What can motivate Lady Health Workers in Pakistan to engage more actively in tuberculosis case-finding?

Mishal S Khan,Aamna Rashid,Naveed Buzdar,Muhammad Ishaq,Farah Naureen,Afifah Rahman-Shepherd,Nelofar Mehboob

doi:10.1186/s12889-019-7326-8

Mishal S Khan, Aamna Rashid + Show 5 more

Open Access

https://doi.org/10.1186/s12889-019-7326-8

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Abstract

BackgroundMany interventions to motivate community health workers to perform better rely on financial incentives, even though it is not clear that monetary gain is the main motivational driver. In Pakistan, Lady Health Workers (LHW) are responsible for delivering community level primary healthcare, focusing on rural and urban slum populations. There is interest in introducing large-scale interventions to motivate LHW to be more actively involved in improving tuberculosis case-finding, which is low in Pakistan.MethodsOur study investigated how to most effectively motivate LHW to engage more actively in tuberculosis case-finding. The study was embedded within a pilot intervention that provided financial and other incentives to LHW who refer the highest number of tuberculosis cases in three districts in Sindh province. We conducted semi-structured interviews with 20 LHW and 12 health programme managers and analysed these using a framework categorising internal and external sources of motivation.ResultsInternal drivers of motivation, such as religious rewards and social recognition, were salient in our study setting. While monetary gain was identified as a motivator by all interviewees, programme managers expressed concerns about financial sustainability, and LHW indicated that financial incentives were less important than other sources of motivation. LHW emphasised that they typically used financial incentives provided to cover patient transport costs to health facilities, and therefore financial incentives were usually not perceived as rewards for their performance.ConclusionsThis study indicated that interventions in addition to, or instead of, financial incentives could be used to increase LHW engagement in tuberculosis case-finding. Our finding about the strong role of internal motivation (intrinsic, religious) in Pakistan suggests that developing context-specific strategies that tap into internal motivation could allow infectious disease control programmes to improve engagement of community health workers without being dependent on funding for financial incentives.

Highlights

Many interventions to motivate community health workers to perform better rely on financial incentives, even though it is not clear that monetary gain is the main motivational driver
Consistent with the concerns raised about the use of Performance-based incentives (PBI) schemes discussed above, empirical evidence shows that financial incentives alone do not maximise the worker’s motivation potential; a large systematic review of interventions designed to influence the performance of community health workers in low and middle-income countries (LMIC) found that improved performance was associated with a mix of incentives, including frequent supervision, continuous training, community involvement and strong coordination and communication between community health workers and health professionals [17]
In order to inform the design of future programmes that aim to incentivise Lady Health Workers (LHW) to have greater involvement in TB case finding, this study investigates the relative importance of different sources of LHW motivation in one high TB-burden country – Pakistan - and explores the level of programme manager support for the scaleup of PBIs to improve LHW engagement in TB casedetection

Summary

Introduction

Many interventions to motivate community health workers to perform better rely on financial incentives, even though it is not clear that monetary gain is the main motivational driver. There is interest in introducing large-scale interventions to motivate LHW to be more actively involved in improving tuberculosis case-finding, which is low in Pakistan. A well-functioning community health worker network has been critical to strengthening the health system in several LMIC by addressing shortages in the number and distribution of trained healthcare providers [2,3,4]. A distinguishing feature of community health workers is that they typically live in and belong to the community they serve, and usually have basic training to provide limited medical and public health services, including neonatal care, immunisation, health education and case-finding for infectious diseases [5]. Many interventions designed to motivate community health workers to do more or better work have relied heavily on provision of financial incentives contingent upon achieving specific targets (performance-based incentives [PBIs]). As a result of this large investment, supply-side PBIs have been implemented and scaled up in many countries, especially in Africa [11]

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