Provider incentives are targeted to improve health worker outcomes, yet the evidence captures their effect more in terms of utilization of services (and quality of care to some extent). This paper assesses the impact of a Results-based Financing (RBF) program in Zimbabwe on health worker satisfaction and motivation. It also tries to underpin the causal pathways of these observed outcomes. Health workers in RBF facilities had higher overall job satisfaction, particularly for compensation (8.436 points, on a maximum scale of 100; p<0.05). They reflected less motivation, specifically for teamwork, recognition, and facility leadership.
Although the overall impact evaluation indicated that the Zimbabwe RBF is high performing, certain design features of the program and their interaction with contextual factors could have explained these puzzling outcomes. Staff expressed their dissatisfaction over the following: reduced unit prices of incentivized services; the relative proportion of incentive amount to their tasks and that of peers; inadequate living accommodation; limited capacity of supervisors; restricted leadership ability of the head of facility; and ‘burn-out’ due to increased patient load. Conversely, they were positively motivated by improvements in working conditions and facility autonomy.
To enable the RBF program to have a greater positive impact on human resources for health (HRH) outcomes, the larger health system issues need to be addressed, such as availability of skilled workers and living accommodation for staff. The program also needs to revisit the unit prices of services and allocation criteria of incentives in a context-specific and consensual manner to ensure a satisfactory income for staff and facilities, and long-term intrinsic motivation. Longer term, capacity development of stakeholders, including supervisors and the head of facility, is needed to improve worker motivation and acceptable team relations in facilities.