Health sector reform and public sector health worker motivation: a conceptual framework.

Abstract

Motivation in the work context can be defined as an individual's degree of willingness to exert and maintain an effort towards organizational goals. Health sector performance is critically dependent on worker motivation, with service quality, efficiency, and equity, all directly mediated by workers' willingness to apply themselves to their tasks. Resource availability and worker competence are essential but not sufficient to ensure desired worker performance. While financial incentives may be important determinants of worker motivation, they alone cannot and have not resolved all worker motivation problems. Worker motivation is a complex process and crosses many disciplinary boundaries, including economics, psychology, organizational development, human resource management, and sociology. This paper discusses the many layers of influences upon health worker motivation: the internal individual-level determinants, determinants that operate at organizational (work context) level, and determinants stemming from interactions with the broader societal culture. Worker motivation will be affected by health sector reforms which potentially affect organizational culture, reporting structures, human resource management, channels of accountability, types of interactions with clients and communities, etc. The conceptual model described in this paper clarifies ways in which worker motivation is influenced and how health sector reform can positively affect worker motivation. Among others, health sector policy makers can better facilitate goal congruence (between workers and the organizations they work for) and improved worker motivation by considering the following in their design and implementation of health sector reforms: addressing multiple channels for worker motivation, recognizing the importance of communication and leadership for reforms, identifying organizational and cultural values that might facilitate or impede implementation of reforms, and understanding that reforms may have differential impacts on various cadres of health workers.

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Social Science a Medicine 54 (2002) 1255–1266
Health sector reform and public sector health worker
motivation: a conceptual framework
Lynne Miller Francoa,*, Sara Bennettb, Ruth Kanferc
aUniversity Research Co., LLC, Partnerships for Health Reform Project, 4800 Montgomery Lane, Bethesda MD 20814, USA
bAbt Associates, Partnerships for Health Reform Project, 4800 Montgomery Lane, Bethesda MD 20814, USA
cGeorgia Institute of Technology, Atlanta, GA 30332, USA
Abstract
Motivation in the work context can be defined as an individual’s degree of willingness to exert and maintain an effort
towards organizational goals. Health sector performance is critically dependent on worker motivation, with service
quality, efficiency, and equity, all directly mediated by workers’ willingness to apply themselves to their tasks. Resource
availability and worker competence are essential but not sufficient to ensure desired worker performance.
While financial incentives may be important determinants of worker motivation, they alone cannot and have not
resolved all worker motivation problems. Worker motivation is a complex process and crosses many disciplinary
boundaries, including economics, psychology, organizational development, human resource management, and
sociology. This paper discusses the many layers of influences upon health worker motivation: the internal
individual-level determinants, determinants that operate at organizational (work context) level, and determinants
stemming from interactions with the broader societal culture.
Worker motivation will be affected by health sector reforms which potentially affect organizational culture, reporting
structures, human resource management, channels of accountability, types of interactions with clients and communities,
etc.
The conceptual model described in this paper clarifies ways in which worker motivation is influenced and how health
sector reform can positively affect worker motivation. Among others, health sector policy makers can better facilitate
goal congruence (between workers and the organizations they work for) and improved worker motivation by
considering the following in their design and implementation of health sector reforms: addressing multiple channels for
worker motivation, recognizing the importance of communication and leadership for reforms, identifying
organizational and cultural values that might facilitate or impede implementation of reforms, and understanding
that reforms may have differential impacts on various cadres of health workers. r 2002 Elsevier Science Ltd. All rights
reserved.
Keywords: Health sector reform; Health workers; Worker motivation
Introduction
Worker motivation
Motivation, in the work context, can be defined as an
individual’s degree of willingness to exert and maintain
an effort towards organizational goals. It is an internal
psychological process and a transactional process:
worker motivation is the result of the interactions
between individuals and their work environment, and
the fit between these interactions and the broader
societal context.
Health sector performance is critically dependent on
worker motivation: health care delivery is highly labor-
intensive. Consequently, service quality, efficiency, and
equity are all directly mediated by workers’ willingness
*Corresponding author. Tel.: +1-301-913-0568; fax: +1-
301-652-3916.
E-mail address: lfranco@urc-chs.com (L.M. Franco).
0277-9536/02/$-see front matter r 2002 Elsevier Science Ltd. All rights reserved.
PII: S 0277 -9536(01 )0 0094-6

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to apply themselves to their tasks. While resource
availability and worker competencies are essential, they
are not sufficient in themselves to ensure desired worker
performance. Worker performance is also dependent on
workers’ level of motivation stimulating them to come to
work regularly, work diligently, be flexible and willing to
carry out the necessary tasks (Hornby a Sidney, 1988).
Worker motivation and health sector reform
Even in a stable work environment, what motivates
workers fluctuates over time. Health sector reform,
essentially a change process, adds additional destabiliza-
tion to the work environment through its efforts to
improve national policies, programs and practices by
altering health sector priorities, laws, regulations,
organizational structure, and financing arrangements.
Yet, even reforms that have tried to improve working
environments and incentives have not always had the
anticipated impact on health system effectiveness.
Workers have often displayed ‘‘unexpected’’ behavior
patterns, reflecting the lack of internalization of health
reform and organizational goals.
Although many technical aspects of health sector
reform in the international context have been researched
and low levels of worker motivation plague public
health systems in developing countries, there has been a
surprising lack of attention to the human (worker)
elements of reforms. Only recently have meetings and
papers begun to address human resource development
issues in the context of health sector reform (Dussault,
1998; Martinez a Martineau, 1996).
Faced with little information about what motivates
health workers and how reforms affect worker motiva-
tion, many countries (and organizations within them)
have implemented measures or incentive programs
designed to stimulate certain kinds of worker behavior
without an empirical base to guide their choice of
interventions. Policy makers have often relied primarily
on financial incentives, as in Indonesia (Chernichovsky
a Bayulken, 1995) and Thailand (Pannurunothai,
Boonpadung, a Kittidilokkul, 1997). There is substan-
tial debate about the prospects for and effectiveness of
performance-related pay in developing country public
sector contexts (Nunberg, 1995). Even when financial
incentives are not explicitly used to promote higher
productivity, the underlying philosophy of many health
sector reform programs often implies that money is a
key motivator in the work context.
While financial incentives may be important determi-
nants of worker motivation, it seems equally evident
that they alone cannot and have not resolved all worker
motivation problems. Moreover, excessive focus upon
financial incentives in the public sector could lead to
negative consequences. Workers may begin to view
financial rewards as more important than other types of
reward (e.g., praise from supervisors or appreciation by
the community), and they could experience a conflict
between their own notion of public sector values and
messages about working for financial gain (Giacomini,
Hurley, Lomas, Bjhatia, a Goldsmith, 1996).
Worker motivation is a complex process and crosses
many disciplinary boundaries, including economics,
psychology, organizational development, human re-
source management, and sociology. This paper discusses
the many layers of influences upon health worker
motivation, and suggests that worker motivation will
be affected not only by specific incentive schemes, but
also by the whole range of health sector reforms which
potentiallyaffectorganizational
structures, channels of accountability, etc. By drawing
attention to this broad range of influences, this paper
aims to help policy makers view worker motivation in a
more holistic manner. This broader view will enable
them to structure reform programs to more effectively
promote worker motivation, and hence, improve health
system performance.
The paper draws primarily upon the existing litera-
ture; however, it was also influenced by a series of
specially commissioned case studies (Abzalova, Wick-
ham, Chukmaitov, a Rakhipbekov, 1998; Munoz,
1999; Mutizwa-Mangiza, 1998).
culture,reporting
Determinants of health worker motivation
Motivational processes in the work context operate at
the level of an individual, and are composed of two
parallel components: the extent to which workers adopt
organizational goals (‘‘will do’’) and the extent to which
workers effectively mobilize their personal resources to
achieve joint goals (‘‘can do’’). Yet, determinants of
these two components originate at many levels: the
individual, the immediate organizational work context,
and the cultural context.
Health sector reforms influence worker motivation
through their effects on organizational structures and
community/client roles. Fig. 1 represents these various
layers.
At the individual level, workers’ individual goals, self-
concept, expectations, and experience of outcomes are
some of the more important individual-level determi-
nants of worker motivation.
coupled with the individual worker’s technical and
intellectual capacity to perform and with the physical
resources available to carry out the task, result in a
specific level of worker performance.
Worker motivation also depends upon the organiza-
tional context in which the worker is situated. Organiza-
tional structures, resources, processes, and culture, as
well as organizational feedback about performance,
contribute to the motivational processes occurring at the
individual level. These affect the individual’s real and
These determinants,
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perceived ability to carry out his tasks, and stimulate
worker adoption of organizational goals.
Although not part of the organizational context,
communities also influence worker motivation through
community expectations for how services should be
delivered, the interactions that workers have with
individual clients, and formal and informal client
feedback on health worker performance.
While the generic concepts of individual, organiza-
tional and community determinants of worker motiva-
tion described above are relevant to all country
situations, the socio-cultural context will affect the
relative importance of the different determinants and
the relationship between them. For example, in many
industrialized countries, flat organizational structures,
and worker involvement are valued and are prominent
determinants of motivation, while societies in many
developing countries are more accustomed to hierarch-
ical structures and give more legitimacy to unequal
distribution of power.
These various layers of determinants operate, whether
the health sector or broader (political, economic, etc.)
environment is stable or changing. Health sector reforms
are likely to affect organizational systems and culture,
and they frequently emphasize stronger links between
performance and reward. Reforms commonly require
training and the development of new capabilities in the
workforce. Many of the reforms currently being
implemented attempt to change the role of the commu-
nity and clients, and provide them with a more effective
means to offer feedback on the performance of health
care providers. These processes all affect worker
motivation.
However, the content of the health sector reform is
only one aspect of its influence on worker motivation.
The manner in which the reform is designed, commu-
nicated, and introduced will also impact on health
worker motivation. Reforms can be designed and
communicated in a variety of ways: for example, top
policy makers can shape the reform with little input
from health workers and communities, with some
participation, or with extensive dialogue and consensus
building. Reforms can be communicated widely and in
great detail, or they can be only vaguely communicated.
Both the content of the reform and how it is commu-
nicated will determine workers’ perceptions (correct or
incorrect) of how these changes might affect them.
A specific example may help illustrate the many ways
in which health sector reform may affect health worker
motivation. An ambitious program of health sector
reform in Zambia has included, decentralization training
in planning and management, the creation of District
Health Boards made up of community members, the
introduction of user fees, and greater attention to
supervisory issues. All of these reforms are likely
to impact upon health worker motivation in some
wayFeither through increasing worker capabilities, or
resources available or channels of accountability or
changing basic employment conditions. While the
reform program has presented many opportunities for
improving work motivation, communication of reforms
has often been ‘‘too little, too late’’ (Lake et al., 2000).
As a consequence, resistance from health workers has
been encountered, and certain reforms, most notably de-
linkage of health workers from the civil service have
been suspended.
This paper seeks to clarify the ways in which worker
motivation is influenced and how health sector reform
can affect worker motivation. The paper is organized in
the following manner. The section on ‘‘the internal
determinants of worker motivation’’ discusses the basic
motivational process as it operates at the level of an
individual. The section on ‘‘organizational factors and
their influence upon worker motivation’’ outlines the
influence of organizational factors on worker motivation
and how health sector reform might impact those
influences. The section on ‘‘cultural and community
influences’’ reviews the cultural influences on worker
motivation and the mutual influence between cultural
values and reform. The paper concludes with a brief
discussion of implications for health sector reform policy.
The internal determinants of worker motivation
Health worker motivation exists when there is align-
ment between individual and organizational goals, and
when workers perceive that they can carry out their tasks.
Workers’ willingness to devote time and effort to work
tasks is not a function of external factors alone, but rather
influenced by the interaction of these factors with unique
personal factors. As a result, the internal motivation
process will differ across individuals in the same environ-
ment. In addition, due to the contribution of changing
environmental factors, an individual’s work motivation
may also fluctuate over time or across situations.
Worker motivation should not be equated with job
satisfaction, although the two concepts are related.
Fig. 1. Influences on health worker motivation.
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Greater satisfaction with one’s job is often associated
with higher levels of work commitment and willingness
to expend personal resources for job accomplishments
(e.g., Hackman a Oldham, 1976), but it is not a
prerequisite for motivation.
Over the years, numerous theories have been posited
to explain how internal and external factors interact to
affect worker motivation (Maslow, 1954; Adams, 1965;
Deci, 1975; Vroom, 1964; Locke a Latham, 1984;
Bandura, 1977). Although these theories differ in terms
of the particular ‘‘person’’ factors emphasized, almost
all theories acknowledge three broad classes of internal
influences on worker motivation: (1) goals, motives, and
values; (2) self-concept and other self variables; and (3)
cognitive expectations about the relationship between
various actions and consequences. These internal factors
affect worker behavior and performance, as well as
mediate how workers process the outcomes or con-
sequences of their actions. Most of the research
supporting this conceptual framework for worker
motivation has been carried out in industrialized
countries, but is also supported by research in develop-
ing countries (Mendonca a Kanungo, 1994). Fig. 2
outlines the internal motivation process.
The following paragraphs describe the three major
internal influences on worker motivation.
Goals, motives, and values: Individuals differ greatly in
terms of the goals, motives, and values they hold with
respect to their work. Not all workers will have the same
mix of motives and goals, and the relative importance of
particular values and work goals will change over time
and situations. Nonetheless, most theorists agree that
such internal factors may be organized into two broad
categories: lower-level needs, motives and goals related
to satisfaction of basic survival needs (e.g., safety, job
security), and higher-level motives and goals related to
fulfillment and self-satisfaction (e.g., sense of compe-
tence, self-determination, fairness). Hertzberg, Mausner,
a Snyderman (1959), based on their research in the
USA, indicated two types of factors that affect work
behavior. Hygiene factors
their presence or absence, determine levels of worker
dissatisfaction:supervision,
work conditions, salary, job security, etc. Motivating
factors determine the level of worker motivation and
satisfaction, and include achievement, the work itself,
recognition, responsibility, advancement, and growth.
arethose which, by
interpersonalrelations,
According to Herzberg, worker motivation stems
primarily from the presence of higher-order motivating
factors in the work environment. In contrast to hygiene
factors, these higher-order motivating factors are viewed
as intrinsically motivatingFthat is, they stimulate
worker motivation in the absence of extrinsic rewards.
Although individuals hold both lower- and higher-
level motives, goals, and values, environmental factors
greatly affect which of these categories of goals are likely
to be most salient at any given time. In particular, as
Herzberg noted, it is difficult to produce positive
motivation if hygiene factors are absent, and recent
studies among nursing personnel in the US provide
partial support for Herzberg’s model (Rantz, Scott, a
Porter, 1996). Herzberg’s model suggests, for example,
that if salaries are not paid in a timely fashion, health
workers are likely to become more concerned with
getting paid and less willing to exert effort at their job as
they seek an alternative means to gain an income and
support their families. However, even when lower-order
motives and goals have been met (e.g., pay is satisfac-
tory), worker motivation may be negatively or positively
influenced depending upon intrinsically motivating
specific work conditions (e.g., recognition).
Self-concept and ‘‘self’’ variables: Self-concept and
associated variables, such as self-esteem and self-
efficacy, also play an important role in determining an
individual’s interest and persistence in performing
difficult work assignments. Self-concept refers to the
individual’s evaluation of his/her competencies in
specific domains, such as health care delivery. Self-
efficacy refers broadly to the individual’s confidence in
his/her ability to accomplish specific work tasks
(Bandura, 1977). Health workers with a strong self-
concept in work-related areas, and a strong sense of self-
efficacy, are more likely to accept difficult organizational
objectives and to persist at the task longer in the face of
obstacles than persons with poor self-concept and low
self-efficacy (Bandura, 1986). Self-concept and other
‘‘self’’ variables may be positively or negatively affected
by external factors, such as when organizations provide
heath workers with training that enhances their work
self-efficacy. A positive self-concept and sense of job self-
efficacy enhances worker motivation by providing
workers with a personal incentive for task accomplish-
ments and by supporting sustained task effort once the
worker has adopted or internalized organizational goals.
Fig. 2. The internal worker motivation process.
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Cognitive expectations: The internal motivation pro-
cess involves the worker’s judgments about the extent to
which an individual’s allocation of personal resources
will yield a positive outcome. Cognitively oriented
theories of motivation indicate that an individual
workers’ decision to adopt organizational goals depends
on both workers’ expectations about whether they can
perform the task and whether the performance desired
by the organization has value to them (Vroom, 1964).
These expectations develop as a result of both internal
and external factors. For example, health workers may
perceive an organizational reward to be inadequate (e.g.
a bonus less than expected), and so reduce their work
effort even though the organization provides an
incentive for performance. Similarly, workers may
demonstrate high worker motivation in the absence of
organizational rewards if they perceive successful
performance as highly intrinsically rewarding, such as
when health workers devote substantial time to accom-
plish group tasks that provide individual workers with
valued social benefits.
The internal components of motivation (goals/mo-
tives/values, self-variables, and cognitive expectations)
mediate the impact of organizational or specific work
goals, and in turn determine the time and effort that a
worker will put into the task at hand. Kanfer (1999)
suggests that such factors affect internal worker
motivation in two ways: (1) by affecting the extent to
which health workers accept and adopt organizationally
prescribed tasks as personal goals, and (2) by affecting
the extent to which health workers effectively mobilize
their resources to accomplish joint goals. The adoption
of organizational goals represents the culmination of the
‘‘will do’’ portion of the internal motivation process, and
is reflected in workers’ task and job commitment. The
effective mobilization of worker resources to accomplish
stated goals represents the ‘‘can do’’ portion of the
internal motivation process, and is reflected by the way
that workers go about accomplishing their goals.
Deficits in either the ‘‘can do’’ or ‘‘will do’’ portions of
the internal motivation process have direct implications
for worker performance, productivity, and satisfaction.
Organizational factors and their influence upon worker
motivation
Organizations influence worker motivation through a
variety of channels: through the organization’s efforts
to improve worker capability; through the provision of
resources and processes; through feedback or conse-
quences related to worker performance; and through
more indirect aspects such as work culture. Fig. 3
highlights these channels, and this section briefly
summarizesthe manner
structures, human resource management policies, and
inwhich organizational
organizational culture impact on health worker motiva-
tion, and how these organizational factors are likely to
be affected by health sector reform.
Organizational structures, processes and resources
Organizational structures, processes, and resources
provide the day-to-day context in which health workers
carry out their tasks. The internal structures of
organizations reflect reporting hierarchies, level of
worker autonomy, clarity of organizational goals,
relative status of different workers and delegation of
responsibility and authority. The processes determine
how work gets accomplished and the level of resources
necessary to accomplish them.
There are several routes through which organizational
structures and processes impact on the two components
of worker motivation: the worker’s adoption of organi-
zational goals, and worker perception of the possibility
of contributing to those goals.
Organizational management structures and processes
influence whether the organization has a clear mission,
articulated goals, and norms and standards for worker
behavior. A strong sense of organizational mission
appears to be one of the key factors motivating workers
and explaining organizational effectiveness (Grindle,
1997). When norms and standards, and associated
processes are clear, it is possible for workers to
understand how they can assist in reaching the goals.
Communication processes within the organization will
determine how well information about the organization,
its goals, norms, and standards are communicated to the
worker.
Organizational support structures and processes shape
workers’ perception about the possibility of task
accomplishment. Ability to perform is not dependent
only upon the worker’s own skills. System-wide support
is also critical: giving sufficient authority and autonomy
to complete the task; ensuring clarity about the roles and
responsibilities of the different individuals involved;
ensuring clear, efficient service delivery, support and
management processes; and furnishing adequate re-
sources (such as drugs, supplies, and equipment) to
carry out organizational processes.
Organizational systems of providing information about
organizational and individual performance determine the
type of feedback received by the worker, and who
provides this feedback. How a worker relates to the
individual or group providing feedback will influence the
value placed upon this feedback.
Health sector reform and organizational structure
There are several key ways in which reforms can
impact upon organizational structure, processes and
resources, and hence affect health worker motivation:
e.g. creating a clearer, narrower organizational mission,
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changing reporting structures and autonomy, creating
more channels for worker feedback, and increasing
resources available to accomplish organizational goals.
Organizational mission: Organizational reform in the
context of health sector reform very often aims at
creating a narrower and clearer organizational mission.
For example, in Zambia, the Ministry of Health was
effectively divided into two separate organizational
structures: one responsible for policy-making, coordina-
tion and regulatory functions, and a second, new
Central Board of Health that would oversee implemen-
tation functions. Similarly, in the UK, purchaser–
provider splits removed the District Health Authority
from responsibility for the organization and delivery of
services and re-focused its mission upon defining needs
and purchasing care.
Autonomy: Public sector health delivery organizations
are typically embedded in cumbersome centralized
bureaucracies which control human resource manage-
ment systems and set (implicit and explicit) norms
for organizational structure and processes. Conse-
quently, many reforms seek to endow greater autonomy
to decentralized units. For example, the establishment
of autonomous hospitals is aimed at freeing organiza-
tions from such structures and giving these organiza-
tions responsibility to adopt more rational work
processes. New structures can make the work environ-
ment more conducive to task achievement, and workers
more likely to think that they can achieve specified
goals.
Feedback: Many health sector reforms try to extend
authority for providing feedback to agents situated
closer to the health worker. For example, decentraliza-
tion often transfers more authority for human resource
decisions to local administrative units, which should be
better informed about worker performance than distant
public service commissions. Similarly, encouragement of
hospital boards, district health boards, and health center
committees try to place more authority for providing
feedback in the hands of local communities (discussed
further in the section on ‘‘cultural and community
influences’’).
Resources: Many reforms focus on increasing the
availability of complementary resources at different
points in the health care system. Schemes may be
initiated to raise extra resources (such as health
insurance or cost recovery schemes) or to improve
efficiency in how existing resources are managed (e.g.
overhaul of drug supply systems).
While reforms may lead to organizational structures
more conducive to worker motivation, the transition
process itself may also have significant, and possibly
negative, effects upon worker motivation. Without
adequate transparency and communication, individual
workers may not understand the new organizational
goals. In addition, changes in structures and processes
may be disadvantageous for some groups. For example,
health care reforms in the UK have granted greater
authority to managers (commonly referred to as
managerialization) at the expense of other professionals
(Ferlie, Ashburner, Fitzgerald, a Pettigrew, 1996).
Human resource management
Human resource management is an organizational
system that incorporates ‘‘activities that mobilize and
motivate people and that allow them to develop and
reach fulfillment in and through work aimed at the
achievement of health goals’’ (WHO, 1989). The core
functions of human resource management include:
procuring the workforce, structuring work, rewarding
staff, controlling staff, training staff, staff participation,
and staff exit (Farnham a Horton, 1996). Human
resource management has a number of tools at its
disposal which facilitate the ‘‘can do’’ and the ‘‘will do’’
components of worker motivation:
Will do:
*Through job definition and job descriptions, human
resource management can help ensure that workers
Fig. 3. Influence of organizational factors and systems on worker motivation.
L.M. Franco et al. / Social Science a Medicine 54 (2002) 1255–12661260

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are aware of organizational goals, and of the role
which they are expected to play in achieving these
goals.
*Through various packages of incentives, such as
salaries, bonuses, promotions, performance-related
pay, and training opportunities, human resource
management can link performance to reward.
Can do:
*Recruitment procedures can ensure a fit between the
tasks required of individuals and the skills and
knowledge that they bring to bear on these tasks.
*Staff development can enhance worker knowledge
and skills, making the worker better able to perform
the tasks expected of them.
*Supervision and performance assessment processes
provide corrective feedback to workers on perfor-
mance.
It has been argued that, with the exception of
manpower planning, many lower- and middle-income
countries have ignored (or at best paid little attention to)
the human resource management functions in health
care (WHO, 1989). As a consequence, regular proce-
dures for recruitment and promotion are often not
established, job descriptions are not available, and
dismissal procedures are overwhelmingly cumbersome.
When basic human resource management systems are
not functioning, scope to use more sophisticated
incentive schemes to motivate workers appears limited
(Moore, 1996). In this context, the recent growth of
interest and work in human resource management
(Dussault, 1998; Martinez a Martineau, 1996) as an
integral part of health sector reform appears very
pertinent.
Health sector reform and human resources management
Health sector reform and human resource manage-
ment have a symbiotic relationship (Martineau a
Martinez, 1996). On the one hand, organizational
reforms in the human resource management system
(such as improved staff mix, elimination of ghost
workers) will further the objectives of health sector
reform (such as efficiency, equity, and quality of care).
On the other hand, certain specific health sector reforms
(such as decentralization, purchaser–provider splits,
privatization, and establishment of autonomous facil-
ities) may transfer responsibility for the human resource
management system, or conversely be constrained by
rigidities in the human resource management system.
Reforms have also often included other human
resource management strategies:
*improving education and training (both as a means
to create incentives for employees and to improve
capacity to perform);
*restructuring salary scales so as to provide a living
wage and hence reduce ‘‘moonlighting’’, and
*creating a closer link between performance and
reward through performance appraisal and perfor-
mance-related pay.
Organizational culture
Organizational culture is the least concrete aspect of
organizational factors. Yet, its impact on organizational
functioning and worker motivation is well recognized. It
can be defined as: ‘‘a shared set of norms and behavioral
expectations characterizing a corporate identity’’ (Grin-
dle, 1997), reinforced through organizational ‘‘rituals’’.
Organizational culture is formed through the interaction
of broader societal culture, organizational structures,
and the personal characteristics of individuals and sub-
groups that make up the organization.
Some organizations have created a culture through
specific and concerted efforts of management, with the
intention of motivating individuals within the organiza-
tion to pursue organizational goals. However, every
organization will have its own specific organizational
culture. Some organizations might value independent
decision making and entrepreneurial spirit that can lead
to greater innovation. Similarly, some organizations
might place more value on collaborative approaches
over individual action and decision making. Rituals,
such as frequent staff meetings and extra-curricular
social bonding activities may reinforce these organiza-
tional values.
In a public health care system, there are multiple
organizations. Where there are strong and charismatic
leaders, a more uniform organizational culture might
permeate throughout a health care system. However,
generally, organizational culture will vary considerably
among individual organizational units (such as different
hospitals and health centers). It is common to find the
performance of one particular health care unit consider-
ably better and staff motivation considerably higher
than another health care unit which operates with
similar structures and levels of resources.
In addition to the mutually reinforcing aspects of
organizational structure and organizational culture, two
important contributors to organizational culture are
discussed here: the characteristics of leadership styles
and the presence of sub-cultures.
Transformational leadership within an organization
can both shape organizational culture and inspire
loyalty to the organization. By communicating both a
vision and goals for the organization, transformational
leaders stimulate the willingness to internalize organiza-
tional goals and to mold worker perceptions of their
ability to contribute to goal attainment.
Sub-cultures are formed within an organization when
a group of individuals in an organization have a
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common set of specific experiences (such as professional
training, or prolonged service in rural areas or overseas
training). In the public health care sector, one of the
most prevalent sub-cultures may be that associated with
clinical professionals. This professional sub-culture,
often further divided between physicians and nurses, is
generally considered to entail: (i) a certain autonomy in
one’s job due to the technical nature of the work and the
difficulty of supervision; (ii) adherence to professional
norms and standards; and (iii) enforcement of norms
and standards through peer group pressure (Leonard,
1993, Ginsburg a Chaturvedi, 1988).
In some countries, the very fact of being a public
sector worker (or civil servant), particularly at more
senior levels, is thought to encourage a set of attitudes
and values commonly referred to as a ‘‘public sector
ethos’’. In England, the values commonly thought to be
shared by civil servants include political neutrality,
loyalty, probity, incorruptibility, honesty, trustworthi-
ness and public service (Farnham a Horton, 1996). A
similar sense of public sector work ethos is reported in
many East Asian countries.
Health sector reform and organizational culture
Health sector reform can have far-reaching effects on
organizational culture (and hence, worker motivation)
by changing the role of specific leaders, by modifying the
relative positions of various sub-groups and sub-
cultures, and by shifting organizational goals and the
inherent values associated with them. For example,
reform programs that place an excessive emphasis upon
financial incentives may diminish the sense of public
sector ethos amongst workers.
Reforms often embody values contrary to those held
by health workers. For example, reforms promoting
competition between providers, or which introduce fees
for health care services, might conflict with individual
worker’s beliefs of health care as a social good, and
hence, make it difficult for workers to commit to new
organizational goals. In Chile, health workers have a
strong belief in the importance of the public sector,
probably as a reaction to Pinochet’s attempts to
privatize the health care system. Democratic govern-
ments since 1990 have aimed to modernize the sector
with little concern as to whether care is offered by public
or private providers. However, proposed policy mea-
sures have frequently been interpreted by health workers
as incremental moves to privatization and have conse-
quently met with resistance (Munoz, 1999). Commu-
nication of organizational objectives (for example, how
modernization may promote greater responsiveness to
clients while retaining key public sector features) may
mitigate this problem, but there may still be an uneasy
transition process. Any reforms that threaten values
shared between workers, whether this be a sense of team
spirit, or a desire for autonomy due to one’s professional
status, are likely to be resisted.
Cultural and community influences
Outside the immediate organizational environment,
the broader cultural and community context will also
contribute to the individual’s motivational processes.
Fig. 4 shows the direct links of community and clients
on the internal motivational process. The broader
cultural influence is more pervasive, affecting health
reforms, communities, organizations, and the individual
worker, and is shown as a backdrop to all other factors.
Culture can be defined as ‘‘all the patterns of thinking,
feeling and acting that are shared by the members of a
society or other bounded social group’’ (Schwartz, 1997).
Fig. 4. Influence of cultural and client factors on worker motivation.
L.M. Franco et al. / Social Science a Medicine 54 (2002) 1255–12661262

Page 9

Culture has, at its heart, shared values, which contribute
to a type of ‘‘mental programming’’ carried out by
family, neighborhood, school, and community. This
‘‘mental programming’’ frames an individual’s notion of
what is possible, what is expected, and what conse-
quences will occur for deviant thoughts and behaviors
(Hofstede, 1980). Several analysts have suggested key
differences between developing country and industria-
lized country cultures, such as the degree to which
individuals find meaning through social relationships, or
through their own uniqueness and individual action.
Similarly, the extent to which individuals are socialized
to comply with the obligations attached to their
hierarchical role in the system, versus a more egalitarian
view which encourages voluntary cooperation, will vary
systematically between cultures (Schwartz, 1997).
Two dimensions of cultural influence on motivation
will be examined here: the relationship between organi-
zational functioning and societal culture, and the effect
on worker behavior of their interactions and links with
their patients.
Culture and organizational functioning
Cultural characteristics will influence organizational
structure, decision making processes, acceptable levels of
autonomy, and organizational culture. Organizations
with internal cultures and structures not in alignment
with the broader societal culture may encounter
difficulties in their functioning. Broader cultural values
translate into specific types of work behaviors. Kanungo
and Mendonca (1994) posit that in developing countries
where cultural values emphasize the collectivistic,
hierarchical, and harmonious, workers and organiza-
tional culture are more likely to emphasize:
*fate beyond one’s control,
*fixed human capabilities,
*the importance of past and present over the future,
and
*focus on short term goals
In turn, workers may prefer to be passive, moralistic
(rather than pragmatic), and authoritarian. Some
difficulties encountered in reform programs may result
from importation of structures and processes that
function best when supported by certain types of
cultural values. For example, transposing certain types
of management structure and processes from Japanese
to American businesses has not had the intended
performance consequences because the collectivist or-
ientation and moral commitment to the organization,
common in Japan, is not part of broader American
culture.
There has been very little research examining how
societal culture affects worker behavior in health care
organizations in developing countries. However, Ait-
ken’s study of health service workers in Nepal (1994)
demonstrates the importance of understanding ‘‘values
in use’’ or implicit cultural values in order to make sense
of health worker behavior. Aitken (1994) describes a
separate informal set of values and objectives parallel to
those formally espoused by the Nepalese bureaucracy.
She proposes that the following statement accurately
describes an unstated, informal organizational goal:
‘‘The purpose of the District Public Health Office is to
create incomes for its staff, not to deliver services.’’ This
goal reflects two additional values: ‘‘posts are seen as
salaries and not work’’ and ‘‘the main duty of staff is to
account for the budget.’’
Culture and provider–patient relationships
In service organizations, societal culture also affects
worker behavior through worker interactions with their
clients. The culture of workers’ clients affects worker
motivation through two main channels: the worker’s
links to the community served, and the degree of
congruence between client expectations and organiza-
tional norms.
Social embeddedness of workers affects their motiva-
tion to provide good service and their desire to be
appreciated by their clients. In instances where there is a
social relationship between patient and provider, provi-
ders may seek to provide more polite and empathetic
treatment. While organizational reforms can attempt to
create and structure relationships between provider and
patient (e.g. through the establishment of village health
committees), cultural factors may be of over-riding
importance. For example, health care workers in north-
east Brazil were more concerned about gaining the
respect of their clients than their supervisors:
When agents talked about why they liked their jobs,
the subject of respect from clients and from ‘my
community’ often dominated their conversationy
Agents saw their clients not only as subjects whose
behavior they wanted to change, but as people from
whom they actually wanted and needed respect.
Tendler and Freedheim (1994)
Client expectations also affect worker behavior.
Although Ministry of Health protocols may support
organizational goals of cost-effective treatment that is
affordable for the government, clients may expect and
value certain types of treatment, such as multiple drug
therapies, injections, or vitamins. When such a situation
occurs, public sector health workers experience a
conflict, and the outcome (in terms of their behavior)
will depend on worker values and their degree of social
embeddedness.
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Culture and health sector reform
Recognition of the specific cultural characteristics of
different country environments may help frame a reform
program which meshes better with health worker values,
and hence is more likely to have a positive effect upon
worker motivation. On the other hand, health sector
reform frequently aims
‘‘developing country environment’’ characteristics. This
may, in the long run, bring about improved performance
but such reforms may face considerable resistance when
attempting to change work behaviors, which are deeply
embedded in the cultural fabric.
The diversity and complexity of local cultural
contexts, combined with the lack of health sector-
specific analysis of the relevance of culture to organiza-
tional functioning, makes it difficult to draw specific
conclusions for the design of health sector reform.
Literature on the relationship between the success of
health reform and local culture is very scarce. A few
examples of how health sector reform might interact
with societal context are provided here.
In Zimbabwe, a number of socio-cultural factors were
identified which were likely to present obstacles to the
successful implementation of reforms (Mutizwa-Mangi-
za, 1998), for example widespread patronage was likely
to undermine efforts to regulate health workers better
and to implement performance-based pay.
Often, a key thrust of reform programs is to create a
stronger link between performance and reward. How-
ever, this may conflict with values present in many
developing country societies which emphasize the
importance of seniority, age, and experience. In these
societies, implementation of merit-based promotion
systems may lead to uneasiness among workers if
younger people are promoted to higher positions than
more senior employees. If the cultural values are very
strong, this may paralyze the organization: employees
may feel reluctant to take orders from younger bosses
and instead seek informal advice from more senior, but
lower level, staff. On the other hand, cultural values in
some developing countries emphasize collective rather
than individual action. In such a cultural context,
reforms resulting in a performance orientation among
a group or team of workers may be found very
acceptable.
Some reforms have tried to reinforce worker links to
their communities by making service providers more
accountable to community members. This has been
attempted through the establishment of district health
boards, hospital boards, empowerment of village health
committees, etc. These new (or re-invigorated) organiza-
tional structures may create an alternative feedback
loop, but their effectiveness also depends upon the
nature of social relations between health staff and the
communities whom they serve.
tochangesome ofthe
Certain broader environmental conditions also impact
on worker motivation. For example, an effective police
and legal system may deter some of the most adverse
forms of worker behavior (such as theft and corruption).
Political systems based upon rent seeking and patronage
may jeopardize the credibility of leaders. The larger
economic situation may bring certain work conditions
(such as salary) into prominence. Externally driven
reform processes with limited local ‘‘ownership’’ are
likely to undermine worker commitment to the reforms.
While acknowledging the critical importance of these
broader environmental factors, there is insufficient space
here to address them in depth.
Implications for health reform policies
The conceptual framework presented here paints a
complex picture of health worker motivation, because
worker motivation is a complex and dynamic process.
By ‘‘unpackaging’’ the various channels through which
worker motivation can be affected, this framework can
be used both to assess already implemented reforms, as
well as assist policy makers seeking to evaluate how
proposed reforms might affect worker motivation.
At the core of the motivation question is how well
individual health worker goals are in alignment with the
goals of the employing organization. This theme runs
through all the implications discussed below. Policy
makers need to assess how well organizational structures
and processes facilitate clear communication of organi-
zational goals, provide timely feedback on performance
to health care workers, and ensure that higher levels of
desired performance are met with greater reward.
Each country experience will be different, as its
culture, organizations, and broader reform environment
are different from others. Thus, there can be no
universal blueprint for how to design reforms that
promote worker motivation. Each country must analyze
itsown particular constellation of organizational
structures, culture, and broader societal culture to
determine how best to approach the design and
implementation of health sector reform. The following
sections outline issues that health policy makers should
consider in developing health sector reform programs
which will facilitate better goal congruence and im-
proved worker motivation.
Multiple channels influencing motivation: It is clear
that health sector reform can and does influence worker
motivation via a number of channels. Often, reform
programs have focused on a very limited number of
channels (e.g. financial incentives) to influence worker
behavior, and neglected other less tangible incentives,
such as the work itself, achievement, and recognition.
Many of these reforms have resulted in little improve-
ment in worker motivation, or even in reductions in
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Page 11

motivation due to unanticipated influences. Hertzberg
argued that the more concrete ‘‘hygiene factors’’ could
only avoid dissatisfaction while the more intangible
factors engendered positive motivation. The categoriza-
tion of financial incentives solely as hygiene factors is
difficult to maintain, since salary increases and bonuses
may be valued both for their financial value and for the
prestige and status they endow. Nevertheless, focusing
solely on financial incentives to improve worker
motivation is likely to be problematic. At a practical
level, most hygiene factors have ‘‘escalating zero levels’’
which means that such strategies can become prohibi-
tively expensive in the long run. But in addition:
Policies depending upon funding tools rely either on
the pre-existence of this drive, or the creation of this
drive (sometimes to the detriment of other drives.)
Giacomini et al. (1996)
There is, currently, very scarce empirical evidence on
what the key determinants of worker motivation are in
developing country health care contexts. Variations in
work environment and broader cultural context may
lead to a different constellation of key determinants.
Given this lack of information, it is critical that policy
makers consider a broad range of motivational determi-
nants, that they initiate incentives which all work in the
same direction (organizational goals), and that the
potential negative effects of new incentives are consid-
ered and counteracted with balancing measures.
Communication and leadership: Health sector reform
sometimes entails quite radical reforms of organiza-
tional structures, processes, and culture. To health
workers accustomed to a particular way of working,
reforms often seem strange and threatening. Clear
communication of the objectives and rationale for
reform are necessary to help bring about goal alignment
between health workers and the broader organization,
and will help prevent de-motivation by reassuring and
reducing levels of uncertainty. Design of reforms needs
to include design of the transition process including
communication and change management strategies.
Strong transformational leaders can play a critical
role in communicating the vision behind reform
programs and also in gaining worker commitment to
implement that vision. Conversely, weak leadership that
lacks credibility is unlikely to gain worker commitment
or willingness to exert effort in order to implement
reforms.
Values: Health sector reforms are rarely confined to
changing organizational structures. The thrust of the
reform is often more far-reaching, and aimed at
changing values within an organization. In such
circumstances, even with effective communication of
reforms, it may not be feasible to generate commitment
among all health workers, without adequate recognition
of prevailing values and examination of implicit and
explicit values associated with the reform. When health
workers feel that the values associated with a reform
program are not values to which they personally can
subscribe, there is likely to be a disaffection with the
reform process and a concomitant lack of motivation.
Differential impacts: Finally, worker motivation is an
individual and a transactional process. Public sector
health worker motivation is not uniform. Different
cadres may have differing determinants of motivation,
as seen in differences among physicians and nurse aides.
In addition, the organizational context in which the
worker is situated will mediate the impact of reforms.
For example, reforms will affect hospital workers and
workers in primary care settings differently.
Worker motivation is a critical component of health
systems performance, and one that is largely under-
studied. In the context of health sector reform, there is a
complex combination of factors which has individual,
organizational, and societal components. Consequently,
effective programs will depend, not only on country level
analysis, but also on regional, local and facility level
efforts. Clearly, further study is essential, and the
conceptual framework presented in this paper offers a
structure for future analysis and research on this vitally
important topic.
Acknowledgements
Preparation of this paper was supported by the
Partnerships for Health Reform (PHR) Project. This
was made possible through support provided by the
United States Agency for International Development
(USAID) under Prime Contract No. HRN-C-00-95-024-
05 awarded to Abt Associates, Inc. The opinions
expressed herein are the author’s and do not necessarily
reflect the views of Abt Associates, Inc. or USAID. The
authors gratefully acknowledge the contributions of
participants at the workshop on Health Worker
Motivation and Health Sector Reform, Bethesda,
October 1998.
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