Background
Theoretical framework
Intervention (PBF) group | Control 1, or enhanced financing not conditioned on outputs | Control 2, or “business-as-usual” | |
---|---|---|---|
Motivation | ++ | + | |
Job satisfaction | ++ | + | |
Attrition | − | − |
Methods
Study design
Quantitative data collection and analysis
Variable | Baseline | Endline | ||||
---|---|---|---|---|---|---|
Intervention (n = 147) | Control 1 (n = 87) | Control 2 (n = 92) | Intervention (n = 166) | Control 1 (n = 92) | Control 2 (n = 99) | |
Female | 0.42 | 0.38 | 0.42 | 0.41 | 0.36 | 0.49 |
Education-primary | 0.06 | 0.08 | 0.05 | 0.04 | 0.01 | 0.05 |
Education-secondary | 0.40 | 0.40 | 0.30 |
0.35
|
0.49
|
0.27
|
Education-college | 0.52 | 0.49 | 0.63 |
0.60
|
0.49
|
0.68
|
Clinical officer | 0.03 | 0.02 | 0.04 | 0.06 | 0.04 | 0.03 |
Nurse | 0.25 | 0.26 | 0.25 | 0.33 | 0.35 | 0.45 |
Midwife | 0.11 | 0.13 | 0.14 | 0.12 | 0.09 | 0.15 |
Environmental health technicians (EHTs) | 0.15 | 0.09 | 0.16 | 0.13 | 0.08 | 0.10 |
Classified daily employees (CDEs) | 0.33 | 0.41 | 0.32 |
0.31
|
0.38
|
0.22
|
Other staff | 0.67 | 0.59 | 0.69 |
0.69
|
0.62
|
0.78
|
Age | 37.43 | 38.01 | 36.21 |
35.82
|
38.51
|
35.49
|
Work-absence | 1.20 | 1.44 | 1.59 | 1.12 | 1.10 | 1.74 |
Work-days | 5.82 | 6.26 | 6.13 | 6.00 | 6.24 | 6.27 |
Work-hours | 51.45 | 55.90 | 54.55 | 52.07 | 50.33 | 49.61 |
Supervision frequency from previous year | 4.52 | 4.32 | 6.65 | 5.62 | 4.58 | 4.54 |
Work experience-total | 10.06 | 11.04 | 9.76 | 8.03 | 9.03 | 7.95 |
Work experience-current facility | 4.55 | 5.40 | 4.39 | 4.27 | 4.67 | 5.09 |
Qualitative data collection and analysis
Facility | Baseline | Endline |
---|---|---|
Assignment | ||
RBF | 23 (30%) | 32 (59%) |
Control 1 | 23 (30%) | 13 (24%) |
Control 2 | 30 (40%) | 9 (17%) |
Type | ||
District Community Medical Office (DCMO) | 10 (13%) | 12 (22%) |
Health center | 66 (87%) | 42 (78%) |
Worker | ||
DCMO | ||
District community medical officer | 2 (20%) | 2 (17%) |
Nursing officer | 2 (20%) | 2 (17%) |
Human resource officer | 3 (30%) | 3 (25%) |
Others (planner, information officer, EHT) | 3 (30%) | 5 (40%) |
Health center | ||
Clinical officer | 3 (5%) | 2 (5%) |
Registered nurse | 2 (3%) | 1 (2%) |
Enrolled midwife | 15 (23%) | 4 (10%) |
Enrolled nurse | 15 (23%) | 5 (12%) |
Environmental health technician (EHT) | 17 (26%) | 7 (17%) |
Classified daily employee (CDE) | 12 (18%) | 7 (17%) |
Lab technician | 2 (3%) | 16 (28%) |
Gender | ||
Male | 42 (55%) | 27 (50%) |
Female | 34 (45%) | 27 (50%) |
Highest academic/professional qualification | ||
Degree | 3 (4%) | 3 (6%) |
Diploma | 29 (38%) | 18 (33%) |
Certificate | 32 (42%) | 17 (31%) |
Senior secondary education | 2 (3%) | 9 (17%) |
Junior secondary education | 10 (13%) | 7 (13%) |
Total | 76 (100%) | 54 (100%) |
Job experience (in years) | ||
Mean (n; standard deviation) | 10.6 (76; 9.2) | 9.8 (54; 8.7) |
Number of years working in district | ||
Mean (n; standard deviation) | 8.2 (76; 8) | 7.9 (54; 6.9) |
Number of years working in a health facility | ||
Mean (n; standard deviation) | 5.2 (76; 4) | 4.9 (54; 5.1) |
Results
Motivation
Intervention v. control 1 (N = 448) | Intervention v. control 2 (N = 462) | Control 1 v. control 2 (N = 345) | |
---|---|---|---|
β (standard error) |
β (standard error) |
β (standard error) | |
Teamwork | 0.39 (3.13) | 0.93 (1.43) | 1.62 (3.51) |
Autonomy | 0.82 (4.31) | 1.31 (1.77) | 1.30 (4.49) |
Recognition | −0.38 (3.28) | −0.84 (1.33) | −0.89 (2.85) |
Change | −2.10 (2.66) | 1.03 (1.24) | 3.83 (2.64) |
Self concept | −0.73 (1.87) | 0.77 (1.08) | 2.21 (2.36) |
Work environment | −1.79 (2.60) | 1.26 (1.26) | 4.31 (3.03) |
Leadership | −3.08 (4.89) | 1.21 (2.61) | 5.55 (5.15) |
Well-being | 1.10 (2.98) | 2.42* (1.24) | 3.93 (2.50) |
There is a small clinic…with [urban clinics having] more nurses than we have here. We have tried to tell them, ‘you guys give us some more nurses because we are over worked here’. However, they behave as if there is more work there than there is here. —Nurse, Gwembe (PBF group)
First of all you have to be proud about your own profession and if you leave it who will handle it? … [If] I leave my job because of the small salary and whatever. I think that’s not right. I am just happy to be what I am as a doctor. The profession itself is a motivating factor. —Provincial Medical Officer, Livingstone (not in a study group)Even when it is over our working hours, we still come to the clinic and attend to our patients because we would not know what would happen; maybe the patient’s condition can be worsen if we do not attend to them early enough. —CDE, Itezhi-Tezhi (C1 group)
Job satisfaction
Intervention v. control 1 (N = 448) | Intervention v. control 2 (N = 462) | Control 1 v. control 2 (N = 345) | |
---|---|---|---|
β (standard error) |
β (standard error) |
β (standard error) | |
Relationship outside facility | 1.64 (2.96) | 0.43 (1.49) | −0.59 (3.12) |
Relationship within facility | −4.16 (2.82) | 0.48 (1.02) | 4.94* (2.59) |
Work conditions | 6.39 (5.12) | 4.37* (2.18) | 2.20 (5.90) |
Recognition | 1.44 (2.84) | 0.09 (1.32) | −1.44 (2.24) |
Opportunities | 4.69 (4.18) | 3.64* (2.00) | 2.30 (5.24) |
Compensation | 8.64** (4.08) | 3.88* (1.99) | −0.82 (4.87) |
Overall satisfaction | −0.48 (3.96) | 4.75** (2.14) | 10.31** (3.94) |
When I lose a client [dies] as a result of a situation about which I could have been able to do something but there is nothing to use, that de-motivates. It’s better if a client dies from malaria in a situation where you were able to give him/her quinine or Coartem. Not where you are supposed to prescribe the drugs and they are not there; that is really de-motivating. —Nurse, Gwembe (PBF group)
We were told by the DMO we could include allowances [in the business plan] only with an authority letter from PBF. So when you look at it …strictly speaking, autonomy was not there. —Nurse, Isoka (PBF group)
For the percentage that was there under PBF; it was not for the DMO to plan for us. When we got that money; 2519 percent of that money was for the center to plan what to buy since we knew the things that we did not have. This has been a plus, because we were able to buy things on our own. —Midwife, Gwembe (PBF group)
We don’t directly receive that [equivalent of PBF amount of] money for us to buy our stuff. The district buys for us…I think that the person receiving it on the other end [in DMO] would not see the importance and may just leave it out. Therefore, we should have been receiving that money directly ourselves; since we are the ones working here and we are the ones who know what we need and what we don’t need. —Staff, Itezhi-Tezhi (C1 group)
Worker attrition
Intervention v. control 1 (n = 448) | Intervention v. control 2 (n = 462) | Control 1 v. control 2 (n = 345) | |
---|---|---|---|
β (standard error) |
β (standard error) |
β (standard error) | |
All staff | −0.03 (0.05) | −0.02 (0.02) | −0.00 (0.06) |
Clinical officer | −0.05 (0.05) | 0.04 (0.03) | 0.14* (0.08) |
Administrator | −0.10** (0.05) | −0.01 (0.01) | 0.07 (0.05) |
Nurse | −0.19 (0.15) | −0.14** (0.06) | −0.09 (0.15) |
For the past two years that we have been with this PBF, I have never heard any staff saying they want to go to the hospital…the same people are comfortable in the health centre…nobody has requested for any transfer or even talking about it. -Nurse, Isoka (PBF group)
Sometime back, some centers used to be manned by unqualified staff but when the [PBF] program came, management was pressured to the extent that we needed to find where we could source some qualified staff, such as from the hospitals to go to the [health] centers… Things have changed now compared to the past because every health facility now has a qualified health staff but then, they are not enough. —DMO, Isoka (PBF group)But with the emphasis on quality as in skilled personnel; that [PBF program] has helped us put every member of staff where they are supposed to be.—EHT, Gwembe (PBF group)