Assessing the Impact of Community Engagement Interventions on Health Worker Motivation and Experiences with Clients in Primary Health Facilities in Ghana: A Randomized Cluster Trial

Abstract

Background: Health worker density per 1000 population in Ghana is one of the lowest in the world estimated to be 2.3, below the global average of 9.3. Low health worker motivation induced by poor working conditions partly explain this challenge. Albeit the wage bill for public sector health workers is about 90% of domestic government expenditure on health in countries such as Ghana, staff motivation and performance output remain a challenge, suggesting the need to complement financial incentives with non-financial incentives through a community-based approach. In this study, a systematic community engagement (SCE) intervention was implemented to engage community groups in healthcare quality assessment to promote mutual collaboration between clients and healthcare providers, and enhance health worker motivation levels. SCE involves structured use of existing community groups and associations to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements made and rewards given to best performing facilities for closing quality care gaps.

Purpose: To evaluate the effect of SCE interventions on health worker motivation and experiences with clients.

Methods: The study is a cluster randomized trial involving health workers in private (n = 38) and public (n = 26) primary healthcare facilities in two administrative regions in Ghana. Out of 324 clinical and non-clinical staff randomly interviewed at baseline, 234 (72%) were successfully followed at end-line and interviewed on workplace motivation factors and personal experiences with clients. Propensity score matching and difference-in-difference estimations were used to estimate treatment effect of the interventions on staff motivation.

Results: Intrinsic (non-financial) work incentives including cordiality with clients and perceived career prospects appeared to be prime sources of motivation for health staff interviewed in intervention health facilities while financial incentives were ranked lowest. Intervention health facilities that were assessed by female community groups (Coef. = 0.2720, p = 0.0118) and informal groups with organized leadership structures like Artisans (Coef. = 0.2268, p = 0.0368) associated positively with higher intrinsic motivation levels of staff.

Conclusion: Community-based approach to health worker motivation is a potential complementary strategy that needs policy deliberation to explore its prospects. Albeit financial incentives remain critical sources of staff motivation, innovative non-financial approaches like SCE should complement the latter.

Fig 1. Staff personal experiences with clients in control and intervention facilities.

Source: WOTRO-COHEiSION Ghana Project (2014).

Fig 2. Workplace motivating factors in treatment and control facilities.

Source: WOTRO-COHEiSION Ghana Project (2014); **p<0.0001 (two tailed test of hypothesis using t-test). Note1: Mean testing was based on pooled baseline and follow-up responses in 2012 and 2014 respectively. Means were derived from a four-point Likert scale from 1 = “Very disappointing” to 4 = “Very satisfactory”. High summated scores per staff motivation area depict better satisfaction with work conditions and vice-versa. Note2: Extrinsic motivation is derived from financial and material work conditions of a job (e.g. salary increment, promotion, accommodation etc.); Intrinsic motivation is derived from the inner joy and satisfaction derived from a job (e.g. societal recognition and respect; appreciation shown by clients etc.).