Strengthening Strategic Reward Framework in Health Systems : A Survey of Narok County , Kenya

Background: Rewards are used to strengthen good behavior among employees based on the general assumption that rewards motivate staff to improve organizational productivity. However, the extent to which rewards influence motivation among health workers (HWs) has limited information that is useful to human resources (HRs) instruments. This study assessed the influence of rewards on motivation among HWs in Narok County, Kenya. Methods: This was a cross-sectional study done in two sub-counties of Narok County. Data on the rewards availability, rewards perceptions and influence of rewards on performance, as well as motivation level of the HWs, was collected using a self-administered questionnaire with HWs. SPSS version 21 was used to analyze descriptive statistics, and factor analysis and multivariate regression using Eigen vectors was used to assess the relationship between the reward intervention and HWs’ motivation. Results: A majority of HWs 175 (73.8%) had not received a reward for good performance. Only 3 (4.8%) of the respondents who received rewards were not motivated by the reward they received. Overall, reward significantly predicted general motivation (p-value = 0.009). Conclusion: In Narok County, the HR’s instruments have not utilized the reward system known to motivate employees. In the study area, hard work was not acknowledged and rewarded accordingly. In addition, there were not sufficient opportunities for promotion in the county. An increased level of reward has the potential to motivate HWs to perform better. Therefore, providing rewards to employees to increase motivation is a strategy that the Narok County health system and its HR management should utilize.


Introduction
The task of developing a strategic rewards framework for organizations is usually challenging but is essential to survive in the competitive and changing health environment.A review of literature on development of reward systems shows that the process cannot be copied from other organizations, but needs to be premeditated, established and advanced within the unique environment of the organization and should address diverse needs of employees (Jiang, Xiao, Qi, & Xiao, 2009).A well-designed incentive program contributes to a measurable change in behavior when organizations tie rewards to vehicles of achieving clearly defined goals.According to Armstrong (2006), reward practice has a potential of enhancing motivation and commitment, increasing job engagement, and developing discretionary behavior.As a result, motivation process is seen as a course of action that encourages employees to establish goals, take action, and work towards attaining the set goals.Employees therefore need to be cognizant of the association between how they are motivated to work towards achieving set goals and the incentives they get.
Rewards are used to strengthen good behavior among employees, which in turn motivates them to improve their productivity (Armstrong, 2010).Any reward system should therefore focus on reinforcing positive behavior.Employees need to be rewarded for working overtime, taking initiative, embracing team work, being reliable, providing outstanding customer feedback, meeting deadlines, and displaying persistent productivity.
Consequently, employers and managers should design or come up with a system to measure or quantify all these aspects so that rewards are given accordingly.Findings from a study conducted in Kenya by Njanja et al., (2013) indicate that a good reward system focuses on rewarding employees and their teams.Such a reward system is thought to encourage employees to perform better, thereby achieving organizational goals and objectives.It has been established that rewarding good behavior makes employees feel that their contribution is valued by the management and therefore improves relationships within the work environment (Njanja et al., 2013;Armstrong, 2010).Doing so enhances employee morale, better customer care, and increased output.However, for rewards to be effective, they have to be seen as fair.This may include openness with regard to information how the reward system works and how teams will benefit accordingly.It is thus considered worthwhile for employees to be involved in designing the reward system and its administration.
While looking at how current reward systems affect performance, (Duberg & Mollen, 2010) found that although salary is central in the reward system, other enticements like bonuses and shares were seen to create a conducive work environment and a happy workforce rather than inspiring them to be more effective.Their findings pointed out that conditions for working with reward systems in the public sector are limited due to inadequate resources and complex large organizational structures with old traditional systems of management.Therefore, new organizational design and structures must be reconsidered if well-designed reward systems similar to those in private care organizations will be effective.Similar evidence from Cambodia indicates that paying incentives can motivate HWs and can increase job satisfaction, staff motivation or patient satisfaction (Akashi et al., 2004).
Several other studies have looked at reward in various establishments and its association with factors such as employee motivation, satisfaction and effect on the quality of work done (Gohari et al., 2013).Overall, findings from these studies demonstrate the effect of reward in enhancing productivity.However, different rewards seem to have varied effect on employee attitude, satisfaction and performance.Nevertheless, there are wide-ranging results when it comes to individual rewards and their effect on workers' motivation.Gohari et al., (2013), posit that the maximum level of workers' motivation to perform happens when they feel their endeavor is rewarded and compensated satisfactorily.It is evident that managers' can benefit greatly from understanding the nature, dimensions and variables of a specific culture or country and how these affect the existing rewards' system and organizational processes.Such awareness according to (Deresky, 2002;Uddin, Luva, & Hossian, 2013) enables managers to develop appropriate policies and determine how to plan, organize, lead and control a reward system.While having a reward system in place may be an overarching human resource management (HRM) intervention, this study went beyond the requirement of having a reward system to assess the actual perceptions of rewards among the HWs and their influence on performance.The goal of this study was to document the status of the influence of rewards on motivation amongst the HWs serving in public health facilities in Narok County, Kenya.

Study Design
A cross-sectional study was done in health facilities in Narok North and Transmara West sub-counties of narok county.

Sample Size and Sampling Procedure
The sample size was 255 HWs calculated using the Yamane 1967:886 formulae with 5% margin of error at 95% confidence level (Yamane, 1967).Sample selection was by two-stage sampling: Stage one was by cluster sampling of two Sub-counties that collectively accounted for the highest proportion of health care workforce from the entire four Sub-counties in Narok County, i.e.Narok North and Transmara West (combined proportion of 68.3%).Stage two incorporated proportionate stratified sampling of HWs of all cadres in the Narok North and Transmara West Sub-Counties.The sampling frame included HWs working in public health facilities in Narok North and Transmara West Sub-Counties.The entire population of 21 county and sub-county health managers was also studied.

Data Collection Procedure and Measurement
Data was collected using self-administered structured questionnaires upon consent from relevant authorities, and confidentiality ensured at all stages.Motivation levels were assessed using (a) Scale of 1 -10 point range where "1" implied being fully demotivated and "10" fully motivated and; (b) Likert scale of 1-5 points on multiple questions on motivation constructs including general motivation, job satisfaction, intrinsic job satisfaction, organizational commitment, conscientiousness, timeliness and attendance.The scale used for questions related to availability of rewards was "yes/no," while questions on reward perceptions and influence of reward on performance used a 3 -degree (D = Disagree, U = Undecided, A = Agree) and 5 -degree (SA = Strongly Agree, A = agree, N = Neutral, D = Disagree, SD =Strongly Disagree) Likert scale respectively to analyze and interpret the answers.
Health managers from the County and Sub-County were not selected for the health workers interview; instead a separate questionnaire was used for them.Their inclusion was adopted in order to take account of their views regarding the perceived influence of rewards on performance.

Data Analysis
Data analysis was performed using the Statistical Package for Social Sciences (SPSS) software version 21 as per the specific research questions and subjected to descriptive analysis using frequencies and percentages.To assess the relationship between the reward intervention and HWs' motivation, factor analysis was carried out on the perceptions of reward such that the factor with the highest factor loading with Eigen vectors more than one was taken into account.After recoding negatively worded questions, factor analysis was also carried out on the dimensions of motivation such that for each dimension the factor accounting for the highest factor loading with Eigen vectors more than one was taken into account.The Eigen vectors developed for both reward and dimensions of motivation were then used for further analysis.In order to test the null hypothesis of no relationship between reward and health workforce motivation in Narok County, multivariate regression was carried out involving the developed Eigen values.

Ethical Consideration
The study was conducted with full adherence of the Scientific and Ethics Review Committee of Kenya Methodist University.Permission to conduct research was also sought from the Narok County Director of Health.Considering that the main ethical issue was participants' right to self-determination, anonymity and confidentiality, the questionnaires were distributed to participants with a participant information sheet, explaining the nature of the study.The questionnaires were administered after duly obtaining consent of the participant.Participants' privacy was maintained by ensuring that they were not exposed to public when filling questionnaires.Anonymity of respondents was assured by concealing their identity, and research data was kept confidential and used for research purposes only.The questionnaire administrator guided the study participants on how to fill the questionnaire and requested them to provide as much data as possible within their capacity.Research assistants came in to assist those who experienced difficulty in understanding the questions.

Response Rate and Socio-demographic Characteristics
The response rate was 92.9% (237 out of targeted 255 HWs).All 21 health managers' questionnaires were returned.A large proportion of the sampled HWs were based at the county hospital 87 (36.7%) and were males 133 (56.1%).Most, 184 (77.6%) of the HWs had completed tertiary colleges.Of those sampled, 84 (35.4%) were nurses.The age bracket of 31to 40 years had the largest proportion of HWs 89 (37.9%), and had worked for less than 10 years in the same facility (86.1%) and county (76.4%), see Table 1.

Rewards Perceptions
A majority 175 (73.8%) of the respondents had not received a reward for good performance in the institution.Out of the 62 (26.2%) respondents that had received rewards for good performance, 40 received non-financial rewards while 22 received financial rewards.Only 3 (4.8%) of the rewarded HWs were not motivated by the reward they received.A majority of the HWs disagreed that they were paid according to their experience 183 (77.2%); that their salaries were according to their responsibilities 178 (75.1%); that their hard work was acknowledged and rewarded accordingly 178 (75.1%); that all HWs knew their fringe benefits 130 (54.9%); that they were satisfied with the fringe benefits they got 179 (75.5%); and that the organization offered sufficient opportunities for promotion 178 (75.1%), see Table 2.

Perceived Influence of Rewards on Performance
Greater proportions of HWs agreed that the rewards they received made them make choices consistent with goals assigned to them 31 (50.0%);perform tasks assigned in good speed 30 (48.4%); perform duties assigned accurately 34 (54.8%); and help them go to the greatest extent to achieve goals assigned to them 30 (48.4%), see Table 3.A greater proportion of health service managers agreed that the rewards provided made HWs perform tasks assigned to them in good speed 10 (47.6%) while a third of them indicated that the rewards provided made HWs make choices consistent with goals assigned to them 7 (33.3%)and helped them go to the greatest extent to achieve goals assigned to them 7 (33.3%)respectively.Another third 7 (33.3%)were neutral on the effect of reward in making HWs accurate in performing duties assigned to them, see Table 4.

Relationship between Rewards and Motivation
Rewards significantly predicted general motivation (p = 0.009) (Table 5).

Discussion
In the present study, the status of influence of rewards on motivation of HWs in Narok County was assessed.The results indicated a response rate of 92.9% (Mugenda, 2008).Many 87 (36.7%)HWs were based at the county hospital, and the majority was males 133 (56.1%).Similar findings were made in Northern Kenya where males comprised 63% of HWs (Kenya Ministry of State for the Development of Northern Kenya and other Arid Lands (MONDKAL) and IntraHealth International, 2012).However, these findings are contrary to the country's estimates that allude that the female gender is more dominant in the health sector in Kenya (Kalibala, et al., 2005).With regard to HWs' level of training, the findings were similar to those made in Machakos, Nairobi and Turkana where it was observed that most HWs were holding diploma-level or higher education at 55.8%, 52% and 48.2% respectively (Ojakaa, et al., 2014).Nurses comprised the largest cadre 84 (35.4%), similar to the assertion that registered nurses formed the majority of health care workers at 28.7% (African Medical and Research Foundation (AMREF), 2012).This study and other data suggest that nurses deliver most health care services.Study findings on age distribution were similar to the national estimates in which it is asserted that more than half the physicians working for the Ministry of Health are younger than 36 years of age (Kiambati, Kiio, & Towett, 2013).
The motivation level of HWs in Narok County has been evaluated elsewhere and found out to be average (Momanyi et al., 2016), suggesting wide variation in the general motivation of the HWs across health systems settings.These variations may be explained by differences in levels of factors contributing to motivation, as well as differences in health care environments (Momanyi et al., 2016).Hence, health systems in diverse settings have different HRM provisions which contribute to differences in HW motivation results.The elements of rewarding, which are considered general in evaluating HWs motivation (World Health Organization, 2006), is one of the factors Daneshkohan et al., (2015) used in their study in Iran.Hence, any motivation level is expected in Kenya, given that the country is currently undergoing health care devolution with expectations of different adoption levels of HRM interventions (Kramon & Posner, 2011).
Additionally, motivation of HWs in Narok County has been evaluated elsewhere using multiple questions on constructs relating to motivation, such as general motivation, job satisfaction, organizational commitment, conscientiousness, timeliness, and attendance (Momanyi et al., 2016).Findings were similar to those made in District hospitals in Kenya where studies reported that the majority of respondents strongly agreed to being hard workers and disagreed that they were often absent from work, while many participants described themselves as demotivated (Mbindyo et al., 2009).Similar findings were also made in three districts in Zambia where it was found that, overall, HWs agreed that they were satisfied with their jobs and were commited to their organization, while conscientiousness, timeliness, and attendance had the highest scores (Mutale et al., 2013).
The status of availability of rewards for good performance in the institution was very low.Accordingly, of the 62 (26.2%) respondents that received rewards for good performance, 40 received non-financial rewards, while 22 received financial rewards.The present findings concur with findings made in Ghana's public health sector where it was observed that there was no difference in base salaries between urban or rural areas.In addition, implementation of monetary and non-monetary incentives for HWs working in rural and remote areas had been seriously neglected by the government, even though experiments with such schemes, including deprived area allowances and car incentives, had been conducted (Bonenberger et al., 2014).Similar findings were also reported in Tanzania where HWs claimed that they do not receive regular feedback on the work they perform and held this out as a serious shortcoming of the workplace management (Songstad et al., 2012).In this study, Narok County scores low in providing incentives to its health workforce.There is a need for the county's health care management team to increase coverage of its reward system from the current level.
Out of the few HWs in the present study who reported to have been rewarded for good performance, only 3 (4.8%) of the respondents were not motivated by the reward they received.Similar findings were reported in Addis Ababa Hospitals where the relationships between rewards (payment, promotion, recognition and benefits) were found to be significantly positively related with nurses' work motivation.The correlation coefficient between payments and motivation (0.74) was the highest among all the variables whereas recognition had the weakest correlation (0.29) among all variables but significant at 95.0% (Negussie, 2012).This may suggest that an increased level of reward among the HWs has the potential to motivate them to perform better.
On the HWs' perceptions on rewards, results showed similar findings to those made among HWs in Uganda reporting that most HWs were dissatisfied with their fringe benefits.They indicated that their salaries were aligned to their job responsibilities, with a majority disagreeing that all HWs knew their fringe benefits while a majority reported that their organization lacked sufficient promotion opportunities but most were uncertain on whether hard work was acknowledged and rewarded (Lutwama, Roos, & Dolamo, 2013).Contrary findings were made among AMREF health care employees in Kenya where most of the respondents indicated that they neither agreed nor disagreed that the availability of promotion opportunities within the organization influenced the level of their motivation as employees (Njambini, 2014).Whilst the issue of salary may be difficult to address at this level, the results suggest that the Narok County health team can do more to motivate its workforce by acknowledging hard work, providing information regarding benefits entitlement and offering sufficient opportunities for promotion as they become available.
Results from this study show that both HWs and health service managers agreed that rewards provided made HWs make choices consistent with organizational goals, perform the tasks assigned accurately and in good speed, and make them go to the greatest extent to achieve assigned tasks.A similar study among HWs in Lagos, Nigeria indicated the existence of a positive relationship between reward system and employee job performance, most especially where agreement reached with the workers' union on salary and incentives were implemented (Abosede & Adekunle, 2012).Nevertheless, contradicting findings were made in Calabar Teaching Hospital where it was revealed that monetary rewards had a positive impact on employees' performance while non-monetary rewards had a negative effect on employees' performance (James et al., 2015).Based on the findings from this study, the reward intervention undertaken by the Narok County health management has a role in motivating the health workforce, thus leading to improved healthcare system performance even though its application among the HWs is at a very low scale.
Rewards significantly predicted general motivation (p = 0.009).This implies that the null hypothesis (i.e., that there was no relationship between rewards and motivated health workforce in Narok County) was rejected.The alternative hypothesis that there is a relationship between rewards and motivated health workforce in Narok County was therefore not rejected.There is empirical evidence that has shown a close relationship between reward and motivated workforce leading to improved performance.The problem of underperformance and de-motivation of HWs as posited by Paul (2009) has often been explained in terms of an asymmetric principal-agent relationship where agents (HWs) lack `incentives to perform and principals (employers and patients) lack sanction and accountability mechanisms.Paul, (2009) in his study on HW motivation and the role of Performance Based Finance Systems in Africa, particularly focusing on district hospitals in Rwanda, found out that both motivation and performance have increased as a result of Performance Based Finance.It has been established that workers in general thrive on constant encouragement, effective rewards and suitable recognition (Abduljawad & Al-Assaf, 2011).According to Abduljawad and Al-Assaf (2011), rewards tend to motivate people to do more and to do it better or continue to do it better.Without rewards, workers tend to lose interest in excelling and innovating.If not properly recognized, they will lose their enthusiasm for perfection and that will in turn diminish their morale and happiness.It should be noted that unhappy employees are less productive, but worse still they will negatively affect the satisfaction of their clients (Abduljawad & Al-Assaf, 2011).Although the present study did not address potential negative effects of rewards, evidence from other industries shows that rewards can also generate other dysfunctional consequences or take many forms of "negative motivational spillover" (Gneezy, 2011;Larkin, 2014;Gubler, Larkin, & Pierce, 2015).Even so, Gubler, Larkin, & Pierce, (2015), portend that rewards are more effective when they recognize good behavior in the past rather than behavior going forward since rewards for past performance are unlikely to have gaming.While the rewarding intervention undertaken by the Narok County health management team predicted general motivation among HWs leading to improved healthcare system performance, managers should monitor rewards closely to make sure that employees do not game the system such that the reward programs do not foster unintended negative effects.
This study, however, had some potential limitations which may have affected the results.The study was limited to two sub-counties in the county.Therefore, generalizability of the results can be considered a limitation of the present study.The present study utilized a self-administered structured questionnaire as its main data collection tool.As a result, the likelihood of respondents rating high on their responses is hard to control; this activity could have an influence on the results.The studied population was comprised of HWs in public health institutions, and this may have missed out an interesting analytical angle had the study included HWs from private institutions.

Conclusion
Rewards have been offered minimally to HWs.Those who had been rewarded unanimously reported that they have been motivated by the reward, and the reward had enhanced their performance.In this study, hard work was not acknowledged and rewarded accordingly, and there were not sufficient opportunities for promotion.HR instruments have not adequately utilized the reward system known to motivate employees.An increased level of reward has the potential to motivate HWs to perform better, and therefore this is an area that the Narok County health system should consider investing more.Strengthening the reward system should include recognition and promotion, and focus on rewarding employees and teams, likely resulting in enhanced productivity.

Table 1 .
Socio-demographic characteristics study participants in Narok North and Transmara West Sub-Counties

Table 3 .
Influence of rewards on performance (perceptions of health workers)

Table 4 .
Influence of rewards on performance (perceptions of Health Service Managers) *95% Confidence Interval.