Presentation at the 3rd Global Symposium on Health Systems Research, Cape Town, South Africa, on October 3rd, 2014

1. Measuring Motivation of Health Workers – A Tool to Investigate the “Intrinsic Motivation Crowding Out Effect”
Julia Lohmann1, Justin Tiendrebéogo2, Rustin Meyer3, Manuela De Allegri1
1 Institute of Public Health, University of Heidelberg, Germany
2 Centre de Recherche en Santé de Nouna, Burkina Faso
3 School of Psychology, Georgia Institute of Technology, USA

2. Source: Fritsche, Soeters, & Meessen, 2014
Performance-Based Financing
PBF aims to enhance performance by “making the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target”. (Eichler, 2006)

3. Research question
„Does Performance-Based Financing crowd out altruistic and intrinsic forms of motivation?“

4. Research Context
Malawi
Impact evaluation of the Results- Based Financing for Maternal and Neonatal Health Initiative
Intervention:
MoH with KfW and
Norad
Research funding:
USAID | TRAction
Royal Norwegian Embassy
Burkina Faso
Impact evaluation of the health sector PBF pilot intervention*
Intervention:
MoH with World Bank
Research funding:
WB Health Results Innovation Trust Fund
Republic of Congo
Impact evaluation of the health sector PBF intervention*
Intervention:
MoH with WB
Research funding:
WB HRITF
* Motivation scale built into WB HRITF health worker survey of the Impact Evaluation Toolkit (available from WB website)

5. Self-Determination Theory
•Individual motivational profile, composed of different types of motivational regulation, as driver of behavior
•Variable over time and situations (e.g. HR interventions)
Source: Adapted from Deci & Ryan, 2000, and Gagné & Deci, 2005
Type of motivational regulation
External
Introjected
Identified
Integrated
Examples
Money, benefits, security, career options
Reputation, pride in oneself
Wish to make a difference
Job as ‚mission‘, calling
Enjoyment of work tasks
Intrinsic
Externally induced
Originating within the person
•Motivation - behavior relationship different for each regulatory type

6. Health Worker Motivation Literature
•Focus on motivation intensity rather than on motivation composition
•„Mutually exclusive“ extrinsic-intrinsic dichotomy

7. Motivation Scale (1)
Introduction
“I will read to you different reasons for which you might be motivated to work. Please think of how you've predominantly felt in the past four weeks when answering. For each of the following reasons, please indicate to what extent these are important or not important to you personally.”

8. Motivation Scale (2)
Dimension
No. of items
Example(s)
External regulation
12
„Because of the benefits that come with my job.”
„In order to earn money.”
„In order to avoid negative consequences.”
Introjected regulation
6
„Because my reputation depends on my work.”
Identified regulation
4
„Because I want to make a difference in people’s lives.”
Integrated regulation
4
„Because my work is more than a job, it’s a mission.”
Intrinsic regulation
6
„Because the work that I do is very interesting.”

9. Motivation Scale (3)

10. Malawi (baseline):
Work Extrinsic and Intrinsic Motivation Scale (Tremblay et al., 2009)
1)Collection of motivational themes (´reasons for working’) from the literature
2)Categorization to SDT levels
3)Modification and addition of items
Pretest, Nouna District, Burkina Faso
1)Expert discussions: Cultural appropriateness, validity
2)Quantitative pretest: ~ 80 health workers
Modification based on psychometric properties and qualitative information
Application (so far) in
1)Burkina Faso baseline (n = 1520)
2)Malawi midline (modified, n = 158)
3)Republic of Congo baseline (n ≈ 800)
Psychometric assessment
(only data from Burkina Faso yet)
Scale Development Process

11. Psychometric Assessment
•Good psychometric properties
•Structure: Good empirical reproduction of theoretical structure
•But: Integrated and identified regulation dimensions empirically not separable

12. Motivational Profile of Health Workers in Burkina Faso
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* Bars indicate +/- one standard deviation
n = 1489

13. Potential PBF Impact
No crowding out (examples):
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9
10
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Crowding out (examples):
3
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INTEG_IDEN
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14. Acknowledgement: This study was funded by the United States Agency for International Development under Translating Research into Action, Cooperative Agreement No. GHS-A-00-09-00015-00 (Malawi), and by the World Bank through the Health Results Innovation Trust Fund (Burkina Faso).
Disclaimer: This study is made possible by the support of the American People through the Unites States Agency for International Development (USAID). The findings of this study are the sole responsibility of the University of Heidelberg and do not necessarily reflect the views of USAID or the United States Government.