The association between financial and non-financial incentives and performance of Posyandu Cadres

Penajam Paser Utara was the first district to provide cash incentives to Integrated Health Post (Indonesia call a Posyandu) cadres for infants and toddlers and was the district with the largest incentive in 2010 at IDR 200,000 per month. However, the provision of incentives was uneven. However, there are still differences in the amount of cash incentives received by cadres. This study aims to determine whether there is a relationship between incentives and the performance of Posyandu cadres in Penajam Paser Utara District. This type of research was quantitative, using a correlational analysis method and a cross-sectional approach with a sample size of 303 respondents. The research was conducted in the Posyandu working area in the Penajam Paser Utara Regency between November and December 2023. Data were collected online using a Google form link provided to respondents via WhatsApp. Data were analyzed using the chi-squared test. The results showed that 251 cadres (82.8%) performed satisfactorily. Three types of non-cash incentives were associated with performance: health benefits, uniforms, and neighborhood support (p-value <0.05). This study concludes that there is a positive relationship between cash and non-cash incentives on cadre performance in the Penajam Paser Utara Region (p < 0.001).


Introduction
Public health is crucial for regional development.Penajam Paser Utara district has a stunting prevalence of 21.8%, which is still high and above the national stunting prevalence.One effort to enhance public health is the implementation of an Integrated Health Post for infants and toddlers (Posyandu).Posyandu cadres played a key role in the success of this programme (A.D. Pratiwi et al., 2020).Posyandu developed well, but in the early 2000, performance began to decline due to the prolonged economic crisis (Ifroh, 2021).This is shown by the decreasing trend in the number of people visiting Posyandu and dropping out of Posyandu cadres (Bidjuni, 2017).The success of Posyandu is influenced by the performance of cadres, and high motivation in Posyandu activities will improve the performance of Posyandu cadres.However, the problem that occurs is that there are still many cadres who are less motivated in Posyandu activities.
Posyandu cadres' performance encompasses skills and active participation in providing health services in line with the government's efforts to improve health through community empowerment (Handayani & Nuryani, 2022).Apart from community empowerment, the government is making efforts to improve performance by providing cash and non-cash incentives to the Posyandu cadres.
Research indicates a positive correlation between monetary incentives and cadre performance.However, issues have arisen regarding incentive distribution in the Penajam Paser Utara Regency, such as Posyandu cadre strikes due to delayed incentives.Evaluating the relationship between incentives and the performance of Posyandu cadres in this district has become the focus of research, given the complexity of issues related to incentive distribution.Therefore, it is relevant to investigate the factors influencing Posyandu cadre performance, including incentives (Sari, 2018).
Several studies have highlighted the relationship between incentives and post-Yandu cadre performance.Research byNurayu ( 2018) andWisnuwardani ( 2021) indicates a positive correlation between incentives and the active involvement and performance of posyandu cadres.However, this research focuses on the Northern Market Scale District, which may have different characteristics and dynamics.The dynamics include geographical differences where the district or location is far from the center of the government, so many factors affect the decrease or weakening of volunteers in the empowerment of the community.Therefore, this research can contribute to providing the best solution for empowering posyandu cadres, particularly in remote areas.
The importance of the role of Posyandu's cadres in public health programs and previous research findings showed a link between the incentives and performance of posyandu cadres.Wisnuwardani 2021) mentions that a lack of empowerment funds and training for posyandu cadres leads to a decline in performance.This is seen in the decline in visits and the dropout of cadres facing many tasks, large coverage, and less ability to respond to the demands of the community.However, since it was ordered to provide incentives to them, it has led to a passionate fate in the work.Therefore, it can be concluded that granting incentives may affect cadres' performance.
The same problem occurred in the Posyandu District of the Penajam North Market.Posyandu cadets suffered a decline in performance, such as a lack of visits to the posyandu, a strike of cadets, and a decrease in public desire to be cadets.In this study, in addition to studying the relationship between cash incentives given by cadres, the researchers also studied non-cash incentives such as seragaram and empowerment training to determine the connection between incentives and the performance of Posyandu baby cadres and news in the district of Penajam Paser North.

Method
The research design used in this study was quantitative with a cross-sectional approach.This study was conducted in the Penajam Paser Utara Regency from November to December 2023.The population of this study was all cadres of infant and toddler posyandu in Penajam Paser Utara District who had previously agreed to participate and were willing to become respondents.Ethical Clearance to conduct research was conducted with ethical feasibility approval letter number 245/KEPK-FK/XII/2023. Stratified random sampling was used to select samples.In total, 303 respondents were included in the sample.

𝑛
where α is the significance level typically set at 0.05 with a 95% confidence level.In this context, Z^2 1-α⁄2 was taken as 1.96.P = Proportion or the proportion of the population with a specific characteristic d = Precision or margin of error allowed.10% (0,1), 5% (0,05%) atau 1% (0,01) (Notoatmodjo,2018) This study was conducted between November and December 2023.Primary data were collected through an online questionnaire distributed to posyandu cadres through Google Forms, assisted by the Health Office of Penajam Paser Utara District, to ensure that the data collected were valid and cadres did not hesitate to become respondents in this study.The questionnaire consisted of several sections covering respondent characteristics ( age, education level, occupation, and marital status), incentive distribution, and posyandu cadre performance.
The results of the questionnaire were then measured using ordinal and nominal data scales.The objective criteria used by the authors were poor if the answer score was ≤ 34 (66.7%), and good if the answer score was > 34 (6.7%).The data collected were then analyzed using the chisquare test to determine the relationship between incentives and the performance of posyandu cadres.The primary data source above is obtained through the questionnaire using the type of question that will be given to the respondents online (google form).The data are then processed by editing, coding, data entry, cleaning data, scoring, and tabulation.Data analysis was carried out by the author in Univariat and Bivariat.
Univariate analysis in this study utilized simple statistical calculations using the following formulas: Explanation: P = Percentage of the achieved result f = Frequency of the targeted variable n = Sample size of the research k = Constant Bivariate analysis of the relationship between incentives and the performance of Posyandu cadres for toddlers in Penajam Paser Utara District uses the chi-square test, a nonparametric method suitable for ordinal-scale data.The conclusions were drawn based on the P-value, where the null hypothesis (Ho) was rejected if the p-value was < 0.05, and the null hypothesis was not rejected if the P-value was > 0.05.

Respondent Characteristics
The posyandu cadre characteristics in the Penajam Paser Utara Regency are presented in  2 indicates that the majority of respondents received cash incentives in the range of IDR 251,000 to IDR 300,000 (40.6%), while the least common was receiving incentives exceeding Rp 300,000 (5.0%).Regarding noncash incentives, the most commonly received incentive was uniform (74.9%), while the least common was recreation (2.0%).Although all cadres received some type of non-cash incentive, not all cadres received the same incentive.

Performance
The distribution of respondents based on the performance of Posyandu cadres in the Penajam Paser Utara Regency area is presented in Table 3.  4 indicates that the majority of respondents had good performance in Posyandu activities (82.8%), while poor performance was observed in 17.2% of the respondents.Based on calculations in accordance with the number of questions and measurement criteria, the higher the answer score obtained, the better the performance of posyandu cadres.

Relationship between Cash Incentives and Posyandu Cadre Performance
The relationship between cash incentives and performance of Posyandu cadres in the Penajam Paser Utara Regency area is presented in Table 4.The chi-square analysis results revealed that Posyandu cadres receiving incentives < IDR 200,000 had a poor performance of 73.0%, while those receiving incentives > IDR 300,000 had a poor performance of 7.0%.This indicates a significant relationship between incentives and performance of the Posyandu cadre.

Relationship between Non-Cash Incentives and Posyandu Cadre Performance
The relationship between non-cash incentives and the performance of Posyandu cadres cannot be analyzed bivariately because, as shown in Table 5, all respondents received noncash incentives.As shown in Table 5, all the respondents received non-cash incentives.

Age Of Posyandu Cadres
The majority of Posyandu cadres in the Penajam Paser Utara Regency are over 45 years old, accounting for 51.2%.This can be attributed to the absence of regulations specifying age limits for cadre services, which allows individuals to become cadres regardless of their age.As a result, many cadres continue to serve even as they age.According to Aprilyanti (2017), the more mature a person's age, the more developed a person's ability to capture and think.This can be seen in the experience and maturity of the soul.A person living a normal life can be assumed to have more experience, wider knowledge, and deeper expertise.

Education Of Posyandu Cadres
The educational characteristics of the respondents indicated that the majority (54.8 %) had completed high or vocational school.Education level influences individuals' capabilities and balance in a harmonious manner.Individuals who become cadres voluntarily dedicate themselves to their communities.Therefore, the education level of cadres varies, emphasizing that the selection of cadres is not based solely on higher education.It is more about the intrinsic qualities of individuals, and those interested in becoming cadres contribute, despite their relatively low numbers (Killista et al., 2021).

Occupation Of Posyandu Cadres
In terms of cadre occupations, the majority were housewives, accounting for 89.1% of respondents.This aligns with theories suggesting a correlation between the type of occupation and cadres' activities or performance in Posyandu activities.Cadres with various occupations or commitments influence their performance and participation in Posyandu activities following a schedule set every month (Handayani & Nuryani, 2022).

Marital Status Of The Posyandu Cadres
The research indicated that the marital status of the respondents were predominantly married (95.3%).Most cadres are married, and approximately one-third have infants living with their families.The responsibility of being a housewife is prioritized, resulting in cadres having limited time for Posyandu activities, particularly when they need to attend to their children and household duties.This, in turn, affects the time available for their duties in Posyandu (Sukandar et al., 2018).

The Relationship Between Incentives And The Performance Of Posyandu Cadres
The results of this study show that out of 60 respondents who receive cash incentives < Rp 200.000,-there are 44 cadres achieve bad performance and 16 cadres achieve good performance.Out of 105 caders who receive a cash incentive of Rs 200.000,-up to Rs 250,000there are five cadres whose performance is bad and 100 caders whose performances are good.Of the 123 caders that receive an incentive of Rs 251.000 to Rs 300,000, there are two cadres that perform poorly and 121 caders that perform well.Based on the statistical test results using Chisquare, p value < 0,001 meaning ha accepted and ho rejected because p value< α (0,05) so it can be concluded that there is a relationship between incentives and the performance of posyandu baby cadres and news in the area of work of the Department of the district of Penajam Pazar North.The results of this study are in line with a study conducted by D. Pratiwi (2018) which concluded that there is a relationship between incentives and the activation of posyandu cadres.
As a volunteer in the field of public health, a cadre is required to provide services voluntarily and sincerely to the community, without expecting rewards or strings attached.Cadres also have the same needs as other people in the form of basic needs, materials, and appreciation from others.This is one reason why incentives influence the performance of posyandu cadres.Ketmoen et al. (2022) state that the success of the posyandu revitalization program in the research work area will be successful if the provision of incentives (such as operational assistance, health, and recreation allowances) to posyandu cadres receives attention.
Several factors influence the performance of posyandu cadres, namely, intrinsic and extrinsic motivation.Instrinsic motivation (from within) posyandu cadres includes age, education level, length of employment, length of time as a cadre, interest, and ability, while extrinsic motivation (encouragement that comes from outside the individual) includes posyandu facilities, cadre training, cadre coaching, incentives, and community support given to cadres.According to Iyong et al. (2020), extrinsic factors are supporting factors in increasing the activity of posyandu cadres.Extrinsic factors in posyandu activities in the form of posyandu facilities and supporting facilities can increase cadres' ability to carry out posyandu activities.
Cadres who receive sufficient rewards will be more active in implementing posyandu activities than those who receive inadequate incentives, so that they will affect the performance of posyandu cadres (Zuliyanti & Hidayati, 2021).According to Arifin et al. (2022), incentives have a positive effect on cadre performance.Providing incentives can increase the enthusiasm of cadres in organizing posyandu.Many factors affect the performance of posyandu cadres, but the most important influences on cadre performance are knowledge, attitudes, incentives, workload, and cadre behavior itself (Bidjuni, 2017).There needs to be a common understanding of the amount of uniform incentives so that it does not cause differences in the spirit of work of posyandu cadres.
Regarding non-cash incentives, such as health benefits, of the 22 cadres who received health benefits, 8 cadres had poor performance and 14 cadres had good performance.In this study, not all cadres received health benefits; therefore, there was an influence between the two variables.In line with Ahmadah's research (2020), employee performance after the existence of health benefits is optimal, as seen from the amount of workload that can be completed in accordance with the time for carrying out tasks owned by each employee.
Health benefits significantly stimulate effect on improving employee performance.In contrast, Wisnuwardani (2021) states that there is no significant relationship between the provision of health benefits and cadre performance.This is because all cadres in this study received health benefits.It is necessary to pay attention to the types of incentives provided and their distribution so that cadres are more motivated and perform better in posyandu activities.
In this study, the provision of incentives affected cadres' performance.Providing incentives can make cadres eager to carry out posyandu activities and do good jobs.However, this method can have an impact on the future; cadres must receive incentives every month in cash or non-cash, either from the local village government or the city government, so that cadres are still willing to do their job as posyandu managers.

Conclusion
The research findings reveal that a significant portion of Posyandu cadres for infants and toddlers in the Penajam Paser Utara Regency share specific characteristics such as being above 45 years old, having completed high school, and being homemakers.The majority receive cash incentives ranging from Rp 251,000 to Rp 300,000 in addition to non-cash incentives.Furthermore, most cadres demonstrated good performance, and there was a positive correlation between received incentives and post-yandu cadre performance.
To promote equity, it is recommended that the Health Department of Penajam Paser Utara Regency implement a uniform standard of cash incentives for all Posyandu cadres without considering regional factors or the number of Posyandu targets.Providing additional incentives to high-performance or highly dedicated cadres may be an effective strategy.

Thank-you note
The researcher would like to thank all those who have helped this research run smoothly, including the relevant parties in the Penajam Paser Utara District.The support and cooperation provided greatly helped in the success of this study.It is hoped that the results of this research can provide benefits and positive contributions not only in an academic context but also in the progress and welfare of society.Once again, thank you for your support and guidance.

Table 2 ,
based on age, education, occupation, and marital status.

Table 1 .
Distribution of Posyandu Cadre Incentives in the Working Area of Penajam Paser Utara Regency

Table 2 .
Distribution of Posyandu Cadre Performance in the Working Area of Penajam Paser Utara Regency

Table 3 .
Relationship between Cash Incentives and Posyandu Cadre Performance in the Working Area of Penajam Paser Utara Regency

Table 4 .
Relationship between Non-Cash Incentives and Posyandu Cadre Performance in the Working Area of Penajam Paser Utara Regency