What Happens When Donors Pull Out? Examining Differences in Motivation Between Health Workers Who Recently Had Performance-Based Financing (PBF) Withdrawn With Workers Who Never Received PBF in the Democratic Republic of Congo

Background: A motivated workforce is necessary to ensure the delivery of high quality health services. In developing countries, performance-based financing (PBF) is often employed to increase motivation by providing financial incentives linked to performance. However, given PBF schemes are usually funded by donors, their long-term financing is not always assured, and the effects of withdrawing PBF on motivation are largely unknown. This cross-sectional study aimed to identify differences in motivation between workers who recently had donor-funded PBF withdrawn, with workers who had not received PBF. Methods: Quantitative data were collected from 485 health workers in 5 provinces using a structured survey containing questions on motivation which were based on an established motivation framework. Confirmatory factor analysis was used to verify dimensions of motivation, and multiple regression to assess differences in motivation scores between workers who had previously received PBF and those who never had. Qualitative interviews were also carried out in Kasai Occidental province with 16 nurses who had previously or never received PBF. Results: The results indicated that workers in facilities where PBF had been removed scored significantly lower on most dimensions of motivation compared to workers who had never received PBF. The removal of the PBF scheme was blamed for an exodus of staff due to the dramatic reduction in income, and negatively impacted on relationships between staff and the local community. Conclusion: Donors and governments unable to sustain PBF or other donor-payments should have clear exit strategies and institute measures to mitigate any adverse effects on motivation following withdrawal.


Supplementary file 3
. Hypothesised relationship of different demographic and health facility characteristics with health worker motivation

Variables Hypothesised relationship with motivation Age
In a study by Prytherch et al., 1 older respondents were significantly more positive in their responses to questions assessing their level of motivation. The authors postulated that older workers may receive greater respect and appreciation for their work from the community and colleagues given their greater level of experience. In other studies, older workers have been found to be more committed to working in the facility than younger workers, and more satisfied with their work overall. 2,3 Sex A study in Zambia found female public sector health workers to be less satisfied than male workers. 4 However, another study found no difference in job satisfaction between males and females when controlling for other socio-demographic variables. 2

Number of dependents
In Tanzania, it was found that the more dependents a health worker had, the more positive they were in response to questions concerning their motivation. 1 This may be because the income of workers becomes more important as their number of dependents increases making workers less likely to respond negatively to these questions. Workers with children have also been found to be significantly more committed to staying in a facility compared to workers without children. 3

Urban-rural status
Opportunities, for example for career development, may be greater in urban areas compared to rural areas which could have an effect on motivation. 5 Developing countries often experience 'urban bias' whereby urban areas experience a greater provision of services and investment compared to rural areas. 6 The relative underinvestment in rural areas may serve to reduce the motivation of workers. Total number of staff delivering healthcare present on the day The number of staff working in a facility at a given time will affect the distribution of tasks and potentially the workload of personnel. This may in turn affect health worker motivation. Workload is an important motivating factor, particularly in the context of limited resources. 7

Number of services offered
The more services offered by a facility, the greater the potential for workers to use a variety of skills and have responsibility for certain tasks. This may have the potential to affect motivation, according to the job characteristics model developed by Hackman and Oldham. 8

Distance of the facility from the village
Distance of the facility from the village has been used here as a proxy for the remoteness of facilities. Globally, it is challenging to recruit and retain workers in remote areas . 9 Nonetheless, Stilwell found that health workers based in remote areas of Zimbabwe displayed a high level of motivation despite a lack of financial incentives compared to workers in less remote areas . 10

Education
Educational background has been shown to be a predictor of intention to leave a health facility. 11 Years in position In Tanzania, respondents who had been working for longer tended to be less critical about the management of the facility. This may be due to their understanding and acceptance over time around the constraints faced by facilities. 1 However, another study in Afghanistan showed that workers who had been working longer at a facility, had a lower intent to stay than those who had been working for a shorter period of time. 3

Type of facility
A cross-country analysis of Tanzania, South Africa and Malawi indicated that workers in public hospitals were less satisfied compared to workers in clinics or health centres. 2 Reference facilities in the DRC are bigger than health centres and offer a broader range of services which may affect the motivation of workers.

Total population of the village
The greater the population served by a facility may result in more patients accessing the facility. The increased workload may in turn affect staff motivation.