Background: We study the role of individual and team-level motivation in explaining large-scale primary care performance improvements in El Salvador, one of the top-performing countries in the Salud Mesoamerica Initiative. Methods: Case study with outlier sampling of high-performing, community health teams in El Salvador. Design includes scoping review of literature, document review, non-participant observation, and qualitative analysis of in-depth interviews following a realist case study protocol. Results: The interplay between program interventions and organizational, community and policy contexts trigger multi-level motivational mechanisms that operate in complex, dynamic fashion. Interventions like performance measurement and team-based, in-kind incentives foster motivation among individual members of high-performing teams, which may be moderated by working conditions, supervision practices, and by the stress exerted by the interventions themselves. Individuals report a strong sense of public service motivation and an overarching sense of commitment to the community they serve. At the interpersonal level, the linkage between performance measurement and in-kind incentives triggers a sense of collective efficacy and increases team motivation and improvement behaviors. The convening of learning forums and performance dialogue increases the stakes for high-performing teams, helps them make sense of performance data, and leads to performance information utilization for healthcare improvements. Closeness to communities creates strong emotional linkages among team members that further increases collective efficacy and social identity. Such changes in individuals, team, and organizational behaviors can contribute to improved delivery of primary care services and explain the gains in performance demonstrated by the program. Conclusions: This case suggests that primary care systems that rely on multi-disciplinary teams for the provision of care can benefit from performance measurement and management interventions that leverage individual and team-level motivation. Realist evaluation can help prioritize policy-relevant research and enhance the design and evaluation of large-scale performance reforms in primary care systems in low- and middle-income settings.
Community health workers (CHWs) play major roles in delivering primary healthcare services, linking communities to the formal health system and addressing the social determinants of health. Available evidence suggests that the performance of CHW programmes in low- and middle-income countries can be influenced by context-dependent causal mechanisms such as motivation to perform. There are gaps regarding what these mechanisms are, and what their contribution is to CHW performance. We used a theory-driven case study to characterize motivational mechanisms among Accredited Social Health Activists (ASHAs) in Bihar, India. Data were collected through semi-structured interviews with CHWs and focus group discussions with beneficiary women. Data were coded using a combined deductive and inductive approach. We found that ASHAs were motivated by a sense of autonomy and self-empowerment; a sense of competence, connection and community service; satisfaction of basic financial needs; social recognition; and feedback and answerability. Findings highlight the potential of ASHAs’ intrinsic motivation to increase their commitment to communities and identification with the health system and of programme implementation and management challenges as sources of work dissatisfaction. Efforts to nurture and sustain ASHAs’ intrinsic motivation while addressing these challenges are necessary for improving the performance of Bihar’s ASHA programme. Further research is needed to characterize the dynamic interactions between ASHAs’ motivation, commitment, job satisfaction and overall performance; also, to understand how work motivation is sustained or lost through time. This can inform policy and managerial reforms to improve ASHA programme’s performance.
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