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

BackgroundHealth 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.PurposeTo evaluate the effect of SCE interventions on health worker motivation and experiences with clients.MethodsThe 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.ResultsIntrinsic (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.ConclusionCommunity-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.

A Review of the National Health Insurance Scheme in Ghana: What Are the Sustainability Threats and Prospects?

“…Alhassan et al [20–24] alluded to this challenge in their study of 64 NHIS-accredited clinics and health centers and over 1,900 households around the catchment area of these health facilities. In these studies, NHIS subscribers generally perceived they were not getting good quality health care like their counterparts paying out of pocket.…”

“…Some of the reviewed papers recommended improvement of staff motivation levels; early reimbursement of health providers, and human resource capacity development at NHIA district offices [13,23,24,27,28] as means to sustain operations of the NHIS. Community education, participation and more autonomy of district NHIS offices were discussed as critical intervention areas towards sustaining Ghana’s NHIS [36].…”

“…Even though there are inadequate scientific impact evaluation studies on the effect of these interventions on quality service provision and decisions to (re)enroll in the NHIS, these interventions have improved client and health staff perceptions on the NHIS in some cases [20,23,24]. …”

“…Studies by Alhassan et al [23,24] found that engaging existing community groups and associations in monitoring health and insurance service quality could help improve service providers’ accountability to clients, health worker motivation levels and relationship with clients. Moreover, community engagement in health has been found to enhance client adherence to medication regimen and honoring of clinic appointment dates [24]. These findings suggest, community involvement in NHIS activities will not only create awareness on new policies but also promote stakeholder support and goodwill for the insurance scheme.…”

Community Health Workers and Pandemic Preparedness: Current and Prospective Roles

“…First, since CHWs play a key role in providing health services, and often work on a voluntary basis, their personal satisfaction, and motivation are central to their involvement in health interventions. While much work has investigated CHW's motivations for routine activities (24)(25)(26)(27)(28), less evidence exists regarding CHWs motivations, satisfaction, and role perception when providing services in environments that warrant special considerations (e.g., during an outbreak). Conducting qualitative research with CHWs regarding their motivations, perceptions, experience, and concerns about working during an infectious disease outbreak could inform larger policy decisions.…”