Elsevier

Social Science & Medicine

Volume 54, Issue 8, April 2002, Pages 1255-1266
Social Science & Medicine

Health sector reform and public sector health worker motivation: a conceptual framework

https://doi.org/10.1016/S0277-9536(01)00094-6Get rights and content

Abstract

Motivation in the work context can be defined as an individual's degree of willingness to exert and maintain an effort towards organizational goals. Health sector performance is critically dependent on worker motivation, with service quality, efficiency, and equity, all directly mediated by workers’ willingness to apply themselves to their tasks. Resource availability and worker competence are essential but not sufficient to ensure desired worker performance.

While financial incentives may be important determinants of worker motivation, they alone cannot and have not resolved all worker motivation problems. Worker motivation is a complex process and crosses many disciplinary boundaries, including economics, psychology, organizational development, human resource management, and sociology. This paper discusses the many layers of influences upon health worker motivation: the internal individual-level determinants, determinants that operate at organizational (work context) level, and determinants stemming from interactions with the broader societal culture.

Worker motivation will be affected by health sector reforms which potentially affect organizational culture, reporting structures, human resource management, channels of accountability, types of interactions with clients and communities, etc.

The conceptual model described in this paper clarifies ways in which worker motivation is influenced and how health sector reform can positively affect worker motivation. Among others, health sector policy makers can better facilitate goal congruence (between workers and the organizations they work for) and improved worker motivation by considering the following in their design and implementation of health sector reforms: addressing multiple channels for worker motivation, recognizing the importance of communication and leadership for reforms, identifying organizational and cultural values that might facilitate or impede implementation of reforms, and understanding that reforms may have differential impacts on various cadres of health workers.

Introduction

Motivation, in the work context, can be defined as an individual's degree of willingness to exert and maintain an effort towards organizational goals. It is an internal psychological process and a transactional process: worker motivation is the result of the interactions between individuals and their work environment, and the fit between these interactions and the broader societal context.

Health sector performance is critically dependent on worker motivation: health care delivery is highly labor-intensive. Consequently, service quality, efficiency, and equity are all directly mediated by workers’ willingness to apply themselves to their tasks. While resource availability and worker competencies are essential, they are not sufficient in themselves to ensure desired worker performance. Worker performance is also dependent on workers’ level of motivation stimulating them to come to work regularly, work diligently, be flexible and willing to carry out the necessary tasks (Hornby & Sidney, 1988).

Even in a stable work environment, what motivates workers fluctuates over time. Health sector reform, essentially a change process, adds additional destabilization to the work environment through its efforts to improve national policies, programs and practices by altering health sector priorities, laws, regulations, organizational structure, and financing arrangements. Yet, even reforms that have tried to improve working environments and incentives have not always had the anticipated impact on health system effectiveness. Workers have often displayed “unexpected” behavior patterns, reflecting the lack of internalization of health reform and organizational goals.

Although many technical aspects of health sector reform in the international context have been researched and low levels of worker motivation plague public health systems in developing countries, there has been a surprising lack of attention to the human (worker) elements of reforms. Only recently have meetings and papers begun to address human resource development issues in the context of health sector reform (Dussault, 1998; Martinez & Martineau, 1996).

Faced with little information about what motivates health workers and how reforms affect worker motivation, many countries (and organizations within them) have implemented measures or incentive programs designed to stimulate certain kinds of worker behavior without an empirical base to guide their choice of interventions. Policy makers have often relied primarily on financial incentives, as in Indonesia (Chernichovsky & Bayulken, 1995) and Thailand (Pannurunothai, Boonpadung, & Kittidilokkul, 1997). There is substantial debate about the prospects for and effectiveness of performance-related pay in developing country public sector contexts (Nunberg, 1995). Even when financial incentives are not explicitly used to promote higher productivity, the underlying philosophy of many health sector reform programs often implies that money is a key motivator in the work context.

While financial incentives may be important determinants of worker motivation, it seems equally evident that they alone cannot and have not resolved all worker motivation problems. Moreover, excessive focus upon financial incentives in the public sector could lead to negative consequences. Workers may begin to view financial rewards as more important than other types of reward (e.g., praise from supervisors or appreciation by the community), and they could experience a conflict between their own notion of public sector values and messages about working for financial gain (Giacomini, Hurley, Lomas, Bjhatia, & Goldsmith, 1996).

Worker motivation is a complex process and crosses many disciplinary boundaries, including economics, psychology, organizational development, human resource management, and sociology. This paper discusses the many layers of influences upon health worker motivation, and suggests that worker motivation will be affected not only by specific incentive schemes, but also by the whole range of health sector reforms which potentially affect organizational culture, reporting structures, channels of accountability, etc. By drawing attention to this broad range of influences, this paper aims to help policy makers view worker motivation in a more holistic manner. This broader view will enable them to structure reform programs to more effectively promote worker motivation, and hence, improve health system performance.

The paper draws primarily upon the existing literature; however, it was also influenced by a series of specially commissioned case studies (Abzalova, Wickham, Chukmaitov, & Rakhipbekov, 1998; Munoz, 1999; Mutizwa-Mangiza, 1998).

Motivational processes in the work context operate at the level of an individual, and are composed of two parallel components: the extent to which workers adopt organizational goals (“will do”) and the extent to which workers effectively mobilize their personal resources to achieve joint goals (“can do”). Yet, determinants of these two components originate at many levels: the individual, the immediate organizational work context, and the cultural context.

Health sector reforms influence worker motivation through their effects on organizational structures and community/client roles. Fig. 1 represents these various layers.

At the individual level, workers’ individual goals, self-concept, expectations, and experience of outcomes are some of the more important individual-level determinants of worker motivation. These determinants, coupled with the individual worker's technical and intellectual capacity to perform and with the physical resources available to carry out the task, result in a specific level of worker performance.

Worker motivation also depends upon the organizational context in which the worker is situated. Organizational structures, resources, processes, and culture, as well as organizational feedback about performance, contribute to the motivational processes occurring at the individual level. These affect the individual's real and perceived ability to carry out his tasks, and stimulate worker adoption of organizational goals.

Although not part of the organizational context, communities also influence worker motivation through community expectations for how services should be delivered, the interactions that workers have with individual clients, and formal and informal client feedback on health worker performance.

While the generic concepts of individual, organizational and community determinants of worker motivation described above are relevant to all country situations, the socio-cultural context will affect the relative importance of the different determinants and the relationship between them. For example, in many industrialized countries, flat organizational structures, and worker involvement are valued and are prominent determinants of motivation, while societies in many developing countries are more accustomed to hierarchical structures and give more legitimacy to unequal distribution of power.

These various layers of determinants operate, whether the health sector or broader (political, economic, etc.) environment is stable or changing. Health sector reforms are likely to affect organizational systems and culture, and they frequently emphasize stronger links between performance and reward. Reforms commonly require training and the development of new capabilities in the workforce. Many of the reforms currently being implemented attempt to change the role of the community and clients, and provide them with a more effective means to offer feedback on the performance of health care providers. These processes all affect worker motivation.

However, the content of the health sector reform is only one aspect of its influence on worker motivation. The manner in which the reform is designed, communicated, and introduced will also impact on health worker motivation. Reforms can be designed and communicated in a variety of ways: for example, top policy makers can shape the reform with little input from health workers and communities, with some participation, or with extensive dialogue and consensus building. Reforms can be communicated widely and in great detail, or they can be only vaguely communicated. Both the content of the reform and how it is communicated will determine workers’ perceptions (correct or incorrect) of how these changes might affect them.

A specific example may help illustrate the many ways in which health sector reform may affect health worker motivation. An ambitious program of health sector reform in Zambia has included, decentralization training in planning and management, the creation of District Health Boards made up of community members, the introduction of user fees, and greater attention to supervisory issues. All of these reforms are likely to impact upon health worker motivation in some way—either through increasing worker capabilities, or resources available or channels of accountability or changing basic employment conditions. While the reform program has presented many opportunities for improving work motivation, communication of reforms has often been “too little, too late” (Lake et al., 2000). As a consequence, resistance from health workers has been encountered, and certain reforms, most notably de-linkage of health workers from the civil service have been suspended.

This paper seeks to clarify the ways in which worker motivation is influenced and how health sector reform can affect worker motivation. The paper is organized in the following manner. The section on “the internal determinants of worker motivation” discusses the basic motivational process as it operates at the level of an individual. The section on “organizational factors and their influence upon worker motivation” outlines the influence of organizational factors on worker motivation and how health sector reform might impact those influences. The section on “cultural and community influences” reviews the cultural influences on worker motivation and the mutual influence between cultural values and reform. The paper concludes with a brief discussion of implications for health sector reform policy.

Section snippets

The internal determinants of worker motivation

Health worker motivation exists when there is alignment between individual and organizational goals, and when workers perceive that they can carry out their tasks. Workers’ willingness to devote time and effort to work tasks is not a function of external factors alone, but rather influenced by the interaction of these factors with unique personal factors. As a result, the internal motivation process will differ across individuals in the same environment. In addition, due to the contribution of

Organizational factors and their influence upon worker motivation

Organizations influence worker motivation through a variety of channels: through the organization's efforts to improve worker capability; through the provision of resources and processes; through feedback or consequences related to worker performance; and through more indirect aspects such as work culture. Fig. 3 highlights these channels, and this section briefly summarizes the manner in which organizational structures, human resource management policies, and organizational culture impact on

Cultural and community influences

Outside the immediate organizational environment, the broader cultural and community context will also contribute to the individual's motivational processes. Fig. 4 shows the direct links of community and clients on the internal motivational process. The broader cultural influence is more pervasive, affecting health reforms, communities, organizations, and the individual worker, and is shown as a backdrop to all other factors.

Culture can be defined as “all the patterns of thinking, feeling and

Implications for health reform policies

The conceptual framework presented here paints a complex picture of health worker motivation, because worker motivation is a complex and dynamic process. By “unpackaging” the various channels through which worker motivation can be affected, this framework can be used both to assess already implemented reforms, as well as assist policy makers seeking to evaluate how proposed reforms might affect worker motivation.

At the core of the motivation question is how well individual health worker goals

Acknowledgements

Preparation of this paper was supported by the Partnerships for Health Reform (PHR) Project. This was made possible through support provided by the United States Agency for International Development (USAID) under Prime Contract No. HRN-C-00-95-024-05 awarded to Abt Associates, Inc. The opinions expressed herein are the author's and do not necessarily reflect the views of Abt Associates, Inc. or USAID. The authors gratefully acknowledge the contributions of participants at the workshop on Health

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