CHAPTER ONE INTRODUCTION 1.

0 Introduction In this chapter the researcher discussed the background of the study, statement of the problem, significance of the study, objectives, research questions, operational definitions, area of study and scope of the study. 1.2 Back ground of the study Globally, many health reform activities are seeking to improve health system performance by improving the available and allocation of resources, promoting more efficiency management and rationalizing the role of government. Yet experience with efforts to improve health system effectiveness has shown that the positive impact anticipated from such reform efforts has been thwarted by the unexpected behaviour patterns of health workers. Effective and efficient health care systems depend critically upon actions taken by individuals working in the systems. Motivation in the work context can be defined as an individual's degree of willingness to exert and maintain an effort towards organizational goals. Motivation is an internal psychological process. It is not possible to motivate people directly, only to create an environment conducive to high degrees of motivation. Further, motivation itself if not an observable phenomenon; it is only possible to observe either the result of the motivational process (such as improved performance) or perhaps, some of the determinants of motivation. Worker motivation is of critical importance in the health sector; health care delivery is highly labor-intensive and service quality, efficiency and equity is directly affected by worker motivation. Factors such as the availability of resources and the technical competence of the worker are not sufficient in themselves to always produce desired work behaviour. Evidence has shown that motivated workers come to work more regularly, work more diligently, and are more flexible and willing. Increased motivation creates the condition for a more effective workforce, but because work motivation is an interactive process between workers and their work environment, good management and supervision are still critical factors in reaching organizational goals (hornby and sidney 1998).

While many aspects of health sector reform in the international context have been researched, there has been a surprising lack of attention to the human resource elements of reforms. Only recently have meetings and papers begun to address human resources development issues in the context of health sector reform (Dussault 1998, Martineau 1996). this paper argues that a core component of the information necessary for policy making is still missing because there remains a dearth of studies about what motivates health workers in developing countries. As a consequence, many countries and organizations within them have implemented measures designed to improve health worker motivation without an empirical base to guide their choice of intervention. In the face of this lack of information about the determinants of health worker work motivation, governments have often relied excessively on financial incentives to encourage more productive behaviour. There are examples of the use of financial incentives as an explicit policy tool in Indonesia (Chernichovsky and Bayulken 1995) and Thailand (Pannurunothai et' al 1997). There is substantial discussion of the prospects for and effectiveness of performance-related pay in developing country public sector contexts (Numberg 1995). Even if financial incentives are not explicitly used to promote higher productivity, the underlying philosophy of health sector reform programs often suggests mopney as a key motivator in the work context. Today, sub-Saharan Africa is coping with 24% of the world's disease burden, while concurrently local local health systems are unresponsive, inefficient, inequitable and even unsafe (WHO 2006). the reason for this under-performance are multiple: nevertheless it has been suggested that motivation and performance of health workers, as the foundation for any health-care system, are a main determinant of health-care service quality, efficiency and equity for example (WHO 2006; Dieleman at' al 2006; Buchan 2005; Franco, Bennet&Kanfer 2002). however, African health systems are not only experiencing one of the greatest staff shortages, but clinical staff is currently faced with weak institutional frameworks and distortive incentive structures, ineffective management practices and adverse work environments at systemic and organizational level, resulting in an overburdened health work force with low levels of work motivation (Mahauer & Imhoff 2006; Ferrinho & Lerberghe 2000). it is believed that this under-performance has not only undermined the capacity of health-care organizations, but even threatens the acheivement of the Millennium Development Goals (MDGs) to: reduce child mortality; improve maternal health;

and combat HIV/AIDS, malaria and other diseases (UN 2007; WHO 2006; Dielemamn & Harnmeije 2006). A vast theoretical literature and immense variety of approaches have been generated and applied in an attempt to scale-up and strengthen existing health-care systems in Africa and elsewhere. In particular, strategies that aim at improving services and the performance of health facilities through optimizing scarce resources available through effective human resource management (HRM) have attracted much attention (Martinez & martineau 1996). The current debate on HRM in the health-care sector is based on both concepts of motivation in the work context, in particular motivation of public health personnel and performance based finance (henceforth: PBF) approaches. 1.2 Statement of the problem There are many reports about health service in Mbale municipality calling for attention towards patients (local media reports). A case in point is the new vision of 8th march 2012, Kyotalengerire reported that, in septermber 2011 Cecilia Nambozo, a former teachers at Busamaga primary school in Mbale bled to death during child delivery. Allegedly, medical officers refused to attend to her because she couldn't raise Ushs.300,000/= they had asked from her. Soon after, another woman was reported to have died in Lyantonde district while giving birth at Kasamby health center IV. The lady was operated on before discovering that the center had no stitches. Therefore from the above, there is need to establish the extent to which cases of poor quality service provision is resulting from lack of motivation. 1.3 Purpose of the study The study seeks to establish the impact of motivation of employees on service quality in Namatala 3

health center, Mbale municipality. 1.4 Objectives of the study To establish how employees are motivated in Namatala health center To find the level of service quality in Namatala health center To ascertain the relationship between motivation and service quality in Namatala health center 1.5 Research questions How are employees motivated in Namatala health center? What is the level of health service quality in Namatala health center? What is the relationship between motivation and service quality in Namatala health center? 1.6 Scope of the study The study focused on the impact of motivation on health service quality because of the various complaints arising from then patients. The study was carried out in Namatala health center in Mbale municipality because the researcher anticipated it to have relevant data to the study. The study investigated data of the period from 2006 to 2011 because the researcher anticipated to get the data required data. 1.7 Significance of the study The study is beneficial to health centers and ministry of health in general by highlighting areas of motivation and their relationship with service quality Health centers will use this study to improve on their service quality at their work place The study aimed to guide academic researchers who will be in need of carrying out further research related to motivation and service quality. The results of this study are to be used as a reference by future researchers who might be

interested in the same field The study benefited the community by creating awareness to motivate employees and also set pro- cautions to care for them The results also helped the researcher as a social worker to develop skills and be able to discover the reason behind using research knowledge, techniques and principles

CHAPTER TWO LITERATURE REVIEW 2.0 Introduction 5

This chapter reviews the existing literature on motivation and service quality and how there are related. To review this, the researcher considered the objectives which include motivation strategies, service quality levels and the relation between motivation and service quality as themes in literature review. 2.1 Motivation Strategies Balunywa (2005) observed that for people to achieve results they must be motivated. Motivation involves the creation of an atmosphere that encourages organizational members to perform their tasks. Motivation involves identifying the needs and desires of employees and attempting to satisfy those needs. It can take the form of financing rewards which satisfy some peoples needs or other jobs well. Other needs including social status are satisfied through recognition of employees and their participants in decision making. Mullins (1089) argued that motivation should be offered at work in order to inspire morale of the employees and perform efficiently to achieve the objectives of the organization. He also emphasized that there should be job enrichment which is learnt to motivate employees. Mbiti (1987) argued that motivation is the idea of getting the members of a team to pull together for the common good of the organizations process. He points out some of the methods of cultivating motivation among workers as attractive salaries, promotion opportunities, annual leave, study tours, in service courses aimed at equipping the employee with modern techniques of performing their duties, fringe benefits such as free medical care, free housing and overtime payments. Green (2003) notes that employee motivation is a complex sum of many factors. Managers have found many ways to motivate their employees to perform to the best of their abilities. He therefore identified the following most effective factors of motivation employees and these include Financial and Non-financial Motivational factors. Financial rewards are common. Most experts recognize that most financial rewards do not last very long but are essential in order to successfully motivate employees. The most common types of financial rewards are salary increases, profit sharing, incentive travel, and paid time-off. Salary increases involve bonuses and raises in base pay. Profit sharing provides opportunities for employees to purchase stock in the company. Incentive travel allows for employees to take

vacation travel that would normally not be taken without the incentive. Paid time-off involves giving employees time off in a variety of ways. Non-financial rewards are rewards that motivate employees for their creative and intellectual ability. These types of rewards lead to employee empowerment. Goal setting, communication, autonomy, responsibility, and flexibility are considered non- financial motivational rewards. Goal setting gives employees opportunities to be involved in the decision- making aspects of a company. Working autonomously with responsibility and flexibility also empower employees to perform at their highest level of expertise. According to Manuel (2006) motivation can be maintained by setting yourself up to where you are constantly reminded and fired up about working out. This can and should be done in several ways. The most effective way is to set up a series of ways in which you can be reminded all the time through literary, audio, visual, as well as face-to-face learning and training. "You will be the same person today in five years except for the books you read and the people whom you most associate with." Manuel (2006) the truism in this quote cannot be denied. If "birds of the same feathers flock together," what can you tell about your motivation and results based on the people whom you most hang around? This question can often present the reason why you may be losing motivation every time you start a new workout program.

Black (2010) quoted that Motivating employees is an important skill for supervisors, managers, and business owners to have. When developing motivation plans, it is important to recognize the individual differences among employees and realize that not all motivation techniques will work for everyone. Each employee must be evaluated to determine what motivates them the most. Below are several ideas for motivating employees and preventing job boredom or job overload.

Job rotation, also known as cross-training, can be very effective for employees that perform repetitive tasks in their job. Job rotation allows the employees to learn new skills by shifting them from one task to another. Job enlargement is a motivation technique used for employees that perform very few and simple 7

tasks. Job enlargement increases the number and variety of tasks that the employee performs, resulting in a feeling of importance. Job enrichment, this method increases the employees control over the work being performed. It allows employees to control the planning, execution, and evaluation of their own work, resulting in freedom, independence, and added responsibility. Flextime allows employees to choose their own work schedule, to a certain extent. For example, if the office is open from 8am until 9pm, the employees can come in at any time during that period to complete their 8 hours. Job sharing, this is a less common method, but very effective at preventing boredom. It allows 2 employees to share 2 different jobs. They could alternate days or weeks, working 20 hours in each position each week. Employee involvement, people want to feel like they are a part of something. Letting the employees be more active in the decision-making related to their job makes them feel valued and important to the company and increases job motivation. Variable-pay programs such as Merit-based pay, bonuses, gain sharing, and stock ownership plans are all great motivators for employees. However, dont just give them out. Offer them as an incentive or reward for outstanding performance.

2.2

Service Quality Levels It is agreed that different people understand different things regarding the service quality as a multi-dimensional notion. Bolton and Drew (1991) and Oliver (1980) defined service quality as the difference between the actual service performance and their expectations. Similar to Bolton and drew (1991) and Oliver (1980), Parasuraman at al (1988) characterized service quality as the degree and direction of discrepancy between customers perceptions and expectations. According to Lewis (1993), the dimensions of service quality focuese on interactions between a service firm and its customers and typically relate to; Technical dimensions that is to say the outcome of the service process to include systems and technology. Functional dimension that is to say, the way the service is delivered to include inter-personal interactions between employees and customers, appearance and personally of service personnel and approachability of personnel.

To corporate image dimensions which is the result of how customers perceive the organization and can be expected to be built up mainly by the technical and functional quality of its services. Parasuraman et al (1985) identified ten dimensions of service quality for example (credibility, security, accessibility, communication, understanding the customers, tangibility, reliability, responsiveness, competence and courtesy). In subsequent research, Parasuraman et al (1988) consolidated the above ten dimensions into five broad dimensions as Tanaibles that is to say, appearance of physical facilities, equipment, personnel and written materials, reliability that is to say, ability to perform the promised service dependably and accurately, responsiveness that is to say willingness to help customers and provide prompt service, assurance that is to say, employer knowledge and courtesy and their ability to inspire trust and confidence and empathy that is to say caring, easy access, god communication, customer understanding and individualized attention given to customers. Sureshchandar et al (2002) suggested that service quality is based essentially on five dimensions/factors critically from the customers point of view. These dimensions/factors are core service or service products which include the following; Human element of service delivery Systematization of service delivery-non human element Service scopes (the environment in which the service is delivered and where the firm and the customer interact Social responsibility Assurance Parasuraman at al (1985) stated that customers perceptions of quality are influenced by various gaps which lead to service quality short falls and in particular, that the quality perceived in a service is a function of the gap between customers desires/expectation and their perceptions of the service that is actually received. In support with this definition, Lewis (1991) proposed that service quality is a measure of how well the service delivered meets customers expectations of a product and service. 9

For years, researchers in social psychology have claimed that there are detrimental effects associated with performance rewards. (Pierce et.al.,2001, 562). The logic behind this claim is that when people are rewarded for a task, they will grow to like the task less and spend less time doing it if the rewards are suspended. Thus, intrinsic motivation is said to be destroyed by the reward system. This article demonstrates, by way of meta-analytic review, that under certain conditions, rewards are found to enhance performance and motivation. (Pierce, et. al., 2001). In view of the above literature when employees are motivated to their individual expectations, performance will automatically be boosted meaning that the high the level of motivation the high the level of service quality will be employees will work with passion and ease hence liking their job. 2.3 Motivation and Service Quality Mbite (1987) contended that motivation has much to do with employees interest in putting utmost effort into their work. He emphasized that motivation is one of the key factors that lead to efficiency and service quality. Saleemi (1997) observed that a good motivation system releases the immense untapped reservoirs of physical and mental capabilities. A number of studies have shown that motivation plays a crucial role in determining the level of service quality. Poorly motivated people can nullify the soundest organization, said allen. By satisfying human needs, motivation helps in increasing productivity and service quality. Mullins (1989) noted that managers hint give attention to the level of motivation of its members to improve on service quality. The managers must also encourage staff to direct their efforts (their driving force) towards the successful attainment of the goals and objectives of the organization. Quality of service has been described to be one of the major contributing factors needed in enhancing customer satisfaction. This is due to the basic fact that it assists goes to create customer

loyalty whilst increasing revenue for the organization if effectively and efficiently practiced. But in order to enhance the research this concept was separated into two different words (i.e.) quality and service. Quality itself has been defined as basically relational and a uncompleted procedure of building, including the sustenance of relationships through assessing, anticipating and satisfying stated and implied needs. Additionally, this term (i.e. quality) is the careful observation of the suppliers work output by customers (Verma 2008 267). Service has also been defined as a task undertaken by an employee or group of employee that benefits another such as customers. Furthermore, this term (i.e. service) in economics has been described to be a type of business activity that is intangible, cannot be reserved for future usage and does not result in direct ownership by either the supplier or recipient. From this it is realized that it is difficult for customers to assess and evaluate the quality of service provided by the organization. Service quality observation results from a contrast of what the customer expected before the service and the apparent level of service received (Krutz & Clow 1998, 89). Moreover, customers can also use this process in the evaluation of the services rendered by the organization and differentiate from other competing services in order to make proper choices to enhance their satisfaction. Expectation of customers then plays a vital role in the assessment of service quality therefore it is essential that service providers develop a schem through which their target customers can adopt in the assessment of their service offerings. (Zeithmal et al 2000, 116) According to Tan & Teong, (2002), the quality of teaching and learning could be divided into four main dimensions which are teaching, assessment, guidance and courses. As stated by Moore (2003), teaching requires the teaching staff to behave in a specific way in order to help another person to achieve his full potential in all aspects. As such, Tan & Teong (2002) share the opinion that students assessment of lecturers teaching would be the most suitable approach for measuring the quality of teaching and learning. According to Yosuke et al (2007), service quality could be divided into two main aspects: core service and additional service. These two services play important roles in influencing customer satisfaction. Therefore, this may indicate that in addition to providing effective teaching, lecturers should also pay attention to the students comfort and facilities as these would also contribute to students level of satisfaction.

11

Ainon et al (2006) conducted a study about students satisfaction with the quality of education in UNITAR. The factors studied were facilities, course content, teaching style, teaching medium, assessment, social activities and others. The study findings showed that the students were most satisfied with the teaching medium, which was conducted in English. The analysis also uncovered four factors which influenced students satisfaction (shown here according to rank of importance): course content, medium of instruction, facilities and lastly the lecturers and the faculty.

CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter prepares the research design, study population, sampling methods, sample size, data sources, data collection instruments, data collection procedures, ethical consideration, data analysis and limitations of the study. 3.1 Research design The descriptive research design was used in this study. A survey was used in collection of data from the population. Both qualitative and quantitative methods were used in then study.

3.2

Study population According to the population and housing census of 2002, the population of Namatala ward was 11,844, where 5977 were males and 5867 were females. Therefore the respondents were sampled from the total population as illustrated in the table below; Table 1 showing the population of Namatala ward Name of ward Males Namatala ward 5977 Source: population census 2002 Females 5867 Total 11844

3.3

Sample size As per the total population of the Namatala above, it was so big for the researcher to reach all the people so she used 50 respondents and among these 25 were patients in the health center, 10 nurses, 5 political leaders, 5 support staff, 4 administrators and 1 doctor to represent the whole population. This was done with the aim of getting adequate information on the topic of study.

3.4

Sampling methods The researcher used purposive method to select the health workers (doctor and nurses), administrators and the political leaders in Namatala. This method was used because it gives reliable information to the research; it is convenient and saves time. The researcher also employed convenience sampling to the support staff and patients who were included in then sample. This technique was used because it helped the researcher to get reliable and vital information as per the topic of study.

3.5

Data sources There are two types of data that is to say; primary and secondary data that the study was based on during research.

3.5.1 Primary data This involved the researcher going in the field to obtain required information for the study from respondents. 13

3.5.2 Secondary data This data was obtained from Internet, text books, reports, brochures, magazines and newspapers. 3.6 Data collection instruments The data from the field was obtained using the following instruments 3.6.1 Interview The researcher asked the respondents a number of questions from an interview guide and the kind of respondents in this case were the patients and the support staff together with the political leaders in Namatala. This method was used by the researcher because it was easy to use, saved time and was superior to the other methods because the data was collected on an interactive basis with the respondents. 3.6.2 Questionnaires This method was used to the technical staff of the Namatala health center like the doctor, nurses and the administrators. Questions were set and sent to the respective respondents by the researcher and she was assisted by the local leader (LC1) of the area (Namatala). This method was used because it gave direct responses to the questions administered in the questionnaires. 3.7 Ethical consideration The researcher got an introductory letter from the head of department social sciences of Uganda Christian University to introduce her to the respondents which let them know that research was purely academic and thus solicited for their cooperation to fill the questionnaires and answer questions as asked by the researcher from an interview guide. 3.8 Data collection procedures The questionnaires were distributed by the researcher to selected respondents with the help of the research assistant; she also had a face to face interaction with the respondents that were selected for interview method. With consultation from the supervisor, the researcher was assured of the validity and reliability of instruments, they were used in data collection process and later data was analyzed.

3.9

Data processing and analysis The data collected was sorted, edited, coded and tabulated in order to have finished and meaningful data.

3.9.1 Editing This was done right from the time of data collection where unnecessary information given by respondents was left out and correct spelling errors before final consumption 3.9.2 Coding This was done after data collection and it involved grouping similar responses from different respondents together 3.9.3 Tabulation The data was then put in table form from figures and percentages. This was done for proper understanding of the findings and interpretations.

CHAPTER FOUR PRESENTATION, DISCUSSION AND INTERPRETATION OF FINDINGS 4.0 Introduction This chapter presents and analyzes data both qualitatively and quantitatively regarding the stated research questions and it also show the extent to which research questions used attempt to give the information on the impact of motivation on service quality in health provision in Namatala health centre III industrial division, Mbale municipality. It also gives attention to the back ground information of respondents where there was 100% representation of pupation since all the respondents honored the researchers request, answered and returned all the questionnaires. This therefore helped the researcher to come up with presentations and interpretations as seen below; 4.1 Social-economic data of respondents 15

This consists of presentation of data according to sex, age and education level of respondents. Table 2 presents the sex of respondents Sex Male Female Total Source: field data 2012 No. of respondents 15 35 50 Percentage 30 70 100

Table 3 presents the age of respondents Age 18 25 26 35 36 and above Total Source: field data 2012 No. of respondents 25 20 5 50 Percentage 50 40 10 100

Table 4 presents the education level of respondents Education level Primary level Secondary level Others Total Source: field data 2012 No. of respondents 10 18 22 50 Percentage 20 44 36 100

4.2

Motivation strategies/ methods This objective was focused on to find out how employees (doctor, nurses, administrators and support staffs) of Namatala health center are motivated. Here, the researcher through interviews and questions noticed that the employees of Namatala health center are motivated through various 17

strategies/ methods among which include financial like salary increase, profit sharing among others and non financial like communication, responsibility, flexibility and promotions among others as presented in the table below;

Table 5 presents the methods of motivation in Namatala health centre Methods of motivation Financial (salary increases, profit sharing, incentive travel, and paid time-off) Non financial (involvement, communication, promotions, word of thanks, responsibility, job sharing and flexibility) Total Source: field data 2012 Responses 18 2 20 Percentage 90 10 100

From the table above, the researcher found out that out of the 20 respondents who included the doctor, nurses, administrators and support staff, 90% revealed that they are motivated through

financial methods most especially salary increases and paid time-off. This concurs with Green (2003) who noted that financial rewards are common as most experts recognize that most financial rewards do not last very long but are essential in order to successfully motivate employees and the most common types of financial rewards are salary increases, profit sharing, incentive travel, and paid time-off where salary increases involve bonuses and raises in base pay. While 10% of the respondents said that motivation can be through non financial rewards like effective communication, promotions, reasonability flexibility among others. Still, Green (2003) agreed with the above responses where he said that Goal setting, communication, autonomy, responsibility, and flexibility are considered non- financial motivational rewards to empower employees to perform at their highest level of expertise. However, in Namatala health centre the result indicated that employees prefer to be motivated through financial rewards such as salary increases and paid time-off in order to perform to effectively. 4.3 Level of service quality in Namatala health centre This objective was also considered in the study in order to find out the level of service quality in Namatala health centre. Here all respondents were considered by the research so as to get clear and reliable information about the objective in question. The researcher mainly focused on establishing the state of service quality in Namatala health centre as reflected in table 6 below; Table 6 presents the level of service quality in Namatala health center Level of service quality Good Fair Poor Total Source: field data 2012 Responses 5 34 11 50 Percentage 10 68 22 100

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Results in the table above showed that 10% of respondents agreed that the level of service quality is good because patients are attended to as they are prescribed for and given some medication. 68% of the respondents said that the level of service quality is fair because patients are attended to by prescribing for them medicines to buy while 22% of the respondents said that service quality is poor because patients are not attended to at all. Therefore with this information the researcher noticed that the impact of motivation on service quality in health provision comes as a result of uncoordinated level of service quality in Namatala health centre since the highest percentage of the respondents agreed that service quality is provided on a fair basis where patients are expected to purchases medicines for themselves and yet government provides these medicine at no cost. 4.4 Relationship between motivation and service quality in Namatala health center The researcher also took into consideration the above objective to be included in the study so as to find out the relationship between motivation and service quality where her main focus was on how motivation affects service quality is in Namatala health centre. With these in mind, the researcher found out that 30% of the respondents said that good motivation of health workers and staff leads to effective and sufficient service quality through financial motivators or methods such as paying salaries, paid time off and promotions among

others and these makes them work towards delivering the intended results. However from the results in table 7 below, there seems to be low motivation of staff as the biggest number of respondents said that motivation in Namatala health center is poor. 70% of the respondents said that due to poor motivation there is ineffective and insufficient service quality and this makes employees at Namatala health centre not to attend to patients as expected. However, the ineffective and insufficient service quality make not only come as a result of poor motivation but also due to overwhelming numbers of patients to available staff and other facilities like medicines, vehicles and other equipment to enhance service delivery. This information is reflected in table 7 below; Table 7 presents the relationship between motivation and service quality in Namatala health centre Motivation Good Poor Service quality Effective and Sufficient Ineffective and Insufficient Responses 15 35 50 Percentage 30 70 100

Total Source: field data 2012

Therefore, with the above information in table 7 since 70% of the respondents agreed that there is 21

ineffective and insufficient service delivery, the researcher found out that there is poor motivation of employees in Namatala health centre.

CHAPTER FIVE CONCLUSIONS, RECOMMENDATIONS AND APPENDICES 5.0 5.1 Introduction This chapter presents the conclusions, recommendations and appendices Conclusion From the above findings revealed that 90% of the respondents supported the view that financial strategies/methods are the best way through which employees of Namatala health center cam be motivated to do their work with ease. 68% of the respondents of the respondents said that the level of service quality is on a fair basis because the patients are given prescriptions on the medicines to be swallowed and sometimes a few medicines are given for a start. While with the relationship between motivation and service quality, ineffective and insufficient of service quality took the highest percentages of responses where 70% said that there is poor motivation of employees.

Therefore, the impact of motivation on service quality in health provision greatly affects the effectiveness of service delivery at Namatala health centre which calls for service intervention by government. 5.3 Recommendation From the above findings, the researcher recommends the following; When developing motivation plans, employers should recognize individual differences among employees and realize that not all motivation techniques will work for everyone. So employers must evaluate each employee to determine what motivates them the most.

There is need for employers to encourage and practice non financial motivators

such as

appreciating work done, delegation and effective communication so as to ensure effective and efficient service delivery to boost the level of motivation and service quality since the financial motivators are expensive to sustain.

Government should equip health centers and other institution of a kind with facilities like medicines and other facilities used in that field so as to boost the level of service quality.

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