The design and implementation of the human resource interventions in South Africa and their influence on the motivation and retention of health workers
Rationale: Financial incentives are amongst the most widely used strategies to improve health worker motivation and retention. There is also growing evidence to suggest that non-financial strategies are just as important as financial incentives. However, evidence on the effectiveness of these strategies in low- and middle-income countries (LMIC) or in rural and remote areas is still limited. Available studies reported that the effectiveness of good incentive strategies with laudable intentions may be diminished as a result of negative consequences caused by weaknesses in their design processes and implementation. Yet, the process of the implementation of human resource for health strategies is less studied in low- and middle- income countries. There has also been limited policy analysis of human resource for health strategies to help explain policy outcomes. Objectives: This thesis sought to conduct a process evaluation of the design and implementation of four incentive strategies and their influence on the motivation and retention of health workers. These were: the rural allowance, the scarce skills allowance, the occupational specific dispensations for nurses, and the hospital revitalisation programme. Methods: Using a multiple-case study design comprising of qualitative and quantitative methodologies, we conducted a retrospective review and analysis of the relevant government documents, press releases and newspaper articles. In-depth interviews were also conducted with 35 key informants, eight hospital managers, five human resource managers and 118 health workers. A health worker survey was carried out with 588 participants. The study was conducted in 10 hospitals and 55 community health centres and clinics in North West and Gauteng provinces in South Africa. For qualitative data, thematic content analysis of documents and interview transcripts was done using the Atlas.ti software. Quantitative data were analysed using Stata (Version 10). The descriptive statistics that were employed included frequencies, percentages, measures of central tendency such as mean and median and distribution of data (standard deviations and IQR). Inferential statistics that were conducted included Analysis of Variance (ANOVA) and Multiple Regression analysis. Results: A notable finding of this study is that all the financial incentive strategies of interest (rural allowance, scarce skills allowance, and occupation-specific dispensation) were fully implemented at the time when the study was conducted while hospital revitalisation programme, the only non-financial incentive, was implemented to a certain degree. The finding that central level policymakers were the key actors driving the overall policy design processes across all the four incentive strategies of interest, suggests a top-down approach in the formulation of these retention strategies. The power of the different actors during the design stages varied across the four incentive strategies of interest; with the National Treasury consistently being an influential actor across all the four incentive strategies of interest because of their role of controlling the government budget. In general, the qualitative findings with different groups of respondents in this study showed that all the four incentive strategies of interest were in principle, regarded as good policies for incentivising the motivation and retention of health workers. This study found that all four incentive strategies were partially effective in the motivation and retention of nurses and doctors. A notable effect of the three financial incentive strategies derived from the qualitative data in this study was that they boosted salaries of the health workers. These findings were contrary to the results of the aJDI scale which demonstrated that the participants were generally dissatisfied with pay and promotion; with the mean scores of 3.8 (SD=3.6) and 6.1 (SD=4.6) respectively. There were no significant differences between groups with regards to the promotion subscale. However, with regard to the pay subscale, there were significant differences for health worker category (p=0.045). Significant differences were also observed for province (p=0.001), with Gauteng respondents reporting lower satisfaction with pay (M = 3.3, SD = 0.34) than North West respondents (M = 4.6, SD = 3.8). The pay subscale in hospitals also reflected significant differences between locations (p=0.02). Two-sample t-tests revealed that respondents who benefitted from the interventions investigated in this study did not have significantly higher overall job satisfaction in either hospitals or clinic. However, the rural allowance, scarce skills allowance and OSD all increased satisfaction with pay for both hospital and clinic respondents. However, the differences were only statistically significant for the rural allowance (t=3.3, p=0.001) and for OSD (t=2.8, p=0.005) among health professionals in hospitals. In hospitals, rural allowance (t=-0.1, p=0.967) and scarce skills allowance (t=-0.2, p=0.840) increased the respondent’s intention to quit, although the differences were not statistically significant. However, the occupation specific dispensation significantly decreased the intention to quit of hospital health professionals (t=-2.2, p<0.05). In clinics, all the financial incentive strategies decreased the respondents’ intention to quit; however, there were no significant differences. The results also illustrates that all interventions under investigation in this study moderately increased the organisational commitment of hospital and clinic respondents. Despite the popularity of financial incentives, this study found that the impact of their admirable intentions can be reduced because of process and implementation weaknesses. The process issues that are raised in this thesis that affected the design and implementation of financial and non-financial incentive strategies are weak coordination, lack of uniformity, sub-optimal communication, lack of training of implementers, and weak monitoring and information systems. In order to avoid loss of morale and staff grievances, careful planning and management of the process of the implementation of financial incentives in particular, is essential. Based on the data, this study developed an integrated conceptual framework that converge ideas from motivation theories and policy analysis to improve knowledge on health worker incentives, motivation and retention. Conclusions: The data presented in this thesis has demonstrated that as opposed to the assumption that financial incentives are easy solutions to addressing problems of health workforce motivation and retention, their implementation is complex. The results also showed that although motivation theories and policy analysis frameworks are often presented in isolation to explain human behaviour and policy processes respectively, these fields are quite complementary in studying the implementation of financial and non-financial incentives in the health sector. Implications: Based on the results of this PhD research, a new integrated approach for understanding the implementation of financial and non-financial incentives is proposed. These results are critical in light of the accelerated pressure towards achieving the health MDGs as well as the recent drive towards re-engineering the South African primary health care (PHC) system, and the implementation of the National Health Insurance (NHI). The success of all these initiatives depends heavily on the availability, competence, motivation and retention of health workers.
A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg, June 2016