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Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover photo: © Vincent Tremeau / World Bank. Further permission required for reuse. Cover design: Maria Lopez TABLE OF CONTENTS Acknowledgments vi Abbreviations vii Executive Summary 1 1. Introduction 4 Conceptual Framework 5 Structure of the Report 6 2. Drivers of Worker Performance in Health Facilities 7 Staffing 8 Merit-Based Recruitment 12 Performance Management 14 Work Environment: Group Problem Solving 15 Financial Incentives 17 Performance-Based Financing 17 Nonfinancial Incentives 22 Training 23 Health Worker Motivation 25 Mental Health and Resilience 28 3. Drivers of Worker Performance in the Health Administration 29 Facility Funding 30 Supportive Supervision 31 Data-Informed Management 33 4. Conclusion 37 Appendix: Detailed Survey Methodology 39 References 41 Figures Figure 1: Conceptual framework 6 Figure 2: Perceptions on staffing challenges 8 Figure 3: Participation in a recruitment competition (percentage of respondents that said “Yes”), overall and by occupation 13 Figure 4: Salary increases over the past 2 years by performance-based financing participation 20 Figure 5A: Comparison of wages between men and women in top-earning occupations 21 Figure 5B: Comparison of wages between men and women in lower-paid occupations 21 Figure 6: Gender differences in on-the-job training, Mali 25 Figure 7: Facility staff’s views on turnover 27 Figure 8: Experiences with receiving facility funding 30 Figure 9: Average interval between supervisory visits 33 Figure 10: Share of respondents agreeing with “Data often captures too many indicators, creating challenges when compiling, interpreting, and effectively utilizing the findings.” 34 Figure 11: Percentage of respondents who did not have training on digital skills and data for budgetary decisions 36 Boxes Box 1: Guidance to develop rural pathways for health workers in LICs and LMICs 11 Box 2: Examples of group problem solving interventions 16 DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE vi Prosperity Insight Acknowledgements This report was prepared by a team led by Zahid Hasnain (Lead Governance Specialist), with team members Ayesha Khurshid (ET Consultant), Turkan Mukhtarova (Consultant), Anju Malhotra (Senior Monitoring and Evaluation Specialist), Jessica Brown (Consultant), Indira Prihartono (Consultant), Yaxin Hu (Consultant), Julia Lohmann (Consultant), and Jennifer Ljungqvist (Consultant). The team would like to thank Debasmita Padhi (ET Consultant) and Zara Raheem (Intern) for their support on the survey analysis, and Flavia Sacco (ET Consultant) for her support on the labor force survey analysis. The team would also like to thank Patrick Eozenou (Senior Health Economist), Richard Sutherland (Senior Governance Specialist), Donna Andrews (Lead Governance Specialist), Halsey Rogers (Lead Economist), Laurence Lannes (Senior Health Economist), Maud Juquois (Senior Health Economist), Charlotte Pram Nielsen (Senior Health Specialist), Ibrahim El Ghandour (Public Sector Specialist), Zubair Khurshid Bhatti (Lead Public Sector Specialist), Adenike Oyeyiola (Advisor), Roby Senderowitsch (Practice Manager), Omowunmi Ladipo (Practice Manager), and Arturo Herrera Gutierrez (Global Director) for their support and overall guidance, as well as the Global Financing Facility for providing the funding for the report. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE vii Prosperity Insight Abbreviations CHW Community Health Worker CoP Community of Practice DHMTs District Health Management Teams HRH Human Resources for Health HRM Human Resource Management ICT Information and Communication Technology LIC Low Income Countries LMIC Lower-Middle Income Countries PBF Performance-Based Financing P4P Pay-for-Performance PPP Purchasing Power Parity SDG Sustainable Development Goal WHO World Health Organization DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE viii Prosperity Insight DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 1 Prosperity Insight ES. EXECUTIVE SUMMARY The health workforce—clinical, administrative, and support staff—is central to the effective delivery of quality public health services. This report aims to (1) synthesize a large body of literature on the key drivers of health workforce productivity, focusing on low-income and lower-middle income country contexts (LICs and LMICs); and (2) elaborate on some of these drivers with descriptive statistics from Mali and Madagascar based on primary data derived from surveys of health workers conducted by the World Bank. The report is organized around a conceptual framework that focuses on the drivers of health worker performance in the health administration and in health facilities. The administration-level drivers focus on core stewardship functions— facility funding, supervision, and data-informed management. Administration staff includes positions from the Ministry of Health, as well as regional and local level public servants working in the health sector. In health facilities, the report analyzes management and work environment aspects that impact staff ability and motivation to deliver services, including recruitment, performance management, teamwork, access to training, and intrinsic motivation. Health facility staff includes doctors, nurses, community health workers (CHWs), midwives, and facility managers, among others. The existing literature, complemented by the descriptive statistics from Madagascar and Mali, offers varying levels of evidence regarding the influence of different factors on the performance of health facility staff. Among these factors, the most compelling evidence is found in the following areas: DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 2 Prosperity Insight • “Rural pathways” or purposefully designed of staff bonuses (for instance, women in Mali rural career paths for health workers—recruiting receive smaller bonuses than men). them from underserved areas, training them • Nonfinancial incentives, such as staff locally, and ensuring a career development recognition schemes and enhanced staff path—are the most effective strategy for monitoring usually with digital tools, can be addressing skill shortages in remote areas. The effective in reducing shirking and improving evidence, however, is largely from high-income motivation. For CHWs, there is good evidence countries that have a sufficient supply of such that recognition schemes like public awards workers in remote locations. can improve motivation. Digitally enabled • Sound personnel management, including goal monitoring can address problems of staff setting, performance evaluations, and regular absenteeism, however the institutional context conversations with staff, can improve health of technology intervention is critical for impact. worker performance. The weakest aspect • Staff training, despite the general skepticism of personnel management is performance often surrounding it, can be effective for both evaluations. In both Mali and Madagascar, service providers and managers, particularly for example, these evaluations are often if designed in a participatory manner, coupled perfunctory exercises, particularly for female with group problem solving, and delivered in staff. They are not routinely conducted, they a combination of classroom-style instruction inadequately distinguish good from poor and on-the-job applications. The Mali and performers, and they lack the necessary Madagascar surveys did reveal that women informal dialogue between managers and staff health workers received less training than that should complement the formal annual men, due to greater time constraints and lack performance evaluation process. of opportunities provided by the authorities. • Teamwork, specifically group problem solving The literature and survey results also point to which entails issue identification and resolution several key findings for health administration: by peer groups in primary and secondary care facilities, can be highly effective, increasing • Stable and predictable facility funding is central engagement and motivation of health workers to the PBF theory of change, and in general and improving outcomes. for effective service delivery. In both Mali and Madagascar, the survey revealed delays • Financial incentives, particularly in the context in facilities receiving funds and significant of performance-based financing (PBF), have political influence on the use of these been extensively evaluated for impacts on resources, particularly on the use of these clinical outputs and outcomes, but less so funds for facility construction and renovation. for effects on health worker motivation. The limited evidence is mixed: health worker • Supportive supervision is most impactful if motivation levels are improving because of the embedded within a larger quality improvement introduction of a performance-oriented culture framework and coupled with training, in health facilities but there are challenges mentorship, and community feedback. related to small individual incentives (as Monthly supervision is more effective than was the case in Mali), payment delays, and quarterly supervision, but the quality of concerns about fairness in the distribution supervision is more important than sheer DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 3 Prosperity Insight frequency. Given the dual role of technical and in Mali and Madagascar, study results show emotional support, a certain level of continuity that there is data overload and the inability and frequency in the supervisory relationship of administrators to compile and analyze is important to building mutual understanding information for management. These findings of contexts, interests, and priorities, as well as underscore the importance of management of mutual trust. Unfortunately, this continuity training, particularly experiential, work-based and frequency is challenging in many low- learning that has been found to be more income and lower-middle income settings, as effective compared with classroom instruction. evidenced by the Mali and Madagascar surveys The report concludes by briefly discussing the which revealed infrequent supervision visits gaps in knowledge and the agenda for future due to lack of sufficient resources and the poor research. It points out that the academic literature attitudes of administrators. on the drivers of health worker performance has • The spread of digital technology, such as concentrated on healthcare clinical professionals Health Management Information Systems and and, increasingly, CHWs and not on managerial, mobile systems (mHealth), can greatly improve administrative, and other nonmedical staff. There the efficiency and transparency of health is limited research on health sector leadership and systems, but these outcomes are conditional stewardship, despite the general acknowledgment upon strong management effectively using the of the criticality of senior and midlevel bureaucrats technology, particularly the data generated to the effective functioning of the health system. from digital systems. Management quality is highly variable in LICs and LMICs: as evidenced DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 4 Prosperity Insight 1. INTRODUCTION The health workforce—clinical, administrative, in developing countries” in ensuring a healthier and support staff—are central to the effective population (UN 2024). Accordingly, many delivery of quality public health services. Since interventions have sought to address local and the 1990s, researchers and policy makers globally global healthcare workforce shortages, retention, have highlighted the need for more effective migration, and skill imbalance issues, in addition human resources for health as a priority reform to poor work environments and human resource in LICs (WHO 2022, 2019a, 2016a). Sustainable planning (Joint Learning Initiative 2004). Development Goal (SDG) 3, target 3.c recognizes The objective of this report is to review a large the importance of “recruitment, development, body of academic and policy literature on the training and retention of the health workforce DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 5 Prosperity Insight key drivers of performance of health workers, need to hire more health workers to address staff and to provide some selective evidence on these shortages and to ensure adequate use of limited drivers from ongoing World Bank engagements fiscal resources given the high share of staff costs in based on primary data collection in two countries health expenditures. A global shortfall of 18 million (Madagascar and Mali). healthcare workers by 2030 is expected, and Africa has only 3 percent of the world’s healthcare The performance of health workers, as measured workers, even though it carries 24 percent of the by their presence in health facilities and their world’s disease burden (WHO 2022). At the same knowledge and ability to correctly diagnose and time, financially, the health workforce constitutes treat common ailments, is poor in LICs and LMICs. a substantial part of the health sector budget, with Data from the Service Delivery Indicator surveys spending on health workers’ payroll averaging from 13 countries in Sub-Saharan Africa reveal 34 percent of total government expenditure on that 43 percent of providers were absent from health in 136 countries (Hernandez-Peña and their facility during an unannounced visit, due to others 2013).1 both ostensibly authorized (e.g., leave, training, or travel) and unauthorized reasons, which is This report uses the WHO definition of the health similar to rates observed in Bangladesh, Ecuador, workforce, or “human resources for health India, and Indonesia (World Bank 2021). The (HRH),” as the persons involved in promoting, quality of care health workers provide when they protecting, and improving population health, are present is also low, as measured by clinical which includes “health service providers” and vignettes of childhood diarrhea with dehydration, “health management and support workers” (WHO childhood pneumonia, adult tuberculosis, adult 2006). Much of the literature on HRH capacity and diabetes mellitus, and childhood malaria with performance focuses on patient-facing healthcare anemia. Across the 13 countries, the accuracy of workers. However, in line with the WHO view of diagnoses ranged from 40 to 70 percent, being HRH, this paper uses “health workers” to signify higher for doctors than nurses, and varying across all who work in the public health system, from the the ailments (for example, only 22 percent correct Minister of Health to the cleaner at a health facility. diagnosis and treatment exists for malaria). Importantly, the paper attempts to highlight the role of management and administrative workers Improving the performance of health workers is who are often overlooked in much of the literature. particularly important in LICs and LMICs given the Conceptual Framework Drawing on the literature, this report uses the delivery chain—from the health administration conceptual framework of a production function of down to the facilities—that influence this health service delivery whereby “inputs,” or human conversion process. While the functions, roles, and and budgetary resources, are converted into responsibilities differ between the administration “outputs,” or health services delivered to citizens and the facilities, there are a set of drivers that (figure 1). The focus of the report are the human shape the actions and behaviors of the personnel resources for health drivers through the service working in these different organizations. 1. Based on data available at the beginning of the 2010s. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 6 Prosperity Insight Figure 1: Conceptual framework Strategies, policies, and legislation Inputs Key HRH drivers Personnel Administration Facilities Outputs Infrastructure Facility funding Staffing and recruitment Goods Supportive supervision Performance management Data-informed Health services management Group problem solving delivered Incentives to citizens Training Attitudes and behaviors Political, socioeconomic, geographic, and gender inequity Source: World Bank. Note: HRH = Human Resources for Health. Structure of the Report The report is structured as follows. Chapter 2 facility funding, supervision, and data-informed follows the conceptual framework and reviews management. In both chapters, the literature the literature on the main drivers of performance review is supplemented with evidence from public of health workers in facilities—staffing and employee surveys in Mali and Madagascar regarding recruitment, performance management, group human resource management practices in health problem solving, financial and nonfinancial facilities and the administration, respectively (see incentives, training, and attitudes and behaviors. detailed survey methodology in Appendix). The Chapter 3 does the same for administrative-level last chapter provides some suggestions for the staff focusing on key stewardship functions of operational uses of this report. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 7 Prosperity Insight 2. DRIVERS OF WORKER PERFORMANCE IN HEALTH FACILITIES This chapter reviews the literature on the main evidence on strategies to enhance staffing in rural drivers of performance of health service delivery areas, and explores topics such as merit-based staff in health facilities, complemented by results recruitment, management quality, aspects of from surveys carried out in Mali and Madagascar. the work environment related to teamwork and Examining the key dimensions outlined in the collaboration, financial incentives, nonfinancial conceptual framework, the review assesses incentives, and training. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 8 Prosperity Insight Staffing Shortages of personnel, inadequate infrastructure, Madagascar, the midwifery and nursing workforce and a dearth of essential supplies are commonly is mostly composed of women (of the nurses and cited as key reasons for health worker midwives surveyed in Mali, 78 percent are women, demotivation.2 Challenges such as pandemics, and in Madagascar, 69 percent are women). consequences of climate change, and armed The remoteness of work locations for these conflict have the potential of further exacerbating largely female workforces can pose a particular the above by not only aggravating sub-optimal challenge for women, who also suffer from more working conditions, but further adding elements of time poverty (UN Women 2023). The majority of personal unsafety and the challenges associated respondents in both countries also stated that with crisis-induced morbidity, mortality, and staffing shortages had become worse in the past displacement to the mix (Qirbi and Ismail 2017; two years. This consensus suggests an emerging Harrell, Selvaraj, and Edgar 2020). crisis, the effects of which have not yet been felt by many, but the growing trends have been visible. In Mali and Madagascar, for example, 62 percent Although majority of the population in Madagascar and 15 percent, respectively, of healthcare today are not directly impacted, the broad respondents from an HRH survey stated that their sentiment that shortages and motivation issues facility was short-staffed (figure 2). Midwives and are worsening indicates more staff may encounter nurses were viewed as the cadres with the greatest challenges if the underlying systemic problems are shortages; and the remoteness of work locations left unaddressed. is one of the primary reasons for these shortages among nurses and midwives. In both Mali and Figure 2: Perceptions on staffing challenges 59% “Staffing has become worse in the past two years” 73% 15% “We are short-staffed” 62% Percentage of staff Madagascar Mali Source: World Bank. 2023. Mali and Madagascar HRH Surveys, Facility Level. 2. See Bhatnagar and George (2016); Henderson and Tulloch (2008); Luboga and others (2011); Shen and others (2017); Mbindyo, Blaauw, and English (2013); Tekle and others 2022; and Bonenberger and others (2016). DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 9 Prosperity Insight Countries in Africa, already struggling with health others 2023; Aluttis, Bishaw, and Frank 2014; Mills personnel shortages, face an exacerbation of and others 2011; Clemens and Pettersson 2008). this crisis due to health workforce migration. While many of these resource limitations are a fixed Estimates suggest that African countries could structural constraint given the level of economic lose up to 70 percent of their health workforce development and instability in LICs and LMICs, to high-income countries, significantly impacting attracting and retaining healthcare personnel in shortages. Particularly in Sub-Saharan nations, rural areas is a policy intervention that can improve the migration of health workers poses a serious the distribution of HRH within available resources. threat to the availability and quality of healthcare, The literature identifies four groups of strategies putting communities at risk as qualified personnel to attract health workers to work in rural areas: emigrate. Beyond the immediate effects, the loss regulatory strategies, educational strategies, of manpower also translates into a forfeiture of incentive schemes, and what has been coined financial investments made by LICs and LMICs in as “rural pathways” or “rural pipelines” (Grobler, training and education of health workers. Various Marais, and Mabunda 2015; Witter and others 2020; push and pull factors contribute to health workers’ O’Sullivan and others 2021; WHO 2010, 2020). decisions to migrate, including better remuneration, professional advancement, political stability, and Regulatory strategies pertain primarily to attempts improved quality of life. Addressing this complex to coerce health workers into certain aspects of issue requires a comprehensive understanding of performance for which little levels of intrinsic the factors influencing migration patterns and the motivation may exist, such as compulsory periods development of strategic interventions to retain of rural service as a mandatory element of joining essential healthcare workers (Toyin-Thomas and DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 10 Prosperity Insight public service. A 2010 review of the effectiveness external drivers of motivation. Evidence on the use of a compulsory service showed the frequency of of financial incentives and performance-based use of such schemes; however, the review also financing to enhance staff retention is reviewed showed some evidence that the effectiveness of a below in the sections on incentives. Like mandatory compulsory service is largely lacking, particularly on service, evidence is lacking regarding benefits aspects of performance beyond mere acceptance conditional on compulsory service, particularly of rural postings. A main issue is often poor regarding actual job performance, beyond mere implementation of compulsory service schemes, acceptance of rural postings. which, despite their noble intentions, tend to be Finally, the concept of the “rural pathway” or extremely unpopular with health personnel. Key “rural pipeline”—used and evaluated particularly contextual factors for successful implementation in Australia and other high-income countries with emerging from the available literature include extremely remote areas—is grounded in research transparent systems and regulations, support in the showing that health workers originally from the larger health system, as well as coupling compulsory rural areas are more likely to accept and stay in service with good supervisory structures and rural posts. “Rural pathway” describes purposely financial incentive schemes (Frehywot and others designed rural career paths, starting with 2010; Khalil and Alameddine 2020). selecting future health workers from underserved Educational strategies include placing professional areas; training them locally (ideally by locally training institutions in rural areas as well as available teachers who will later continue to act mandatory placements in rural areas during as mentors and support persons); and ensuring professional training. Both strategies are grounded adequate working conditions, targeted support, in the idea that making rural areas an integral part of networking opportunities, and most importantly professional education would attract students from career development paths (Durey, Haigh, and the rural areas—who will then be more likely to work Katzenellenbogen 2015). As such, rural pathways in rural areas, as discussed in “the rural pathway” have the potential to tackle the full range of external strategy below—as well as permit a gradual and internal motivational drivers. In addition, familiarization of students from urban areas with the some evidence suggests that “rural pathways” realities, advantages, and disadvantages of living when complemented by female-tailored policies and working in the rural areas so as to attract them (supportive teams, capped hours, and female to rural service and to build realistic expectations support and mentorship) may have the potential to foster retention (WHO 2020). Available studies to expand and retain the female health workforce indicate that educational strategies can be quite in remote and rural areas (O’Sullivan, McGrail, and effective, and have a dose effect in the sense that May 2021). the longer the exposure to living and working in Although elements of rural pathways are in use rural areas, the higher the likelihood of accepting in several LICs and LMICs, a recent WHO-funded and retaining rural roles (WHO 2020). review did not identify any comprehensive schemes Incentive schemes for rural retention include (O’Sullivan and others 2020). For instance, a mix of strategies such as scholarships and loan programs rural pathway elements with regulation has been linked to obligatory rural service, higher salaries employed in Burkina Faso, where the government and rural allowances, and various interventions to decided to recruit certain health worker cadres make working and living conditions in rural areas as regionally rather than at central level in response to amenable as possible. As such, they tackle various severe shortage outside the two major cities, with DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 11 Prosperity Insight the stipulation that they can only hold posts in the I n response to this situation and in recognition of the region for which they had been recruited (Kouanda potential of rural pathways, O’Sullivan and others and others 2014). The policy has not been formally (2020) developed an evidence-based checklist evaluated for its impact, but Kouanda and others to guide the development of comprehensive rural (2014) describe key implementation challenges pathway schemes for health workers in LICs and ranging from participation of key stakeholders LMICs, with funding from WHO. Key elements are in decision-making and design and lack of buy- summarized in box 1. in by key stakeholders down to a number of implementation issues leading to the gradual maceration of the policy. BOX 1: Guidance to develop rural pathways for health workers in LICs and LMICs Methods: Desktop review of existing LIC and LMIC rural health workforce policies, scoping review of evidence on LIC and LMIC rural pathways, and consultation with an Expert Reference Group. Checklist: The resulting checklist describes reflective questions for policy makers in eight action categories. 1. What do our rural communities need? What rural health policies/plans exist to support action? What global, national, or local partnerships could help? 2. What rural healthcare teams, working within what scope, are needed? Do we already have workers with the skills for this scope of work? 3. How can we select workers for this role from the community? 4. How can we effectively educate and train people in rural areas and for the breadth of skills needed by rural communities? 5. How can we ensure practice conditions in the community promote health worker satisfaction, recruitment, and retention? 6. How can trained rural workers be accredited and recognized for transferability of the qualification? 7. How can rural workers be professionally supported? 8. Are the activities and outputs of the program being implemented as planned? What are the intended outcomes of rural pathways and how can we collect data to measure this effect? Each overarching question is followed by specific sub-questions, and substantiated by reference to literature. The checklist further contains guidance on the process of going about developing a rural pathway, including who should be involved and how. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 12 Prosperity Insight Merit-Based Recruitment Merit-based recruitment of competent and decades, several countries implemented teacher- driven staff is the cornerstone of government hiring reforms that selected new teachers based effectiveness. While all human resource primarily on candidates’ scores on standardized management (HRM) practices need to function exams. Evaluations of these reforms in Colombia, well for a high-performing management system, Ecuador, and Mexico found that teachers hired the starting point is attracting and selecting the through examinations had higher technical ability right people. If the human resource “inputs” are (as measured by grades in university) than those not fit for advertised positions in the first place, or hired through discretionary mechanisms (such as do not possess the general competencies required selection by trade unions), though the effects on to work effectively and are not motivated to serve student learning outcomes were mixed (Araujo and the public, it will be significantly more challenging others 2020; Busso and others 2023). to use other aspects of HRM practices (such as Survey results show that merit-based recruitment performance management, compensation, and is quite limited for health workers in Mali and training) to compensate for this shortfall and have Madagascar (figure 3). The HRH surveys measured such staff deliver high-quality public goods and merit by asking respondents whether they had been services. Research has shown that merit-based hired through a public recruitment competition recruitment is a strong predictor of high public- and, if so, what type of assessment criteria— sector performance. Hiring based on the quality of written test and interview—they underwent. The the candidate, rather than on personal or political survey revealed that most surveyed staff were connections, forms a basic pillar in a performance- brought on board without undergoing a competitive oriented bureaucracy model (Meyer-Sahling and selection process in either Madagascar (almost 80 others 2021). Meritocracy correlates with economic percent) or Mali (almost 70 percent). There are also growth and lower levels of corruption and nepotism differences in the competitiveness of recruitment (Fukuyama 2013), which in turn is associated with across the health professions with a gendered greater motivation and higher performance of civil dimension. In Mali, while 72 percent of doctors servants (Meyer-Sahling and others 2018). surveyed went through a public competition, most Vacancies for public sector health jobs in LICs and nurses and midwives did not (68 and 61 percent, LMICs attract many candidates, hence effectively respectively). While the lack of participation in screening these candidates for both ability and a public selection process is consistent across public service motivation is important. While the occupations, the lower participation of nurses and LIC and LMIC focused health literature has not given midwives may have important implications on the sufficient attention to this topic, there is a small ability and motivation of these mostly female staff, body of literature regarding other service delivery which is important given that in most facilities personnel and the importance of hiring based these are the only medical personnel providing on competencies rather than political affiliation basic health services. that is relevant for HRH. Much of this literature is on Latin America where, over the past couple of DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 13 Prosperity Insight Figure 3: Participation in a recruitment competition (percentage of respondents that said “Yes”), overall and by occupation a. Overall Madagascar 21% Mali 34% a. By occupation 72% 39% 32% 24% 20% 16% Doctor Nurse Midwife Madagascar Mali Source: World Bank. 2023. Mali and Madagascar HRH Surveys, Facility Level. Another critical implication to consider is that, for with even fewer completing technical degrees or countries like Madagascar and Mali, the overall tertiary education.3 This challenge in identifying a scarcity in finding technically qualified applicants pipeline of educated girls and women in the public for competitive selection of predominantly female health workforce further emphasizes the need for occupations such as nurses and midwives is implementing rural pathways for health workers, likely linked to the low education levels of women with focus on increasing the number of qualified in general. According to World Bank data, only female candidates for these jobs, especially in 25 percent of girls in Mali and 35 percent of girls underserved areas. in Madagascar complete lower secondary school, 3. World Development Indicators. Lower Secondary Completion Rate, Female – Mali, Madagascar. World Bank, Washington, DC (accessed January 11, 2024). DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 14 Prosperity Insight Performance Management Management quality plays a key role in the their evaluation results were neither discussed performance of personnel and service delivery. nor utilized in a meaningful manner. This lack of Personnel management, particularly robust acknowledgment can lead to disillusionment and a performance evaluations, regular conversations decreased sense of purpose in their roles, leading between managers and staff, and coaching to a poorly motivated public service that both the and mentoring are important influencers of Romanian and Croatian public services were found worker performance. Case studies on health to have. in Sub-Saharan African countries indicate that In Mali, the survey found that some key elements organizational culture—wherein flexibility, problem of performance management were present in the solving, participation, teamwork, and shared health facilities, though the evidence suggests that professional norms are valued and upon which the these are largely pro forma exercises. Most facility entity holds a strong sense of mission—is a more staff (74 percent) have monthly performance important determinant of performance than an evaluations; however, fewer staff (55 percent), entity’s renumeration or control structures (Grindle report having regular informal conversations and Hilderbrand 1995). Other studies from South with their manager. Similarly, in Madagascar, Africa, Taiwan, and China linked transformational 84 percent of facility staff report having received leadership and award systems that challenge direct supervision from their managers, but employees with interesting work and make them only 60 percent had a chance to discuss their feel valued and a sense of belonging, to higher performance with the manager in a formal or job satisfaction (Castro and Martins 2010; Tsai informal capacity. These discrepancies suggest 2014; York, Colasanti, and Josephson 1988). The a notable gap between the prescribed standards impact of any performance incentive scheme, such and the practical implementation of performance as individual rewards under performance-based management. Regular conversations between financing (PBF) programs, is conditional on the managers and staff not only offer invaluable insights robustness of the performance evaluation system. into individual performance but also play a crucial Across various public sectors globally, there role in nurturing staff engagement, motivation, and exists a significant variation in the effectiveness professional development. of performance evaluations. In Romania, a The academic literature does not explore gender World Bank survey of the administrative staff differences in performance management, but across several ministries revealed that a striking the survey results from Mali and Madagascar 95 percent of public servants received the highest are striking and suggestive of discrimination. attainable evaluation rating, highlighting a potential Men are more likely than women to have their lack of differentiation in evaluating performance. performance regularly evaluated. In Mali, Performance appraisals are meant to have formal 41 percent of male doctors or medical officers implications for staff promotions, accountability, receive monthly performance evaluations, and pay, yet the inflated ratings may diminish their compared with 21 percent of female doctors or impact on administrative decisions. The situation medical officers, and a similar discrepancy was is comparable in Croatia (through a similar survey), observed among male and female CHWs. Similarly where 93 percent of civil servants received the top in Madagascar, 29 percent of male doctors receive two ratings, and a sizable proportion reported that DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 15 Prosperity Insight monthly performance evaluations as compared women (36 percent), and when they are, they are with only 7 percent of female doctors. These gender likely to be promoted more than once or twice. differences in formal evaluations may contribute No woman was promoted more than twice in five to gender differences in career progression. For years, which was especially true for head of service example, in Mali, men reported being slightly more or more senior positions. likely to be promoted (39 percent) compared to Work Environment: Group Problem Solving Group problem solving is an important aspect of positive effects, with improvements ranging from teamwork emphasized in the literature that impacts large to small (Rowe and others 2018), mirroring individual knowledge and attitudes, and service what has been found in high-income settings delivery. Group problem solving encompasses a (Hill and others 2020). Effects also appeared range of interventions that are characterized by to strengthen over time (Arsenault and others problems being identified and solutions being 2022). The literature, however, does not distill key developed in collaborative (peer) groups, rather elements and contexts of successful interventions, than in a top-down fashion by superiors, although or key success factors in relation to intervention groups can be composed of individuals at various design (e.g. specific model, intensity) or context, levels of the hierarchy. Providing a platform for peer except suggesting that group problem solving may knowledge sharing, building skills, and capitalizing be more effective in primary than in secondary care on group dynamics and creativity to develop context- settings (Hill and others 2020). tailored and acceptable solutions have the potential This lack of best practices emerging from the to address bottlenecks such as for instance issues available evidence may relate to the fundamental around health worker skill levels or inefficiencies idea behind group problem solving—bottom- in resource use. They may also impact various up, participatory, and context-specific problem motivational drivers, such as through improvement solving—which in a way contradicts the notion of of the working conditions or through enhancing the very existence of generalizable best practices. interpersonal relationships in work teams (social However, it is plausible to assume that group incentives). Finally, they may act on internal drivers problem solving is more successful in organizations of motivation, for instance, by strengthening with a preexisting performance culture that values health workers’ perceived agency, self-efficacy, change, initiative, and participation, and that and sense of belonging and commitment. Box provides sufficient resources to effect change. 2 provides three examples to illustrate how However, creating such elements might be the group problem solving might look in practice. result rather than the precondition of group In 12 studies from LICs and LMICs, group problem problem solving. solving strategies showed almost exclusively DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 16 Prosperity Insight BOX 2: Examples of group problem solving interventions Group problem solving to improve Integrated Management of Childhood Illness in Kenya An intervention was conducted to provide training in group problem solving to district health management teams (DHMTs) and to encourage them to establish and train problem-solving teams in primary care facilities (Tavrow, Malianga, and Kariuki 2004). Teams, composed of existing facility staff, were meant to identify facility-specific barriers to Integrated Management of Childhood Illness (IMCI) adherence, and seek and lead the implementation of facility-level solutions to address them, with regular coaching and support by the DHMT as part of their routine supportive supervision activities. About one and a half years into the intervention, all intervention facilities had implemented solutions to an identified problem. Most teams tried to address frequent lack of IMCI drugs and demoralizing health workers, and work with health center management committees to improve drug availability. Intervention facilities performed significantly better in critical IMCI case management tasks compared to control facilities. Community Health Workers Community of Practice to improve tuberculosis contact investigation in Uganda Hennein and others (2022) report experiences from a pilot Community of Practice (CoP), intended to inform the development of a wider intervention and impact evaluation. They organized the first-ever CoP among the CHWs of two tuberculosis clinics as a forum to learn from each other and identify their own areas for improvement—gaining its ground from the normal, informal communications among the CHWs. CoP members were encouraged to meet on a weekly basis, under rotating leadership, to provide an opportunity for regular exchange of views, sharing of experiences and stories of successes and challenges, developing common goals, and engaging more broadly. These aims reflect the three core elements of CoPs: (1) a subject of shared interest (domain); (2) social interactions and relationships (community); and (3) shared frameworks, ideas, tools, and stories (practice). To catalyze discussions, the research team fed performance data into the CoP meetings (Wenger, McDermott, and Snyder 2002). Five months into CoP initiation, CoP members had instituted three activities in addition to the two proposed by the research team (feedback report review, weekly meetings): (1) real-time communication through WhatsApp and phone; (2) didactic education sessions on specific topics identified by CoP members, organized by the research team and delivered by invited experts; and (3) clinic-wide staff meetings to provide updates on contact investigation to those eventually in charge of managing identified tuberculosis cases. Participating CHWs reported feeling a motivating and inspiring shared sense of ownership of the CoP. They described how the CoP not only allowed them to exchange experiences and knowledge, thereby building their technical capacity and improving their self-efficacy, but to also benefit from social support, contributing to strengthened social and professional identities. Plan-Do-Study-Act cycles to reduce maternal, perinatal, and neonatal mortality in Malawi The results of a cluster randomized trial of a multi-component quality improvement initiative including both community- and facility-level quality improvement activities reported interesting results (Colbourn and others 2013). At facility level, the intervention consisted of breakthrough series collaboratives and coaching staff in DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 17 Prosperity Insight quality improvement methods. Breakthrough series collaboratives differ from other problem-solving groups in that they are structured, and are short-term rather than continuous learning activities, bringing together heterogeneous staff from multiple sites and of multiple professional backgrounds. The collaborates focused on key interventions to reduce maternal and neonatal mortality, such as the post-partum hemorrhage prevention protocol. Four collaborative learning cycles were followed by small tests of proposed change in the framework of Plan-Do-Study-Act cycles. While no impact on maternal mortality could be established (given the insufficient observation data due to the rareness of the event), the impact evaluation found positive effects on neonatal mortality particularly for the combined community and facility-based intervention package. Financial Incentives Financial and “quasi-monetary” incentives have posts (Willis-Shattuck and others 2008; Henderson long been a fundamental part of many health and Tulloch 2008), but high effectiveness in worker remuneration packages in LICs and LMICs, the implementation of vertical, donor-funded with health workers often able to receive a broad programs (Martínez and Martineau 2002). Reasons range of salary top-ups and benefits (e.g., housing, are manifold and context-dependent, but usually subsidized education) on top of their base salaries related to inadequate amounts in relation to other based on a range of factors. parts of complex remuneration packages as well as in relation to the costs, financially and otherwise, Traditionally, such incentives and benefits have of assuming particular roles (Bertone and Witter rarely been tied to day-to-day performance, 2015). An important consideration also relates to but rather to performance in a broader sense, temporality of effects. While improvements to the such as for instance accepting to work in rural working conditions, including remuneration, might or otherwise unattractive areas and posts, or to be highly effective in the short term, individuals tend assume additional work responsibilities, often in to get used to changed realities quickly, adjusting the context of time-limited, donor-funded projects. their internal benchmarks and expectations. This is also related to the fact that in many LICs and LMICs, health workers are civil servants and as such, in contractual arrangements that extend Performance-Based Financing to other sectors such as education, decisions In the early 2000s, there was a surge in using on incentives and benefits need to be taken in financial incentives in healthcare, especially careful consideration of other sectors to avoid in Sub-Saharan Africa, with the introduction dissatisfaction of civil servants outside of the of performance-based financing (PBF). Unlike health sector. traditional bonuses linked to specific roles, PBF ties incentives directly to daily performance in Available evidence suggests limited effectiveness delivering healthcare. The idea behind PBF is to of incentives and benefits in retaining staff in rural boost the use and quality of healthcare services. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 18 Prosperity Insight It does this by encouraging healthcare providers problem solving, which prescribes a bottom-up to match their services with what the community or at least a participatory approach to identifying needs and what the health system requires. and solving local challenges, PBF subscribes to Providers do this by signing contracts that outline a more all-encompassing and value-free idea of specific performance goals. Meeting these goals entrepreneurship, where for instance purely top- results in financial rewards. At the same time, PBF down approaches are perfectly acceptable so long gives healthcare facilities more independence as they lead to better healthcare provision. in management and strengthens supervisory PBF has been extensively evaluated. As noted systems (Renmans and others 2017; Fritsche and above, impact evaluations focus exclusively on others 2014). frontline care provider performance (often only PBF functioning is usually explained with agency primary care) and population impact, whereas theory (Savedoff 2010). Specifically, it is assumed impact on performance of the administrative that healthcare providers’ (agents) interests are hierarchy is unclear. A recent Cochrane review, not always aligned with those of the population including 59 evaluations of PBF and other Pay- (a principle upheld by the Ministry of Health in for-Performance (P4P) schemes in 25 countries general). From a health financing perspective, (primarily in Sub-Saharan Africa and Asia), reasons lie in inadequate separation of core health concluded mixed effects and high heterogeneity financing functions, particularly purchasing and due to differences in intervention design and service provision, as both fall under the Ministry contextual factors (Diaconu and others 2021). The of Health in many low-income and lower-middle authors highlight that although the body of evidence income public healthcare systems. With budget is continually growing, the strength of evidence is allocation and salaried staff as main purchasing still often weak. Another review of a set of impact arrangements, few levers for alignment of interests evaluations concluded that PBF can result in gains exist. PBF acts as such a lever by using performance to service utilization, but only has limited impacts contracts and financial rewards to communicate on quality (Walque and others 2022; Walque and expectations and financially reward compliance. Kandpal 2022). The authors further compared PBF to direct facility financing (operating budgets and On the one hand, the wish to generate additional provider autonomy, but not performance pay) and income is expected to motivate health facilities and demand-side financial support (e.g., conditional health workers to provide care of high quality to cash transfers, vouchers), showing that the all individuals in need. On the other hand, revenue performance-based payment modalities add little generated through PBF, coupled with enhanced value over and above flexible payment systems managerial autonomy, is expected to allow health and provider autonomy. In explanation, they found facilities to improve their infrastructure, equipment, that shortfalls in quality of care are only to a small and resource situation to enable improvements in part attributable to individual health worker effort, service delivery. Like the group problem solving whereas to a considerable extent to structural interventions above, PBF is grounded in the limitations. In conclusion, they advocate for the fundamental assumption that local structures elements of direct facility financing, autonomy, are in the best position to identify and solve their transparency, and community engagement, and specific problems. In fact, in practice, performance recommend moving away from performance- improvement in PBF facilities often essentially conditional payment mechanisms, at least in takes a group problem solving approach, even if not under-resourced, centralized health systems. explicitly labeled as such. However, unlike group DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 19 Prosperity Insight In terms of intermediate outcomes or presumed (3) a fair and transparent system of distributing mechanisms of change, PBF and/or P4P seems incentives, particularly among individual health to be effective in increasing availability of inputs workers at health facility level; (4) use of a wide range in frontline care provision (human resources, of indicators; and (5) involvement of communities infrastructure, equipment, medicines, and other and drawing on existing structures in results supplies), although there is little indication of verification. The review further suggests that PBF effects on provider absenteeism (Diaconu and works best in health facilities that are sufficiently others 2021). Results are also encouraging for staffed and skilled to deliver the incentivized facility managerial autonomy (low certainty services; in contexts with already decentralized evidence). For other assumed mechanisms of financial systems, where health facilities have change or intermediate outcomes such as health autonomy over funds; and in systems with efficient facility management quality and governance banking systems allowing timely transfer of funds. as well as provider motivation and satisfaction, The individual incentive impact of PBF is dependent there is little indication of effects. Qualitative on the quality of performance management, which and mixed methods research on how PBF affects is often weak in LICs and LMICs, and the size of health worker motivation suggests that PBF does the incentive. The Mali and Madagascar surveys not simply leave health workers unaffected in revealed, as noted above, that while monthly their willingness to do well (Lohmann, Muula, performance evaluations were taking place, and others 2018; Lohmann, Wilhelm, and others informal conversations with managers were less 2018; Bhatnagar and George 2016). Rather, health frequent. The Mali HRH survey also found limited workers often report significant improvements in use of financial incentives tied to performance for their work environment, positively contributing facility staff. Sixty percent of facility staff did not to their perceived ability to do well, which they receive any salary increases in the past year, with perceive as highly motivating. Many feel motivated 55 percent of staff in the PBF treatment facilities by altered social dynamics through a renewed receiving no salary increases (figure 4). Treatment performance focus and transparency of work facilities did provide more performance-based performance, as well as recognition for effort bonuses (18 percent) compared to control groups signaled by the performance rewards. Yet, they (5 percent), while unconditional salary increases equally report significant challenges, many of were the most generic form of financial incentive which are related to monetary aspects, such as in both treatment and control facilities (24 percent delays in payment of PBF rewards and issues of and 28 percent, respectively). When asked about fairness in individual staff bonuses, acting as major the size of the most recent monetary bonus, demotivators effectively cancelling out the positive 36 percent of respondents from treatment facilities, motivational effects of other aspects of PBF. and 56 percent from control facilities, stated that A realist evaluation accompanying the Cochrane it was less than 5 percent of their salaries. Among review unpacks the design modalities and those who did receive a salary bonus, men tended conditions under which PBF seems to have worked to receive larger bonus amounts compared to comparatively better (Singh and others 2021). It women. A smaller percentage of men compared highlights the following “good practice” design with women received very small bonuses of less features: (1) incentive amounts that result in than 5 percent (35 percent male versus 41 percent 10 percent or more increase in overall salary of female). On the other hand, men were more incentivized individuals; (2) incentivization that likely to receive bonuses larger than 11 percent occurs at all levels of the health system hierarchy; (16 percent male versus 13 percent female). DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 20 Prosperity Insight Figure 4: Salary increases over the past 2 years by performance-based financing participation 55 24 Treatment 18 2.4 .28 65 28 Control 4.9 1.9 .75 0 20 40 60 Percentage No increase General increase Individual performance increase Other Promotion Source: World Bank. 2023. Mali HRH Survey, Facility Level. More broadly, gender-based wage discrepancies of the top two wages compared to male nurses, were observed within each occupation category. with 71 percent of female nurses earning one of In Mali, survey results show that men outearned the top two wages compared with 72 percent of women in professions at both the higher and lower male nurses. income levels. For example, 74 percent of men Gender wage gaps like those of doctors were doctors earned the top salary of more than CFA also apparent for the lower skilled, less well-paid 175,000, compared with 67 percent of female health professions where men were less likely to doctors (figure 5A). Women doctors were also be at the lowest pay scale than women (figure 5B). more than five times more likely to earn a much For example, female pharmacists are twice as lower wage: between CFA 5,000 and CFA 7,500, likely to earn less than CFA 50,000 compared to compared to their male counterparts. Wages were male pharmacists and only one-third as likely to more even in the more feminized but highly skilled earn CFA 75,000 or more. For community health profession of nursing. Female nurses were more workers, 78 percent of women compared with likely to earn the highest wages compared to men. 55 percent of men earned the lowest wage. However, they were slightly less likely to earn one DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 21 Prosperity Insight Figure 5A: Comparison of wages between men and women in top-earning occupations 100% 23% 30% 80% 67% 74% 60% 42% 49% 40% 20% 23% 24% 29% 28% 10% 2% 0% Female Male Female Male Doctor or medical officer Nurse (SEN/SRN) ≥175,000 ≥75,000 - <17,500 <7500 Source: World Bank data; World Bank. 2023. Mali HRH Survey, Facility Level. Note: SEN = State Enrolled Nurse, SRN = State Registered Nurse. Figure 5B: Comparison of wages between men and women in lower-paid occupations 100% 12% 13% 16% 33% 9% 80% 29% 60% 50% 47% 40% 78% 55% 20% 37% 20% 0% Female Male Female Male Pharmacist Community health worker ≥75,000 ≥50,000 - <75,000 <7500 Source: World Bank data; World Bank. 2023. Mali HRH Survey, Facility Level. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 22 Prosperity Insight Among top earning occupations, doctors were likely than men to earn one of the two lowest wage more likely to earn the highest wage, while wages categories and the least likely to earn higher wages were more equal between male and female nurses. compared to men. Among lower-paid occupations, women were more Nonfinancial Incentives Given the challenging work conditions and financial Bhatnagar and George 2016; Kalk, Paul, and concerns, research emphasizes the vital role of Grabosch 2010). nonfinancial incentives or social motivators. These For a CHW, a comparatively solid evidence base incentives, both positive (like social recognition) speaks in favor of recognition schemes, standalone and negative (like stricter monitoring through digital or in combination with financial incentive technology), are crucial. Positive relationships components (Gadsden and others 2021; Naimoli with colleagues, managers, patients, and the and others 2015; Bhaumik and others 2020). community, along with a sense of belonging and Specific interventions include for instance public commitment to the organization, enhance health awards for exceptional performance, letters of workers’ motivation. These factors boost their thanks from government officials, or certificates for social standing and self-worth, while their absence completing certain duties, as well as measures to acts as demotivators (Mathauer and Imhoff 2006; recognize and provide visibility to CHWs as a health Mbindyo and others 2009; Pandya and others worker cadre. 2022; Sirili and others 2018; Chimwaza and others 2014; Thi Hoai Thu, Wilson, and McDonald 2015). Absenteeism is a major problem in many low- income and lower-middle income healthcare There are limited evaluations of nonfinancial systems, especially in rural areas. Reasons vary recognition and rewards, especially for healthcare from valid causes like planned leave or illness professionals. One of the exceptions is a study to questionable ones such as dual practice or in India, which reveals that team-based goals, personal matters. Validity depends on local norms appreciation tokens, performance transparency, and cultural context (Belita, Mbindyo, and English and recognition certifications notably improved 2013). Addressing absenteeism involves various the performance of maternal health service teams culture-dependent strategies, from spot checks to (Carmichael and others 2019). Another study broader efforts targeting organizational culture. in Zambia found that rewarding public health extension workers with public recognition for selling Digital monitoring of healthcare workers can curb contraceptives, with each sale rewarded with absenteeism, but there are both benefits and stars, was more effective than financial incentives drawbacks to this technology. In India, it improved (Ashraf, Bandiera, and Jack 2014). Further, studies attendance and skilled birth deliveries, yet it also on the motivational mechanisms of PBF highlight led to staff resentment and attempts to bypass the powerful motivational potential of measuring the system. Additionally, many local governments and making performance transparent to peers and didn’t take action against absent workers due to the public, independent of the financial incentives bureaucratic rules or political factors (Dhaliwal that follow (Lohmann, Wilhelm, and others 2018; DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 23 Prosperity Insight and Hanna 2014). In rural clinics in Pakistan, Based on evidence from high-income countries, smartphone monitoring of health supervisors however, it is likely that “soft strategies” including doubled facility inspections and decreased worker organizational change interventions aimed at absenteeism, although the impact on absenteeism attendance culture, improvements in the working depended on local politics (Callen and others conditions, health and wellness programs, and 2018). Similar studies on other service providers, possibly incentive schemes are likely better notably teachers, also underline the importance suited and more effective in LIC and LMIC health of local context, regulations, management quality, systems, particularly at primary level in rural areas, and incentives to enable digital monitoring to than regulatory mechanisms aiming at enforcing create an impact. presence (Kisakye and others 2016). Training Surveys of private and public sector staff in Africa, Watson and others 2018). Overall, numerous Asia, and Europe found that training can strengthen authors argue for a combination of classroom and workers’ skills, engagement, and performance, and on-the-job training that is informed by participants’ can increase morale and motivation (Ameeq-ul- needs, with an emphasis on reflective learning- Ameeq and Hanif 2013; Amos and Natamba 2015; by-doing and team-based learning (Choonara and Manzoor and others 2019). A systematic review others 2017; Türk and Saue 2019). Classroom- of health system strengthening interventions based training may increase workers’ technical highlighted how on-the-job training can motivate knowledge, but mentorship, coaching, sponsorship, workers and even reduce attrition rates (Ayanore and intergenerational cooperation could ensure and others 2019). Another recent systematic review such skills translate into changed work behavior of strategies to enhance health worker performance and ultimately into better performance (Chanyalew, in LICs and LMICs specifically found that in-service Yitayal, and Atnafu 2022). Effective leaders with training is consistently effective, particularly when the requisite management skills are essential to coupled with supervision or group problem solving, helping that process move forward. Some argue and when targeting healthcare professionals, but that a person’s learning transfer process is affected less so for community and other lay health workers by their and the trainers’ abilities, the training (Rowe and others 2018, 2021). Yet, some scholars design, and the work environment (Sørensen criticize the available evidence of training’s impact 2017). Ultimately, in order to maximize the impact on performance as being largely from higher- of any new training initiative, capacity-building income countries and the private sector, of low programs should consider who are best placed to quality, and as non-experimental or at times teach and spread the much-needed knowledge indicating only limited or no effectiveness (Ayeleke and how to do so. For example, practical, problem- and others 2016; Dieleman and Harnmeijer 2006; driven, and action-based learning programs Grindle and Hilderbrand 1995). tailored to participants’ ability and the local context can improve bureaucrats’ understanding and An array of training tools have been explored, adoption of management reforms (Brinkerhoff and including the common use of workshops, internet- Brinkerhoff 2015; Choonara and others 2017; Türk based or self-directed learning, communities and Saue 2019). of practice, and technical assistance (Decorby- DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 24 Prosperity Insight Healthcare professions worldwide are closely In Madagascar, the survey highlighted a notable regulated, ensuring professionals meet certain disparity in the availability of ongoing professional standards. This regulation involves accrediting development opportunities among facility staff. training institutions and licensing individual health Forty-three percent of respondents reported not workers through professional organizations or receiving any training in the past two years and government bodies. While there is less evidence expressed concerns that their training needs were on the effectiveness of accreditation and licensing not adequately assessed. Further, more than half in related areas, these practices provide essential of those who reported not receiving any training safeguards in healthcare (Aftab and others 2021; pointed to the absence of training opportunities Saks 2021; Antwi and others 2021; Braithwaite and being offered as the primary cause. others 2012). Upholding or renewing licenses is Women also faced greater obstacles in receiving often an administrative act in many health systems training (figure 6). In Mali, a higher percentage of in practice, and enforcement is not always thorough female employees (21 percent) did not have access on shortfalls, for instance, in Ethiopia (Alemneh to training compared to their male counterparts and others 2022). Accreditation and licensing can (12 percent). When probing the reasons behind improve performance by maintaining education this discrepancy, a larger proportion of women standards, continuous training, and ethical conduct. pointed to constraints such as time limitations, a They address capacity issues and various external limited array of training options, and insufficient (like social incentives and pressure) and internal opportunities provided by their institutions. (such as self-confidence and professional identity) Similarly in Madagascar, a greater proportion of motivational factors. Although specific evidence women (46 percent) reported a lack of training in LICs and LMICs is limited, case studies suggest compared with men (37 percent). Significantly, their positive impact (Touré and others 2021). more than half of those who missed training in the The World Bank HRH surveys revealed that training, past year attributed their situation to the absence when available, is often not well designed. In of training opportunities. There are also important Mali, 83 percent of health workers cited receiving gender differences in the type of training received. training in the last two years, either provided by Female health workers in Mali were only half as the health administration or by an external party. likely to receive at least some training from external Those who had not undergone training cited sources compared to male workers (33 percent limited opportunities provided by their facility versus 60 percent). They were also less likely than (23 percent), not being selected for training men to receive training in high value areas such as (21 percent), or finding the training irrelevant health financing, a bias with important implications (11 percent). However, only 62 percent agreed that given its potential relationships to facility their training needs were adequately addressed. funding decisions. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 25 Prosperity Insight Figure 6: Gender differences in on-the-job training, Mali 70% 60% 60% 46% 50% 37% 40% 29% 30% 21% 20% 12% 10% 0% Did not receive any training* Received training Training in health financing** from outside institution* Women Men Source: World Bank data; World Bank. 2023. Mali and Madagascar HRH Surveys, Facility Level. Health Worker Motivation A large body of literature has explored various motivation “originating from within” without such aspects of health worker motivation—whether an external stimulus. Research has shown that it is a personality trait, largely stable over time, although motivation of any type can be effective in or situational and fluctuating; and whether it is driving performance, intrinsic motivation tends to “intrinsic” or “extrinsic.” Not surprisingly, the have favorable properties over extrinsic motivation literature concludes that motivation can be both a in that it is more stable over time and generalizes trait and situational (Wasserman and Wasserman better across settings, situations, and behavior 2020). Understanding motivation as a trait is useful (Van den Broeck and others 2021). Intrinsic types when thinking about habitual tasks—it reflects of motivation further better predict quality of work, a person’s overall willingness to perform when as opposed to quantity (Cerasoli, Nicklin, and Ford conditions are good. On the other hand, looking at 2014). Finally, intrinsic motivation relates not motivation as a state is helpful for specific goals, only more favorably to performance, but also to like aiming for a particular outcome. Depending on other desirable outcomes such as organizational the job and workplace, this difference is essential commitment or wellbeing, whereas the opposite for hiring and choosing the right people. tends to be true for extrinsic motivation (Gagné and Deci 2005; Van den Broeck and others 2021; Extrinsic motivation is derived from an external Miquelon and Vallerand 2008). Recent empirical stimulus or “driver,” such as financial or nonfinancial studies confirm the importance of intrinsic incentives. In contrast, intrinsic motivation is motivation and mission orientation for health DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 26 Prosperity Insight worker performance. In Pakistan, doctors that Earnings within the public sector play a critical role score higher on an index measuring public service in attracting and retaining skilled workers, yet the motivation were less likely to be absent from link between income and higher staff motivation work or to fabricate health reports (Callen and is complex. Additional income may motivate others 2018). performance, serving as a sign of valuation and recognition of effort and achievement. In case The World Bank HRH survey revealed high levels of perceived inadequacy or unfairness, they may of intrinsic motivation, despite the limitations of signal lack of valuation and recognition. While it is resources and infrastructure, among facility staff acknowledged that health workers might perceive in Mali and Madagascar. In Mali, for example, most their wages as low, it is important to note that staff stated that they were more motivated now overall wages in LICs and LMICs are generally low. than when they joined public service, primarily In comparison to the private sector and formal wage due to the challenging nature of their work and employees, the public sector, on average, offers the opportunity to serve citizens. In both Mali and higher wages to health workers. Nevertheless, the Madagascar, however, a considerable proportion of expectations and perceptions of wages also matter, staff facility staff were considering leaving their jobs and the surveys’ findings indicate that a significant due to low extrinsic motivation. When asked about majority, 73 percent of facility staff in Mali and 61 their likelihood of remaining in the same facility percent in Madagascar, believe they would receive over the next two years, 43 percent of facility staff higher salaries if employed in the private sector in Mali and 73 percent in Madagascar expressed than their current positions in the public sector. their intention to continue working in their current This mismatch between actual wage premia and facility (figure 7). However, a substantial proportion perceived wage premia may reflect differences in (46 percent in Mali) remained undecided about wage structure, as wage growth in the public sector their plans, and a small percentage indicated is usually more compressed and workers may be the possibility of leaving within the next two basing their expectations in comparison to the years in both countries. The reasons given were higher end of the private sector wage distribution. low salaries, limited career prospects, and the challenges associated with remote work locations. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 27 Prosperity Insight Figure 7: Facility staff’s views on turnover a. Staff’s future plans 73% Will likely keep working here 43% 16% Haven’t decided 46% 11% I would like to leave my facility in the next two years 10% Madagascar Mali b. Reasons for staff turnover 10% 27% Mali 7% 14% 6% 9% Madagascar 9% 52% Lack of recognition Low salaries Poor career opportunities Remote location Source: World Bank. 2023. Mali and Madagascar HRH Surveys, Facility Level. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 28 Prosperity Insight Mental Health and Resilience As the above description of external drivers interventions (Kunzler and others 2020; Heath, illustrates, health workers work under immense Sommerfield, and von Ungern-Sternberg 2020; pressure and often demanding work environments. Melnyk and others 2020). They deal with morbidity and mortality daily, suffer Evidence on intervention effectiveness is generally from high rates of workplace violence (Liu and limited and almost exclusively from high-income others 2019; Njaka and others 2020), and work settings (Cleary and others 2018; Kunzler and on the frontlines of managing the consequences others 2020; Venegas and others 2019; Melnyk of humanitarian crises and natural disasters. High and others 2020; Heath, Sommerfield, and von levels of burnout and other mental health issues Ungern-Sternberg 2020; Rogers 2016). A recent among health workers worldwide are therefore Cochrane review concluded that for interventions not surprising (Aiken and others 2012; Lohmann, labeled as psychological interventions to foster John, and Dzay 2022). There is little research on resilience, there is some evidence of higher levels the performance-related consequences of poor of resilience and lower levels of depression and psychological wellbeing among health workers in stress, but evidence has low certainty to date, LICs and LMICs, but the few available studies from with usually short follow-up time frames (Kunzler high-income country contexts demonstrate the and others 2020). The available evidence does adverse consequences of poor mental health on not allow judgments on the relative importance of quality of care and patient safety.4 intervention frequency—investigated interventions In the wake of the COVID-19 pandemic, there is ranged from one-hour sessions to multi-month new interest in interventions to improve health programs—and mode of delivery, such as face- worker resilience to adversity and to foster mental to-face, online, or hybrid. In low-income settings, health. Available interventions include self-care there is a study from Sierra Leone evaluating a interventions (e.g., exercise, sleep, hygiene, multi-week counseling and psychosocial training personal relationship focused interventions, prior to the Ebola pandemic aimed at helping health mindfulness and self-awareness training, stress workers improve their coping skills by addressing management and relaxation training), interventions workplace stressors, introducing support services, aimed at improving working conditions and and improving interpersonal relationships (Vesel organizational justice, interventions to foster and others 2015). Evaluation results indicate coping skills (grounded for instance in cognitive positive effects on coping skills and stress levels, behavioral therapy or problem-solving therapy), albeit with a rather low-certainty study design. and to a limited extent disaster preparedness 4. See Grover and others (2018); Kim and others (2018); Ojedokun, Idemudia, and Kute (2013); Panthee, Shimazu, and Kawakami (2014); Negueu and others (2019); and Sharma and Dhar (2016). See also Aiken and others (2012); Davey and others (2009); Hall and others (2016); and Wilkinson and others (2017). DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 29 Prosperity Insight 3. DRIVERS OF WORKER PERFORMANCE IN THE HEALTH ADMINISTRATION This chapter presents evidence on the main HRH and Madagascar. It focuses on how these drivers drivers of personnel working in the central and influence the core stewardship functions like local health administration based on a review of facility funding, supportive supervision, and data the literature and the surveys carried out in Mali informed management. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 30 Prosperity Insight Facility Funding The sustainable and equitable financing of high- in the receipt of their allocated facility funds quality health systems remains a central challenge (figure 8). In Madagascar, among those facilities toward achieving universal health coverage (UHC). experiencing delays (68 percent of all facilities), 78 Hospitals and health systems are under constant percent experience delays lasting longer than six pressure to cut costs while maintaining and months. Notably, delays in facility payments were improving a high-quality and robust organization. more prevalent in facilities managed by women The COVID-19 pandemic has exacerbated the (71 percent) compared to those managed by men financial challenges that facilities are facing. (65 percent). In Mali, less than half of all facilities Adequacy of funding is essential for the success of cited not receiving facility funds on time, where PBF as the approach relies heavily on consistent delays are lasting more than six months for half funding for health facilities, which is transferred of all facilities. In addition, men were more likely directly to their accounts, and on facility autonomy to report being involved in facility fund decision- in using the funds and in involving community making in PBF facilities in Mali, with 78 percent of leaders in managing the facility (Witter, Bertone, men reporting involvement with financial decision- and Diaconu 2021). making compared with 65 percent of women. In both Mali and Madagascar, a substantial share of facility managers reported substantial delays Figure 8: Experiences with receiving facility funding 78% Delays lasted more than 6 months 50% 68% Did not receive on time 49% Madagascar Mali Source: World Bank. 2023. Mali and Madagascar HRH Surveys, Facility Level. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 31 Prosperity Insight In both countries, staff also reported significant facility construction and renovation were subject political influence in the use of facility funds. The to political pressure. These findings may imply survey asked facility staff about their views on possible misallocation of resources, delayed or whether decisions regarding budget administration inadequate infrastructure improvements, and and facility construction and renovation were compromised patient care. Ensuring transparency subject to political influence. Almost half of all in financial processes can help mitigate concerns facility staff in Madagascar (48 percent) and in about political pressure. Mali (51 percent) reported that decisions on Supportive Supervision Supportive supervision has long constituted a Evidence on the impact of supportive supervision key pillar in healthcare management, although is limited. On average and across a broad range of its implementation remains often poor in LICs settings and performance measures, interventions and LMICs (Avortri, Nabukalu, and Nabyonga- to strengthen supervision showed moderate effects Orem 2019; Vasan and others 2017). Supportive if standalone, but with substantial variation by supervision involves observing and evaluating setting and intervention design (Rowe and others practices, providing feedback and guidance, and 2018; Arsenault and others 2022). It is crucial to addressing problems collaboratively. Unlike top- recognize that many studied interventions were down approaches, it emphasizes constructive funded externally, raising doubts about their interaction between supervisors and workers. It integration into routine healthcare practices. offers not just technical guidance but also emotional Additionally, most interventions had short-term support, recognition of effort, and motivation. This is follow-ups, leaving long-term effects uncertain. crucial for frontline healthcare providers who often While the evidence is limited for definitive work in isolation, fostering a sense of belonging and conclusions, certain factors have been identified commitment (Rabbani and others 2016; Kok and as key to the success of supervision-related others 2018; Madede and others 2017). Effective interventions (Deussom and others 2022; Hill and supportive supervision directly improves healthcare others 2014; Avortri, Nabukalu, and Nabyonga- workers’ skills and addresses obstacles to their Orem 2019; Ballard and Montgomery 2017; Vasan performance. It also enhances their motivation and others 2017; Dieleman, Gerretsen, and van der by improving working conditions, providing Wilt 2009). social incentives, and boosting self-confidence. First, interventions work better when they are part In LICs, especially in primary care, supportive of a broader quality improvement plan or combined supervision is commonly a mix of group and with training or mentorship. Many low-income individual sessions. Supervisors, often district settings lack structured supervisory systems health management teams, visit facilities to and clear guidelines for performance, especially oversee various issues, using structured checklists. beyond facility-level metrics and core clinical Supportive supervision can also involve experts processes. This lack of clarity can demotivate from higher levels of the health ministry or even both supervisors and those being supervised local government officials, depending on the health (Nyamhanga, Frumence, and Hurtig 2021; Bradley system’s organization. and others 2013). DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 32 Prosperity Insight Second, supervision by both direct line managers location of feedback delivery are less significant, and external assessors has been proven as effective. offering flexibility in adapting to different contexts. Success factors include technical expertise, Fifth, the use of data, particularly from health teaching skills, emotional support, and the quality information systems, to support supervision is of relationship between supervisors and workers. inconclusive due to the lack of tangible performance Peer supervision, although tested, is less favored indicators. New studies reveal that mHealth and due to potential tensions and increased workload. other technology applications show promise, but Community-based approaches, especially for the evidence to draw strong conclusions is limited. community health workers, have mixed results. For example, one study explored the potential While self-assessments have limited standalone for an mHealth app to generate health worker impact, they show value when integrated into larger performance metrics for supportive supervision supervision or quality improvement programs. (Savai and others 2022). The app, originally for Third, monthly supervision is found to be more patient data, was upgraded to track detailed health effective than quarterly sessions, emphasizing worker metrics like patient numbers and working the quality of supervision over mere frequency. hours. Although the study did not assess its impact Continuity and regularity in the supervisory on performance, it highlighted the app’s potential relationship are crucial for mutual understanding to provide crucial performance data previously and trust. However, maintaining this consistency unavailable for supportive supervision. is challenging in many low-income settings due In Madagascar, staff working in the health to resource shortages and frequent staff turnover, administration at the central, regional, and both of which hinder high-quality supervision district levels reported that supervision is linked (Nyamhanga, Frumence, and Hurtig 2021; Bradley to facility performance, yet more than 40 percent and others 2013). Mobile phones are often used to of all administrative staff reported that regular remedy these challenges and have been proven as facility supervisory visits are not being conducted effective means of enhancing communication and (figure 9). While the presence of supervision is exchange when in-person visits are not possible encouraging, the lack of frequent visits suggests (Deussom and others 2022; Feroz, Jabeen, and that there is room for improvement, particularly Saleem 2020). given the benefit of regular supervision. Fourth, timely and positive feedback is crucial for effective supervision, while the method and DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 33 Prosperity Insight Figure 9: Average interval between supervisory visits 42 40% 30% 25 Percentage 20% 13 11 7 10% 1 0% Don’t Every Every Twice a year Once a year Once in conduct one 1-3 months 2-4 months two years Source: World Bank. 2023. Madagascar HRH Survey, Administrative Level. While there appear to be facility supervisions in both and 30 percent in Madagascar recognized the countries, survey findings reveal various challenges importance of understanding the local context for to effective supervision. In Madagascar, 81 percent effective supervision. These findings underscore of respondents cited a lack of financial resources the crucial role of contextual knowledge in as a major hurdle to adequate supervision in tailoring supervisory approaches to the specific healthcare facilities, followed by time constraints needs and challenges of healthcare facilities and (34 percent). Similarly, in Mali, financial resources their communities. A deep understanding of local and supervisors’ attitudes were identified as key dynamics, cultural norms, and healthcare practices obstacles to better supervision in healthcare enables supervisors to make well-informed facilities (30 and 29 percent, respectively). decisions and offer relevant guidance. Conversely, 65 percent of respondents in Mali Data-Informed Management Digital technologies such as mobile technologies Brinkerhoff and Bossert 2008; Curristine, Lonti, (mHealth) and Health Management Information and Joumard 2007; Fryatt, Bennett, and Soucat Systems (HMIS) can greatly increase public 2017; Holeman, Cookson, and Pagliari 2016; Yip administrative capacity. They have the potential to and Hafez 2015). Kenya, Uganda, Ethiopia, and both track and showcase administrative processes Guinea have successfully used digital technologies and service delivery, increasing efficiency, to set up remote sensing, responsive, early warning transparency, and accountability in the process; disease surveillance systems and have managed provide data for evidence-based decision-making; medical records more efficiently for patients, which or raise awareness around public health initiative ultimately strengthened their health systems. (World Bank 2023; Beschel and others 2018; However, the utilization of empirical data to inform DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 34 Prosperity Insight healthcare management and decisions is quite though not all, performance indicators (Heerdegen variable elsewhere, with some countries utilizing and others 2020; Macarayan and others 2019; less than 5 percent of health data to strengthen Fetene and others 2019). The study in Ghana also health systems, improve health financing and found a positive relationship between managers’ public health, and increase reach for underserved leadership and management ability and both their populations (Ayanore and others 2019). own and subordinate performance (Avoka and Seidu 2017). Implementing these technological solutions depends on the infrastructure available and In both Mali and Madagascar, the survey findings the capacity and incentives of staff, particularly underscore the challenges in effectively utilizing administrators, to utilize technology for its collected data within the healthcare system. intended purpose. The LIC and LMIC literature Seventy-one percent of respondents in Madagascar on management capacity in the health system and 55 percent of respondents in Mali report is relatively limited, but available studies have that the data often capture a substantial number found highly variable management capacity both of indicators, which present challenges when in health facilities and the administration, as compiling, interpreting, and effectively utilizing the well as variation in health worker or institutional information (figure 10). While the intention behind performance as a function of managers’ capacity. capturing a comprehensive set of indicators is to Studies from Ghana and Ethiopia linking self- ensure a quality assessment of facility performance, reported management capacity to facility or district it can inadvertently lead to information overload performance have found out that units with higher and hinder the ability to derive actionable insights. management capacity perform better on some, Figure 10: Share of respondents agreeing with “Data often captures too many indicators, creating challenges when compiling, interpreting, and effectively utilizing the findings.” Madagascar 72% Mali 55% Source: World Bank. 2023. Mali and Madagascar HRH Surveys, Administrative Level. Training programs may then focus on administrators’ technical knowledge and understanding of certain work functions or address workers’ behavior, including their self-efficacy and application of that knowledge (Decorby- Watson and others 2018). For instance, some quantitative and experimental studies concluded that training programs on leadership or management combined with performance-related pay schemes or courses teaching emotional intelligence, conflict management or empowerment in particular, have improved job performance (Olu and Adesubomi 2014; Seidle, Fernandez, and Perry 2016), as reviewed in more detail in chapter 2. In Ethiopia, the combination of training on data analysis, data presentation, and data use in decision-making; mentorship programs to spread these lessons; and post-training action plans has helped increase the effective DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 35 Prosperity Insight use of health information systems (Chanyalew, Teams (DHMTs) in Ethiopia, employing team-based Yitayal, and Atnafu 2022). and experiential learning strategies and leading to the formation of leadership teams, resulted in Given the importance of management quality and significantly higher district performance on various leadership in low-income and lower-middle income dimensions including quality of care (Desta and health systems discussed above, leadership others 2020). capacity development interventions for managers are increasingly popular in recent years in LICs and Summarizing the evidence on a subset of LMICs (MacKechnie and others 2022). Whereas leadership interventions, namely those directed traditional medical leadership roles were grounded in improving leadership in concrete, frontline in clinical or academic achievement, leading patient care rather than broader organizational to “old-school” supervisory models focused leadership, Mianda and Voce (2018) conclude that primarily on tasks, the importance of leaders’ experiential, work-based learning is most effective. ability to mentor, motivate, and collaborate are Edmonstone (2018) offers an explanation by increasingly recognized as key to implementing discussing the context-dependency of appropriate supportive supervision. and effective leadership from a theoretical and historical perspective. He argues that given the Leadership programs assessed in the literature non-universality of good leadership, the context range from short-term (one day to several weeks) dependency of good leadership practice and to multimonth or rarely even multiyear programs, action, or experiential learning approaches, where and are usually hosted face-to-face in academic best practices are developed and evaluated by institutions, targeting “active” leaders at all levels the learners rather than presented by an outside of the hierarchy, students, and other prospective entity, are likely the most effective capacity leaders, or both (MacKechnie and others 2022). development tool. Themes covered varied across interventions, but common to most were communication, In both Mali and Madagascar, several administrators organizational structure and leadership, and highlighted a critical deficiency in essential personal development. Similarly, a variety of training for data analysis, further compounding learning methods were used including, in order of the issue (figure 11). Notably, in Madagascar, as frequency, workshops and lectures, problem-based well as in Mali, a substantial proportion of public learning activities, groupwork, experiential learning administration staff (76 percent and 39 percent, and fieldwork, case-based discussions, didactics, respectively) reported a lack of training in digital coaching sessions, seminars, and journaling. skills, signaling a significant gap in their capacity to effectively utilize digital tools and platforms. By and large, evaluated leadership programs Furthermore, an equally concerning situation is seem effective in developing personal leadership that in Madagascar (73 percent) and in Mali (56 skills and are impactful from an organizational percent), a significant majority lacks training in perspective, as evidenced for instance by resulting data analysis for budget decisions, a skill essential policy or workplace culture changes (MacKechnie for making well-informed budgetary decisions. This and others 2022). To date, only few studies have was even more prevalent for women than men. In robustly assessed the impact of leadership capacity Mali, 73 percent of female administrators surveyed development interventions on leader and/or reported not having received training on budgetary subordinate performance, but those available show decisions, compared with 51 percent of men. The promising results. For instance, a study found that a absence of comprehensive training in these critical leadership training for District Health Management DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 36 Prosperity Insight areas hampers the ability of staff to effectively a significant need for training on the analysis and analyze, interpret, and leverage the collected data utilization of the collected data. This, in turn, can for informed decision-making and optimal resource foster a more informed and proactive approach to allocation. While implementing data collection healthcare management, enabling administrators systems that are user-friendly and intuitive can to make better-informed decisions. encourage more widespread utilization, there is Figure 11: Percentage of respondents who did not have training on digital skills and data for budgetary decisions 76% 73% 56% 39% Mali Madagascar No training on digital skills No training on data for budget decisions Source: World Bank. 2023. Mali and Madagascar HRH Surveys, Administrative Level. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 37 Prosperity Insight 4. CONCLUSION Despite the large academic literature on HRH on administrative data sources and sharing of a set reviewed in this report, significant knowledge gaps of key comparable indicators to generate in order remain, particularly in LICs and LMICs. Global, to fill the data gaps and enable annual monitoring comparable data on the health workforce is limited, of the workforce. The academic literature on as labor force and household surveys, which are the the drivers of health worker performance has source of the data presented in this report, are not concentrated on healthcare clinical professionals designed to enable granular, disaggregated data and, increasingly, CHWs and not on managerial, on employment and wages by the diverse types of administrative, and other nonmedical staff. There health workers. There needs to be more emphasis is limited research on health sector leadership and DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 38 Prosperity Insight stewardship, despite the general acknowledgment several reforms. These include strengthening of the criticality of senior and midlevel bureaucrats merit-based recruitment, improving leadership to the effective functioning of the health system. and management, strengthening interventions to increase motivation, and enhancing the The report has shown that surveys of HRH can representation of women in leadership positions in provide new data on staff experiences with key the health workforce. Project activities to support HRM drivers of health worker performance, and on merit-based recruitment could involve technical the reasons for gender segregation in the health assistance for developing a competency framework sector, and these data can be used to inform for administrative positions, as well as support to ongoing and planned World Bank operations in establishing assessment centers and designing LICs and LMICs. The report has identified several criteria and modalities for screening candidates avenues for further research that can be analyzed for both clinical and administrative positions. using newly found data, such as the various aspects Findings also suggest, where feasible, investing in of management quality that matter most for worker rural pathways to ameliorate the shortage of health performance, and how to improve motivation using workers. The report highlights the importance teamwork and nonfinancial rewards that may be of leadership and management, and combining more feasible in the fiscally constrained contexts of traditional classroom instruction with group LICs and LMICs. problem solving of real-world problems, which can The report also underscores that HRH needs to be be incorporated into World Bank operations. prioritized in World Bank operations, and suggests DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 39 Prosperity Insight APPENDIX: DETAILED SURVEY METHODOLOGY Mali Survey the core health staff in each facility. The aim was The target population for the survey included all to include a facility manager, a doctor, a nurse, a respondents in the service delivery chain of all ten midwife, and a community health worker (CHW) districts in the region of Koulikoro, three districts in as these five cadres are integral to the functioning the region of Mopti (Bandiagara, Bankass, Mopti), of health facilities. By capturing insights from and three districts in the region of Segou (Baraouéli, facility managers, doctors, nurses, midwives, and Bla, Ségou) and the Ministry of Health staff. Target CHWs, the study seeks to provide evidence that regions were selected based on existing World Bank encompasses the experiences and viewpoints of operations. Respondents at the administrative the core health facility staff. level (central, regional, and commune) and The survey had a high response rate of 79 percent facility level were surveyed face-to-face using with more than 2,300 interviews completed. At questionnaires for facility staff, administrators, and the facility level, 2,015 respondents participated public officials. in the survey, comprising 386 facility managers The survey firm reached 397 health centers (381 and 1,629 facility staff, with an overall response Centres de Sante Communautaires (CSCOMs) and rate of 81 percent. At the administrative level, the 16 Centre de Santé de Références (CSREFs)) out of team surveyed 311 civil servants at the central, 415. Some of the CSCOMs could not be accessed regional, and district levels, with a response rate of because of the security situation in that locality. 72 percent. The lower response rates at the district To ensure a diverse representation of key HRH level can be attributed to the fact that most districts cadres at the facility level, the survey employed had only one staff member, while the target for a sampling strategy that specifically targeted each district was two interviews. DETERMINANTS OF HEALTH WORKER PERFORMANCE: A REVIEW OF THE EVIDENCE 40 Prosperity Insight Madagascar Survey At the facility level, the team interviewed 1,698 The survey included facility staff and public facility staff. Telephone interviews were conducted administration employees from ten regions and with staff members in health centers located the capital: Analanjirofo, Androy, Anosy, Atsimo outside the district capital communes. Among Andrefana, Atsimo Atsinanana, Ihorombe, Menabe, the interviewees, 389 were facility managers, and Sava, Sofia, and Vatovavy Fitovinany. Target regions 1,117 were facility staff. were selected based on existing World Bank In Madagascar, the team also combined the survey operations. A total of 2,126 individuals working in with focus group discussions among a diverse group the health sector (in public administration and at of employees from various levels and departments the facility levels) participated in the survey. The within the Ministry of Health. 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