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
Health 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
1
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
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
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%)
SA: Positive outcomes
Partially successful in enticing
health professionals
“since our nurses started getting
rural allowance we were able to
attract more nurses” (Hospital
Manager)
“the OSD made a huge difference
because we are able to recruit
people from private sector”
(Hospital Manager)
Some understanding that those
who were specialised deserved to
get it
“ I don’t have the skills so I don’t
deserve to get it (scare skills
allowance” (EN)
SA: Negative outcomes
Divisive
“Rural Allowance is only paid to professional nurses. Enrolled
nurses and assistant nurses are not getting it” (Enrolled Nurse)
“We all work in theatre with that trained theatre nurse and I am
not a trained theatre nurse, but we are doing the same job”
(Professional Nurse)
Temporary
effect
“ You give people Rural Allowance but salary excites you only
for the first 3-4 months. And we know the more you earn the
more you want” (Hospital Manager)
Lack of
uniformity
“it was not implemented correctly because the declaration of
what is rural depended on the provinces”, (Policy Maker)
Does not
serve to
attract HWs
“If I work in Kimberly I get it, if I work in Cape Town I get scarce
skills. So that would not attract anyone from Cape Town to
work at this place” (GP)
Erosion of
team spirit
“You find that nurses who used to be good are very aggressive
now just because they did not get anything” (PN)
South Africa: Implementation challenges
Rural Allowance
Scarce Skills
OSD
•
•
•
•
•
•
•
•
•
•
• High degree of
anticipation
• “Rushed”
implementation
• Lack of clarity
• Lack of communication
• Not outcome orientated
• Not evidence based
• No systems for M&E
Definition of ‘rural’
Not outcome orientated
Excluded junior nurses
Lack of communication
No systems for M&E
Excluded some cadres
Not evidence based
Not outcome orientated
Lack of communication
No systems for M&E
“I cannot say if they have been effective because we haven’t
done any research” Policy maker
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?
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
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)
Acknowledgements
 The Motivation Project Team
 The Motivation Project was funded by Irish
Aid and administered through the Health
Research Board.