Experiences and Motivations of Polio Eradication's Front-Line Workers in Pakistan

This paper describes a study commissioned by the United Nations Children's Fund (UNICEF) in order to determine how ground-level personnel working on behalf of the Polio Eradication Initiative (PEI) workers in Pakistan see their work and to provide recommendations for how to better support and motivate them.

As described here, the PEI relies on several different classes of frontline workers, who are most responsible for interpersonal communication (IPC) at the household level (door to door) and in the community, including:

1. Lady Health Workers (LHWs) "are a particularly valuable resource; as women, they can go inside houses to vaccinate newborn infants and young children (something that a male vaccinator would not be permitted to do in many Pakistani households). In some districts, not all LHWs perform their polio duties, and in others, they do not perform them at the level of quality needed to secure the elimination of polio. Understanding what might better motivate these women is thus important."
2. So-called "volunteers" are described here as "people with no formal connection to the health department who work on polio rounds on an ad-hoc basis. As they do not have formal health department employment, these workers may have different goals and frustrations than regular staff in carrying out polio work. (It is important to note that most 'volunteers' see work on polio as employment, not volunteer work, and may not necessarily take the altruistic pride in their work that their appellation suggests.) As polio eradication relies heavily on such "volunteers" in many key districts, an understanding what might inspire them to strive for extremely high vaccination coverage is important."

Semi-structured interviews and a simple survey instrument revealed that "LHWs and volunteers alike were often motivated to work by severe financial need....Low pay and late pay were the primary reasons for job frustration, mentioned by every ground-level worker interviewed....In addition, many workers cited lack of positive feedback and lack of avenues for advancement as drivers of frustration."

"The primary recommendations, to address the complaints voiced by nearly every interviewee, are to raise pay to a rate at least equivalent to that of unskilled labor, and to ensure that pay comes on time. Monitoring of pay delivery for completeness and timeliness could help the situation. Additional support to cover out-of-pocket expenses incurred during campaigns would be warmly welcomed by most workers."

In addition, several other steps are recommended to increase ownership and motivation of ground-level workers. For instance:

• Trainings could incorporate in-depth epidemiological updates along with detailed performance goals for a given round. "During training, discussion of potential methods for reaching these targets should be held with input from the workers themselves. These strategies could help in providing workers with knowledge and ownership of polio eradication activities."
• To address community acceptance, strengthen media presence in key areas and strengthen worker skills in social mobilisation. "At a minimum, workers should be provided with responses to common questions or objections, for example in an FAQ [frequently asked questions] document. Ideally, this should not be a cookie-cutter strategy but should be responsive to ongoing social mobilization challenges in a given area. For example, following the widely circulated media story about the child who allegedly died after receiving polio drops, workers could have been provided with specific messages and strategies for countering the fears this story raised. Many such social mobilization issues are national, and communications material for them could come from the national level. Others are local or regional, and thus require local or regional strategies. However, in either case, leadership on support and training in key skills could come from the national level."
• "[A] system of positive reinforcement for good work should be instituted, starting with the creation of round-specific key performance indicators with clearly communicated monitoring systems. Workers who meet these performance indicators should be recognized. Drawing on the experience of smallpox eradication, the possibility of cash rewards for meeting certain select externally verified performance targets should be considered."

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