“It is both a truism that no nation develops beyond the capacity of its public service, and there is broad consensus … that our public service is broken and dysfunctional. The quality of public servants and the services they provide to our nation are both below expectations. From the glorious days … when the best and brightest graduates competed to join the administrative service …, our public service is now seen as employer of the dull, the lazy and the venal. We need to retrieve our old public service – effective, well paid and largely meritocratic, attracting bright people imbibed with a spirit of promoting public good.” – Adapted from Reforming our Dysfunctional Public Service – Nasir Ahmad El-Rufai
Over the past four months, there has been several developments that have highlighted the deficiencies, generally within the civil/public service, and specifically within the health sector. Given I am a civil servant employed within the health sector, I am acutely aware of these challenges that have plagued us for more than a decade since I have returned home to serve my country. These are not only my sentiments but are also those of the top policymakers in our present administration. Here are a few excerpts from a recent statement, address and press conference to prove my point.
“It is a well-established fact that this Government inherited a major dysfunction within the Ministry of Health that was brought about by poor relations between the Permanent Secretary and the CMO, and the Permanent Secretary and the former Minister of Health. To be precise, this dysfunction is well known in regional medical circles.” – Statement by Minister of State with Responsibility for Health Hon Senator Wendy C. Phipps
“To be brutally honest, over time, the traditionally high regard of a nursing career has been called into question by some persons who access our health care systems and institutions and have found them wanting. Some of the criticisms are well-placed, coming from family members and patients, fellow nurses and doctors, and even private sector partners. These complaints run the gamut of concerns and observations, including the following:
- Some of these nurses are rude, insulting and lazy, and don’t know how to speak to people.
- Some of these nurses act as if they are granting people a favour, forgetting that we are in hospital and are paying for their services.
- Some young nurses don’t seem to view nursing as a calling: for them, nursing is just a job. They are nothing like those older nurses from long ago, who really took a genuine interest in people – because back then, nursing was a vocation that was taken seriously.
- When hospitalized patients press the buzzer for help, some nurses think it hard to respond, often leaving the patient unattended until the next shift comes on.
- Some of our younger nurses are not confidential: they take patients’ business out into the street.
All of these complaints and observations have been documented by the management of our hospitals, our health centres, and our Ministries of Health in the Federation. Moreover, they have been consistently addressed in countless in-service training sessions, and in one-on-one consultations between senior management and some of the offenders. Unfortunately, it sometimes happens that when some of these experiences and observations are reported there is a reluctance to go on the record and clearly document the incidents. Without a formal complaint, it becomes difficult to take appropriate and corrective action.” – Address to officially launch Nurses’ Week 2016 By Hon Wendy C. Phipps Minister with Responsibility for Health, Social Services, Community Development and Gender Affairs Monday, May 9, 2016
“The statement by Prime Minister Dr. the Honourable Timothy Harris came in response to a reporter’s question about how long he feels is too long for someone to wait to get an appointment to see him.
Prime Minister Dr. the Honourable Timothy Harris said at the press conference that functionaries in his office make appointments. It may have been helpful to determine the man’s needs so he could be guided correctly. If the man wants to meet in relation to the country’s medical services, to use an example, it would be best for that man to speak first with the Minister of Health, Honourable Eugene Hamilton or the Junior Minister of Health, Senator Wendy Phipps, or even before meeting with a Health Minister he should speak with the Permanent Secretary, Mr. Andrew Skerritt, PS in the Ministry of Health. The Prime Minister added that he and his Cabinet want people to understand there is a system at work where functionaries are being held to account. They therefore do not have to go to a politician to get things done.
When this chain of command is enforced, civil service professionals will not have to work in constant anticipation of being bypassed and having rank pulled on them. Adhering to the chain of command will also avoid debilitating bottlenecks that place unnecessary demands on the Prime Minister and his Cabinet. Rather than micromanaging every issue, the government leaders should be allowed to delegate responsibilities to surrogates and specialists, as private sector leaders would usually do.” – CIVIL SERVICE PROFESSIONALS PLAY MEANINGFUL ROLE IN FULLY ENGAGED, CARING TEAM UNITY ADMINISTRATION: Team Unity Does Not Support Ten-Man-In-One Political Culture
Interestingly, so far, the only solution I have seen contemplated to rectify this dysfunction has been a monetary incentive which goes by the catchy phrase “pay-for-performance.”
“Prime Minister Dr. the Honourable Timothy Harris and Cabinet Secretary, Mrs. Josephine Huggins met with more than 100 civil service professionals on Thursday and Friday.
The series of meetings formed part of the Government’s ongoing efforts to communicate clear expectations to its staff, improve employee engagement and workplace relationships, and ensure sustainable performance in the public sector.
On the matter of ensuring sustainable performance, Prime Minister Harris inspired a lot of discussion last December when he announced in his 2016 Budget Address that the Team Unity Administration intended to improve efficiency in the public sector by implementing the increasingly popular pay for performance practice.
“The intent is to motivate individuals to perform at their optimal levels with the expectation that commensurate rewards will result from their work effort. At the outset, a pilot programme will be considered that carves out a modest allocation of funds from existing programmes to finance an incentive-based programme that rewards outstanding work effort,” Dr. Harris said in his Budget Address to the nation…
…Speaking with the civil service professionals this week, Prime Minister Harris expounded on his Administration’s view that compensation should match an individual’s impact on and contribution to the organization.
“If you perform exceptionally well, you will be rewarded exceptionally well. If you are performing consistently well, your Permanent Secretary must fast track you through the scales. If you are not performing, you must not get any increment. If you are not performing and you are unwilling to change, then we’d have to find alternative things for you to do. You have to get your friends who are not industrious and creative on that page,” the Prime Minister said.
Prime Minister Harris said his Administration would establish tangible performance metrics, i.e. what ought to be rewarded and incentivized. The Prime Minister also said the performance metrics would consider several factors rather than just a civil service employee’s length of tenure.
“We want the system to be able to recognize and reward people who are doing superb work and to hold them up as persons whom others should emulate. I think that is the new culture we want to create, and over time we are going to get there,” the Prime Minister said.
Dr. Harris added, “Years of service certainly would not be the only criteria. We have to look at a composite measure because you could be here long and be behaving badly.” …
…The Prime Minister said this week that the Government shall contract experts to work with its human resources department in setting up and structuring a performance-based programme. Prime Minister Harris added that His Excellency Dr. Everson Hull, Ambassador and Permanent Representative to the Organization of American States (OAS) for St. Kitts and Nevis, is working with the Government on this matter.
It is increasingly clear that serious organizations throughout the world see pay for performance as the way to go. For instance, on March 31st, the Harvard Business Review published the results of the 2016 Compensation Best Practices Report based on research conducted by Payscale, Inc. The HBR article titled When Unequal Pay Is Actually Fair reports “the number of companies that offer bonuses or other forms of pay for performance has increased 6% over the last two years” and “highly successful companies – those who are leaders in their market and have surpassed revenue expectations – are the most likely to adopt this compensation policy.” The article also states, “It appears there is a growing trend toward using bonuses to pay for performance, as half of these top performing companies are increasing their budget for bonuses in 2016.”- PM HARRIS SHEDS LIGHT ON HIS TEAM UNITY ADMINISTRATION’S PLANS TO IMPLEMENT PERFORMANCE-BASED PAY IN THE PUBLIC SECTOR
Unfortunately, in the public sector, the evidence that pay-for-performance works to remedy the dysfunction is mixed, and in some countries, the situation has gotten worse. For example:
“The use of financial incentives for service providers is increasing in developing countries. Using a field experiment in the DRC, we show that introducing a pay-for-performance mechanism in the health sector reduced facilities’ revenue and, more importantly, service utilization and child health. Classic explanations for the detrimental effect of incentives, such as motivational crowding out or switching away from non-incentivized actions, do not seem to play a role. In fact, the workers provided more effort, but this effort was evidently misplaced, suggesting that incentives can have detrimental effects in environments where performing is difficult relative to worker capacity.” – Misplaced Effort: Impact of a Pay-for-Performance Scheme in the Health Sector
“Current reforms in the public sector are characterized by the introduction of businesslike incentive structures, in particular the introduction of “pay for performance” schemes in public institutions. However, the public sector has some specific characteristics, which might restrict the naive adoption of pay for performance. Our article analyzes whether the impact of pay for performance on performance is bound to conditions, and if this is the case, under which conditions pay for performance has a positive or a negative effect on performance. We explore this contingency in a meta-analytic review of previous experimental studies on the effects of pay for performance on performance. We further show why pay for performance sometimes negatively affects personal efforts. With an experimental vignette study we demonstrate (a) that motivation is likely to be a key influence on the effect of performance-related pay on performance, and (b) that pay for performance is generally more costly as it appears because it almost always produces hidden costs of rewards. Our findings help to explain the modest success of pay for performance in the public sector….
… Our meta-analysis clearly demonstrates that the task type moderates the effect of pay for performance on performance. Pay for performance has a strong, positive effect on performance in the case of noninteresting tasks. Pay for performance, however, tends to have a negative effect on performance in the case of interesting tasks. The vignette study reveals (a) why pay for performance sometimes undermines performance and (b) how pay for performance produces hidden costs, which also need to be accounted for.
- Pay for performance causes a cognitive shift, that is, it strengthens extrinsic motivation for behavior (causes a price effect) and at the same time weakens intrinsic motivation for behavior (causes a crowding-out effect). Depending on the strength of these two opposing effects, pay for performance either hurts or promotes personal efforts: The more intrinsic motivation was there at the beginning, the more of it can be destroyed.
- Hidden costs arise even if the price effect is stronger than the crowding-effect. The loss of intrinsically motivated behavior has always to be compensated by external rewards.
– Pay for Performance in the Public Sector—Benefits and (Hidden) Costs
(Please also see: Doubts About Pay-for-Performance in Health Care from the Harvard Business Review)
So here is the problem. Using pay-for-performance to incentivize positive outcomes in the public sector is not dealing with the root cause of the dysfunction in the first place. For example, the root cause of the dysfunction between the chief technocrat, chief administrator and the chief policy maker in the Ministry of Health may have been due to personality differences, communication disorders, and lack of mutual trust and respect among all those concerned. How is using external incentives going to remedy these glaring social internal deficiencies?
With regards to the nurses, if some of them are found wanting, maybe they have challenging physical, mental and social health issues that are not being addressed. If some of them are only in the profession because of the monetary gain and not the calling or compassion that attracts many of us to the caring sector, how is more monetary incentive going to inculcate their empathic sensibilities and compassion that may have been lacking in the first place?
Speaking for myself and my colleagues, most of us are called upon year after year to do more with less, and many of us are not given the tools and medications needed to treat our patients effectively and as best as we were trained to do. Many of us are giving 200% of our time just to keep the hospital afloat, and are balancing the care of our private patients with our family duties and responsibilities!!! How is paying us more going to reduce our burden and mitigate the burnout many of us are already feeling physically, mentally and socially? The extra funds is best invested in helping improve our institutional capacities and human resources so that the burden can be shared by all of us so our patients get the best care, attention and treatments that they deserve. This would only help sustain the internal motivations, the passion or calling that brought us to the health profession in the first place, rather that us gaining solace in our deteriorating health by an increasing bank account.
And most important for me, with regards to the policy makers micromanaging critical issues that should be the job of lower functionaries, what are we to do when we have dysfunctional functionaries and our concerns are not relayed up the chain of command to those who need to know our plight? I am convinced that many policy makers and administrators have their roles confused and do not realise that they are there to serve us, the grass-roots health caregivers so that we get the right tools and right work-space environment to serve our patients to the best of our abilities.
We are cognizant of the fact that our salaries do not come from the pockets of the policy maker or the administrators but from the pockets of citizens, who are the tax payers of the country. Our job is not to make the lives of those above us easier, but for those above to make our lives easier. That is why they have been given the power and responsibility to serve, and it is in this light the flow of information needs to ascend from bottom-up and the flow of resources need to descend from bottom down. If we are happy and our patients get what they need and deserve, then it is a win-win-win-win situation for all concerned inclusive of our patients, health care providers, administrators and policymakers. The same reasoning goes for other public sectors, be it education, utility, sports or public works.
I get the distinct impression that the managers and administrators above us do not want to “bother” or “burden” those above with the deficiencies and challenges in the system, and hence many at the top are oblivious to what we have to deal with at the bottom. It is like those at the top have power without responsiblities and those at the bottom have responsibilities without any power to get what they need to function well in their jobs and serve the county to the best of their abilities.
From my point of view, the root cause of the dysfunction in the civil service is due to channels of communication from the bottom to the top being sabotaged (for whatever reason) by intermediate functionaries, and lack of resources flowing from the top to the bottom by those same intermediaries. These intermediaries may feel that they are cutting costs and saving the public purses in the short-term, but in the long run, truth be told, they are putting people’s lives and livelihood at risk, not only the patients but also the health care worker themselves.
I do not see how pay-for-performance will help our situation, but only make things worse in the long run. On the other hand, if we insist that the politicans lead by example, and the pilot project start with them, and their pay is pegged to a composite measure of social, physical, mental and environmental wellbeing in their constituency, and this depends on us grass-roots getting the tools we need, then and only then, can I see where pay for performance would work. This has to be a collective effort, and would only work if what is good/bad for us below is also good/bad for those at the top. Until and unless the performance is taken up at the community and national level, where all indicators of physical, social, mental and environmental health and well-being are taken into account, and our policy leaders are made transparent and accountable for their ultimate policies, and ultimate power is wedded to ultimate responsibilities, nothing will change. By ensuring that all of us at the bottom are well-educated and well cared for and have meaningful jobs and well equipped to each play our part in nation building from the bottom-up and increase the capacity of our public service, our productivity as a nation would continue to flounder and our ability to grow and develop would be perpetually handicapped.
Besides the extrinsic incentives, there needs to be more structural adjustment within the civil service and a better understanding of our roles and expectations of one another from civil servant up to ministers. An important resource that sheds light on better policy making that takes into consideration this bidirectional sharing of information and resources can be found at The Institute for Government. In their press release entitled Institute publishes recommendations for better policy making, they noted:
“The Institute for Government has published the results of its year-long research into better policy making. It has found that despite attempts to improve policy making under the last government, reforms fell short and left civil servants and ministers feeling frustrated…
Our research is based on interviews with 50 senior civil servants and 20 former ministers, and an analysis of 60 evaluations of government policy. It found:
- policy making reform attempts too distant from the real world of policy making – ignoring the role of ministers, and pressures to produce new short-term policy initiatives
- relations between ministers and civil servants too often falling short of what they both wanted to see
- ministers feeling they were brought into the policy process too late
- civil servants unclear about ministers’ overall goals
- limited challenge – either of ministers by civil servants or within the civil service
- lack of a learning culture in the civil service – in particular, patchy use of evaluations departments commissioned.
The Institute has proposed a series of changes to embed better policy making into the system. They build on the new Civil Service Policy Skills Framework – but drive those changes further and faster. We call for:
- agreement on a new set of ‘policy fundamentals’ – the building blocks of good policy
- a public statement by each department on how it will meet those ‘policy fundamentals’
- a Policy Director in each department – to co-ordinate policy work and ensure good planning, challenge, review and capability – and make sure ministers are involved early
- a new responsibility for the permanent secretary to ensure that ‘good policy process’ has been followed, extending existing responsibility for value for money
- a new Head of Policy Effectiveness in the Cabinet Office – to build capacity and ensure independence in evaluations and proper learning
- new emphasis on both ministers and civil servants recognising the value each brings to the policy making process…
…Last year we asked members of the Political Studies Association what they thought were the “most successful” policies of the last 30 years.
Our report, ‘Making Policy Better: Improving Whitehall’s core business’, sets out seven fundamentals of good policy making:
- Clarity on goals
- Open evidence-based idea generation
- Rigorous policy design
- Responsive external engagement
- Thorough option appraisal
- Clarity on role of central government and accountabilities
- Effective mechanisms for feedback and evaluation…
- Read our recommendations: Making Policy Better sets out recommendations for a new approach to policy making, and for changing the policy making system to increase the incentives for better policy making.
- See our evidence and analysis: Policy Making in the Real World summarises attempts to improve policy making since 1997
- Read our working paper: System Stewardship examines the future of policy making with government decentralising services and trying to tackle more complex problems with multiple actors and decision makers”
Sometimes, tough love for country and our leaders is needed, and it is in this light that I provide this submission for their consideration.