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Background:: Maternal mortality is still a burden worldwide, and Ghana’s maternal and child mortalities are still high. Incentive schemes have been effective in improving health workers’ performance thereby reducing maternal and child deaths. The efficiency of public health services in most developing countries has been linked to the provision of incentives. Thus, financial packages for Community Health Volunteers (CHVs) serve as enablers for them to be focused and committed to their work. However, the poor performance of CHVs is still a challenge in health service delivery in many developing countries. Although the reasons for these persistent problems are understood, we need to find out how to implement what works in the face of political will and financial constraints. This study assesses how different incentives influence reported motivation and perceptions of performance in Community-based Health Planning and Services Program (CHPS) zones in the Upper East region. Methods:: A quasi-experimental study design with post-intervention measurement was used. Performance-based interventions were implemented for 1 year in the Upper East region. The different interventions were rolled out in 55 of 120 CHPS zones. The 55 CHPS zones were randomly assigned to four groups: three groups of 14 CHPS zones with the last group containing 13 CHPS zones. Several alternative types of financial and non-financial incentives as well as their sustainability were explored. The financial incentive was a small monthly performance-based Stipend. The non-financial incentives were: Community recognition; paying for National Health Insurance Scheme (NHIS) premiums and fees for CHV, one spouse, and up to two children below 18 years, and; quarterly performance-based Awards for best-performing CHVs. The four groups represent the four different incentive schemes. We conducted 31 In-depth interviews (IDIs) and 31 Focus Group Discussions (FGDs) with health professionals and community members. Results:: Community members and the CHVs wanted the stipend as the first incentive but requested that it be increased from the current level. The Community Health Officers (CHOs) prioritized the Awards over the Stipend because they felt it was too small to generate the required motivation in the CHVs. The second incentive was the National Health Insurance Scheme (NHIS) registration. Community recognition was also considered by health professionals as effective in motiving CHVs and work support inputs and CHVs training helped in improving output. The various incentives have helped increase health education and facilitated the work of the volunteers leading to increased outputs: Household visits and Antenatal Care and Postnatal Care coverage improved. The incentives have also influenced the initiative of volunteers. Work support inputs were also regarded as motivators by CHVs, but the challenges with the incentives included the size of the stipend and delays in disbursement. Conclusion:: Incentives are effective in motivating CHVs to improve their performance, thereby improving access to and use of health services by community members. The Stipend, NHIS, Community recognition and Awards, and the work support inputs all appeared to be effective in improving CHVs’ performance and outcomes. Therefore, if health professionals implement these financial and non-financial incentives, it could bring a positive impact on health service delivery and use. Also, building the capacities of CHVs and providing them with the necessary inputs could improve output.
The Upper East region is located in the northeastern corner of Ghana, bounded by Burkina Faso to the north and the Republic of Togo to the east. It covers an area of 8,842 square kilometers. The 2010 Census put the population of the Upper East region at 1,046,545, which is predominately rural [46]. The qualitative study was carried out in eleven districts (Kassena-Nankana Municipality, Bolgatanga Municipality, Kassena-Nankana West District, Builsa North District, Builsa South District, Bongo District, Talensi District, Bawku Municipal, Bawku West District, Binduri and Garu-Tempane Districts) in the Upper East region of Ghana. At the time of initiating the CHPS + project the region had 13 districts, but due to redistricting the number of districts has increased to 15. The 11 districts were selected because they were either part of the intervention or control districts: two CHPS zones in each of the 11 districts were selected to participate in the study. A quasi-experimental study design with post-intervention measurement was used. Performance-based interventions were implemented for 1 year in the Upper East region. A total of 55 CHPS zones received the incentive interventions. The 55 CHPS zones were randomly assigned to four groups: three groups of 14 CHPS zones with the last group containing 13 CHPS zones. The four groups represent the four different incentive schemes. Since the randomization was at the CHPS zone level, all CHVs working in the same CHPS zone received the same incentive. Several alternative types of financial and non-financial incentives as well as their sustainability were explored. The financial incentive is a small monthly performance-based per-diem. The non-financial incentives are community recognition; paying for NHIS premiums and fees for CHV, one spouse, and up to two children below 18 years, and; quarterly performance-based awards for performing best-performing CHVs. We conducted 30 In-depth interviews (IDIs) and 31 Focus Group Discussions (FGDs) with health professionals and community members. Qualitative research approaches were used to evaluate the CHV incentives. The indicators included: Feedback on the performance of the CHVs by the CHO, Community Health Management Committees (CHMCs), CHVs, and community, and it involved conducting FGDs and IDIs with the targeted stakeholders. We randomly selected two CHPS zones from each intervention area and targeted the following group of persons: women, men, CHOs, CHMCs, and CHVs. Women and men were selected through key informants for the FGDs. CHOs working in the selected CHPS zones were eligible for IDIs. We purposively selected 3 CHOs from each of the intervention areas who have been involved in supervising the volunteers for the interview, and also purposively selected CHMCs that work in the selected CHPS zones for the FGDs. The first 10 CHVs who consented to participate in the study were invited to participate in one FGD in each of the selected zones (Table 1). Distribution of Study Respondents We recruited graduate research assistants from the study districts and trained them on the interview guides and the processes involved in conducting FGDs and IDIs. As part of the training, a pilot test was conducted in the non-intervention districts to assess the clarity and appropriateness of the interview guides before the commencement of actual data collection. Data collection lasted from 1st October 2019 to 30th November 2019. The data collection process required making prior appointments with respondents before conducting the interviews. A three-member team was formed in each district for the field activities. Each district team comprised a supervisor and three interviewers each for the FGDs and IDIs. The district supervisor provided oversight responsibility during data collection. They assisted data collectors in locating sampled communities and organized FGDs and IDIs. As much as possible, the principal investigator and the co-investigators, and supervisors observed FGDs, IDIs, and interviews administered in the study districts and supervisors offered suggestions or addressed challenges when necessary. The FGDs and IDIs with community stakeholders were conducted in the local languages while those with the health providers were in English. We audio-recorded all interviews and discussions and transcribed them verbatim into English. We reviewed the transcripts thoroughly for accuracy and completeness and corrected them to facilitate coding by theme. The Principal Investigator (ES) and two other Co-Investigators (RA and IK) sorted the transcripts by sources and conducted multiple readings, writing memos in the margins of the text in the form of short phrases, ideas, or concepts arising from the texts. We used these memos to iteratively develop coding categories. Using thematic analysis, we closely examine the data to identify common themes–topics, ideas, and patterns of meaning that came up repeatedly and themes that were atypical in response to each question. Transcripts were imported into NVIVO 11.0 for open, axial, and selective coding by three separate coders (ES, RA, and IK). Coders met regularly to discuss the process of coding, revise the codebook as necessary, and resolve any uncertainty in coding. The themes were used to generate reports that allowed us to describe the thoughts and opinions within the interviewee group (e.g., community stakeholders) as well as compare responses across groups (e.g., community stakeholders and health professionals).
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