Health Worker Satisfaction and Motivation : An Empirical Study of Incomes , Allowances and Working Conditions in Zambia

Health worker salaries in Zambia are low by any standard. In recent times there have been real reductions in the salaries of health workers. This has resulted in significant attrition in the public sector as health workers are attracted to the private sector or leave Zambia entirely, leaving a large deficit in public sector health workers. In this study we examine the relationship between health worker incomes and their satisfaction and motivation. Cross-sectional data collection was undertaken using both quantitative and qualitative methods. A refined survey instrument was used for the quantitative data method. Document review (past and current records) was employed for the qualitative method. Data was collected in three regions that represent extremes in overall remuneration and benefits. Lusaka represented the favourable area while Monze and Nyimba represented less favourable areas for study in Zambia. There are hefty disparities between different health workers. There are also enormous salary differentials for the same workers between the public and private sectors. These salary differentials explain the experience of public to private “traffic” of health workers as well as casual private sector work by public sector health workers. In addition, there are negligible efforts by government to reduce the benefits gaps among key public health cadres. The low incomes received by public health workers in Zambia have many negative implications: it begets absenteeism, results in low output, poor quality health care, and the departure of health workers to the private sector and overseas.


Introduction
Health worker salaries in Zambia are low by any standard (Lehmann, Dieleman and Martineau 2008;Barnighausen, and Bloom, 2009).In very recent years, as a strategy to lessen the observed problem of health worker attrition as a result of low salaries there has been an increase in the share of allowances and other forms of incentives which are intended to reduce attrition rates, and enhance the re-distribution of staff between geographical deficit and surplus areas.In spite of the overall observed increase in nominal salaries, health workers salaries have not kept pace with inflation.Thus, there have been real reductions in the salaries of health workers.This is primarily because government has not been able to make salary increments that are sufficiently large enough to improve the purchasing power of health workers (Vujicic, Ohiri and Sparkes, 2009;Goldsbrough and Cheelo, 2007).This is having an impact upon worker motivation (Vujicic, Zurn, Diallo, Adams and Dal Poz, 2004;McCoy, et al., 2008).
The objectives of this study were to: 1) Outline the levels of income, allowances and the working conditions of various types of health workers in both the public and private sectors; 2) Examine the implications of these factors for worker satisfaction and the motivation of public health workers to remain in public sector employment or to look for alternative employment opportunities.

Samples and Sampling Procedure
Cross-sectional data collection was undertaken using both quantitative and qualitative methods.Document review (past and current records) and semi-structured questionnaires were employed.

Data Collection
Data was collected in three regions that represent extremes in benefits and therefore overall earnings for health workers.For example, additional incentives are provided to workers posted to work in areas considered to be 'hardship' due to relative inaccessibility, harsh weather conditions, sparse population and economic disadvantage.Lusaka represented the favourable area (urban) while Monze and Nyimba represented less favourable areas (rural) for study.

Survey Questionnaires
The survey questionnaires were refined at an Alliance for Health Policy and Systems Research meeting in Burkina Faso in early 2008.The survey instruments were based upon the Immpact Toolkit titled 'Health Worker Incentives Survey (HWIS)' from the University of Aberdeen (University of Aberdeen, 2007).The instrument is attached as Appendix 1.
The self administered/structured questionnaires were used to collect data on various health worker salaries and benefits in the public and private sectors.The data collection took place in late 2008.Data collected included housing allowances, retention allowances, field subsistence allowances (per diems), uniform allowances, and other household income.
A random selection of private and voluntary health facilities was undertaken from a listing of the facilities in the respective regions.A stratified sampling frame was constituted by region and type in line with policy relevance, as shown in Table 1.Stratification and random selection of representative facilities was done for the administration of the structured questionnaires to health workers.The larger facilities, basically hospitals (for all categories), which are also relevant to policy are much fewer and were all included for data collection purposes.A total of 234 health workers were interviewed in three districts namely, Lusaka, Monze, and Nyimba.The majority of the cadres interviewed were nurses (42%) followed by paramedics (24%) and midwives (16%).The other categories captured such as doctors, medical assistants, dental therapists and clinical officers accounted for only 6%, 7%, 3%, and 2% of total workers respectively.Given the important role of doctors we have included them in the analysis that follows, however the other three latter categories have been omitted due to their small absolute numbers.

Public Sector
The sources of income for health workers are multifaceted and cover the whole gambit of public and private health sector work and non-health sector work.These are outlined in detail in Tables 2 and 3. Medical Income -Health worker salaries and benefits are determined by an array of factors.The most significant of all factors is the salary scale in which the professional cadre falls which depends on the level of education, skill base, and duration of service.There are two categories of salary scales that exist in the health sector.The Medical Salary Scale (MSS), which is an 11 point scale ranging from MSS01 to MSS11 for all categories except doctors and dentists.The other is the Medical Doctor's Salary Scale (MDS) that ranges from MDS01 up to MDS05.The allowances and benefits which individuals receive are functions of their salary scale, their location and their length of service.
Rural Hardship Allowance -Rural hardship allowance is given to selected health workers who serve in rural and remote areas in places that are ten kilometres from any paved road.This is intended to cushion them against the factors that dissuade health workers from serving in economically disadvantaged areas.In rural districts such as Nyimba and Monze, health workers receive rural hardship allowances.However, not all cadres are entitled to the allowance even if they serve in rural areas.The survey results showed that overall only 3% of the total respondents reported to have received rural hardship allowance.
Housing Allowance -In Lusaka province, 87% of cadres reported receiving the housing allowance.The results in Monze and Nyimba show that more than 65% and 77% of the cadres in each province respectively, receive the housing allowance.Those receiving housing allowances are not staying in institutional houses.The majority of health workers are not provided with accommodation but are allowed to find their own accommodation and receive the allowance.However, rental costs for a standard house do not match the allowances forcing these workers to find alternative accommodation in peri-urban unplanned townships and commute to their rural positions.This factor helps push health workers into seeking alternative income sources.
Other Allowances -As a response to desperate labour shortages in rural areas, the Ministry of Health introduced the Zambia Health Worker Retention Scheme (ZHWRS) in 2003.Some doctors received a top-up retention allowance.It was envisaged that under the scheme, doctor attrition rates would be reduced and recruitment into vacant established posts for doctors would be achieved.Doctors receive a monthly allowance of $222.The private sector also gives similar allowances to their doctors which amounts to $333.The success of the ZHWRS has been mixed.
In general it can be deduced that apart from the salaries which health workers receive, allowances contribute over 20% over and above base income to health worker total remuneration.This does vary widely among different health workers.

Additional Medical Income -
The practice of engaging in extra private health work and non-health work is common among public health workers.For instance, 20% of the total respondents indicated that they are engaging in private health work.Out of all those interviewed paramedics (26%) and nurses (27%) indicated that they are engaging in private health work.
However, there are differences across the regions with Lusaka showing more cadres engaging in private health work than rural areas.In Monze about 12% of the total health cadres interviewed are engaging in private health work.The results also show a 50% participation of medical officers in private health work.In Nyimba there is no private health practice available to supplement income.This outcome is evidence for the skewed spatial distribution of health cadres towards urban centres where private health work can be easily accessed.
Non health income -Many health workers are also engaging in non health related income generating activities.
The results of the survey indicates that 24%, 13%, 36% of the total cadres interviewed in Lusaka, Monze, and Nyima respectively indicated that they are engaging in other non health income generating activities.In Monze, the proportion of midwives and nurses engaging in non health income generating activities was higher relative to other two locations.The most common form of other income generating activity for each given category was cropping and informal trading.
Overall Worker Income -Public Sector -Doctors are the highest paid with a mean monthly pay of $1,433 followed by midwives and nurses with $358 and $357 respectively.Paramedics follow with a monthly salary average of $328.
In terms of allowances, doctors get higher allowances than other cadres.Doctors are the only ones entitled to the retention allowance which amounted to $222 monthly.The housing allowance is highest for doctors at $133 followed by midwives and paramedics at $44 and nurses with the lowest amount of $22 per month.
Besides salaries and allowances, health workers also obtain additional income from other sources such as private health work, private non health work and other household members.The data shows that doctors get the highest amounts in terms of incomes from these sources.Doctors reported average monthly incomes of $333 from private practice followed by paramedics, nurses and midwives with $111, $78 and $67 per month respectively.
Additionally, income from non health work is dominated by midwives with $267 followed by doctors, paramedics and nurses at $222, $111 and $78 per month respectively.
Overall Household Income -Public Sector -Income from other household members constitutes a significant component of health worker income.For instance, doctors reported an average monthly income from other household members of $1000 followed by midwives with $489 while nurses and paramedics reported $333 and $222, respectively.The cadres with the lowest incomes also had the lowest contribution from other household members.A significant contribution to health worker household income comes from other members of their families (mainly spouses).

Private Sector
Overall Income -Private Sector -Private sector salaries are higher for all cadres as shown in Table 4.The salary of a private doctor is twice that of a public sector doctor.The salaries of midwives, nurses and paramedics in the private sector are also almost twice of the same cadres in the public sector.Housing allowance for a medical doctor was $666 per month which is about six times that of a doctor in the public sector.The housing allowance of paramedics in the private sector is three times that of paramedics in the public sector.The contribution of other household income for private sector workers is also more than for public sector workers.As can be seen from comparing Tables 2 and 4, health workers have a clear financial incentive to move to the private sector.The 2008 foreign exchange rate of Zambian kwacha varied between ZMK5,160 to ZMK3,090 to the US dollar during the year.A mean conversion rate of ZMK3,800 to US$1 has been used here for conversion purposes.

Job Satisfaction and Motivation
A more serious implication of low salaries is the impact these have on the motivation of the public health worker.Job satisfaction is a function of several variables including salaries or wages and allowances, the work environment and other non-monetary factors.With respect to job satisfaction, 40% of public health workers interviewed had moderate satisfaction, neither high nor low and another 40% were spread equally across low and very low job satisfaction, that is, only 20% had high or very high job satisfaction.The data also revealed that almost 80% of public female workers had moderate or very low job satisfaction whilst only about 60% of males reported the same.48% of respondents indicated that they were considering quitting their current job.This is significant given the current and persistent health worker shortage.Nurses and midwives expressed the most interest in quitting followed by paramedics.In terms of region, health workers in rural areas are more likely to quit their jobs than their urban counterparts.The results showed that the cadre type considerably explains their decisions to quit jobs with higher level cadres (doctors) more likely to quit than lower level cadres.Although the small number of doctors in the sample cautions against this statement.In contrast, sex, and region variables were insignificant in explaining health workers decisions to quit jobs.This means that cadres who are more highly demanded by the private sector and in other countries are more likely to quit their jobs.The cadres most likely to quit are midwives, medical officers and paramedics.
The income levels and work load of public female workers greatly influence their low or moderate satisfaction levels.Female nurses reported having higher workloads and slightly lower pay levels than men.These variables act together and lead to low job satisfaction and decisions to look for alternatives to their current job.
Low salaries contribute to health workers resigning from the public sector.In an environment of staff shortages, dilapidated buildings, non-functioning equipment and frequent drug shortages, it is difficult for health workers to remain motivated.Staff housing is another area of discontent.The rural housing allowance is usually insufficient to cover rental rates.
Health workers have also not been given the opportunity to rise up the salary scale through personal development programmes.There have not been program initiatives despite recent deliberate policies aimed at improving and encouraging the career development of health workers.

Discussion
The observed level of extra income activities across all health worker cadres and regardless of employer suggests that the incomes earned by health workers are insufficient to support themselves and their families.This situation results in a negative impact on the motivation of health workers and encourages them to engage in a range of activities and behaviours to remedy this situation.These factors/activities are now discussed in detail.

Moonlighting
The most common activity whereby the health worker remains in their current job but increase their income is to engage in moonlighting.Private health work is a common practice for public sector health workers in Zambia (Makasa, 2008).There are various factors that influence health workers' decision to engage in private health work.The primary reason is their low incomes.Doctors, nurses and medical officers in the public sector are in high demand by private health facilities on a part time basis.The availability of private health facilities also influences the decision of public workers to engage in private health work.Private health facilities and consequently private health practice opportunities are much more available in urban than rural areas.This practice leads to among other things, absenteeism, low output and poor quality health care in the public sector (Iipinge et al., 2009).
Paramedics and nurses are more likely to undertake private health work than doctors and other cadres.The low incomes of public health workers ensures that the private sector will continue competing for public staff thereby necessitating the need to increase salaries and the number of available staff, particularly nurses and midwives through increased funding of health training institutions.

Exiting
The challenges associated with migration of health workers from Zambia are well known (Makasa, 2008;Lusale 2007).Thus, adequate remuneration is a necessary requirement to address the shortage problem.However, it is not a sufficient condition for such a strategy (McCoy et al., 2008).
Our survey results indicate that low salaries contribute to the shortage/staffing crisis of health workers in the public sector.No effective solutions to the crisis have been identified or implemented thus far.Nurses and midwives have the highest likelihood to quit public sector jobs.Since these cadres have lower salaries and benefits but are also the ones most demanded by the private sector, the government should formulate policies to retain them.The current retention scheme only covers medical doctors leaving out these highly vulnerable yet key health cadres in both urban and rural areas (Koot and Martineau, 2008;Mwale, 2009).

Policy Implications
It is imperative to increase public sector health salaries and benefits (Tjoa et al., 2010;Chopra et al., 2008).There are hefty salary disparities across sectors for health workers.There are enormous salary differentials for the same cadres between the public and private sectors.These salary differentials explain the experience of public to private "traffic" of health workers.In addition, there are negligible efforts by government to reduce the benefit gaps among public health cadres.Consideration of non-income related factors such as recruiting from rural areas, payment of higher allowances and ensuring all prospective beneficiaries receive their entitlements must also be implemented.
The history of the public wage bill is not encouraging if an increase in resources for health workers salaries is necessary.The public sector wage bill remained relatively stable at 5% to 6% of the gross domestic product (GDP) throughout the 1990s.In the early 2000s, Zambia experienced a sharp increase in the public sector wage bill.This ratio was 5.9% in 2000, and by 2003 it had grown to 8.4% (Zambia Ministry of Finance and National Planning (ZMFNP), 2005).Furthermore, the government calculated that 47% of domestic revenue was being used to pay civil servants (Zambia Ministry of Finance and National Planning (ZMFNP), 2007).This left few resources for instance, to finance health service delivery, leading to an increased dependence on donor resources (Zambia Ministry of Finance and National Planning (ZMFNP), 2005).This trend was unsustainable.Zambia's public sector wage bill was about average in relation to other Sub-Saharan African countries.The IMF urged the government to introduce a hiring freeze in 2002 to control the wage bill, but doctors and nurses were specifically excluded (International Monetary Fund, 2007).An assessment of salary scale for all civil service employees was conducted and recommendations were issued in 2002 to reduce the number of salary grades, decompress the salaries, and consolidate some allowances into salaries.The unions agreed to the decompression but rejected the consolidation of allowances into salaries, leading to high allowances.The high allowances and salaries were not budgeted for and resulted into overruns in the 2003 budget (Zambia Ministry of Finance and National Planning (ZMFNP), 2005).In response another hiring freeze was put, and the IMF introduced rigorous measures to keep the wage bill within the agreed limit of 8% of GDP.The public sector wage bill decreased to 7.8% of GDP in 2004.This decreasing trend continued until 2006, and the wage bill was still at the same level in 2008 (International Monetary Fund, 2007).

Conclusions
The low income and allowances and poor working conditions of public health workers affect health care and the health system in many ways.It affects health workers' motivation, performance, morale, and the ability of employers to attract and retain staff.It is due to low incomes that public health workers are moonlighting to supplement their incomes by providing health care services privately, engaging in other income-earning activities and leaving the country.
Relatively low pay is causing dissatisfaction and loss of motivation, and migration towards higher earning jobs.The size of pay differentials between private and public sectors is affecting the morale, working relationships, and the available mix of cadres in the public sector.Differences in pay and income are more generally affecting both retention and distribution of health workers, whether between urban and rural areas or between the public and private sector.Therefore, there is no better time than now to motivate health workers in terms of wages, salaries and allowances and their work environment so as to boost their work satisfaction and retention.
However, dealing with the income problem remains complicated.The critical issues to be addressed have been outlined.There is a need to motivate health workers by increasing their salaries and allowances and improving their work environment so as to increase motivation and their job satisfaction.It is also imperative to address the huge salary differentials across cadres and health sectors.

Table 4 .
Mean Composite Monthly Income by Job Type: Private Sector