Digital payments of health workers within vaccination campaigns: a mixed

Discussion This convergent parallel mixed-methods study from Chad contributes new evidence on how digitising payments affects health worker motivation and satisfaction in a fragile, low-income setting. We found that transitioning from cash to mobile money was associated with higher self-reported work motivation and, in some contexts, greater job satisfaction, particularly among facility managers in provinces already implementing PBF. Non-managers, in other words frontline vaccinators, did not experience consistent benefits, and some reported frustrations with the new payment system. These nuanced outcomes can be interpreted through the lens of the ET, which posits that motivation thrives when workers believe that effort will lead to good performance (expectancy), that performance will be rewarded (instrumentality) and that the reward is valued (valence). In our context, the digital payment intervention appears to have strengthened these linkages for managers, especially where PBF already signalled credible performance rewards, while many vaccinators, particularly outside PBF areas, perceived lower value or certainty, dampening motivational gains. Our findings align with a growing body of literature from sub-Saharan Africa showing that, under the right conditions, digital payments can improve worker experiences.17 Across recent campaigns in multiple African countries, over 80% of frontline workers have preferred digital payment over cash due to a reduced personal risk, convenience and faster disbursements.17 56 Timeliness, in particular, is repeatedly linked to better morale and satisfaction; prompt, predictable compensation conveys respect, reduces stress and reinforces commitment to duties.16 17 56 This convergence supports the interpretation that reliable digital transfers can strengthen the expectancy and instrumentality components of motivation by making the reward more immediate, traceable and believable. At the same time, our results underscore that digitisation is not a panacea; its impact varies with implementation design, local infrastructure and how directly workers themselves experience the benefits. A central design feature in Chad was the semidirect disbursement model, where managers at multiple levels received transfers into mobile wallets and then cashed out and paid frontline vaccinators in cash. This arrangement accelerated and secured fund flows upstream but left frontline workers dependent on managers for cash-out. Qualitative interviews revealed how this partial digitisation introduced extra steps and uncertainties for vaccinators, limiting perceived gains in speed or autonomy. The contrast with direct-to-worker designs is notable: when all managers are paid directly, results show more uniformly positive experiences and reduced leakage because funds move straight to the intended recipient and accountability is clearer.56 Our findings suggest that paying only managers via mobile money can inadvertently make frontline vaccinators feel bypassed or disadvantaged, lowering satisfaction even when motivation rises modestly. Several vaccinators described mobile money as ‘complex’ or ‘unreliable’ and reported noticing faster payments, echoing experiences elsewhere where digital systems are poorly executed or when cash-out is costly or inconvenient.57 Digital literacy and trust moderated these effects. Our qualitative data indicated that less educated workers and those with limited exposure to technology were more likely to view the mobile money system with suspicion, whereas their more digitally savvy colleagues adapted readily and appreciated the innovation. This heterogeneity resonates with regional studies showing that perceived risk, prior experience and trust strongly shape adoption.58 For our setting, the implication is practical: rolling out a platform is insufficient without targeted capacity building, including simple training, helplines and peer support tailored to cadres with lower digital familiarity. Without such scaffolding, digitisation risks widening existing hierarchies, with managers accruing more of the benefits. Encouragingly, qualitative accounts indicated that with even modest support, many initially hesitant workers became more comfortable with mobile payments, suggesting that trust building and just-in-time assistance can mitigate early frictions.56 Digitisation also reshaped perceived roles along the payment chain. Under cash-based processes, provincial and district managers physically handled funds, a task intertwined with status and responsibility. With mobile payments, funds flowed directly to managers’ SIMs across levels, reducing cash handling and altering routines. Some district-level managers felt their responsibilities had been diminished and a few worried that digital systems might replace them in this function. From an ET lens, such role changes can reduce valence if a valued task disappears without a compensating source of meaning or recognition.24 59–62 This is a predictable change management challenge, where reforms designed to improve transparency by bypassing intermediaries may be experienced as a loss of control.59 61 62 Clear communication about new responsibilities, coupled with strengthening supervisory planning and reporting functions, can help maintain manager motivation.59–66 On balance, removing discretionary cash handling from facility managers likely strengthens accountability and frees time for leadership and supervision. Consistent with this, interviews described administrative efficiencies and greater transparency mirroring efficiency gains observed in other immunisation programmes that digitised payments.17 The interplay between digital payments and PBF is a key contribution of this study. Quantitatively, associations between mobile money and higher motivation and job satisfaction were strongest in provinces already implementing PBF, particularly among managers, suggesting a complementary relationship. This is plausible given evidence that well-designed PBF can influence provider motivation when credibly implemented, and that digital payments reliably improve payment timeliness, transparency and auditability in health campaigns, thereby creating conditions that reinforce PBF’s instrumentality signal.17 67–74 We observed the highest motivation and satisfaction among managers in PBF areas, consistent with a synergistic mechanism: prompt, visible disbursements bolster trust that performance will be rewarded, making effort more worthwhile.75–77 Conversely, in settings without PBF or for cadres not directly benefiting from it, digital reforms sometimes generated disappointment or perceptions of ‘crowding out’, particularly under semidirect implementation that left vaccinators reliant on managers for cash.78 79 Reports from other contexts echo these patterns: when digital systems introduce delays, fees or access barriers—such as long distances to agents or liquidity shortages—managers may prefer cash despite digitisation’s theoretical advantages.57 70 80 81 Although rigorous causal evidence on digital-PBF interactions remains limited, adjacent literatures support the mechanism we observe: where incentive schemes hinge on credible, timely payment, digital delivery systems can help them perform as intended.82–85 These findings align with broader multicountry evidence that payment timeliness and completeness are central determinants of health worker motivation and satisfaction. Zhang et al86 found that salary delays were widespread and consistently associated with lower motivation, reduced job satisfaction and higher absenteeism among primary care workers. This reinforces the interpretation that disruptions in payment systems, regardless of whether payments are delivered digitally or in cash, can undermine workforce morale and performance. In this light, our finding that overall payment receipt in mobile money provinces during rollout likely reflects transitional frictions, including liquidity constraints, staggered onboarding and cash-out barriers, rather than a failure of digital payments per se. Recognising and addressing these early-phase challenges may be essential for maximising the motivational benefits of digital reforms. Policy implications Our findings suggest that digital payments should be tailored to context rather than implemented as one-size-fits-all reform. First, shifting to direct-to-worker transfers is critical to maximise transparency and ensure frontline staff experience the benefits, avoiding the burdens created by semidirect arrangements. Second, transaction costs and access barriers—such as withdrawal fees, long distances to agents and liquidity shortages—must be addressed, for example, through removal or negotiated fee reductions, expanded agent networks or alternative cash-out channels. Third, digital literacy and trust require investment. Simple training, user support mechanisms and clear communication can reduce scepticism and build confidence in mobile money systems. Fourth, integration with PBF (or analogous performance schemes) appears advantageous. Aligning reliable, traceable digital payments with performance incentives helps ensure that timeliness and credibility reinforce broader motivation signals rather than operating in parallel. Finally, change management matters, especially where digitisation alters roles, proactively redefining responsibilities and recognising new supervisory or data functions can sustain manager motivation. Limitations The study has several limitations that should be considered when interpreting the findings. First, as an observational study in a real-world setting, we could only establish associations rather than prove causality. Unmeasured confounders such as differences in leadership, baseline infrastructure or worker characteristics between provinces may have influenced the results. We attempted to control for major factors, including the presence of PBF, but residual confounding cannot be ruled out. Second, the semirandomised rollout of the digital payment intervention means there may have been selection biases. Provinces with better prior performance or resources might have been more likely to implement mobile payments early, potentially overestimating the benefits. Third, our quantitative measures relied on self-reported perceptions of motivation, satisfaction and payment experiences. These subjective outcomes are prone to reporting bias. For example, participants aware of being in a ‘digital’ province might have been more inclined to report improved motivation due to courtesy bias or optimism about a donor-supported innovation. Likewise, those facing technical issues might have been disproportionately negative. We mitigated this by assuring confidentiality and triangulating with qualitative data, but some bias remains possible. Fourth, the qualitative component, while invaluable for explaining the why and how digital payments shaped worker experiences, was limited in its balance across cadres and settings. Managers were more represented than frontline vaccinators, and perspectives from non-PBF provinces were comparatively fewer. As a result, some frontline or non-PBF-specific experiences may have been under-represented, and the depth of triangulation across groups is narrower than ideal. Finally, our findings are from a specific context and may not generalise to all settings. Countries differ in mobile money ecosystem maturity, network coverage, banking infrastructure and workforce dynamics. Despite these limitations, the study provides timely insights by combining quantitative and qualitative evidence on a relatively under-researched health systems intervention. We believe the lessons learnt can inform digital payment initiatives in similar low-resource and fragile contexts, especially in sub-Saharan Africa.