Skip to 0 minutes and 10 secondsBARBARA MCPAKE: Much public health practise and health system management seem to assume that health workers do what they're told, like robots, or only ever do things with the public interest and the benefits of their patients in mind, like angels. If either of these were true we wouldn't need to worry about incentives. We could either, instead, make sure that all staff, the robots, had detailed instructions about what they're supposed to do. Or, leave them, the angels, to make all the decisions being best placed to understand how to use their time to maximise benefits for the public and patients. Whether you see it as fortunate or unfortunate, real health workers are human beings.

Skip to 0 minutes and 49 secondsThey are probably neither particularly angelic human beings nor particularly robotic ones. In their work lives, like in all of ours, they consider the attributes of jobs, including the working environment, the pay, and other benefits, the prospects for advancement along a career path, and the extent to which they enjoy the tasks involved and find them fulfilling or not. If we want health workers to perform, in other words, we want them to play the role that produces best outcomes for the health system, then we need to recognise health workers concerns and ensure that good performance is consistent with good rewards.

Skip to 1 minute and 24 secondsIf we ignore these concerns, and just rely on robotic and angelic impulses, then we shouldn't be too surprised if performance is less than optimal. I just suggested that some of the things health workers care about are, the working environment, the pay and other benefits, the prospects for advancement along a career path, the extent to which they enjoy the task involved and find them fulfilling. This is a mix of financial and non-financial factors. Sometimes people interpret the word 'incentive' just to refer to the financial ones, but that's not how we're using it here. It's also a mix of what have been called hygiene factors and motivational factors.

Skip to 2 minutes and 4 secondsAccording to Herzberg's two-factor motivation theory, hygiene factors are the minimum needed for someone to feel they have a job they are satisfied with. Examples might be the salary level and a basically comfortable working environment. Without these basic conditions being adequate workers are likely to be looking for a better job. But Herzberg argues that these play little role in motivating performance in the job. Higher and higher salaries and more and more comfortable working conditions do not result in staff working harder and harder. Motivational factors are those that encourage better performance in the job. Manager feedback, personal fulfilment, realistic opportunities for career advancement, motivate performance, according to Herzberg.

Skip to 2 minutes and 48 secondsAnother categorization, based on the work of Clark and Wilson in 1961, divides incentives into material, solidary, and purposive incentives. Material incentives largely overlap with financial ones, they are tangible rewards including wages, benefits such as health insurance. But according to Clark and Wilson, also include patronage benefits, which are often overlooked, even though patronage systems are clearly a dominant mode of social organisation in many settings. Solidary incentives might be translated as social incentives, the social life that may be associated with a particular professional role, the society of work colleagues, the status a professional role may confer. Purposive incentives relate to the shared ownership of the objectives of the work rule.

Skip to 3 minutes and 35 secondsFor health workers, they may be motivated by the opportunity to make a difference to the health of patients, for example. Whatever type of incentive we're talking about, they can be strong and weak, terms which are rarely defined by those who use them. Strong can mean that considering a financial or a material incentive, they are large in relation to the individual or household economy of the health worker, and they are highly variable in response to the effort exerted by the health worker to deliver on health system objectives. Weak implies the opposite, and implies that there is little to be gained by working harder.

Skip to 4 minutes and 10 secondsAlthough these terms tend to be used about financial or material incentives there's no reason why they can't be recognised with similar descriptors when we're talking about job fulfilment or solidary incentives. We might find that a health force is not performing as much because it is very difficult to get job fulfilment. For example, because their ability to support patients to achieve health gains is undermined by a lack of needed equipment or supplies, or a lack of cooperation on the part of patients. And we may also be able to explain some motivational problems by looking at the social environment in workplaces. They may be unfriendly, characterised by autocratic management and rivalries between employees.

Skip to 4 minutes and 51 secondsIf we only think about financial incentives we may miss a lot of opportunities to affect health workforce productivity for the better. There may be a case for salary modes of payments that are unresponsive to performance. That case arises from the identification of the problem of perverse incentives. A couple of fictional examples of incentives proving perverse illustrate this problem. The problem of perverse incentive arises because the body that pays health workers, the payer, cannot closely observe all the features of health workers interactions with patients. In the case of nighttime deliveries, the payer would like to offer the bonus only when the birth is naturally occurring at night time.

Skip to 5 minutes and 31 secondsWhat may be happening is that induction of labour is being delayed or women are being offered caesareans when the baby might arrive naturally the next morning. Or no matter when the baby is born, the records may be altered to ensure the time of birth qualifies for the bonus. In the case of family planning uptake, perhaps the payer might want more people to receive more information about the benefits of family planning and for them to be encouraged to take up a modern method, but cannot observe that people are instead being forced or duped into unwanted procedures. In cases where problems of observability are large, it might be argued that it's better to avoid strong incentives in case they become perverse.

Skip to 6 minutes and 10 secondsAll this implies that the task of managing incentives is not straightforward. Health professionals are expected to manage a complex range of tasks, and they're not all easy to observe and reward. Health work is often teamwork, and singling out particular workers for the team's achievements can be divisive. You might consider whether team rewards are more appropriate. For example, in one project in Uganda, health staff most appreciated the translation of a bonus paid for hospital performance into a staff party and universal distribution of bales of clothing, and disliked when different health staff were rewarded differently. This suggests that a fuller set of incentives, particularly including targeting solidary incentives, can be helpful.

Skip to 6 minutes and 52 secondsIncentive mechanisms that result in a large proportion of income being dependent on a bonus effectively shift risk to employees. This is unpopular. People value the security of knowing how much they will earn. Thinking about the incentive mix rather than relying on a single bonus or promotion system has been recommended. Single systems may be most liable to perverse manipulation. Monitoring performance, feeding back, and ensuring that rewards follow as promised are critical elements that have sometimes been overlooked.

Skip to 7 minutes and 25 secondsMotivational theory suggests that people only respond by applying extra effort in their work if they understand what is required to secure the benefit, believe they are capable of achieving the performance in question, and believe that they will in fact receive the reward if they succeed. In other words, they need to trust those administering the system.

Motivation and incentives

Some people associate the private sector with strong incentives, and weak incentives with the public sector. A common belief is that in the private sector, there’s a strong relationship between people’s pay and their productivity, that staff are quickly rewarded for doing good work, and that there is good measurement of productivity. Similarly, people may perceive the public sector as failing to respond to health worker effort with reward, and promoting staff on the basis of length of service rather than their performance.

This view of health sectors tends to describe health workers in the public system as unproductive, unmotivated and inefficient, whereas health workers in the private sector are described as hardworking, motivated and efficient.

What’s your view? Does this match your experience? Please comment below on how you see the incentives and performance in the public and private health sectors in your country.

In my view, we do find examples of these stereotypes in real life, but we also find their opposites. Especially, we often find dynamic and motivated individuals in the public sector, but we can also find private sector health workers who are not motivated to provide a good quality service.

It’s worth considering whether the motivational theories can explain this, and whether the incentives actually influencing health workers are the same as the ones we might predict from our knowledge of private and public sector working conditions. For example, it could be that dynamic and motivated public employees are strongly motivated by purposive incentives which overcome disincentives in other areas, such as a lower salary. Or it could be that the public sector is not as bad at rewarding performance as it’s made out to be. Perhaps, for example, the ability and hard work of staff is recognised by promotions in the public sector.

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