Changes in health worker knowledge and motivation in the context of a quality improvement programme in Ethiopia.

A knowledgeable and motivated workforce is critical for health systems to provide high-quality services. Many low- and middle-income countries face shortages in human resources and low health worker motivation but are also home to a burgeoning number of quality improvement (QI) programmes. This study evaluates whether and how motivation and clinical knowledge in three cadres of health workers changed in the context of a QI programme for maternal and newborn health in Ethiopia. This mixed-methods study used a pre-post comparison group design with matched comparison areas. We interviewed 395 health workers at baseline in April 2018 and 404 at endline in June 2019 from seven districts (woredas) with QI and seven comparison woredas. Three cadres were interviewed: health extension workers, facility-based skilled midlevel maternal and newborn care providers, and non-patient-facing staff. A qualitative component sought to triangulate and further elucidate quantitative findings using in-depth interviews with 22 health workers. Motivation was assessed quantitatively, exploratory factor analysis was used to categorize motivation dimensions, and regression-based difference-in-difference analyses were conducted. Knowledge was assessed through a clinical vignette. Qualitative data were analysed in a deductive process based on a framework derived from quantitative results. Although knowledge of the QI programme was high (79%) among participants from QI woreda at endline, participation in QI teams was lower (56%). There was strong evidence that health worker knowledge increased more in areas with QI than comparison areas. Three motivation dimensions emerged from the data: (1) 'helping others', (2) 'pride and satisfaction' and (3) 'external recognition and support'. We found strong evidence that motivation across these factors improved in both QI and comparison areas, with weak evidence of greater increases in comparison areas. Qualitative data suggested the QI programme may have improved motivation by allowing staff to provide better care. This study suggests that although QI programmes can increase health worker knowledge, there may be little effect on motivation. Programme evaluations should measure a wide range of outcomes to fully understand their impact.

Stated job preferences of three health worker cadres in Ethiopia: a discrete choice experiment.

Attracting, training and retaining high-quality health workers are critical for a health system to function well, and it is important to know what health workers value in their roles. Many studies eliciting the labour market preferences of health workers have interviewed doctors or medical students, and there has been little research on the job preferences of lower-skilled cadres such as community health workers, mid-skilled clinical care staff such as nurses and midwives, or non-patient facing staff who manage health facilities. This study estimated the job preferences of public health sector community health extension workers (HEWs), care providers including nurses and midwives, and non-patient-facing administrative and managerial staff in Ethiopia. We used a discrete choice experiment to estimate which aspects of a job are most influential to health worker choices. A multinomial logistic regression model estimated the importance of six attributes to respondents: salary, training, workload, facility quality, management and opportunities to improve patient outcomes. We found that non-financial factors were important to respondents from all three cadres: e.g., supportive management [odds ratio (OR) = 2.96, P-value = 0.001] was the only attribute that influenced the job choices of non-patient-facing administrative and managerial staff. Training opportunities (OR = 3.45, P-value < 0.001), supportive management (OR = 3.26, P-value < 0.001) and good facility quality (OR = 2.42, P-value < 0.001) were valued the most amongst HEWs. Similarly, supportive management (OR = 3.22, P-value < 0.001), good facility quality (OR = 2.69, P-value < 0.001) and training opportunities (OR = 2.67, P-value < 0.001) influenced the job choices of care providers the most. Earning an average salary also influenced the jobs choices of HEWs (OR = 1.43, P-value = 0.02) and care providers (OR = 2.00, P-value < 0.001), which shows that a combination of financial and non-financial incentives should be considered to motivate health workers in Ethiopia.