Abt Associates Inc.  In collaboration with:I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University’s School of Public Health

Untangling Intrinsic Motivation of Health Workers in Uganda and Malawi

Ilana RonResearch Associate, Abt AssociatesPrepared by: Ilana Ron, Allison Goldberg, Paul Kiwanuka-Mukiibi

June 16, 2011

Presentation Outline

Conventional Wisdom and Overarching Research Questions

Brief Overview of Study Methodology Limitations of Study Results from Data Analyses Summary and Parting Thoughts

Background and Conventional Wisdom

Funded by USAID/Washington and USAID/Malawi as part of Health Systems 20/20 project

Faith-based institutions (often Christian Health Associations) are better able to attract, retain, and motivate staff than their public counterparts

Recent attention by donors given to a wide variety of financial and non-financial incentive schemes to improve health worker performance and motivation

Overarching Research Questions

What are the levels of intrinsic motivation, retention, and performance factors for health workers in public, faith-based (Christian Health), and private for-profit facilities in Malawi and Uganda?

What are drivers of intrinsic motivation for health workers in these sectors? How might intrinsic motivation be improved?

How important is faith as a predictor of intrinsic motivation for health workers?

Brief Overview of Methodology

Equal probability systematic sample selected Uganda: 311 health workers from 91 health

facilities (all size levels) interviewed from 20 districts Malawi: 602 health workers from 163 health

facilities from every district in Malawi interviewed; in addition, 612 clients interviewed

Both qualitative and quantitative data collection Very rich dataset on intrinsic motivation; over 900

health workers from all cadres interviewed

Limitations of Study

Sample size in each cadre is too small to drill down into results for each cadre; results are a profile of a cadre overall

Faith-based sector included Christian Health facilities, not Muslim facilities

Data around intrinsic motivation, retention and job satisfaction are not matched with health outcomes; we do not know if more motivated health workers actually perform better (but we assume that they do)

RESULTS

Intrinsic Motivation Factors

Feeling of being good at the job Feeling of being able to successfully complete all

assigned tasks Feeling of being proud of job and position at the

facility Opportunities for growth and development Role of faith Daniel Pink definition: internal motivators like

enjoyment of work, genuine achievement, personal growth

Malawi: Comparison of Means on Overall Morale & Job Satisfaction and Overall Intrinsic

Motivation Across SectorsPublic Sector

(N=415)Private Sector

(N=47)CHAM with SLA

(N=17)CHAM w/out SLA

(N=116)

Mean Score on Morale & Job Satisfaction Index

27.21 (26.7-27.7) 28.94 (27.0-30.8) 26.74 (24.45-29.03) 27.13 (26.18-28.08)

Mean Score on Intrinsic Motivation Index

35.03 (34.7-35.3) 35.00 (34.1-35.9) 34.67 (32.9-36.4) 34.7 (34.2-35.2)

Average levels of overall morale & job satisfaction and overall intrinsic motivation are not substantively different across sectors

Overall, health workers across all sectors report that they are only generally satisfied with their jobs, yet highly motivated to complete them

Malawi: Impact of Compensation and Faith & Religion on Intrinsic Motivation

Intrinsic Motivation Index

Public Sector N Private

Sector N CHAM with SLA N CHAM w/out

SLA N All Sectors N

Compensation Satisfaction Index -.08 (-.19-.014)

413 -21 (-.544-.12)

47 -.39 (-1.1-2.9)

17 .26* (.07-.45)

117 -.04 (-.13-.04)

594

Religiosity Index .52* (.38-.67)

412 .80* (.23-1.4)

47 .21 (-1.11-1.5)

17 .27* (.02-.52)

116 .46* (.34-.58)

592

Importance of Religion in the Workplace Index

.17*(.02-.32)

416 .37 (-.10-.85)

47 .64 (-.55-1.8)

17 .40* (.12-.68)

117 .22* (.09-.34)

597

Health workers’ overall level of satisfaction with compensation is not significantly associated with their overall level of intrinsic motivation. This means that compensation is not a driver of health worker motivation, except in the case of CHAM facilities without SLA (.26*).

Strong religious values are significantly associated with health workers’ overall level of intrinsic motivation

The importance of working in a religious environment is associated with higher levels of overall job satisfaction (but less strongly than individual religiosity)

Uganda: Motivation and Satisfaction Factors

Uganda: Predictors of Intrinsic Motivation

Strongest predictors of satisfaction and motivation: Adequate equipment and supplies to do job Professional development opportunities Feeling of being “good at job” Fair pay [*not high pay*] compared to others doing similar work

Only predictor of satisfaction and motivation related to faith: Feeling that religion can help a health worker serve a client well

Extrinsic Motivation Factors

Compensation

Benefits

Malawi: Impact of Compensation and Intrinsic Motivation on Retention

Retention Index Public Sector N Private

Sector N CHAM with SLA N CHAM

w/out SLA N All Sectors N

Compensation Satisfaction Index .00 (-.07-.07)

415 .22 (-.03-.48)

47 .19 (-.27-.65)

17 .14 (-.03-.31)

117 .05 (-.01-.12)

596

Intrinsic Motivation Index .17* (.11-.24)

416 .07 (-.15-.30)

47 .09 (-.27-45)

17 .17 (-.03-.27)

117 .15 *(.09-.20)

597

Health workers’ overall level of satisfaction with compensation is not significantly associated with their intention to stay at the facility where they are working Reasons to stay at facility: convenience (e.g. house and family are nearby and transport is

accessible) and the opportunity to learn from experienced colleagues

Health workers’ intrinsic motivation is significantly associated with the decision to retain employment in the public sector. Intrinsic motivation is only a primary driver of retention in public sector facilities

Uganda: Compensation and Retention Factors

Summary and Parting Thoughts

Very large dataset; only a very small sub-section of results able to be presented today

Several key themes emerging: Intrinsic motivation levels are largely not associated with satisfaction

about compensation package Particularly in the public sector, intrinsic motivation is a primary driver

of retention Biggest drivers of intrinsic motivation: professional development,

opportunities for promotion, fairness of compensation Religiosity is an important driver of motivation but exists at the

individual and workplace level in the public as well as the FBO sector Striking the balance between intrinsic and extrinsic motivators is key

but difficult

Abt Associates Inc.  In collaboration with:I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University’s School of Public Health

www.HealthSystems2020.org

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