Using results

The Zambian government is using evidence from an IPA evaluation to improve health care delivery in rural areas.

An evaluation led by researchers from Harvard Business School and the London School of Economics found that when recruiting community health workers in Zambia, emphasizing career incentives rather than social incentives attracted workers who were more qualified and performed better on the job. These workers conducted 29 percent more household visits and organized twice as many community meetings, while also seeing the same number of patients. In response, the Zambian Ministry of Health has begun using career incentives in its nationwide recruitment of community health workers.

The Challenge 
Health worker.jpg
A health worker.
Will Boase

Community health workers may be one solution to the shortage of formal health workers in the developing world.  Recruited from their communities, trained, and then deployed back to their communities, these workers are thought to have the necessary relationships, local knowledge, and sense of community responsibility to deliver health services to these underserved areas. While small-scale, informal community health worker programs of this kind have existed for years, recently many countries in Sub-Saharan Africa have sought to formalize the cadre and implement national programs at scale.  

As the Zambian government got ready to launch their Community Health Assistant (CHA) program in 2010, the Ministry of Health wanted to adopt effective recruitment and motivation strategies for the new cadre. IPA-Zambia had a longstanding relationship with the Ministry of Health in Zambia, especially through Professors Nava Ashraf and Oriana Bandiera. The researchers designed an evaluation in close collaboration with the ministry that addressed the government’s key questions.

The Evidence 

The study found that advertising career incentives, such as opportunities for promotion and further professional development, attracted CHAs that were more qualified and had the same level of intrinsic motivation as those recruited with social incentives. The CHAs recruited with career incentives performed significantly better on the job: those recruited with career incentives conducted 29 percent more household visits and organized twice as many community meetings. They also managed to see the same number of patients at the health post and maintain the same quality of care. Furthermore, after one year, retention rates were identical in both groups, but longer-term data is required to establish the long-run effects on retention. Read a full description of the evaluation here.

Recruitment posters for social incentives program (left) and career incentives program (right).
Ashraf et al. (2014)
The Impact 
The Government of Zambia used the evidence from this evaluation to help optimize its community health worker program. The Ministry of Health is using career incentives for a nationwide campaign to recruit 5,000 community health workers by 2018—a massive investment in a country with only 6,000 nurses. These community health workers will undergo a year of formal training, and will then be posted back to their rural communities, where they will do most of their work directly within the community, rather than operate from a health facility. The national strategy aims for CHWs to be the first line of health care for Zambians living in the most remote regions of the country. 
The adoption of the career-oriented recruitment strategy in Zambia is estimated to translate into 315,000 additional household visits and 70,000 more community meetings. 
Broadly speaking, we hope to spark a wave of further research on the extent to which career-oriented recruitment strategies can improve outcomes across new contexts and other public service sectors.

Researcher Oriana Bandiera blogs about the study here, and researcher Nava Ashraf talks about how the evaluation illustrates the value of working with partners here.

If you know of other organizations that are using these results, or have any corrections or updates to make to this case study, please contact