title: Can performance-based incentives improve motivation of nurses and midwives in primary facilities in northern Ghana? A quasi-experimental study.
abstract: BACKGROUND
  Lack of an adequate and well-performing health workforce has emerged as the biggest barrier to scaling up health services provision in sub-Saharan Africa. As the global community commits to the Sustainable Development Goals and universal health coverage, health workforce challenges are critical. In northern Ghana, performance-based incentives (PBIs) were introduced to improve health worker motivation and service quality.
  
  
  OBJECTIVE
  The goal of this study was to determine the impact of PBIs on maternal health worker motivation in two districts in northern Ghana.
  
  
  METHODS
  A quasi-experimental study design with pre- and post-intervention measurement was used. PBIs were implemented for 2 years in six health facilities in Kassena-Nankana District with six health facilities in Builsa District serving as comparison sites. Fifty pre- and post-intervention structured interviews and 66 post-intervention in-depth interviews were conducted with health workers. Motivation was assessed using constructs for job satisfaction, pride, intrinsic motivation, timelines/attendance, and organisational commitment. Quantitative data were analysed to determine changes in motivation between intervention and comparison facilities pre- and post-intervention using STATA™ version 13. Qualitative data were analysed thematically using NVivo 10 to explore possible reasons for quantitative findings.
  
  
  RESULTS
  PBIs were associated with slightly improved maternal health worker motivation. Mean values for overall motivation between intervention and comparison health workers were 0.6 versus 0.7 at baseline and 0.8 versus 0.7 at end line, respectively. Differences at baseline and end line were 0.1 (p=0.40 andp=0.50 respectively), with an overall 0.01 difference in difference (p=0.90). Qualitative interviews indicated that PBIs encouraged health workers to work harder and be more punctual, increasing reported pride and job satisfaction.
  
  
  CONCLUSIONS
  The results contribute evidence on the effects of PBIs on motivational constructs among maternal health workers in primary care facilities in northern Ghana. PBIs appeared to improve motivation, but not dramatically, and the long-term and unintended effects of their introduction require additional study.
authors.affiliation: School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; gapiung@gmail.com.
authors.forename: Gifty Apiung
authors.initials: GA
authors.lastname: Aninanya
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Natasha
authors.initials: N
authors.lastname: Howard
authors.affiliation: Navrongo Health Research Centre, Navrongo, Ghana.
authors.forename: John E
authors.initials: JE
authors.lastname: Williams
authors.affiliation: Department of Statistics, Bolgatanga Polytechnic, Bolgatanga, Ghana.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Apam
authors.affiliation: Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland.
authors.forename: Helen
authors.initials: H
authors.lastname: Prytherch
authors.affiliation: Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Svetla
authors.initials: S
authors.lastname: Loukanova
authors.affiliation: Department of Philosophy, Religion and Theology, Moi University, The Eldoret, Kenya.
authors.forename: Eunice Karanja
authors.initials: EK
authors.lastname: Kamara
authors.affiliation: School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
authors.forename: Easmon
authors.initials: E
authors.lastname: Otupiri
keywords: Ghana; constructs of motivation; health worker; motivation; performance-based incentives