1. 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 Ron Research Associate, Abt Associates Prepared by: Ilana Ron, Allison Goldberg, Paul Kiwanuka-Mukiibi June 16, 2011

2. Presentation Outline Conventional Wisdom and Overarching Research Questions Brief Overview of Study Methodology Limitations of Study Results from Data Analyses Summary and Parting Thoughts

3. 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

4. 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?

5. 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

6. 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)

7. RESULTS

8. 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

9. Malawi: Comparison of Means on Overall Morale & Job Satisfaction and Overall Intrinsic Motivation Across Sectors Public 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

10. 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)

11. Uganda: Motivation and Satisfaction Factors

12. 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

13. Extrinsic Motivation Factors Compensation Benefits

14. 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 employmen t in the public sector. Intrinsic motivation is only a primary driver of retention in public sector facilities

15. Uganda: Compensation and Retention Factors

16. 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

17. 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 Thank you