title: 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.
  
  
  OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands.|Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Accra, Ghana.
authors.forename: Robert Kaba
authors.initials: RK
authors.lastname: Alhassan
authors.affiliation: Department of Economics, University of Ghana, Legon, Accra, Ghana.
authors.forename: Edward
authors.initials: E
authors.lastname: Nketiah-Amponsah
authors.affiliation: PharmAccess Foundation, Amsterdam, Netherlands.
authors.forename: Nicole
authors.initials: N
authors.lastname: Spieker
authors.affiliation: Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Accra, Ghana.
authors.forename: Daniel Kojo
authors.initials: DK
authors.lastname: Arhinful
authors.affiliation: Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands.|PharmAccess Foundation, Amsterdam, Netherlands.
authors.forename: Tobias F
authors.initials: TF
authors.lastname: Rinke de Wit
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003150:Community Health Workers; D005260:Female; D005869:Ghana; D006282:Health Personnel / Q000191:economics / Q000523:psychology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009042:Motivation / Q000941:ethics*; D011320:Primary Health Care / Q000191:economics / Q000941:ethics; D011787:Quality of Health Care / Q000191:economics / Q000941:ethics; D012456:Salaries and Fringe Benefits