title: Incentives to change: effects of performance-based financing on health workers in Zambia.
abstract: Performance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers' job satisfaction, motivation, and attrition in Zambia. It uses a randomized intervention/control design to evaluate before-after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group.
  
  
  
  Mixed methods are employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion seeks to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program.
  
  
  
  Econometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centers were staffed with qualified personnel and the personnel had role clarity.
  
  
  
  In Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.
authors.affiliation: Department of Health Policy and Management, Graduate School of Public Health and Health Policy, City University of New York, 55 West 125 Street Room 806, New York, NY, 10027, United States of America. Gordon.Shen@sph.cuny.edu.
authors.forename: Gordon C
authors.initials: GC
authors.lastname: Shen
authors.affiliation: Health, Nutrition, and Population Global Practice, The World Bank Group, 1818 H Street, NW, Washington, DC, 20433, United States of America.
authors.forename: Ha Thi Hong
authors.initials: HT
authors.lastname: Nguyen
authors.affiliation: Health, Nutrition, and Population Global Practice, The World Bank Group, 1818 H Street, NW, Washington, DC, 20433, United States of America.
authors.forename: Ashis
authors.initials: A
authors.lastname: Das
authors.affiliation: Department of Gender Studies, University of Zambia, P.O. Box 32379, Lusaka, Zambia.
authors.forename: Nkenda
authors.initials: N
authors.lastname: Sachingongu
authors.affiliation: Health, Nutrition, and Population Global Practice, The World Bank Group, 1818 H Street, NW, Washington, DC, 20433, United States of America.
authors.forename: Collins
authors.initials: C
authors.lastname: Chansa
authors.affiliation: Health, Nutrition, and Population Global Practice, The World Bank Group, 1818 H Street, NW, Washington, DC, 20433, United States of America.
authors.forename: Jumana
authors.initials: J
authors.lastname: Qamruddin
authors.affiliation: Development Research Group, The World Bank Group, Washington, DC, United States of America.
authors.forename: Jed
authors.initials: J
authors.lastname: Friedman
mesh_terms: D000328:Adult; D000533:Altruism; D001291:Attitude of Health Personnel; D003695:Delivery of Health Care; D005260:Female; D006282:Health Personnel; D006801:Humans; D007588:Job Satisfaction; D008297:Male; D009042:Motivation; D010559:Personnel Management; D010563:Personnel Turnover; D011787:Quality of Health Care; D012052:Reimbursement, Incentive; D011795:Surveys and Questionnaires; D000066477:Work Performance; D017132:Workplace; D015024:Zambia
keywords: Health system strengthening; Human resources for health; Mixed methods; Organizational behavior; Pay-for-performance; Performance-based financing; Zambia