conducted in Indonesia, Hamid and Wibisana (2022) evaluated salary's role in engagement in strikes by employees.Through a quantitative study, Hamid and Wibisana (2022) demonstrated that the amount of salary and payment dates had a significant effect on the unrest of employees.However, the study was not in the context of HCWs which represents a gap that the current study seeks to fill.
An Ethiopian study by Russo et al. (2019) was conducted on nurses based in the emergency departments of Aabet and Alert hospitals.Through a cross-sectional descriptive research design, data was gathered with the help of structured questionnaires.The results unearthed that non-competitive salaries different from the private sector, delayed salary increments, and salary amounts had a significant effect on nurses' likelihood to take part in strikes.Further, the study found that the existence of a gap between the salaries of nurses and the current situation of the country's economy led to nurses' engagement in strikes to compel the government to adjust their salaries with inflation.

Materials and methods
This study adopted a descriptive research design inorder to determine, and describe the different monetary resource factors influencing the strikes in the public hospitals in Nairobi County.The study was carried out at Kenyatta National Teaching and Referral Hospital, Mbagathi Hospital, Mama Lucy Kibaki Hospital, Pumwani Maternity Hospital and Ngara Health Centre.KNTRH is located at Upper Hill 2 km within the CBD, the hospital has 6,000 staff, and a bed capacity of 1,800 with an average of 3,000 patients attended to daily.Mbagathi Hospital which is located near Kenyatta market at Ngumo, the hospital has 200 staff, and a bed capacity of 320 beds with a daily average of 500 patients being treated daily.Mama Lucy Kibaki Hospital is located in Umoja II Embakasi West Constituency off Kangundo Road, the hospital has 468 staff, and a bed capacity of 150 beds with an average of 800 patients seen daily.Pumwani Maternity Hospital which is located in General Waruingi Street in Pumwani area Kamukunji Constituency, the hospital has 206 staff, and a bed capacity of 354 beds with an average of 250 patients seen daily.Ngara Health Centre is located in Ngara, Along Park Road near Guru Nanak Hospital in Starehe Constituency.The facility has 50 staff members, a bed capacity of about 24 beds, and a daily average of about 100 patients seen daily.This research targeted a population of over 6,000 healthcare workers working at KNTRH, Mbagathi Hospital, Mama Lucy Kibaki Hospital, Ngara Health Center, and Pumwani Maternity Hospital.The sample size who participated in the study was done through a stratified random sampling technique.The researcher allocated weights to the various hospitals based on the proportion of healthcare workers in those facilities.The proportion of the sample size allocated for each hospital was based on the weights allocated.
The sampling frame for this study involved a sample size to be 400 Healthcare workers.The study adopted semi-structured questionnaires for data collection.The raw data was cleaned and coded, and thereafter, analyzed both descriptively and inferentially using SPSS version 26.0, and presented using columns and frequency distribution tables.The inferential analysis was done using Pearson chi-square where P-value <0.05which signifies association.

Results
The results and analysis of the findings were presented using quantitative and qualitative data.The outcomes were elaborated using descriptive and inferential statistics.

Socio-Demographic Characteristics of the Respondents
From the responses, most of the respondents as shown by 55. 2% (191) were female.In terms of the age of the respondents in years, more than half of the respondents as shown by 55. 8% (193) were aged 31-40 years.The majority of the HCWs as indicated by 63.9% (221) were married while another majority as shown by 68.8% (238) had a college level of education.According to the responses, a total of 62.4% (355) had worked in the respective facility for duration of a 6 or more years.Close to half of the HCWs, 49.1% (170) earned a salary ranging between KES 50, 000 to KES 100, 000 (see Table 1).

Monetary Resource Factors Influencing Strikes among HCWs in Public Hospitals in Nairobi County
The study assessed the monetary resource factors influencing strikes among healthcare workers in public hospitals in Nairobi County.Respondents were asked to indicate whether their salary was commensurate with their education level.The majority of the respondents, as shown by 86.4% (299), indicated that their gross salary is not commensurate with their education; 13.6% (47) indicated that their salary was commensurate with their education (see Table 2).3show that more than half of the respondents as demonstrated by a total of 67.1% (232) were of the opinion that the status of their salaries was either poor or fair.The status of the commission as indicated by more than half of the respondents, 59.8% (207) was poor.According to 45.7% (158), the status of allowances was also poor.A larger portion of the HCWs as demonstrated by 39.9% (138) indicated that the status of extra work pay was poor.Most of the HCWs in public hospitals in Nairobi County as shown by 55. 8% (193) indicated that the status of their benefits was poor.Another majority, 57.8% (200) were of the opinion that the status of bonuses was also poor.Respondents were asked to compare different forms of pay between the public and private health sectors in Kenya in different aspects and the results tabulated as shown in Table 4.The majority of the HCWs as indicated by 66.8% (231) indicated that the public health sector witnesses a delay in payment of monetary dues as compared to the private sector to a great extent.Further, a total of 48.8% (169) of the HCWs were of the opinion that HCWs in the private sector are paid higher monetary incentives in comparison to their public counterparts to a great extent.Based on 48.0% (166) of the HCWs who participated in the study, to no extent are monetary deductions higher for public HCWs as compared to private HCWs.

To no extent
To some extent

To a great extent
To a very great extent The public health sector witnesses delays in payment of monetary dues as compared to the private sector 65 (18.8%)50 (14.5%)101 (29.2%) 130 (37.6%)HCWs in the private sector are paid higher monetary incentives in comparison to their public counterparts 113 (32.7%) 64 (18.5%) 96 (27.7%) 73 (21.1%)Monetary deductions are higher for public HCWs as compared to private HCWs 166 (48.0%) 106 (30.6%) 37 (10.7%)37 (10.7%)Respondents were further presented with Likert scale responses where they were required to indicate their level of agreement/disagreement on the influence of Monetary Resource Factors Influencing Strikes among HCWs in Public Hospitals in Nairobi County.The analysis is as presented in Table 5.  249) of the respondents agreed and strongly agreed that low salary payment has a significant effect on strikes by HCWs.A total of 76.9% (266) of the respondents agreed and strongly agreed that inequality in payments in comparison with other professionals in the public sector and private sector lead to strikes by HCWs.Further, 71.4% (247) were in agreement that delays in increasing salaries trigger strikes by HCWs in the public health sector.It is further evident that 81.2% (281) were in agreement that non-payment of dues in the public health sector is linked to high incidences of strikes by HCWs.On the statement "Existence of a gap between the salaries of HCWs and the current situation of the country's economy lead to strikes by HCWs", 78.9% (273) of the respondents were in agreement.

Inferential Statistics on Monerary Resource Factors influencing Strikes among HCWs in Public Hospitals of Nairobi County, Kenya.
Chi-square test statistic was adopted to evaluate whether strikes were dependent on various monetaryfactors at a 5% level of significance.The Chi-Square results show that salary status ( 2 (3,  = 346) = 39.248,p-value<0.001)had a statistically significant effect on engagement in strikes.The odds ratio (OR) = 3.610 with confidence interval (CI) = 2.072, 6.289) for those whose salary status is poor.Therefore, those with poor salary status are 3.610 times more likely to engage in strikes as compared to other better salary statuses.Status of allowances ( 2 (3,  = 346) = 63.457,p-value<0.001)had a statistically significant effect on strikes by HCW with an OR = 2.835 and CI = 1.692, 4.749) for those with poor status of allowances.Therefore, those whose status of allowances was poor were 2.835 times more likely to engage in strikes as compared to those with better allowances.Status of extra work pay ( 2 (3,  = 346) = 10.183,p-value=0.017)also had a significant effect on strikes by HCWs.The OR = 1.472 with CI = (0.892, 1.764) with poor status of extra work pay as the baseline.This means that those with poor status of extra work pay were 1.472 times more likely to engage in strikes.Status of benefits ( 2 (3,  = 346) = 15.840,p-value=0.001)had a statistically significant effect on strikes by HCWs.The OR = 1.674 with CI = (1.414,2.095) with poor status as the baseline; an implication that those with poor status of benefits were 1.674 times more likely to engage in strikes.Lastly, status of bonuses ( 2 (3,  = 346) = 59.382, p-value<0.001)have a statistically significant effect on strikes by HCWs.The OR = 1.708 and CI = (1.435,2.155) with poor status as the baseline.Therefore, it is 1.708 times more likely to engage in strikes for poor status of bonuses category of HCWs as compared to other better status of bonuses.The findings of the study demonstrated that salary status, status of allowances, status of extra work pay, status of benefits and status of bonuses have a statistically significant effect on strikes by HCWs in public hospitals of Nairobi County.The findings concur with Vincent and Gichinga (2017) who found monetary rewards to have a significant effect on industrial unrests in Kenya's Coast Provincial General Hospital.These findings also agree with Saad and Hasanein (2018) who noted that monetary factors are among the extrinsic factors that influence issues such as job satisfaction and motivation and therefore regarded as one of the leading causes of strikes in the health sector.Further, Akin-Otiko et al. ( 2019) conducted a study in Ghana and found that nurses engage in unrests through strikes due to payments inequality with other professionals and unfulfilled payment agreements.Ampofoet al. ( 2022) also evaluated strikes' actions in the health sector of Ghana and found that monetary factors such as delays in salary increments trigger strikes in Ghana.Haque (2020) on the other hand conducted a study in Bangladesh and found HCWs to take part in strikes due to non-payment of dues owed to them.
In another study conducted in the USA by Russo et al. (2019), growth in GDP and widening differences in salaries and wages across healthcare professionals lead to strikes.Disputes in wages leading to strikes are as a result of HCWs comparing their salaries and wages with those in the private sector or similar comparable levels.In Indonesia, Hamid and Wabisana (2022) found that salary amounts and payment dates significantly affected unrests in the health sector.The findings also agree with Fernando (2020) who conducted a study in Sri Lanka airline sector and found that salary amount, delays and discrepancies influence engagement in strikes.

Conclusion
The objective of the study was to assess the monetary resource factors influencing strikes in public hospitals in Nairobi County.The majority of the respondents indicated that salary in public hospitals in Nairobi County was not commensurate with education level.Most of the respondents indicated that the status of their salaries, commissions, benefits, and bonuses was poor.Slightly less than half of the respondents opined that the status of their allowances and extra work pay was poor.The majority of the respondents indicated that the public health sector witnesses a delay in payment of monetary dues and that HCWs in the private sector are paid higher monetary incentives.From the Likert scale responses, the majority of the respondents were in agreement that low salary payment, inequality in payment, delays in salary increment, non-payment of dues and gaps in salary, and current economic situation lead to strikes by HCWs.Statuses of salary, allowances, extra work pay, benefits, and bonuses had a statistically significant effect on strikes by HCWs.The study also found that the ORs for statuses of salary, allowances, extra work pay, benefits, and bonuses exceeded one (1) with "poor status" as the baseline.This implied that it was more likely for HCWs who perceived the statuses of salary, allowances, extra work pay, benefits, and bonuses as poor to engage in strikes as compared to those who perceived them to be better.
From the findings of the study, it can be concluded that there are monetary factors that have an influence on strikes by HCWs.Some of the significant monetary factors that affect strikes by HCWs in public hospitals include salary status, status of allowances, status of extra work pays, status of benefits, and status of bonuses.Further, it can be concluded that there are

Table 2 Whether Salary is Commensurate with Education Level
Respondents were also presented with monetary resource factors and asked to indicate their status.The findings on monetary resource factors status in Table

Table 5 : Likert Scale Responses on Influence of Monetary Resource Factors Influencing Strikes among HCWs in Public Hospitals in Nairobi County. Strongly Disagree Disagree Undecided Agree
Based on the results in Table5, 72.0% (