Burnout at the Frontline: The Effect of a Reproductive Health Voucher Program on Health Workers in Uganda

Abstract

Background: Low job satisfaction among healthcare workers in developing countries can increase risk of burnout and have a negative effect on the quality of services. Novel financing strategies such as voucher programs, which aim to increase the utilization of services by the poor by offering physical vouchers for subsidized care, may unintentionally exacerbate burnout for health care workers by creating higher workloads. Methods: A semi-structured survey that included both closed and open-ended questions as well as a locally-adapted job satisfaction scale was used to collect information on provider perceptions of changes in job satisfaction, workload, staffing and salaries since the start of a health voucher program at facilities in fifteen districts in western Uganda. Results: Voucher providers reported feeling more rewarded and more motivated than comparison providers. While frontline workers at both sites were less satisfied than their managers overall (p<0.0001), satisfaction scores were on average higher at voucher facilities than comparison facilities for both types of providers (p<0.0001). The qualitative responses from frontline workers describe a high level of frustration at voucher facilities that was mitigated by additional compensation. Conclusions: Providers at voucher facilities may experience a more enabling work environment but job satisfaction differences between manager and frontline workers may intensify when staffing, workload and incentives are not addressed. Strategies to support staff when implementing new demand creation programs should be prioritized. Incentive strategies for staff and management guidance for facilities managers will be important components of successful voucher programs. Key Message Providers at health facilities that implement voucher programs experienced lower job satisfaction when workloads increased without additional compensation. Frontline workers such as nurses experience this more acutely than clinical officers and head midwives. Voucher programs may have unintentional consequences on health worker burnout unless these issues are considered in the implementation of the program.