The Antiplasmodial Activities of Bufonidae (Toad) Venom Crude Extract on Plasmodium Berghei in Swiss Albino Mice

The Antiplasmodial Activities of Bufonidae (Toad) Venom Crude Extract on Plasmodium Berghei in Swiss Albino Mice by Ayim JO* in Open Access Journal of Biogeneric Science and Research

Abstract

Malaria remains one of the most prevalent and ravaging infection across Africa especially in Nigeria. Malaria parasite success or proliferation in its host have been linked to the ability of the parasite to show resistance to diverse anti-malarial drugs, thereby leading to the utilization of natural products from animals and plants as a potential strategy for identifying novel antimalarial drugs. Thus, this study aimed at screening toad venom for its antiplasmodial potency in swiss albino mice. Toads were collected from July to August 2019. The acute oral toxicity and biochemical characterization of the toad venom was determined. The experimental mice was administered varying curative doses (130, 173 and 217 mg/kg) of the toad venom crude extract and standard drug once daily for 3 days. In-vivo antiplasmodial activity was evaluated by a curative test, after infecting the mice model with Plasmodium berghei. From the results obtained, parasitemia was highest in the control group while the group treated with Artemether-lumerfantrin (ACT) had the least parasitemia. Thus, the mean parasitemia in relation to the different treatments varied significantly (P < 0.05). Nevertheless, the mean parasitemia in albino mice in relation to the highest dosage of toad venom versus ACT treatments showed no significant difference (P > 0.05). The mean change in haemoglobin (Hb) and as well as pack cell volume (PCV) levels in albino mice after four days in relation to treatments with toad venom and ACT showed a significant difference (P < 0.05) whereasthe red blood cell (RBC) level did not vary (P > 0.05). This study shows that the toad venom reduced the parasitemia in the group that was treated with 217 mg/kg toad venom which is thus comparable to the group treated with 8mg/kg standard drug (ACT). Sequel to the potency demonstrated by toad venom against plasmodial activities, it is crucial to generate a reliable and economic bufo-genic therapeutic product, while being conscious of the protection of these species. The study recommends an affirmatory research in relation to the isolation and characterization of the active anti-plasmodial agents responsible for the curative activity observed and as well as consider species-specific active compounds.

Keywords: Bufonidae; acute oral toxicity; biochemical characterization of toad venom; antiplasmodial potency of toad venom; Plasmodium berghi; Swiss albino mice; haematological parameters

Introduction

Malaria disease is characterize by a flu-like illness, accompanied by fever and chills; that may be fatal, if not treated [1]. It is caused by a protozoan parasite of the genus Plasmodium [2]. Malaria disease contributes greatly to the world disease burden and accounts for many death cases recorded in hospitals. According to a recent World malaria report released in February 2020, there were 229 million cases of malaria in 2019, up from 228 million cases in 2018 and 219 million cases in 2017 respectively [3,4]. The estimated number of malaria deaths stood at 435 000 in 2017, a similar number to the previous year. Nigeria among other African countries recorded more death cases due to malaria with about 25% malaria occurrence [1]. This is apparently an indication that malaria is highly endemic in Nigeria. This presents a severe economic and health burden to the country with about 97% of the population at risk of infection [5].

Four species of Plasmodium are recognized to cause malaria in man, this includes: Plasmodium falciparum, P. vivax, P. malariae, and P. ovale, transmitted by over 70 Anopheles species. Among the malaria parasites, P. falciparum is the most severe and blamable for 90% of all malaria deaths [6]. P. berghei have been described in African murine malaria with others being Plasmodium chabaudi, Plasmodium vinckei and Plasmodium yoelii. Due to P. berghei  ability to infect rodents and the relative ease of genetic engineering, it is thus used as a well-known model organism for the investigation of malaria in man [7]. This makes this species efficient in research programs for development and screening of anti-malarial drugs and malaria vaccines that are effective [8].

Plasmodium’s life cycle is intricate, involving many developmental stages and sites, both in the vector and the animal host [9]. Although its intricate infectious cycle presents several sites for the development of specific drugs, finding a universal drug against malaria has been a perplexing task [10]. The main problem with the presently available anti-malarial drugs is the constant resistance developed by some parasites as opined by [4, 11-14]. The mode of action of the drugs used at the present time for the treatment of some parasitic infections are yet not very known, aiding mutations and initiating drug resistance by the parasites [15-18]. Artemisinin resistance has been described by White [12] and Dondorp et al. [19] in malaria endemic areas, threatening malaria control, treatment, and eradication of global efforts. As it is arising with anti-bacterial drugs, the abuse and the mono-therapeutic use of anti-parasitic drugs is also leading to resistance, increasing preoccupation about a growing arrival of new cases and inefficacy on the treatment of recurrent cases [12, 19-21]. The utilization of natural products has delivered a potential strategy for identifying novel antimalarial drugs. The utilization of animals, fungi, bacteria and plants are important springs of biologically active substances with structural variety and novel mechanisms of action, which can possibly provide patentable products [22-25].

The skin secretions and venom of amphibians are rich sources of bioactive compounds, such as peptides, bufadienolides, alkaloids, proteins and biogenic amines, which have contributed meaningfully to human health and most pharmaceutical researches [26,27]. Yang et al. [27] maintained that the toad toxins from the parotoid or skin glands have significant therapeutic value for a good number of diseases. Against this backdrop, this study screened toad venoms for its antiplasmodial potency in Swiss albino mice infected with P. berghei.

Material and Methods

Toads Collection

Toads were collected from July to August 2019 between the hours of 0700 and 1000 from rice fields located on Latitude 8º 35´0.09ʺ E and Longitude 8º 28´18.45ʺ N beside the fence of the Take-Off Site of Federal University of Lafia, Nasarawa State, Nigeria. They were collected into a ventilated container and conveyed to the Department of Zoology Laboratory in the Permanent Site of Federal University of Lafia for extraction.

Extraction Of Crude Venom Extract From Toad

The process of extraction of toad venom was according to Gao et al. [28]. The toad was massaged and then the parotoid macro-glandules was pressed out. The toad was then released to its natural environment. The collected secretion was lyophilized and stored in a freezer at the Federal University of Lafia.

Biochemical Characterization

Determination of the quantitative and qualitative chemical components of the venom was achieved by Mass Spectrometry using a Mass spectrophotometer at the Spectral Laboratory and Services, Tudun wada Kaduna South, Kaduna State, Nigeria. The Shimadzu Fourier transform Infrared Spectrophotometer- FTIR 8400 S was used for the determination of the functional groups present in the venom. Gas Chromatography Analysis of toad venom was done using gas chromatography (Perkin-Elmer 8500). The Scanning Electron Microscope energy dispersive X-ray spectroscopy (SEM-EDS) Phenom Prox, manufactured by phenom World Eindhoven (Netherlands) was used to carry out the morphology analysis (that is; analysis of the chemical elements present in the toad venom).

Experimental Animals

Twenty-five laboratory albino mice, weighing between 14g and 37g were purchased from National Veterinary Research Institute Vom, Plateau State. All animals were fed with formulated feeds and water was administered ad libitum. The animals were allowed to acclimatize for a period of 7 days prior to their randomization into the various experimental groups.

Coding And Weighing Of Animals

The mice were marked with a permanent ink markers on different anatomical parts of the body of each animal. These include, the head (HD), back (BK), tail (TL), right leg (RL), left leg (LL), right side (RS), left side (LS), right arm (RA), left arm (LA), back strip (BKST), head and back (HDBK), head and tail (HDTL), head and right leg (HDRL), head and left leg (HDLL), head and right side (HDRS), head and left side (HDLS), head and right arm (HDRA), head and left arm (HDLA), head and back strip (HDBKST), back and tail (BKTL), back and right leg (BKRL), back left leg (BKLL), back and right side (BKRS), back and left side (BKLS), back and right arm (BKRA). The weight of each animal was measured using the electronic compact scale.

Toxicity Study

The median oral lethal dose of the toad venom was determined in mice according to Lorke [29]. The toxicity test was carried out in two phases at the in-vivo laboratory of National Institute for Pharmaceutical Research and Development (NIPRID), Federal Capital Territory, Abuja, Nigeria.

Phase 1: Nine Swiss albino mice were divided into three groups with each having three individuals. The groups were administered varying doses of 10, 100 and 1000 mg/kg respectively of the toad venom and then placed under observation for 24hours in order to monitor their behaviour as well as mortality.

Phase 2: Another set of three animals, distributed into three groups of one animal each were administered varying doses of 250, 500 and 750 mg/kg respectively of the toad venom and observed for 24hours in relation to behaviour and mortality.

Then the LD50 was calculated by the formula by Lorke [29]:

LD50=√((D_0 x D_(100 )))

Where

D0 = Highest dose that gave no mortality,

D100 = Lowest dose that produced mortality.

Grouping, Infection And Treatment Of Infected Swiss Albino Mice

Twenty-five mice were marked and infected with Plasmodium berghei obtained from NIPRID and randomly divided into five groups of five mice per group. Parasites were maintained through serial blood passage in mice wherein the mice previously infected with Plasmodium berghei and with a high parasitemia level served as the donor. Blood samples was taken from the donor and diluted with phosphate-buffered saline such that 0.2 ml injected intraperitoneally into the experimental animals contained 1 × 107 infected erythrocytes. The blood of the mice were screened for infection before inoculation with parasite.

The curative method described by Ryley and Peters [30] was used. Treatment commenced following confirmation of parasitemia in the mice. Groups 1, 2 and 3 were treated with 217 mg/kg, 173 mg/kg and 130 mg/kg respectively of crude toad venom extract whereas group 4 mice were treated with 8 mg/kg of Artemisinin Combination Therapy (Arthemeter-lumerfantrin) tablet which was crushed and diluted in distilled water before administration, while those in group 5 were infected and received no treatment (control group). Administration of treatment was done orally once daily by gavage using a mouse feeding tube for four days for the standard drug used. The parasitemia of experimental mice was establish before every treatment was administered.

Determination of Parasitemia

Blood samples were collected by bleeding the mice through the tail vein. Thin blood smears were made on clean glass microscope slides. The films were dried in air and then fixed in methanol and stained with 10% Giemsa solution [31]. The stained film was then observed under the binocular compound microscope and viewed for parasitemia. The percentage parasitemia were determined by counting the number of parasitized red blood cells (pRBC) for at least six different fields.

Percentage Parasitemia = (Parasitized RBCs)/(Total RBCs) x 100

Hematological Parameters

Using the methods described by Cheesbrough [32], the Packed Cell Volume (PCV), haemoglobin (Hb) and erythrocyte (RBC) counts were determined. These parameters were determined for each mouse before infection and after treatment. Blood samples were collected from the tail of each mouse with a heparinized capillary tube with one end sealed with plasticine.

Data Analysis

Data obtained were analyzed using R Console software (Version 3.2.2). Shapiro-wilk normality test was carried out and the data was observed to be normally distributed. One-way analysis of variance (ANOVA) was used to compare the mean parasitemia in albino mice in relation to toad venom and ACT treatments. Also, mean change in body weight and as well in haematological parameters were compared using one-way ANOVA. ANOVA test was followed by a post-hoc Tukey’s Honest Significant Difference (Tukey HSD) test where there was significant difference between the means of the treatments. The level of significance was set at P < 0.05.

Table 1: Analysis of the chemical components of toad venom crude extract using the GC-MS.

Table 2: Protein and non-protein functional groups present in toad venom crude extract at different peaks using the FTIR.

Table 3: Analysis of chemical elements present in the toad venom crude extract using the SEM-EDS.

Figure 1: Mass spectroscopy of toad venom crude extract showing the abundance of the chemical compounds at different peaks.

Figure 2: The functional groups present in the toad venom crude extract at different peaks.

Figure 3: Mean parasitemia in Swiss albino mice in relation to treatments with toad venom and ACT.

Results

Determination of the Biochemical Compounds in the Toad Venom Crude Extract

The results of the biochemical analysis of the toad venom crude extract showed that 9,12-Octadecadienoic acid (Z,Z) compound was the most dominant at peak 3 as shown in Figure 1 which had a rate of 38.615 at a proportion of 49.76% (Table 1) followed by n-Hexadecanoic acid (29.04%) then Octadecanoic acid (7.03%), Squalene (5.48%), 1-Hexadecyne (3.87%), Butyl 9,12-octadecadienoate (2.95%) while Hexadecanedioic acid was the least compound (1.87%). (Figure 2) showed that the toad venom crude extract contains 18 active functional groups in which Nitrogen-Hydrogen Oxygen stretch of 93.18% was the most active functional group. The toad venom crude extract was predominantly characterized by the presence of the amino group made up of 8 functional groups, followed by the nitro-group having 6 functional groups while the non-protein group was made up of only 4 functional group as shown in Table 2.

The SEM-EDS analysis revealed that the toad venom crude extract contains 11 chemical elements, out of which carbon had the highest atomic concentration and weight of 61.76 mol/dm3 and 41.04 g/mol respectively, followed by oxygen (25.04 mol/dm3 and 22.29 g/mol) while iodine and aluminium had the least atomic concentration and weight of 0.24 mol/dm3 and 0.90g/mol respectively (Table 3).

Determination Of The Oral Toxicity (Ld50) Of The Toad Venom Crude Extract

The oral toxicity experiment conducted using the Lorke’s method indicated that the toad crude venom extract caused mortality at a dose of 1000 mg/kg after one hour. Hyperactivity, convulsion and constant stooling were observed prior to the death of the animals. However, on the administration of 750 mg/kg, hyperactivity, diarrhea and calmness were observe within one hour, but there was no mortality recorded. The oral toxicity of the venom established was 866 mg/kg.

Mean Parasitemia In Swiss Albino Mice Across Treatments With Toad Venom And Act

The overall parasitemia was highest in the control group and least in the group treated with ACT. Therefore, the mean parasitemia in albino mice in relation to treatments showed a very high significant difference (F120 = 10.34, Adjusted R2 = 0.2315, P < 0.0001, Figure 3). A closer look at the parasitemia in albino mice between those treated with the highest dosage of toad venom and ACT treatments showed no significant difference (P > 0.05) as shown in Table 4.

Change In Body Weight Of Swiss Albino Mice After Four Days Of Treatment

After the treatments, the highest weight gain was observed in treatment with 8 mg/kg ACT (Group 5) and the least weight in the control group (infected but not treated). Thus, the mean change in body weight of albino mice after four days of parasitemia treatment in relation to treatments with toad venom and ACT showed a very high significant difference (F20 = 6.694, Adjusted R2 = 0.4869, P = 0.001374), (Figure 4, Table 5).

Mean change in haematological conditions of albino mice after four days of treatment:

Hemoglobin (Hb)

The mean change in Hb level in albino mice after four days in relation to treatments with toad venom and ACT showed a significant difference (F10 = 4.863, Adjusted R2 = 0.5246, P = 0.01942), (Table 6, Figure 5).

Mean Change In Red Blood Cell

The mean change in RBC level in albino mice after four days of parasitemia treatment in relation to treatments with toad venom and ACT showed no significant difference (F10 = 1.929, Adjusted R2 = 0.2098, P = 0.1821, Table 6, Figure 6).

Mean Change In The Pcv Level

The mean change in PCV level in albino mice after four days of parasitemia treatment in relation to treatments with toad venom and ACT showed a very high significant difference (F10 = 6.014, Adjusted R2 = 0.5889, P = 0.009893, Table 6, Figure 7).

Table 4: Turkey multiple comparisons of means of parasitemia 95% family-wise confidence level.

Table 5: Tukey multiple comparisons of means for change in body weight between treatments 95% family-wise confidence level.

Table 6: Effects of toad venom extract on the haematological parameters of Albino mice, Values were presented as Mean ± SE; n= 5 for each group.

Table 6:  Hierarchical Regression Results.

Figure 4: Mean change in body weight of albino mice in relation to treatments with toad venom and ACT after four days.

Figure 5: Mean change in hemoglobin level in albino mice in relation to treatments with toad venom and ACT after four days.

Figure 6: Mean change in RBC level in albino mice in relation to treatments with toad venom and ACT after four days.

Figure 7: Mean change in PCV level in albino mice in relation to treatments with toad venom and ACT after four days.

Discussion

The biochemical analysis revealed the presence of 9,12-Octadecadienoic acid (Z,Z-) and n-Hexadecanoic acid in the toad venom which is consistent with the findings of Abubakar and Majinda [33] who recorded similar compounds from a GC-MS analysis and the preliminary antimicrobial activity of Albizia adianthifolia and Pterocarpus angolensis. Among other compounds isolated, 9,12-Octadecadienoic acid (Z,Z-) and n-Hexadecanoic acid showed the best antimicrobial activity against E. coli. The presence of squalene, in this study is symbolic of the antitumor potency [34] of the venom and thus, the assurance of little or no cytotoxic activity in vivo. Opinions from Lozano-Grande et al. [35] suggests that squalene is a chemotherapeutic and chemo-preventive agent which inhibits tumor growth and stimulate the immune system in the treatment of diseases.

Amino compounds like Triethylamine, Diethylamide and Aniline that were observed in this study agrees with the findings of Krieg et al. [36] who characterized arymethylamino steroids as a class of compounds with remarkable activity against P. berghei in mice and P. falciparum and Schistosomes (in vitro). It may be inferred that the parasite inhibition observed in this study may be as a result of the presence of these active proteins.

The presence of Carbon, Nitrogen and Oxygen is indicative that these elements make up a significant portion of the nucleic acid, amino acid, sugars and fatty acid molecules found in the toad venom [37].

The experimentation of the oral toxicity (LD50) of the toad venom crude extract indicates that the venom becomes lethal to the laboratory albino mice at a dose of 866 mg/kg. Clinical signs of toxicity observed includes: hype-reactivity, diarrhea, sedation, convulsion, constant stooling and death. The presence of lead and Chromium in the toad venom recorded in this study could have accounted for the mortality observed in the mice [38]. This agrees with Arena and Drew [39] who opined that the oral toxicity of toad venom is 0.36mg/kg and the common adult clinical dosage is 3-5mg/day, thus it becomes lethal above a dose of 135 mg/day. Although, the administration of 130 mg/kg in this study as a curative dose yielded no mortality. Similarly, this is consistent with that of Gadelha et al. [40] who observed no clinical signs of toxicity or even death on the administration of 25 mg/kg dose.

Parasitemia in Swiss albino mice decreased within the four days of treatment (Figure 3). This possibly suggests that the toad venom would be a good source of antiplasmodial drug because the parasitemia in the albino mice was almost two times less in comparison to those in control group. This concurs with the finding of Banfi et al. [41] who experimented the in-vitro antimalarial activities of compounds isolated from Rhinella marina venom (cane toad) and observed it was effective and efficient against P. falciparum. Banfi and colleagues isolated Marinobufotoxin, Dehydrobufotenin, Marinobufagin and bufalin, out of which the Dehydrobufotenin revealed to be most active against malaria and showed the absence of cytotoxicity in-vitro. This finding is also in tandem with that of Gao et al. [28] who revealed that peptides isolated from scorpion venoms are active against Plasmodium species.

The low parasitemia observed in the group treated with ACT (Artemether-lumerfantrin) clearly showed that it is effective in the control of malaria parasites in animals. This is in agreement with the findings of Ihekwereme et al. [42] who reported  parasite inhibition in P. berghei infected mice treated with the standard drug (artemether-lumefantrin). Similarly, Nyandwaro et al. [43] demonstrated the efficacy of the standard drugs in the treatment of malaria in Swiss albino.

The lack of variation in parasitemia in albino mice in relation to the highest dosage of toad venom and ACT treatments probably shows that the toad venom can serve as an alternative to the standard drug (ACT) when administered at a higher dosage since ACT was formulated primarily against Plasmodium falciparum in man. Correspondingly, it can be argued that chloroquine has been used for many decades against malaria in man and it is also active against murine malaria. It is therefore worthy of note that the P. berghei is sensitive to chloroquine [44-46]. The effective inhibition of the toad venom against P. beghei, in-vivo is in tandem with a recent finding by Banfi et al. [47] in Brazil who demonstrated an in-vitro inhibition of Plasmidium falciparum using toad venom. This is a further reflection of the isolation of peptides from animal venoms against protozoan infections, as the peptides scorpine isolated from scorpion venom was responsible for the mortality of P. berghei gametocytes at 15µm and 100% reduction of P. falciparum at 5µm [48].

Hematological parameters like hemoglobin (HBG), red blood cell (RBC) count and packed cell volume (PCV) are indicative of anemia in Plasmodium parasitized individuals [49]. Consequently, this research considered changes in the hematological conditions of Swiss albino mice after four days of malaria infection and associated treatments. The observed changes in hemoglobin level in albino mice after four days of parasitemia treatment in relation to treatments suggests that the toad venoms contains some anti-anemic components. This is similar with the findings Banfi et al. [41] who recorded a drastic reduction in cytotoxity on the use of compounds isolated from the cane toads. The highest hemoglobin values were observed in the group 4 (217mg/kg venom) and the least was observed in the control group this may be as a result of the phagocytic action of the parasite on haemaglobin, consequently digesting it into haem and globulin for its consumption. This concurs with the findings of Cyril-Olutayo et al. [50] and Mokennem [51] who recorded an improved haematological parameters on the use of extracts from Anogeissus leiocapus and Croton species respectively, in-vivo.

The lack of variation in the mean change in RBC levels in the mice after four days of parasitemia treatment in relation to the treatment with toad venom and ACT possibly suggests that parasite targets the RBCs despite treatment. On the average, the untreated group had the least number of RBC value as a result of damage of the red cells caused by the erythrocytic stages of the malaria parasites [52,53].

The variation in the mean change in PCV level in Swiss albino mice after four days of parasitemia treatment in relation to treatment with toad venom and ACT may be as a result of the parasite inhibition pace and varying response in the experimental mice. Although the infected and untreated group had the least PCV value probably due to the destruction of red blood cells which in turn affected the percentage of the packed cells. This further shows that the reduced percentage of PCV is an indication of anaemia in malaria infected individuals. However, improved PCV values were observed in both the treatments with toad venom and ACT [54].

Conclusion

Malaria parasite success or proliferation in its host have been linked to the ability of the parasite to show resistance to host immune defense and the diverse anti-malarial drugs. However, this study has shown that pharmacological foundation of toad venom have some antiplasmodial effect against the non-human form of the parasite and could therefore be further investigated for use in the development of prospective drug for the treatment of malaria. From this findings, it is observed that the effectiveness of toad venoms at a very high dose (as was used in this study) was comparable to that of ACT. Hence, it supports the use of toad venoms in folk medicine as it is practiced by the Chinese.

Regardless of the therapeutic contributions of the bufo-genic products in medicine and Public health, there is still a limited research and manufacture of toad-derived drugs. This study therefore recommends the exploration of these potent chemicals in the treatment of parasitic ailments following appropriate quantification and modification by pharmaceutical companies. Also, an affirmatory research, both in-vivo and in-vitro proceeded by the isolation and characterization of the active anti-plasmodial agents responsible for the curative activity observed and considering species-specific active compounds should be carried out.

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Organizational Rewards and Performance of Health Centre Iv Workers in Greater Mbarara District, Uganda by Johnson Atwiine* in Open Access Journal of Biogeneric Science and Research

Organizational Rewards and Performance of Health Centre Iv Workers in Greater Mbarara District, Uganda by Johnson Atwiine* in Open Access Journal of Biogeneric Science and Research

Abstract

The purpose of this paper is to study relationship between organizational rewards, and performance of Health Centre IV workers in greater Mbarara District. This study used cross-sectional, explanatory and correlational approaches, and it utilised health center IV’s workers’ data that were collected by using a questionnaire survey from a sample of 200 health workers from 11 health centres from greater Mbarara district. Results revealed that rewards, were significantly associated with health workers’ performances. Contrary to previous thinking, organizational rewards and constructs do not significantly predict health workers’ performance. Once health centre IV’s have appropriate reward strategies for their health workers in health facilities, they are likely to work hard by meeting deadlines, being available at their work station and they would eventually enhance on job performance. This study focuses on rewards, and performance of health workers’ in health centres iv in greater Mbarara and it is possible that these results are only applicable to the public health centres iv in greater Mbarara. More research is therefore needed to further understand the relationship between rewards, and performance of health workers in other sectors such as the private health sector and in other areas of the country like northern, central and eastern Uganda. The results are important for health policy development and implementation, for example, in terms of primary health care and reporting lines for the health workers so as to enhance on their performance in public health sector. The results of this study will provide health practitioners with better insights in some reward practices that could be adopted by government/health practitioners so as to improve the performance of health centres IV workers.

Keywords: Organizational rewards, Performance of Health Center IV Workers.

Key messages

The results from this study are important for health policy development and implementation, for example, in terms of primary health care and reporting lines for the health workers so as to enhance on their performance in public health sector. As far as the authors are aware, no research has hitherto been undertaken that investigates the relationship between reward practices on health workers’ performance in health centres IV in greater Mbarara district. Thus, the results of this study will provide health practitioners with better insights in some reward practices that could be adopted by government/health practitioners so as to improve the performance of health centres IV workers.

Abbreviations: AMOS: Analysis of Moments of Structures; CFA: Confirmatory Factor Analysis; CFI: Comparative Fit Index; GFI: Goodness of Fit Index; HSSP: Health Sector Strategic Plan; MTR: Mid-Term Review; PBF: Performance Based Training; RMSEA: Root Mean Square Approximation; NFI: Normed Chi-square Index; SEM: Structural Equation Modeling; SPSS: Statistical Packages for Social Scientists; TLI: Tucker Lewis Index; UK: United Kingdom; VIF: Variance Inflation Factor

Introduction

The study reports the results of the study carried out to establish the association between organizational rewards and employee performance in health centre IV in greater Mbarara district. Many approaches have been developed and adopted worldwide to improve the employee’s performance including salary enhancements, performance bonuses, and promotion and recognition strategies. The aim of all strategies is how to effectively motivate employees to maximise their performance. One common method of motivation is to tie rewards to employee performance which has been focused in this study.

The impact of rewards on employees’ performance is well known phenomenon in the available literature of human resources. A large number of studies have verified that reward is a powerful tool to enhance employee behaviours leading to performance improvement. However, some other studies also observed the negative consequences of rewards such as an environment of favouritism, sexism and racism, nepotism and tribalism.

According to [1] there are two basic types of rewards, financial and non-financial and both can be utilised positively to enhance performance behaviours of employees. Financial rewards mean pay-for-performance such as performance bonus, job promotion, commission, tips, salary etc. Non-financial rewards are non-monetary and it is a social recognition such as acknowledgment, certificate, and genuine appreciation etc. The non-financial rewards are also called non-material award [2].

Financial rewards like money are therefore important and powerful factor in motivating healthcare workers, it also a vital avenue for meeting the basic needs of healthcare workers such as housing and other costs like food. According to research surveys piloted in some nations, like North Vietnam [3], Mali [4], Ghana [5] and the UK [5], the implication of basic salary in supporting the survival needs of workers beyond subsistence is a critical motivator. Hence, financial incentives are considered significant drivers for work morale and employee inspirations, which sustain higher levels of output.

Relatedly, other researchers argue that an increment in salary is not enough to resolve the problem of reduced motivation among healthcare workers [6]. Furthermore, it suggests that to motivate healthcare workers and nurture enhanced commitment to their career, healthcare institutions should place an emphasis on non-financial motivational factors- especially in view of the economic challenges threatening healthcare institutions and systems [7]. Therefore, sustaining pay levels and consistent service-related payments are essential for staff motivation and morale [8], paying to improve performance is based on assumption that health workers need incentive schemes to perform [9]. However current evidence shows that changes in performance are not due to incentives alone, but a host of other factors like promotion, career development, training etc. [10]. Researchers on incentive schemes were un successful due to implementation obstacles and how to examine the total remuneration system, and gaps remain in the evidence about the effect of complex remuneration system on performance of health workers [10].

However, another research study piloted in Africa by [11], stressed how non-financial factors motivated employees. This involved the platform for workers to continue in their professional development and career growth and development, as well as robust communication mechanisms that aim to strengthen employer-employee relationships and communication between coworker.

The available research data recommended that salary structures across nations and are often designed in complex ways. Health workers also commonly use other sources of income like agriculture, private clinics to supplement their formal pay [12]. Salaries and revenues of health workers differs widely, whether between nations by comparison with the cost of living or between public and private sectors [8].

Despite the analysis of the achievements and failures of health changes, in general, slight attention has been given to the human resources yet they play a significant part in determining the accomplishments of the health reforms in the entire country [13]. For prosperity and harmony, there is a need to adopt different organizational factors to improve health care services. This means that the executive arm of government and other officers in the Ministry of Health need to be informed about the organizational factors affecting the daily operations of health workers in Health Centres IV. Hence to cater for this need, the researcher sought to establish the association between organizational rewards and performance of Health workers in Health Centres IV in Greater Mbarara District.

The mid-term review (MTR) of the Health Sector strategic plan that took place in 2010, acknowledged poor workforce performance characterized by absenteeism, low productivity, negative attitudes towards patient care, rampant dualism and high turnover as major constraints to the achievement of the HSSP 11, (Health Sector Strategic Plan) whose overall objective was to obtain a good standard of health for all citizen in country (Uganda) for the mandate in promoting a good health care and productive life [14]. The report recommended that Ministry of Health should develop a comprehensive health workforce motivation, and retention strategies for the health sector as a government initiative to improve their workers’ performance. The strategies are fully formulated but are not yet fully implemented [14].

The labour force of Uganda over the previous decade have witnessed a number of industrial unrests particularly among public sector workers [15]. For instance, in most of the years, health workers have laid down their tools, despite government refusing to cater for their demands [16]. As a matter of fact, in the mid-2018, the government of Uganda threaten to employ Cuban doctors after a developing an impasse with health workers who were striking over rewards particularly salary increment [15]. Due to this, health service delivery is faced by a series of factors limiting its employee performance, particularly stemming from meager salaries paid to health workers, unclear promotional strategies etc [17].

However, there is scarcity of scientific evidence to ascertain the extent to which rewards for health workers influence their performance particularly in health centre IVs’ which are in rural communities where the situation of health services is at its lowest [18]. The objective of this study is to find out the relationship between organizational rewards and performance of health centre IV workers in Greater Mbarara District.

More specific objectives are to find out;

To establish the relationship between Salary and performance of health centres IV workers.

To determine the relationship between Performance bonus and performance of health centres IV workers.

To establish the relationship between Recognition and performance of health centres IV workers.

To establish the relationship between Promotion and performance of health centres IV workers.

Based on the above objectives, the present study seeks to test the following hypothesis

H1: There is a positive relationship between Salary and performance of health centres IV worker

H2: There is a positive relationship between Performance bonus and performance of health centres IV workers

H3: There is a positive relationship between Recognition and performance of health centres IV workers

H4: There is a positive relationship between Promotion and performance of health centres IV workers

Theoretical Background and Hypothesis Development

This study was set forth on Social exchange Theory [19]. This theory proposes that the standards human beings use to assess costs and rewards vary over time and from individual to individual. Social exchange includes both a belief of association and some conception of a shared commitment in which both parties perceive responsibilities to each other.

Social exchange theory observes exchange as a social behaviour that may result both in economic and social outcomes. It also brings satisfaction when people obtain fair earnings for their expenditures [20]. This theory also weakens the power of social structures and forces, which unintentionally form our perception of the world and our experiences within it, and play a strong role in determining our relations with each other [21].

HI Salary is positively related to performance of health centres IV workers.

Salary and workers’ performance

Salaries /amount of salaries are extended to workers and can be well understood as a manner of enhancing performance among workers. This can well be explained in the role of money as a condition to strengthen, an incentive which is capable of satisfying needs, and anxiety reducer that serves to remove feelings of dissatisfaction [22]. In the same spirit [23] report that two views of human nature underlay early research into employee motivation. The first view centres on Taylorism, which is seen people as mainly lazy and work-shy, and thus held that these set of workers can only improve their performance through external stimulation. The second view was based on Hawthorn findings, which held the sight that workers are motivated to work well for “its own sake” as well as for the social and monetary benefit.

Some studies such as [24] contend that money is indeed a motivator and improves performance. This is because it can be perceived by individuals as a goal in itself; as a way of giving contentment to workers, and as a symbol of internal recognition or external status. Divergent studies have also discovered that salary is a poor motivator and can hardly influence the level of performance. It is further argued that it may yield temporary compliance rather than sustained enhancement. It does not amend behaviour, merely a superficial conformity with what the organization signals to be important. Workers’ performance-related pay highlights individual contribution whereas the task might require teamwork; may cause short term effect on performance than long outcome on performance [25].

H2 Performance bonus is positively related to performance of health centres iv workers.

Performance bonus and workers’ performance

Performance bonus refers to a payment system through which individual, group or performance is directly and monetarily compensated [26]. [27] suggested that performance-based pay is a structure that designed at compensating a worker centered on his/her performance. Performance incentive scheme is that of a base upon which individual worker and institutions rest [28]. In as much as a worker acknowledges when, why and what is expected of him/her in terms of tasks, then the institutional goals are attainable and a worker feels being empowered [29]. Furthermore, performance-based pay is termed as a reward given to a worker within a compensation range that is competitive with that paid for similar work/tasks in different institutions. It is also based upon merit as empirically appraised in the firm's performance appraisal program, with a chance to receive above market pay for workers demonstrating extraordinary performance [29].

Consequently, workers’ performance is basically outcomes attained and accomplishments made at work. Performance refers to keeping up plans while aiming at the results. Although performance evaluation is the heart of performance management [30], the performance of an individual or an institution depends greatly on all institutional policies, practices, and design features of an institution. [31].

In recent time, institutions have believed in converting their reward system to performance-based pay system [32]. The basic drive of any performance-based reward system is to relate workers’ salaries directly to their performance [33]. Linking rewards to performance strengthens workers to increase their efficiency [29]. Performance-based reward system permits workers to a basic income and the chance to get extra reward if their outputs surpass the set performance standards [34].

Robbins and Coulter [35], argued that the social sciences have suggested many theories to investigate how payment raise that is linked to workers’ performance might excite workforce to add more effort and set that effort on the achievement of organizational performance objectives. In contrast, some literature have shown less positive links between performance-based pay system and employee performance, while some studies have argued that implementation of performance-based pay system eventually builds a major obstacle in its success. It is not that workers do not like the system [36]

Boachie-Mensah and Dogbe [27], added that poor implementation and poor management practices are the common impediments to performance-based initiatives. Performance-based pay system is considered less acceptable [37]. This is as of result being limited to one-dimensional monetary information. It had a reflective orientation, short-term vision, and a friable strategic content [29].

H3 Recognition is positively related to performance of health centres IV workers.

Recognition and workers’ performance

Recognition is the acknowledgement, gratitude, or endorsement of the positive happenings or behaviours of an individual or team [38]. According to [39], recognition refers to praise or a personal note of acknowledging achievements including small gestures that are important to employees. Gostick and Elton [39] complete that if workers’ recognition is conducted appropriately, it enhances productivity and customer service levels, and reinforce employee engagement and satisfaction. [40] contemplates that recognition leads to improved communication (employees are more likely to propose solutions and new ideas), better cooperation (workers are more likely to propose to help and go the extra mile), and lessened absenteeism and turnover (workers will exhibit higher job satisfaction and loyalty).

Recognition ranks as one of the most powerful motivators and plays a key role in effective reward practices [41]. These unceremonious rewards entail minimal planning, efforts or expense and can be given for several reasons including recognition for a job well done, a birthday, a service anniversary, special favour, completing a disagreeable task, or saving the company time or money. Effective recognition procedures can also include verbal and written praise, public praise, and symbolic gestures by managers or line managers [42]. Recognition efforts that are timely, sincere, and personal can serve as a major means of motivation to employees.

Also, [42] state that managers need to be in constant contact with the employees if they are to determine what they most value and then find ways to act systematically on those desired forms of recognition and rewards as they perform well. This suggests that managers need to vary the forms of recognition, adding new things, experimenting with them, and eliminating others that have run their course and are no longer motivating workers. If managers are timely, sincere, and specific in thanking employees when they have done good work it will maintain credibility in the recognition process.

Nelson [42] further reveals that managers need to be specific and timely when providing recognition, which will help create positive feelings that will affect employee performance. According to Gostick and Elton [39], if employee recognition is to provide favourable outcomes, it needs to be applied within a context of goal-setting, open communication, trust and accountability. A good recognition program has to communicate attitudes and behaviours that are recognized by the organization

H4 Promotion is positively related to performance of health centres IV workers.

Promotion and workers’ performance.

Effectiveness of promotions as a strategy for motivating and enhancing employee performance [43] propagates that promotions involve a change of the assignment to that of a higher level in the organization. The new job normally provides an increase in pay and status and demands more skills and carries more responsibility. Promotions enable an organization to utilize the skills and abilities of its personnel more effectively thus, good performance is realized. The three principal criteria for determining promotions are merit, seniority, and potential [44]. Promotions, however, are sometimes constrained by the fact that many institutions do not follow these three principles (merit, seniority and potential). Often the problem is determining how much consideration to give to each factor. A common problem in organizations is that promotion primarily depends on past performance and seniority that sometimes leads to the promotion of employees to levels of their incompetence.

Therefore, promotions must be fair, based on merit and untainted by favouritism [45]. In some instances, even fair and appropriate promotions can create several problems. For instance, members of an organization who are bypassed feel resentful, which may affect their morale and productivity. In Uganda's context, there is always a problem of failure to retain staff especially higher cadres. This is evident in the most health facilities in the country due to brain drain. Similarly, [45] contends that this problem has its roots in conditions of service and job satisfaction. There is no practical way to indicate that a man was impassioned outside the area of his/her competence without prejudice to his/her career, the up or out promotion policy ignores the possibility that a person may have the ability to perform with excellence in a lower grade job even though he may not have the ability for a higher-grade job [46].

Methodology

Design, Study Sites and Sample

The study employed a cross-sectional survey design, where descriptive, correlational and explanatory approaches were used. In a cross-sectional study, a particular phenomenon is studied at a particular period of time. Cross-sectional designs are appropriate for studies designed at finding out the manifestation of a phenomenon, situation, problem or attitude, by identifying a cross-section of the population at a given time. Therefore, Cross-sectional research design is a form of observational study that investigates data collected from a population, or a representative subset, while correlational research design is a quantitative approach of research in which there are two or more variables from similar group of subjects from which a relationship can be determined if it happens or not [47].

Study Sites

Greater Mbarara is composed of 4 districts; Mbarara, Ibanda, Isingiro and Karuhura which were created in 2005. The study population comprised of 11(Eleven) Health Centres IV in greater Mbarara District which include: Mbarara Municipal Health Centre IV, Bwizibwera Health Centre IV, Kinoni Health Centre IV, Bugamba Health Centre (Mbarara), Kabuyanda Health Centre IV, Nyamuyanja Health Centre IV, Rwekubo Health Centre IV, Rugaaga Health Centre IV (Isingiro), Ruhoko Health Centre IV (Ibanda), Kiruhura Health Centre IV and Kazo Health Centre IV. These were only designated health centre IVs in Greater Mbarara.

The study targeted population of health workers from 11 health Centre IVs in Greater Mbarara District. These health workers comprised of medical officers, clinical officers, nursing officers, laboratory attendants, non-medical staff and support staff. Since the study has a population of 409, Krejcie & Morgan (1970) sample size selection model was employed to generate the study sample size. In this sample size of 200 participants were selected using both stratified and systematic sampling techniques.

Table 1: Sample distribution by category.

Table 2:  Variable and their Measurement.

Table 3: Standardized weights for Organizational Rewards.

Questionnaire and Measurement

A semi-structured questionnaire was developed using item measures and scales developed and tested by previous scholars [48]; [49] and [50]. The questionnaire comprised of mainly closed-ended questions and they were anchored on a five-point Likert scale ranging from strongly disagree to strongly agree (05) to allow respondents register the degree of agreement. A pre-test of the instrument undertaken to establish the reliability and validity of the instrument before the main survey. It was self-administered by the researcher and his researcher assistants through interview approach and the exercise was carried out with in a period of three months to provide ample period to the completion of the questionnaire by the respondents. This was intended to achieve consistency and accuracy in answering the questions. (Tables 1 & 2) shows variable and their measures reliability scale.

Data Processing and Analysis

After the fieldwork, the data were entered into Statistical Package for Social Science (SPSS) version 21 and subjected to a thorough cleaning before hypothesis testing. Two statistical software packages were utilized to analyse the data collected. Specifically, SPSS version 21 was used for preliminary data analysis, while Analysis of Moments of Structures (AMOS) version 21 was used for Structural Equation Modelling (SEM) guided by confirmatory factor analysis.

CFA Measurement Model for Organizational Rewards

Organizational reward was measured using salary, bonus and fringe benefits, promotion and recognition. The results showed that although the standardized parameter estimates of the initial measurement model were all significant (p<.001), the model provided a poor fit as indicated by the poor fit-indices. The model was re-specified by iteratively removing five (‘OR1’ ‘OR2’, ‘OR5’, ‘OR6’, ‘OR10’ and ‘OR16’) out of fifteen items that did not meet the acceptable criteria. The removal of the weak correlated items did not change the content of the construct as it was conceptualized (Figure 1).

The findings confirmed the validity of the final model with excellent model fit statistics for this construct measure as reported in (Table 3), even though the chi-square was still significant. The measurement model can be judged as providing an acceptable fit even though the chi-square value is statistically significant (Anderson & Gerbing, 1988), especially with a large sample size. Other assumptions for convergent validity were also met. The composite reliability for organizational rewards is .798, which is within the acceptable level as indicated by Nunnally (1978).

Results

Descriptive Statistics of the Study Variables

The descriptive statistics generated in this study included means and standard deviations. On a 5-point scale, the means for organizational reward and workers’ performance are 3.205 and 3.361 with standard deviations of 0.5199 and 0.999, respectively. According to Field (2009), when deviations are small compared to mean values, it is evident that the data points are close to the means, and hence, calculated means highly represent the observed data.

Correlation Analysis

The correlation results are presented in (Table 4). The results indicate a statistically strong significant relationship between organizational reward and performance of health Centre IV workers in greater Mbarara District (r=.474, p=.000). This provides support to hypothesis which states that there is a significant relationship between organizational reward and workers’ performance among health Centre IV workers in greater Mbarara District. This means that positive changes in organizational reward are associated with positive changes in workers’ performance. The results further show that hypotheses 1, 2, 3 and 4 which cover the relationship between the elements of organizational reward and workers’ performance appear to be supported as well with salary having a stronger association followed by bonus and fringe benefits and for the case of promotion and recognition they have the same association with workers’ performance

The motivation of this study was driven by the possibility of differences in contribution of organizational rewards in explaining workers’ performance. To do this, first, we regress organizational rewards as a global variable with the control variables (level of education of the health workers) on workers’ performance. This is followed by a hierarchical regression where we determine the contribution of each element of organizational rewards in explaining workers’ performance.

Regression analysis results for

Regression involving organizational factors as a global variable

Two models were specified as:

Model 1: WP = b0 + b1E+ ε

Model 2: WP= b0 + b1E +b2OR + ε

Where:

WP = workers’ performance

b0 - is a constant

b1E – is the unstandardized B coefficient of level of education of the health workers

b2OR – is the unstandardized B coefficient of organizational Rewards

ε is the error term

Figure 1: CFA for Organizational rewards.

Table 4:  Correlation results and descriptive statistics

Table 5: Regression of Organizational commitment (standardized coefficients).

Table 6:  Hierarchical Regression Results.

Testing relationships between the elements of the Organization rewards and workers’ performance

Organizational rewards were conceptualized with three (3) factor variable (salary, bonuses and fringe benefits and promotion), the confirmatory factor analysis retained all the three indicators. The four factors were subjected to a regression analysis and the results are presented in (Tables 5 & 6).

In model 1, we regress the control variables (Level of education of the employees) on workers’ performance and the results show that much as the variables explain 0.01% of the variance in workers’ performance, their contribution effect is insignificant. Organizational rewards were added to the equation in model 2, and the results indicated that Organizational rewards explain 22.4% of the variance in workers’ performance. Overall, the model explains 21.7% of the variance in workers’ performance. We also examine the variance inflation factors (VIFs) in our models to test for multi-Collinearity. The highest VIFs were well below the threshold value of 10 suggested by Field (2009) indicating that multi-Collinearity does not pose a problem to the regressions. However, the results do not tell us the particular element of Organizational rewards that has a greater effect. If we are to develop training packages to improve Organizational rewards and the consequent workers’ performance, there is need to dissect Organizational rewards and identify the areas of emphasis. This led us to conduct a hierarchical regression analysis.

Regression involving the elements of organizational factors

Four models were specified as:

Model 1: WP = b0 + b1E+ ε

Model 2: WP= b0 + b1A + b2sS+ ε

Model 3: WP = b0 + b1A + b2S+ b3BF + ε

Model 4: WP= b0 + b1A + b2S+ b3BF + b4P + ε

Model 4: WP= b0 + b1A + b2S+ b3BF + b4P + b4R +ε

Where:

WP = workers’ performance

b0 - is a constant

b1A – is the unstandardized B coefficient of level of education of the health workers

b3S– is the unstandardized B coefficient of Salary

b4BF– is the unstandardized B coefficient of Bonuses and fringe benefits

b5P– is the unstandardized B coefficient of Promotion

b5R – is the unstandardized B coefficient of Recognition

ε is the error termε is the error term

The results in model 1 show that the control variable does not make a significant contribution in explaining adoption of workers’ performance. This suggests that our models are not sensitive to confounding factors and the models are highly plausible. The addition of salary in model 2 reveals an extra contribution effect of 26.4% (R2∆=.264) in the variance explained workers’ performance and the results indicate that salary is a significant predictor of workers’ performance (β=.559, p=.000) implying that a unit increase in salary will result in to 0.559 units increase in workers’ performance. The addition of bonuses and fringe benefits in model 3 accounts for the extra 0.01% (R2∆=.001) of the variance explained in workers’ performance. The model results also show that bonuses and fringe benefits are not significant predictors of workers’ performance (β=-.008, p>.05). The results in model 4 indicate that additional of promotion have significant effect on workers’ performance and it explains 4.1% (R2∆=.041) of the variations in the workers’ performance and the results indicate that a unit increase in promotion of the workers would result in to 0.116 units increase in workers’ performance (β=-.008, p<.001). Finally, the results in model 5 indicate that recognition of the workers explain 2.4% (R2∆=.024) and a unit increase in recognition of the workers would result in to 0.182 units increase in workers’ performance (β=.182, p=.000). When predictive power and strength of all the four elements are compared, salary has a greater effect on workers’ performance. The results also validate hypotheses 1, 2, 3 & 4. Overall, the model explains 31.1% of the variance in workers’ performance. The remaining 68.9% is catered for by factors not covered in this study.

Discussion

The results show that organizational rewards and workers’ performance are positively related, and the association is statistically significant (r=.474, p=.000), thus the stated hypothesis is accepted. This indicates that positive changes in organizational rewards are associated with positive changes in health centre IV workers. This was supported by [51] who found that the absence of rewards will create an unfriendly environment, thus weakening workers and may cause them to pull out of their jobs. For these reasons, rewards are progressively important because they appeal, maintain and motivate employees to achieve high levels of performance and to stimulate and strengthen the desired behaviour of the workers. Organizations often use financial rewards to avoid employee disappointment and to motivate employees, although it may not be the best motivator for the long term [52].

The results show that all the respondents agree that salary influences their commitment and performance. This was in agreement with [53] who argued that employees who receive a good pay are likely to be dedicated to the health facilities simply because they would not afford to lose the big salaries. That is why health workers have been involved in strikes or sit down strikes and engaging government in different fora to improve their remunerations. This is an indication that if the government has to deal with health workers grievances of remunerations, focus should be premised on salary other than fringe benefits, promotion and recognition. This shows that in an event that a health worker receives adequate salary, there are higher chances that he/she will be committed and will perform better in the absence of other work related benefits.

This was in agreement with Richard [22] who stated that salaries /amount of salaries given to employees can be well understood as a way of improving performance among employees. This can well be explained in the role of money as a condition to reinforce, an incentive which is capable of satisfying needs, and anxiety reducer that serves to erase feelings of dissatisfaction among employees.

On contrary, some studies [54], urges that although salary is acknowledged by employees, managers should never use this as a tool to motivate their employees and improve on the performance. Should this occur, there is a transformation that the core principle of the reward would be forgotten. However, the above findings indicate that bonus, fringe benefits and promotion do not play a significant role as far as the health workers performance is concerned. This was also supported by [55], who noted that assessment of performance-based financing (PBF) plans in a few settings found bonus payments to be demotivating in cases where the distribution is not transparent, perceived inequitable and perceived unfairness in distribution of resources and decision-making process create no impact on the performance of health workers.

Majority of the respondents supported the idea salary improves performance, they said that the salary enhancement that took place in the country especially for scientists, helped them to improve on their performance though the salary is still not commensurate. This was supported by (Richard, 2014) who elucidated on the role money as a condition to strengthen an incentive which is capable of satisfying employees’ needs and anxiety so as to remove feelings of dissatisfaction so as enhance on the productivity and employee availability.

Majority of respondents supported giving bonus and recognition as a form of reward. This would come as result of performing their duties in time, responding to emergencies in time, attending to patients and be quick at delivering health services from their respective health facilities. This was in agreement with (Willis-Shattuck et al.,2008) who show some seriousness in valuing the workers by providing monetary and non-monetary rewards which consisted of recognition and cash bonuses to workers and these are given separately from the salary and should be fairly allocated based on their performances so as to continue with improved productivity.

Research Limitations

This study focuses on rewards, and performance of health workers’ in health centres iv in greater Mbarara and it is possible that these results are only applicable to the public health centres iv in greater Mbarara

We therefore highlighted two limitations for this study: First, the study was limited to health centre IVs in greater Mbarara district and it is possible that the results may only be generalized to health sector not only in Uganda but also in other communities of the world. Secondly, we majorly focused on health centres IV workers and their performance, we suggest that further research could be carried out in other levels of health care system in Uganda like; private health sector, health centres ii, iii, hospitals and regional referral facilities respectively using the same methodology or even using mixed methods.

Conclusions and Recommendations

The purpose of this study was to find out the relationship between salary and performance of health workers’ in greater Mbarara district. This was achieved through a questionnaire survey of 200 health workers in health centres IV representing 98% response rate. Results indicate that rewards are significant predictor of health workers’ performance.

Overall findings of this study have important implications to both academics, practitioners and government. For academics, the results suggested salary is strong predictor of health workers’ performance in health centres IV in greater Mbarara district. For health practitioners, they should recognize different remuneration strategies that influence performance positively like; bonus, merit pay and good salary policy. Also they should consider other non-financial rewards like recognition, promotion and career development programs for their health workers. For government, the findings are important, when it comes to budgeting, planning and spending, it should aim at meeting health workers’ needs and desires so as to reduce on labour turnover in the health sector.

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