Recruiting and motivating health workers in Zambia

• Incentives in the selection of public service delivery workers are essential to improving their motivation.

• Researchers used field experiments with community health assistants in Zambia to evaluate different recruitment strategies.

• Compared to social incentives, career incentives attract more productive applicants.

• The findings from this project led to a significant policy change and directly influenced a major World Health Organization (WHO) guideline on community health workers.

Governments are the primary provider of services for the poor in developing countries. Yet, low productivity among government employees is a significant problem. The Government of Zambia approached the IGC about assisting them with the evaluation of their new National Community Health Assistant (CHA) programme.

This project addressed the growth policy challenges faced by Zambia and other developing countries by providing direct guidance to the Government of Zambia as it aims to recruit, train, motivate, and retain 5,000 new Community Health Assistants by 2017. The study will provide policy guidance on how, in the face of severe human resource constraints, governments can best manage their human resources and deliver basic services by adjusting two key human resource levers: recruitment and incentives.

The projects findings allay the concern that career benefits may lead to adverse selection by attracting those who are not intrinsically motivated. More importantly, it was observed that the large and robust selection effects on job performance. After 18 months of deployment, CHAs recruited with career incentives conduct 29% more household visits (their primary job task), organize twice as many community meetings, and see an equal number of patients at the health facility, with no differences in retention.

This project has influenced government recruitment and compensation policies and a scale-up project is in progress. In October 2018, the WHO recommended, as part of a major guideline document on managing community health worker (CHW) programmes, that “a career ladder should be offered to practising CHWs, recognizing that further education and career development are linked to selection criteria, duration and contents of pre-service education, competency-based certification, duration of service and performance review.” This recommendation, one of 15 in the WHO guideline document, is based entirely on the findings from this study.

This project has been followed up by the IGC project: Recruiting and motivating community health workers.