motivation

Staff motivation: Staff motivation:

The impact of non-financial The impact of non-financial

incentives and Quality Management toolsincentives and Quality Management tools

M.L.PANDIA

Contents:

• GTZ‘s stake in HRH

• The link between (low) motivation and migration

• Some study findings

• Conclusions and need for further action

stake in HRH

Technical cooperation• Support for process and change management• Capacity building and HRM/HRD• Substantial experience in Quality Management

=> Improvement of staff skills and working

conditions for staff

Low job satisfaction / low motivation

Push factor of migration

Poor performance



Poor performance

Performance improvement

Staff retention

Challenge



Poor performance

Performance improvement

Staff retention

What is the role of non-financial incentives & Quality Management tools?

Challenge

Motivation and the role of non-financial incentives

Even with an adequate salary, health workers (HWs) may not be motivated.

Even without an adequate salary and under poor working conditions, there are motivated and performing HWs.

Empirical evidence


Even with an adequate salary, health workers (HWs) may not be motivated.

Even without an adequate salary and under poor working conditions, there are motivated and performing HWs.

Common agreement on:Non-financial incentives are an essential

component to increase motivation.

Empirical evidence

Multicountry study on motivation and incentives

in process:

4 country studies(El Salvador, Nicaragua, Benin, Kenya, possibly Tanzania)

• Semi-structured, qualitative interviews • with 40-50 medical doctors and nurses from the public, private and NGO sector

in each country

• Focus group discussions

completed:

Self-administered survey• among MoH officials (counterparts) & GTZ-Health staff

• 29 Responses; 18 from Africa


Research aspects• Motivating factors• Career / migration plans• Quality management tools• Project experiences: what works, what doesn‘t?


Research aspects• Motivating factors• Career / migration plans• Quality management tools• Project experiences: what works, what doesn‘t?

Objectives=> Assessment of the role and effects of non-financial incentives and QM tools on motivation

=> Identification of potential approaches to improve motivation and to retain staff in rural areas

Country study KenyaViews of health workers on migration

“If everyone had a chance to go, everyone would go” (nurse, 40 years, government clinic)

“Not all here have gone. So you can say we are motivated” (laughs) (MD, 55 years, Mission hospital)

“Most of my colleagues think about leaving the country” (nurse, 31 years, government clinic)

“Migration has never been a serious thought for me. I don’t have the connections you need in order to go” (nurse, 46 years, government clinic)

“It is too hectic in the city. I prefer to stay in the rural area” (MD, 42 years, Mission hospital)

Country study KenyaViews of health workers on their work

“We have no motivation here, but we work” (nurse, 51 years, Mission hospital)

“With the given workload due to understaffing, even easy tasks get difficult” (nurse, 32 years, government clinic)

“Supervision gives you moral support” (nurse, 30 years, government clinic)

“The lack of equipment and lack of drugs is very frustrating and depressing. You cannot do quality work.

“I have not yet lived up to my own ideal. It is hard under given external conditions to achieve one’s goal” (MD, 28 years, government hospital)

Country study Kenya:Some observations

• Before joining the health profession, most health workers did not seem to have been aware of the working conditions and salary grades.

• The main reason for moving to the capital is further career development and training.

• Once established, many health workers prefer to stay in rural areas given the conditions in cities.

• Many health workers have thought about or tried to migrate, but felt unable to go abroad.

• BUT: Despite the frustrations, there is lots of commitment and professional ethos!

Non- / financial incentives applied

0

10

20

30

40

50

60

70

80

Survey findings

in %

N = 18 countries

Study

leaveTraining Awards Performance

related payBonus

Incentives to stay in remote areas

Exists in most countries:– Financial incentives– In-kind benefits (housing, transport)– Improvement of career opportunities (further training,

better promotion scores)– „Release paper“ after agreed period in rural areas

Other measures to reduce shortages in rural areas: – Decentralised training institutions – Recruitment of retired staff – Contracted personnel

Survey findings

Quality Management tools

0

10

20

30

40

50

60

70

80

MD

Nursesin %

Survey findings

N = 18 countries

Regular meetings

Regular supervision

Feedback Performance assessments

0

10

20

30

40

50

60

70

80

Staff satisfaction surveys

Leadership & management training

Disciplinary action enforced

Clear formulation of expectations and organizational goals

Survey findings

Quality Management tools

N = 18 countries

in %

Some examples of good practice

Refresher training: very high retention rate in the project area (Zambia)

Housing for clinicians, clear career structure, CME, agreed number of years of services in hospitals:improved staff satisfaction and retained staff (Ethiopia)

Awards, closer supervision, team building: increased service output (higher EPI and antenatal coverage) and less applications for transfers (Ghana)

Survey findings

Suggestions for effective incentive schemes

Mix of financial and non-financial incentives• Performance based, or rather efforts related pay/ incentives• Individual/group performance targets• Career development plan • QM tools: quality culture, quality circles, teambuilding,

supportive supervision, feedback, participatory problem assessment

• Awards and sanctions• Benchmarking, competition• Free time• “Exposure”: Participation at international conferences

Survey findings

Difficulties in implementing incentives

• Transparent criteria for performance related payment: Difficulties in definition and implementation (political interference, lack of good governance)

• Sustainability of (financial) incentives -> become quickly part of the benefit package

• High staff turnover -> sustainability of training?• Competition with other organisations that provide

(higher) monetary incentives

Survey findings

Difficulties in implementing incentives (cont.)

• Old habits, difficulty of changing long-term institutionalised norms and rules (e.g., age over merit, bureaucracy)

• Cultural constraints: avoidance of being outstanding, reluctance of taking on responsibilities beyond one’s duties

• Irrelevant in a context of extreme staff shortage?

Survey findings

Conclusions• There is no blueprint

Each region/facility needs its specific mix of incentives

• Working hypothesis seems to be confirmedMotivation can be considerably increased with non-financial incentives and QM tools.But problems of sustainability and transparent application

• Practical and simple methods are needed to monitor the impact of incentives on motivation.

• Link HRH measures with good governance agenda

Conclusions• Need for donor co-ordination and code of conduct

• Medium term commitment (contract) with staff that is sponsored by donors for further studies/training

• Allocation of study opportunities and study facilities at the decentralised level

• Stronger focus on internal motivation – Ambition: career, further qualification– Professionalism and ethics– Altruism

Thank you very much

for your attention!

Comments!

Feedback!Questions?

Open questions

• Can motivation be improved “externally” (by financial or rather non-financial incentives), or is the willingness to perform and motivation ultimately an “intrinsic” predisposition?

• Does the application of QM tools lead to personally internalised behavioural changes?

• Are there other values and entry points within the local cultures on which to build upon?

Motivational determinants

Individual

Organizational factors

Cultural factors

Cf. Franco et al. 2002

Goals, motives, values, self-efficacy, expectations

HRM, structures, processes, communication, mission

Cultural values, also regarding the patient-provider relation

Ways to increase motivation

Individual


Cultural factors

Financial incentives


Individual


Cultural factors

Financial incentives Non-financial incentives


Individual

Organisational factors

Cultural factors

HR related

Quality management

tools Financial incentives Non-financial incentives


Study objectives

• Assessment of the role and effects of non-financial incentives and QM tools

• Identification of potential approaches to improve motivation

• “Religion matters a lot. It makes you feel for the other” (nurse)

• We have no motivation here, but we work (nurse, Mission hospital)• My motivation is on the higher side, after all, I do the work. Like most

workers here. Not all here have gone. So you can say we are motivated (laughs) (doctor, Mission hospital)

• High to very high. I still do my work, do what I have to do. After all I have signed my contract and I receive money for it. No-one has forced me to do that (doctor)

• if everyone had a chance to go, everyone would go (nurse, 40 years, public)• Asked whether he wants to work in a city: No. The city life is too expensive

for my salary. I want to establish myself in a rural area, open my own clinic (clinical officer, 33, public)

• It has never been a serious thought for me. I don’t have the connections you

need to go (nurse, 46 years, public).

Non- / financial incentives applied

0

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60

70

80

90

Stu

dy

leave

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Aw

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Perf

orm

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rela

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Bonus

Survey findings

in %

N = 29 countries

Management and QM tools: Staff supervision and recognition

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Reg

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Reg

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Fee

db

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Per

form

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asse

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MD

Nurses

in %

Survey findings

N = 18 countries

Management and QM tools:Staff surveys, leadership, disciplinary

action

0

10

20

30

40

50

60

70

80

Staff satisfaction surveys

Some form of leadership & management training

in %

Disciplinary action enforced

Survey findings

N = 29 countries

Clear formulation of expectations and org. goals


Push factor Poor of migration performance

Staff retention Performance improvement

What is the role of non-financial incentives &

Quality Management tools?


Research aspects• Motivating factors, job satisfaction• Career / migration plans• Incentives and quality management tools• Project experiences

Objectives=> Assessment of the role and effects of non-financial incentives and QM tools

=> Identification of potential approaches to improve motivation

Reasons for ineffectiveness of incentive schemes

– Insufficient package and thus low impact– Not performance-related, intransparent– Not effectively implemented, bureaucratic– Incentives have become an integral part of the

benefit package

Survey findings


Empirical evidence: • Even with an adequate salary, health workers

(HWs) may not be motivated.• Even without an adequate salary and under

poor working conditions, there are motivated and performing HWs.

Common agreement on:• Non-financial incentives are an essential

component to increase motivation.

motivation

Education

staff motivation

non financial incentives

health workers hws

government clinic migration

country nurse

quality work

incentives research

rural areas