Abstract
BackgroundCommunity health worker (CHW) motivation is an important factor related to health service quality and CHW program sustainability in low- and middle-income countries. Financial and non-financial motivators may influence CHW behavior through two dimensions of motivation: desire to perform and effort expended. The aim of this study was to explore how the removal of performance-based financial incentives impacted CHW motivation after formal funding ceased for Alive and Thrive (A&T), an infant and young child feeding (IYCF) program in Bangladesh.MethodsThis qualitative study included seven focus groups (n = 43 respondents) with paid supervisors of volunteer CHWs tasked with delivering interpersonal IYCF counseling services. Data were transcribed, translated into English, and then analyzed using both a priori themes and a grounded theory approach.ResultsResults suggest the removal of financial incentives was perceived to have negatively impacted CHWs’ desire to perform in three primary ways: 1) a decreased desire to work without financial compensation, 2) changes in pre- and post-intervention motivation, and 3) household income challenges due to dependence on incentives. Removal of financial incentives was perceived to have negatively impacted CHWs’ level of effort expended in four primary ways: 1) a reduction in CHW visits, 2) a reduction in quality of care, 3) CHW attrition, and 4) substitution of other income-generating activities.ConclusionsThis study provides new evidence regarding how removing performance-based financial incentives from a CHW program can negatively impact CHW motivation. The findings suggest that program decision makers should consider how to construct community health work programs such that CHWs may continue to receive performance-based compensation after the original funding ceases.
Highlights
Community health worker (CHW) motivation is an important factor related to health service quality and Community Health Workers (CHWs) program sustainability in low- and middle-income countries
Studies on performance-based incentive programs in some settings have shown that withdrawing performance-based financial incentives can decrease health worker motivation, job attendance, and quality of care [37, 38], yet the evidence is limited regarding the effects of removing performancebased financial incentives after introducing them to existing CHW programs in low-resource settings. This study addresses this gap by exploring how the removal of performance-based financial incentives was perceived to impact CHW motivation after formal funding ceased for an infant and young child feeding (IYCF) program in Bangladesh
2 years after A&T ended, exposure to volunteer CHWs for interpersonal counseling was higher in intensive intervention areas than comparison areas; it had still experienced a decrease from 87.4% to 59.3% in intervention areas [44]. While this decline in program activities is likely a result of multiple factors and complex processes, the objective of the present study is to focus on how the loss of financial incentives contributed to this decline via CHW motivation
Summary
Community health worker (CHW) motivation is an important factor related to health service quality and CHW program sustainability in low- and middle-income countries. Since CHW roles have expanded over the past few decades, an increasingly relevant challenge for program decision makers is how to optimize CHW performance without overburdening workers with tasks they lack the time and capacity to perform [12]. Another salient concern is maintaining high levels of CHW motivation [13]
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