Lee, Inseok; (2025) Understanding Ghanaian Community Health Workers Motivation and Performance and the Role of Incentives in These. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

This PhD examines factors influencing the motivation and performance of Ghana’s volunteer community health workers (CHWs). A cluster-randomised trial covered 669 CHWs across 120 CHPS zones in the Upper East Region; random-intercept regression was paired with in-depth interviews and focus-group discussions. CHWs showed high intrinsic commitment grounded in altruism and community trust, yet motivation alone did not guarantee better performance. Awards increased monthly home visits by 57 % (p=0.04) and National Health Insurance Scheme raised days assisting supervisors by 62 % (p=0.005). A small quarterly stipend produced no benefit and lowered motivation once payments stopped. More than 70 % of the variance in both outcomes was explained by CHPS-zone context, highlighting the power of local environments beyond any single incentive. Socio-demographic factors also mattered. Each 10-year age increase raised assistance days by 6 % (95 % CI: 0 - 12 %). Female CHWs conducted more home visits (p=0.03) and assisted their supervisor more often (p = 0.02). CHWs working as civil or public servants conducted 35% fewer home visits and 45% (p=0.005) fewer assistance days than farmers (p<0.001). A key methodological output is a 39-item CHW motivation scale, built from local statements, refined through qualitative work, and psychometrically validated (Cronbach’s α = 0.90). Its four factors offer programmes a concise, reliable way to track motivation or test new interventions. Qualitative data explained the numbers: respectful, regular supervision, dependable material support, and positive community relationships enabled good performance, whereas their absence hindered even highly motivated CHWs. The findings indicate that enhancing CHW motivation and performance requires a comprehensive support strategy that integrates reliable material support, effective supervision, and strong community engagement, tailored to local socio-demographic conditions. These insights provide practical guidance for designing sustainable CHW programmes in low-resource settings.

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