“The right equipment, sundries … alone gives me a reason to go and work” Health workforce incentives and dis-incentives during the COVID-19 pandemic: Experiences from four African countries
Authors: Kiwanuka Suzanne N , Babirye Ziyada , Kabwama Steven N. , Tusubira Andrew K. , Kizito Susan , Ndejjo Rawlance , Bosonkie Marc , Egbende Landry , Bondo Berthold , Mapatano Mala Ali , Seck Ibrahima , Bassoum Oumar , Leye Mamadou MM , Diallo Issakha , Fawole Olufunmilayo I. , Segun Bello , Mobolaji Salawu M , Bamgboye Eniola A , Dairo Magbagbeola David , Adebowale Ayo Steven , Afolabi Rotimi. F , Wanyenze Rhoda K. 
Published: June 2023

Background
The COVID-19 pandemic presented a myriad of challenges for the health workforce around the world due to its escalating demand on service delivery. In some settings incentivizing health workers motivated them and ensured continuity in the provision of health services. We describe the incentive and dis-incentives and how these were experienced across the health workforce in the Republic Democratic of Congo (DRC), Senegal, Nigeria and Uganda during the COVID-19 response. The disincentives experienced by health care workers during the pandemic were documented.
Methods
A qualitative study of a multi-country research involving four African countries namely: - DRC, Nigeria, Senegal and Uganda to assess their health system response to COVID-19. We conducted key informant interviews (n = 60) with staff at ministries of health, policy makers and health workers. Interviews were face to face and virtual using the telephone or zoom. They were audio recorded, transcribed verbatim and analyzed thematically. Themes were identified and quotes were used to support findings.
Results
Health worker incentives included (i) Financial rewards in the form of allowances and salary increments. These motivated health workers, sustaining the health system and the health workers’ efforts during the COVID-19 response across the four countries. (ii) Non- financial incentives related to COVID-19 management such as provision of medicines/supplies, on the job trainings, medical care for health workers, social welfare including meals, transportation and housing, recognition, health insurance, psychosocial support, and supervision. Improvised determination and distribution of both financial and non-financial incentives was common across the countries. Dis-incentives included the lack of personal protective equipment, lack of transportation to health facilities during lockdown, long working hours, harassment by security forces and perceived unfairness in access to and inadequacy of financial incentives.
Conclusion
Although important, financial incentives ended up being a dis-incentive because of the perceived unfairness in their implementation. Financial incentives should be preferably pre-determined, equitably and transparently provided during health emergencies because arbitrarily applied financial incentives become dis-incentives. Moreover financial incentives are useful only as far as they are administered together with non-financial incentives such as supportive and well-resourced work environments. The potential for interventions such as service delivery re-organizations and lock downs to negatively impact on health worker motivation needs to be anticipated and due precautions exercised to reduce dis-incentives during emergencies.