Allison Goldberg PhD Candidate Columbia University May 17, 2012

1. Estimating the effects of financial and non-financial incentives on health worker motivation: a national study in Malawi Allison Goldberg PhD Candidate Columbia University May 17, 2012

2. Presentation Outline • Background • Study Methodology • Results • Policy Implications • What’s Next?

3. Background • Malawi has some of the worst health worker to population ratios in the world. In 2003, it was estimated that ~ 4000 doctors, nurses, and midwives were serving a population of ~ 12 million.* • In 2004, the MOH of Malawi launched the 6-year Emergency Human Resources Programme (EHRP) to increase the number of health workers primarily through 52 percent salary top-ups.** • An evaluation of the EHRP showed the programme to be effective. The total number of health workers increased by 53 percent – from 5,453 in 2004 to 8,369 in 2009.** • A strategy to retain and maximize Malawi’s newly scaled-up workforce was not developed. • * Manafa O, McAuliffe E, Maseko F. et al. 2009. Retention of health workers in Malawi: perspectives of health workers and district management. Human Resources for Health 7: 65 • **DFID. July 2, 2010. Evaluation of Malawi’s Emergency Human Resources Programme (EHRP): EHRP Final Report. Produced by Management Sciences for Health (MSH) and Management Solutions Consulting (MSC) Limited.

4. Background (cont’d) • Why Study Motivation? • Researchers and policy-makers recognize that a motivated health workforce is critical to job retention and service delivery performance* • Financial and non-financial incentives have been shown to improve health worker motivation at the aggregate level in SSA.* This relationship is less clear in Malawi. State Capacity International Donors Financial & Non-Financial Incentives Motivation Retention Service Delivery Performance Health Outcomes • Manafa O, McAuliffe E, Maseko F. et al. 2009. Retention of health workers in Malawi: perspectives of health workers and district management. Human Resources for Health 7: 65 • World Health Organization (WHO). 2006. The World Health Report – Working Together For Health. Geneva: World Health Organization. • Franco LM, Bennett S, and Kanfer R. 2002. Health sector reform and public sector health worker motivation: a conceptual framework. Social Science & Medicine54: 1255-66. • Wibulpolprasert S and Pengpaibon P. 2003. Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Human Resources for Health1: 12. • Willis-Shattuck M, Bidwell P, Thomas S et al. 2008. Motivation and retention of health workers in developing countries: a systematic review. BMC Health Services Research8: 247.

5. Study Methodology • Study Design • Survey conducted by the USAID-funded Health Systems 20/20 project from October to December 2010 • Data was collected from 163 health facilities across Malawi’s 27 districts • Health facilities from the public, private for-profit, and faith-based sectors were sampled using an equal-probability, systematic sampling design • Up to 4 health workers were interviewed per facility, allowing for a maximum of 640 health workers to be selected • 602 health workers across every health cadre were included

6. Study Methodology (cont’d) • Data • Potential Control Variables • Gender • Age • Religiosity • Years in Health Care • Years in Current Position • Health Sector Motivation • A composite score devised using the validated Intrinsic Motivation Inventory (IMI).* • The 7 items on the IMI subscale were averaged for each respondent. • The 7 items were measured on a 1 to 5 scale, ranging from strongly disagree to strongly agree. • Financial Incentives • Non-Financial Incentives • Adequacy of Compensation • Fairness of Pay • Other Benefits (e.g. Paid Vacation) • Perceived Value • Autonomy • Job security • Composite Score of Performance Management & Support Factors • Independent Measures of Performance Management & Support * Ryan RM. 1982. Control and information in the intrapersonal sphere: an extension of cognitive evaluation theory. Journal of Personality and Social Psychology43: 450–46.

7. Study Methodology (cont’d) • Analysis Strategy • Descriptive statistics about health worker composition and characteristics • A stepwise estimation procedure, using the backward elimination technique at the .2 significance level, was used for model selection • Multivariate regressions were used to assess the association between the financial and non-financial incentives on health worker motivation in Malawi All analysis were conducted using STATA statistical software. Sample weights were used to account for variation in the number of health workers, across health sectors and geographic clusters, in the sample.

8. Results • Descriptive Results • Most health workers are male (61 percent) and in their 30s (42 percent). • Almost all health workers identify as being religious (98 percent), which is expected given the centrality of religion to life in Malawi.* • 58 percent of health workers have worked in healthcare for 1 to 5 years, which means that a majority became health professionals during the EHRP period. • 72 percent of health workers have been in their current position for 1 – 5 years. • Health workers from the public (70 percent) and faith-based (22 percent) sectors make up a majority of the sample, which is expected given that these sectors provide ~ 97 percent of health services in Malawi.** • * Yeatman SE and Trinitapoli. 2008. Beyond denomination: The relationship between religion and family planning in rural • Malawi. Demographic Research 19(55): 1851-82. • ** Ministry of Health (MOH), Republic of Malawi. 2004. Human Resources in the Health Sector: Towards a Solution. • Blantyre. 2004.

9. Results (cont’d) • Multivariate Analysis Results

10. Results (cont’d)

11. Key Messages • Despite the multiple financial and non-financial factors that have been previously identified as contributing to the motivation of health workers in sub-Saharan Africa, it is a strong performance management and support system as well as flexibility and autonomy in the workplace that appear to be the most important predictors of health worker motivation in Malawi. • Interestingly, compensation, may actually de-motivate staff in the health workforce. This is an important consideration for Malawi’s next HRH strategy.

12. Policy Implications • Non-Financial Incentives • Potentially less expensive and more sustainable than implementing financial incentive programs • Costs are incurred (e.g. training, supervision from higher-level staff, and follow-ups) but the long-term benefits, improvements in the organizational infrastructure of local health systems, outweigh the costs. • Complementing HRH programs that the Malawian government and donors already support • Re-emphasize how financial incentives are structured under PBI programs. • Increasing the opportunity for health professionals to earn intrinsic rewards, like autonomy and value, which are critical to making improvements in QOC indicators* * Leonard KL and Masatu MC. Nov 2010. Professionalism and the Know-Do Gap: Exploring Intrinsic Motivation among Health Workers in Tanzania. Health Economics, 19(12): 1461-1477.

13. Policy Implications • Non-Financial Incentives (cont’d) 3. Leveraging Malawi’s decentralized health system • Malawi’s health system is made of district management teams that have stewardship for the local health care delivery system. • Augment this system to include better supervision and management and performance support at the facility level.

14. Policy Implications (cont’d) • Financial Incentives • Clarify the relationship between compensation and health worker motivation • Test two potential explanations in the literature for the negative association between financial incentives and motivation • Motivation Crowding Theory* • Financial Fairness** • * Frey BS and Jegen R. December 2001. Motivation Crowding Theory. Journal of Economics Surveys.15(5): 549-611. • ** Pink D. 2009. Drive: The Surprising Truth About What Motives Us. New York: Riverhead Books.

15. Policy Implications (cont’d) • Motivation Crowding Theory* • Criticizes basic assumption in economic theory that people are self-interested and therefore will not put effort into anything unless financially rewarded. • Argues that monetary rewards can negatively impact motivation when a non-monetary relationship is transformed into a monetary one. • In other words, an individual’s motivation may decrease if their motivation is based on intrinsic, rather than extrinsic reasons. • The pro-social orientation of health work and • Malawians’ strong religious values may interact with • compensation to explain this relationship • * Frey BS and Jegen R. December 2001. Motivation Crowding Theory. Journal of Economics Surveys.15(5): 549-611.

16. Policy Implications (cont’d) 2. Financial Fairness* • There are two types of fairness, internal fairness and external fairness • Internal Fairness: Individual compensation commensurate with colleagues • External Fairness: Individual compensation commensurate with others doing similar work in similar organizations. • When an individual believes that their compensation is internally or externally unfair, compensation can interact with the perception of unfairness to negatively affect motivation • Differences in the salary structures of health workers both • within and across health facilities in Malawi** makes this • explanation possible • Pink D. 2009. Drive: The Surprising Truth About What Motives Us. New York: Riverhead Books. • ** Bowie C, Mwase T, and Chinkhumba J. April 2009. Health workers income and expenditure in Malawi: an assessment of the relative contribution of incentive schemes to take home pay and the extra living costs of rural posts. Blantyre, Malawi:

17. What’s Next? • Consultation with the MOH’s HRH Technical Working Group in Malawi about the design of their next 5-year HRH strategy • Investigation into the potential explanations for the negative association between compensation and health worker motivation using objective measures of compensation • Formal country comparison between Uganda and Malawi on the determinants of health worker motivation

18. Acknowledgements • MOH officials and the health professionals who took time away from their work to participate in this study. • USAID/Malawi and colleagues at Abt Associates Inc., Columbia University, and Management International for their involvement and support.

19. Questions? Thank You! Contact: Abg2141@columbia.edu