Performance-Based Financing in Kenya: Motivating Health Workers and Spurring Change

Thanks to performance-based financing (PBF), changes are afoot at health facilities across Samburu, a semi-arid county in Kenya’s Rift Valley.  These changes are most visible in the freshly painted maternity rooms, the presence of suggestion boxes, and even in the flowerbeds out front. Less immediately visible, but vital, are the positive changes in the way that frontline health workers approach their duties.

Three years after its introduction, it is clear that PBF has increased health workers’ motivation.

“We worked like robots.”

Before the introduction of PBF, the motivation of health workers in Samburu County was generally low. The challenges of delivering care in remote, short-staffed facilities, and poorly equipped facilities coupled with a lack of support and supervision from District Health Management Teams (DHMT) left even the most dedicated workers feeling demoralized and underappreciated. The turnover rate was high, and workers resisted being posted to facilities and dispensaries in the county. “We worked like robots,” remarked a team member at an especially isolated dispensary. “But with PBF, everything has changed.”

A recent qualitative study funded by the World Bank reveals that PBF has, indeed, had a profound impact on staff motivation and that four factors, in particular, have contributed.

1.      Financial Compensation

The financial compensation associated with PBF has positively impacted health provider motivation. Health facilities that pre-agreed, measurable performance targets are eligible to receive performance bonuses a part of which is then shared by health workers using a transparent process. The potential to receive such payments in recognition for their hard work has proven to be an especially motivating factor for health workers at public and private health centers and dispensaries alike. The financial compensation that staff receives is more than just a bonus, however. In Samburu, where staff turnover was once quite high, the performance bonuses became a lifeline—they have helped health workers to meet their everyday needs.

2.      Increased Workload

The introduction of PBF has increased health workers’ workload. With newly incentivized activities, such as growth monitoring, and more women seeking antennal care and delivering at health facilities, health workers are now busier than ever. Instead of causing burnout, the increase in workload has actually been motivating. As one midwife noted, “Delivering four clients in a month as a midwife—that’s being idle, and nobody likes to be idle.” Health facility staff views the increased workload positively because it allows them to serve their clients and also offers the opportunity to receive additional financial compensation.

Health workers have also interpreted the increase in workload as confirmation that they are doing good work that the community values. The same midwife added, “When mothers come for your services, you feel that they are appreciating them. But if they don’t come, you think that there is something wrong.” Knowing that Samburu’s mothers and children appreciate their work has been a motivating factor for health workers across the county.

3.      Tangible Changes at Facilities

PBF has brought visible changes to health facilities and to the quality of services delivered. These changes, such as improved waste pits, privacy curtains, and fencing, have been motivating to health workers. Indeed, they are proud of the investments they have made using PBF funds because these investments have improved the quality of services that they deliver to the community. One nurse at a health center described the pride she felt in being able to offer tea to new mothers. Simple changes, such as these, have proven to be an important motivating factor.

4.      Increased Collaboration and Cohesion

The introduction of PBF has strengthened the relationship between health workers and members of the DHMT, and this has really motivated the health workers. Thanks to their more frequent visits, health workers feel that the DHMT has assumed a more collaborative role and actively appreciates their work. A staff member at a health center explained it this way: “Now we feel that the DHMT come[s] to support us, not to harass us.”

Bridging the Gap between Health Workers and Clients

The community has noticed PBF’s impact health worker motivation in the way that workers treat clients. A new mother at a health facility offered, “I am happy with the way that the nurses handle us when we come.” Another echoed this sentiment: “Nurses talk to us very kindly these days. They also try to make sure that everybody gets what they came to look for.” Together with increased community outreach, such encouraging interactions have reduced the perceptions in distance between health workers and their patients. As another worker at a health facility noted, “PBF has really bridged the gap between health workers and the clients.”

Challenges

Despite the positive impact that PBF has had on health worker motivation, there have been challenges. Samburu is home to semi-nomadic pastoralists, who herd their cattle in accordance with the seasons. As a result, their visits to health facilities are irregular. These seasonal fluctuations can dishearten health workers and potentially have a negative impact on their motivation. Treating fewer patients affects workers’ opportunities to earn bonuses—a major motivating factor. Adjusting performance targets to account for these fluctuations will help to address this challenge.

Many health facilities and dispensaries have experienced delays in receiving PBF funds, which can be discouraging for workers. “The delay in sending the money can demoralize people. They have worked hard and are expecting to get something.” Ensuring that PBF funds are disbursed on time will help to sustain health provider motivation.

Moving Forward

With support from the International Development Association (IDA), the World Bank’s fund for the poorest, and the Health Results Innovation Trust Fund (HRITF), the Government of Kenya is set to scale up PBF in an additional 20 counties over the next two years. Harnessing increased motivation and leveraging health worker enthusiasm for PBF will help to make the scale-up a success—and bring the changes seen Samburu to women and children across the country.