The Effect of Reward Practices and Health Service Delivery in Health Facilities—Kwania District Uganda ()
1. Introduction
Health service delivery is a key factor of National development (Ministry of Health (2016) and indeed efficiency in health system in America, Europe, and Asia has resulted in increased GDP per capita (Regmi, 2012). As reported by Nabukeera (2016), the function and performance of the health sector ultimately contribute to the health status of the population. Nonetheless, several studies have found that the quality, effectiveness, efficiency and economy of any health service depend on; cost of the health service, accessibility, timeliness, distance to health unit, professional conduct of health workers, provider-patient communication, treatment and care of patients, teamwork, skills, and staff compassion (rewards): Van Elk, Van De Bildt et al. (2019); Rodriguez-Monguio et al. (2009); Asandului et al. (2014); Thi Thu Ha et al. (2015) and Hasumi & Jacobsen (2014).
In Uganda, health services are structured from national and regional referral hospitals with a full range of services down to district hospitals, health centre (HC) IVs at county level, HCVIIIs at sub-county level, HCII at parish level and village health teams (VHT) at village level. Health centres IV, III, II and VHTs, offer health services such as Preventive, promotional, outpatient, curative, maternity, inpatient, laboratory services (Ministry of Health (2016) and Carroll et al. (2015)) and Kwania District has only HCVI downwards.
There is, however, a huge public outcry of poor health services in Uganda (Mukasa et al., 2019). A study by Okuonzi (2014), reported that; the quality of health care had fallen to 30% or less, most people are dissatisfied and technical efficiency among health facilities had fallen from 41% to 39% only. Another report asserts that Health workers steal drugs and they are corrupt (Monitor, 2016). In a separate study, UNHS 2016/17, the major barriers for communities in accessing health services at the public health facilities include unavailability of medicines/supplies (23%), followed by long waiting time (13%), long-distance (12%), limited range of services (14%) and understaffing (10%) (Ministry of Health, 2018). Mukasa et al. (2019) reported that Health workers lacked motivation especially the intrinsic and extrinsic reward type thus leading to rampant absenteeism, late coming on duty, early departure, negligence of duty and dual employment. A study by Emilia et al. (2015), in Calabar teaching hospital Nigeria, revealed that reward has a positive impact on employee performance. Moreover, there are many challenges reported about health service delivery, the effect of reward system on health service delivery has not been well documented in Kwania District. This being the first study to address the vice, its findings will go a long way to combat and stop the suffering of our people. This study purposed to examine the relationship and effect of intrinsic and extrinsic reward practices on health service delivery.
Objective
1) To explore the effect of extrinsic reward practices on service delivery in health facilities.
2) To assess the effect of intrinsic reward practices on service delivery in health facilities.
2. Methods
Using a cross-sectional study design, a structured pre-coded and pretested self- generated questionnaire of Cronbach Alpha of 0.82 was self-administered to sample of 132 health workers randomly selected from HCIV, HCIII and HCII in Kwania District between September-November 2020. The study population comprised of the health workers in thirteen health facilities in Kwania District totalling to 146 of which 31 were in HCIIs, 74 in HCIIIs, and 41 health workers in health centre IV. The sample size of 132 represents approximately 2.5% margin of error within a 95% confidence interval. The research proposal was presented to and approved by the faculty research committee of Faculty of Management Science of Lira University. After obtaining informed consent, the follow quantitative data was collected: biographic information, the independent variable that consisted and relates to the reward system variables such as: 1) Extrinsic rewards—salary, compensation, cash bonuses and 2) Intrinsic rewards like: career advancement, recognition/praises, promotion. The dependent variable was Health Service Delivery examined in terms of: cost, timeliness, access and satisfaction. Analysis relied on SPSS version 20, the result presented in tables and statistical significance level acceptable a p values = 0.05 or less.
3. Results.
1) Biographic
As shown in Table 1, the total number of respondents were 132, the majority of whom were youth aged between 18 and 35 years of age 59.1% (n = 78) followed by adults within the age group of 36 - 60 years 40.9% (n = 54) (Chi-square = 39.59, p = 0.001). The mean age was 34.27 years (SD ± 7.521), mode 30years. By gender, male respondents were slightly more than female: 69 (52.3%) and 63 (47.7%) respectively but this difference was not statistically significantly (chi-square = 0.273, p = 0.602). Significantly, the majority of health workers in Kwania District are certificate holders (n = 81, 61.4%), followed by diploma (n = 42, 31.8%) and degree (n = 9, 6.8%) (Chi-square = 59.04, p = 0.0001) and greatest proportion of whom are enrolled nurse 38 (28.8%).
Significantly, more youth (18 - 35 yrs) agree that their external reward like salaries, bonus is well-practiced compared with the adult 36 - 60 yrs of age (21.8% vs 11.2%, p value = 0.023). Thus young employees are more satisfied with the extrinsic rewards like salaries, bonuses, and other compensation than older one. However, there was no significant difference in the way health workers perceived their intrinsic reward practices in the various age groups. Similarly, there was no significant variation in health workers perception of either the extrinsic or intrinsic reward practices in their facilities within different gender, academic qualification and job position (p value > 0.05).
![]()
Table 1. Biographic characteristics.
2) Correlation Reward Practices and Health Service Delivery
According to Table 2, Health Service Delivery (HSD) correlates positively with the various reward system. In particular, HSD has a significant and positive but weak correlation with intrinsic reward (r = 0.260, p value = 0.05). On the other hand, Extrinsic rewards have a very weak insignificant but positive correlation with service delivery (r = 0.126, p value > 0.05).
Therefore whereas the reward systems positively correlate with HSD, it is only the intrinsic reward system like promotions, praises, career advancements, recognitions that significantly correlate with Health service delivery.
3) Multiple Regression Analysis
Table 3 shows how variance in reward practices was tested prior to subjecting
![]()
Table 2. Correlations between reward practices (extrinsic & intrinsic) and health service delivery.
*Shows significance at the 0.05 level.
![]()
Table 3. Robust Regression for predicting Health service delivery
***p < 0.01, **p < 0.05, *p < 0.1.
it to regression analysis (R2 = 0.062, F-test = 4.237, p value = 0.000). From the Table, the intrinsic reward appears a significant predictor of health service delivery (p value <0.009,
). Therefore, another factor constant, a unit increase in the Intrinsic rewards among the health workers would significantly increase the service deliveries by 0.169 times [95% CI (0.043 - 0.296), (p value = 0.009)]. However in comparison, the extrinsic reward does not significantly predict health service delivery, (β = 0.001, p value = 0.985). Thus, a unit increase in the extrinsic reward system only increases Health service delivery by 0.001 times with [95% CI (−0.116 - 0.119]). Nonetheless, extrinsic and intrinsic rewards account only for 6.2% of the variation in health service delivery in Kwania District (Adjusted R2 = 0.062), hence remaining 93.8% is accounted for by other factors that this study did not investigate.
4. Discussion
According to the annual Health Sector Performance Report of 2014/15, 85% of the health workforce in Uganda is made up of youth and only 14% are adults aged 40 - 60 years (Omaswa, 2017). Hence the health sector is dominated by young people due to the nature of their work which requires flexibility. Similar findings were noted in this study in that the majority of health workers were young people between 18 and 35 years, mode 30 years, followed by adult in the age group of 36 - 60 years. Regarding the reward systems, the youthful employees were more satisfied with the extrinsic reward compared to adults. For employees less than the median age of 25 years, turnover intention is driven more by job satisfaction than pay satisfaction (Choudhury & Gupta, 2011). Indeed Older employees also tend to perceive extrinsic rewards like salary increases, to be lower and are less likely to see the need to improve work-related skills for the same pay (Ilke Inceoglu, Segers, & Bartram, 2012).
This study found no significant difference in the gender composition in health facilities in Kwania District, though the gender composition consisted of more males (52.3%) than females (47.3%) respectively. Omaswa et al. (2017) also found male domination of up to 63% amongst health workers. Certificate holders form the majority of health workforce in Kwania District, accounting for 61% of the health work force. Omaswa et al. (2017) similarly found certificate holders to account for 63% of health workers. With respect to the job position in the health facilities, enrolled nurses form the majority (28.8%). WHO in 2012 also reported that a greater proportion of health workers tend to be nurses (WHO, 2012).
Whereas HSD has a significant and positive but weak correlation with intrinsic reward (r = 0.260, p value = 0.05), its correlation with the Extrinsic rewards is very weak and insignificant (r = 0.126, p value > 0.05). Furthermore, although, reward system accounts for 6.2% of the required motivation for health workers towards service delivery, the intrinsic rewards practices like praises, recognition, promotions, career advancement proved to be the only significant method that affects HSD. The extrinsic reward appears to be insignificant in health service delivery and a unit increase in it only leads to 0.1% increase in HSD. Other researchers in the same field under different research settings have reported similar findings. They aver that Non-monetary rewards such as recognition, status, employment securities, thank you, and praises from the management are capable of increasing employee performance.
Hee et al. (2016), in their study to assess the effect of intrinsic motivation on the job performance in the health tourism hospital, revealed that intrinsic reward was important in improving nurses’ job performance in the hospital. A study by Okeke, Ugwu, Nebeife, & Ngige (2020) found that intrinsically rewarded employee works at the high level of productivity and strive to develop professionally hence a well-managed non-financial reward stimulates employee performance towards top performance in the organization. Another study by Aktar (2012) to assess the relationship between intrinsic rewards and employees’ performance in Bangladesh found a positive relationship between rewards and employees’ performance. Furthermore, the most important intrinsic factors that motivate nurses are a sense of achievement, recognition, job security and flexible working hours as these have a positive impact on employees’ commitment, task performance, morale on the job, satisfaction and timely service delivery in health as well as banking sector Asiedu (2017) and Rizwan Muhammad, Ahmad et al. (2016).
However other studies allude that the extrinsic reward is equally important. According to Ijosiga, Abdul Wahid, & Picho (2016), monetary rewards such as pay, pensions and allowances were regarded as the most motivational factor to institute peak performance. Revenio & Dalluay (2017), found that the level of salary, vacation leave employees get from the management, and the scope of learning new skills were capable of improving employee performance. Another study by Abuhashesh et al. (2019), reported that 58.5% of the employees indicate low salary and a negative organizational culture as factors that affect service delivery. In Ethiopia, Negussie (2012) found that their nurses were more de-motivated by the lowest payment they receive. In Uganda lack of commitment to work, absenteeism, illegal private practice, demand for big financial allowances, abrupt attrition and pilferage of health care supplies are attributable to low pay (Barugahara, Maniple, & Mugisha, 2008).
5. Conclusion and Recommendation
Intrinsic rewards have a significant influence on health workers’ performance and hence health service delivery while extrinsic rewards have no significant influence on these employees’ performance. Extrinsic reward becomes more important as employees’ ages increase on the job. Public health facilities should focus on devising and practicing various forms of intrinsic reward systems such as; career advancement, promotion, praises, appreciation, democratic solution to problems, etc. in order to improve health workers’ performance and hence health services.