How workers respond to social rewards: evidence from community health workers in Uganda

This paper investigates the effect of a non-financial incentive-a competitive annual award-on community health workers' (CHWs) performance, an issue in the public health literature that has not been explored to its potential. Combining data on a competitive social 'Best CHW' award with the monthly performance of 4050 CHWs across Uganda, we examined if introducing social recognition awards improved the performance of CHWs. In contrast to predominant explanations about the effect of awards on motivation, our first multilevel mixed-effect models found that an award within a branch (consisting of ∼30 CHWs) was negatively associated with the performance of the local peers of the winning CHW. Models focused on non-winning branch offices revealed two additional findings. First, a branch showed underperformance if a CHW from any of the three neighbouring branches won an award in the previous year, with average monthly performance scores dropping by 27 percentage points. Second, this negative association was seen only in the top 50th percentile of CHWs. The bottom 50th percentile of CHWs exhibited increased performance by 13 percentage points. These counter-intuitive results suggest that the negative response from high performers might be explained by their frustration of not winning the award or by emotions such as envy and jealousy generated by negative social comparisons. Our results suggest that more fine-grained examination of data pertaining to motivators for CHWs in low-income countries is needed. Motivational incentives like awards may need to be customized for higher- and lower-performing CHWs.