Discussion Outline

1. The Relevance of Intrinsic Motivation to Health Systems Strengthening: Reflections from Uganda and Malawi Ilana Ron Levey May 17, 2012

2. Discussion Outline • Overview of intrinsic motivation in the HSS literature and beyond • Overview of study goals and design in Uganda and Malawi • High-level Uganda results and the role of faith in intrinsic motivation • In-depth exploration of the drivers of intrinsic motivation in Malawi • Relevance of intrinsic motivation as a measure and concept in HSS efforts

3. Overview of Intrinsic Motivation • Concept is broad and spans across health, psychology, and business literature, as well as popular culture • Work motivation refers to the psychological processes that have direct implications for individual behavior in the context of work • Combination of individual personality traits, individual and institutional values, and organizational systems and structures • Recent attention to organizational attributes that foster an enabling environment for motivation

4. Components of Intrinsic Motivation • 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, and mastery of subject matter

5. Components of Extrinsic Motivation • External motivation that comes from sources outside the individual • Rewards provide satisfaction and pleasure that the task itself does not • Normally structured as salary top-ups or bonuses • Satisfaction with or anticipation of an external reward is as important as the task at hand

6. Why Recent Attention to Intrinsic Motivation? • Concept was defined in 1964 and has been heavily explored by researchers • Recent calls to humanize health systems and bring back a focus on individual behavior • Focus on decentralization of health systems • Assumption that improved motivation leads to better health outcomes (WHO, 2006) as well as higher levels of retention • Need to understand intrinsic motivation in the context of PBI (Leonard) • Perception that PBI is about extrinsic motivators • Sustainability of incentive schemes

7. Growing Interest in the Connection Between Faith and Motivation • PEPFAR increasingly funding faith-based institutions for service delivery • Conventional wisdom that faith-based institutions (often Christian Health Associations) are better able to attract, retain, and motivate staff than their public counterparts

8. Exploring Intrinsic Motivation in Uganda and Malawi: 2010-2012

9. Original Research Questions of Cross-Country Study • 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? • How does satisfaction with compensation impact intrinsic motivation? • 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?

10. General Methodological Concerns • Worker motivation refers to an unobservable set of psychological processes- intrinsic motivation measures are validated but entirely self-reported • Experimental studies on motivation have been conducted in laboratory settings → very different than the complex natural setting of a health facility in a developing country • Vagueness and lack of theoretical framework to explain motivation (very prevalent in popular culture) • Hawthorne effect: particularly acute given the sensitivities of discussing money and job satisfaction in a challenging economy? • More developed methods to measure provider knowledge and quality ( vignettes or mystery clients) than for motivation

11. 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

12. High-Level Results from Uganda

13. Views on Adequacy of Compensation

14. Overall Satisfaction with Job

15. Adequacy of Equipment and Supplies to Complete Job

16. Fewer Differences than Expected Related to Religion • Almost all health workers see their employment as a religious mission • Almost all health workers feel that religion can help them serve their clients better • Almost all health workers think it is important to work in a religious environment • Only significant difference…. Religion is more often discussed at work at faith-based facilities than at public sector facilities • Take-away message: on any individual level, almost all health workers are religious but differences are largely institutional

17. Accounting for the Variation between the Sectors

18. Qualitative Explanations of Motivation • Thematic analysis of feeling valued: • Verbal “thank-you” from supervisor • Investment in training, payment for education, and conference opportunities • Employer values my opinion and delegates “stretch” tasks • Religious concepts: • More free to discuss religion and repentance with patients in a faith-based facility • More free to practice religious ritual (attend church, prayer discussions) during the work day in a faith-based facility

19. Study Methodology Limitations • Sample size in each cadre is too small to drill down into results for each cadre; results are a profile of a sector 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

20. Take-away Messages from Uganda • Strong differences in views on compensation between the sectors does not lead to differences in job satisfaction and intention to remain at the facility • Few faith or religiosity differences at the individual level; primary difference is institutional • Some key predictors of variance in motivation have to do with self-esteem issues that can be fostered at an institutional level (saying thank you) • Important component for PBI: If I work hard and perform well, I will be rewarded- KNOWING that hard work is appreciated and being rewarded may be more important than the actual reward

21. Relevance of Intrinsic Motivation as a Measure for HSS • Elements of intrinsic motivation can be fostered during PBI schemes; more emphasis on rewarding and valuing hard work than the actual monetary reward • Difficult to foster motivation at a central or national level; most pertinent interactions are at the supervisor and facility level • Need to better refine definition of motivation and harmonize methods to measure it, particularly in experimental studies that can get at the relationship to health outcomes • HRH efforts should reach out to experts in human behavior, psychology and business productivity experts to “humanize” the field • Important to understand intrinsic motivation within the context of performance management systems and the need to balance HRH management at the national, district and facility levels

22. Future Directions and Some Remaining Questions • How unique are the intrinsic motivation attributes for health workers in the developing world? Economy mobility, high vacancy rates and prestige of the health care field are important factors but the global business literature on intrinsic motivation is highly consistent. • How can we test efforts to improve intrinsic motivation in an experimental manner? • How do we best structure PBI schemes to maximize extrinsic and intrinsic motivators (taking into account that this may differ by individual)?