Evidence-informed policymaking for health workers in Zambia
Female condoms can help prevent HIV and other sexually transmitted infections and give women the ability to take protection into their own hands. However, at the time of the evaluation, female condom uptake had not been high in Zambia, unlike in other parts of Southern Africa.
To improve the uptake of health goods, non-profit and public organisations often rely on the services of community members, yet research on the motivation and performance of these agents is scarce.
In 2009, the Society for Family Health in Lusaka planned to rely on hairdressers and barbers as a novel distribution channel to promote their CARE brand of female condoms. Trained hairdressers and barbers were expected to promote and distribute female condoms, as well as to provide information to customers about the dangers of unprotected sex and the benefits of using condoms properly. However, it was not clear how these agents could be selected and motivated to carry out these tasks.
Researchers from the Harvard Business School and London School of Economics collaborated with the Society for Family Health to evaluate how different incentive designs would work to motivate 1,222 agents located in 200 distinct geographical areas.
Researchers also engaged with officials at Zambia’s Ministry of Health and were aware even at the evaluation design stage that the findings could be salient to the ministry, as they planned to set up a new cadre of community health workers called community health associates.
Between 2009 and 2010, the evaluation tested four incentive designs for effects on the agents’ participation in the programme, condom sales and intrinsic motivation to serve in a social cause. The intervention arms were: (1) standard volunteer contracts offered by NGOs; (2) small monetary rewards on the basis of condom sale performance; (3) large monetary rewards on the basis of condom sale performance; and (4) non-financial social recognition in the form of stars posted on a thermometer displaying condom sales.
The findings showed that the type of incentive scheme did not affect participation from the hairdressers and barbers. The non-financial reward was a cost-effective means to elicit effort. Agents in the star or social recognition group sold more than twice as many condoms as those in any of the other groups. Star treatment agents were 12 per cent more likely to sell at least one pack of female condoms and 13 per cent more likely to sell 12 or more packs than agents in the business-as-usual volunteer contract group.
The star treatment elicited more effort from agents who expressed greater pre-treatment motivation for the social cause. No evidence was found to suggest that financial incentives crowd out intrinsic motivation. Agents who were offered financial rewards, either large or small, were as effective as stylists in the business-as-usual group.
Finally, the evidence indicated that the effect of incentives on effort depended on whether social comparisons were possible and how much agents valued monetary rewards.
Type of impact: Improve the culture of evidence use
When decision makers or implementers demonstrate positive attitudinal changes towards evidence use or towards information the research team provides. Examples include strengthening monitoring and evaluation systems, increasing understanding of evidence and openness to using it, integrating these systems more firmly into programming or commissioning another evaluation or review.
This is one of 3ie’s seven types of evidence use. Impact types are based on what we find in the monitoring data for an evaluation or review. Due to the nature of evidence-informed decision-making and action, 3ie looks for verifiable contributions that our evidence makes, not attribution.
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Following a review of evidence that included the findings of the 3ie-supported evaluation and a meeting with the researchers, the director of public health and research at Zambia’s Ministry of Health asked the researchers to find the most effective ways to recruit and motivate community-based health workers. These interactions in July 2010 led to three subsequent evaluations. These evaluations have informed health worker recruitment in Zambia and have also been cited in the World Health Organization’s 2018 guideline to optimise community health worker programmes.
International Initiative for Impact Evaluation (3ie), 2020. Evidence-informed policymaking for health workers in Zambia [online summary], Evidence Impact Summaries. New Delhi: 3ie.
Improving the motivation and performance of health workers in Africa
This research impact case study on the website of the London School of Economics and Political Science profiles the collaboration between the researchers of the 3ie-supported evaluation and Zambia’s Ministry of Health.
Evidence impact summaries aim to demonstrate and encourage the use of evidence to inform programming and policymaking. These reflect the information available to 3ie at the time of posting. Since several factors influence policymaking, the summaries highlight contributions of evidence rather than endorsing a policy or decision or claiming that it can be attributed solely to evidence. If you have any suggestions or updates to improve this summary, please write to firstname.lastname@example.org