The challenges of implementing financial incentives for health workers in South Africa, Malawi and Tanzania

1. The challenges of implementing financial incentives for health workers in South Africa, Malawi and Tanzania Posy Bidwell1, Steve Thomas1, Prudence Ditlopo2, Maureen Chirwa3 & Paul Revill1 1Health Policy & Management, Trinity College Dublin, Ireland 2 Centre for Health Policy, University of the Witwatersrand, South Africa 3 Department for Community Health, College of Medicine, Malawi

2. Issues Financial incentives are a popular strategy to address the HRH crisis The Motivation Project evaluated incentive initiatives that currently being implemented in South Africa, Malawi and Tanzania Despite the financial incentives: 96% in Tanzania reported the salary they received was not proportional to the work they did ‘moonlighting’ a source of income for ¼ HWs in Malawi Only 1/3 in SA satisfied with the incentives

3. Aim To explore the processes involved in implementing financial incentives To use Hogwood & Gunn’s (1984) conditions for implementation to be successful, e.g. Sufficient time and resources Evidence based policy Clear objectives Clear communication In order to identify barriers to implementation

4. Brief description of the financial incentives • South Africa • 2004: Rural Allowance (8-22% annual salary) • 2004: Scarce Skills (10-15% annual salary) • 2007 Occupational Specific Dispensation (salary adjustment of 20-80%) • Tanzania • 2006 Salary increase (122-178%) • Malawi • 2005 Salary top-up (52%)

7. South Africa: Implementation challenges “I cannot say if they have been effective because we haven’t done any research” Policy maker

8. Implementation conditions that were commonly not fulfilled in all 3 countries • Poor Communication • High degree of anticipation for OSD • Tax on 52% top ups • Implemented at a time of poor relations • Tanzania salary top ups implemented following strike action • Lack of consistency • Definition of ‘rural’ left to province’s discretion • Tanzanian salary increases • Evidence based?

9. Key Lessons • Salary is an important invention (Bennett et al. 2000) • Better paid providers: • Don’t look for other jobs • Don’t supplement income through other means (Dieleman et al 2003, Kyaddondo & Whyte 2003) • However: • Careful timing is needed • Need to prepare for any fall-out • The implementation process can weaken the impact of the policy

10. Communication is key! • Financial incentives are highly sensitive • Clear communication is vital in order to manage expectations • “There was no clear communication to the nursing profession resulting in confusion. And even managers within the health services found it difficult to understand. As a result, when nurses queried whether they are eligible or not, the responses they got were often not helpful”. (Policy-Maker)

11. Acknowledgements • The Motivation Project Team • The Motivation Project was funded by Irish Aid and administered through the Health Research Board.