Health workers in the Democratic Republic of Congo: an exploration of their motivation, incentives, and the effects of an intervention to improve their remuneration by government

Health worker motivation influences the performance of health services. In the Democratic Republic of Congo (DRC), not all health workers are remunerated by the government, negatively affecting their motivation. This leads workers to seek revenue from other sources, including user fees and private practice, but the extent to which different sources make up their total revenue has not been quantified. To improve motivation, donors have employed performance-based financing (PBF), which represents another, albeit unstable, source of income. The research for this thesis was set within a health systems strengthening programme called ASSP (access to primary health care) in the DRC, which phased out donor-financed PBF from a previous programme and implemented a complex intervention aiming to increase the prevalence of government payments to health workers. Using mixed methods, this study: describes the sources and amounts of income making up a health worker’s total remuneration; develops and validates a tool to measure health worker motivation; compares differences in motivation amongst workers who previously received PBF with workers who never received PBF; and, evaluates the complex intervention described above. Several income sources make up a health worker’s total remuneration. A valid tool measuring health worker motivation was developed and indicated workers who previously received PBF scored significantly lower on almost all motivation dimensions compared to those who never received PBF. With respect to the complex intervention, an adaptive approach to implementation and evaluation was needed given the dynamic nature of the health system. The findings have important policy implications. Better coordination amongst actors involved in health worker remuneration is needed, and incentive structures should be based on dimensions of motivation relevant to workers. For fragile states, the implications of transitioning away from donor payments and the importance of continuing work on civil service pay reform are identified.