Dr. Gordon Shen, Professor at the CUNY Graduate School of Public Health and Health Policy, and colleagues examined the effect of performance-based financing on health workers’ job satisfaction, motivation, and attrition in Zambia. The findings were published in the journal Human Resources for Health
[Photo: Dr. Gordon Shen]
Performance-based financing has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper uses a randomized intervention/control design to evaluate before-after changes for three groups: performance-based financing (intervention group), enhanced financing (control 1 group), and a pure control (control group 2).
The research team employed mixed methods. The quantitative portion comprised a baseline and an end line survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of performance-based financing or enhanced financing on several key performance indicators. The qualitative portion sought to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the performance-based financing program.
Econometric analysis showed that performance-based financing led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The enhanced financing group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remained motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provided two explanations for higher overall job satisfaction in the enhanced financing group than in the performance-based financing group: better working conditions and more effective supervision from the District Medical Office. The performance-based financing group had higher satisfaction with compensation than the control groups because they have higher compensation and financial autonomy, which was intended to be part of the performance-based financing intervention. While performance-based financing could not address all the reasons for attrition, it did lower turnover because those health centers were staffed with qualified personnel and the personnel had role clarity.
The research team concluded that in Zambia, the implementation of performance-based financing schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.