The effect of performance-based financing interventions on health worker motivation and job satisfaction: experimental evidence from six national pilots

Abstract

A long-standing concern suggests that performance-based financing (PBF) may undermine the intrinsic motivation of health workers by heightening extrinsic motivation concerns via the novel introduction of financial incentives. However, the theoretical effect of PBF on worker motivation and job satisfaction is ambiguous as these programs may also improve working conditions, staff engagement, and other factors that determine health worker morale. We use data from six evaluations of national pilots to empirically assess the effect of PBF on worker motivation and job satisfaction. In these six pilots (in Cameroon, Kyrgyz Republic, Nigeria, Tajikistan, Zambia, and Zimbabwe) geographical units (or health facilities) were either randomized or quasi-experimentally assigned to receive PBF or the alternatives of direct facility financing (DFF), enhanced supervision (ES), or business-as-usual comparison arms. Baseline and endline health worker surveys were carried out in the context of these national pilots. The primary outcomes investigated here are health worker motivation and job satisfaction. Secondary outcomes include sub-constructs of health worker motivation and job satisfaction extracted using exploratory factor analysis. For two countries out of six - Nigeria and Kyrgyz Republic - we find increases in overall worker motivation and null effects in the other four when contrasting with the business-as-usual comparison. For five countries out of six (all but Cameroon) we find increases in job satisfaction. Further, PBF did not have any systematic motivating or demotivating effects when compared to the health system intervention alternatives of DFF and ES (each in a subset of countries), except in Nigeria where satisfaction in the PBF arm was lower when compared with DFF. All told, these results contain practically no evidence of an adverse effect of PBF on overall health worker motivation or job satisfaction and indeed suggest a beneficial impact in some country settings.

Keywords: Crowding-out; Health workers; Job Satisfaction; Motivation; Performance-based incentives.