Abstract
Background:We study the role of individual and team-level motivation in explaining large-scale primary care performance improvements in El Salvador, one of the top-performing countries in the Salud Mesoamerica Initiative.Methods:Case study with outlier sampling of high-performing, community health teams in El Salvador. Design includes scoping review of literature, document review, non-participant observation, and qualitative analysis of in-depth interviews following a realist case study protocol.Results:The interplay between program interventions and organizational, community and policy contexts trigger multi-level motivational mechanisms that operate in complex, dynamic fashion. Interventions like performance measurement and team-based, in-kind incentives foster motivation among individual members of high-performing teams, which may be moderated by working conditions, supervision practices, and by the stress exerted by the interventions themselves. Individuals report a strong sense of public service motivation and an overarching sense of commitment to the community they serve. At the interpersonal level, the linkage between performance measurement and in-kind incentives triggers a sense of collective efficacy and increases team motivation and improvement behaviors. The convening of learning forums and performance dialogue increases the stakes for high-performing teams, helps them make sense of performance data, and leads to performance information utilization for healthcare improvements. Closeness to communities creates strong emotional linkages among team members that further increases collective efficacy and social identity. Such changes in individuals, team, and organizational behaviors can contribute to improved delivery of primary care services and explain the gains in performance demonstrated by the program.Conclusions:This case suggests that primary care systems that rely on multi-disciplinary teams for the provision of care can benefit from performance measurement and management interventions that leverage individual and team-level motivation. Realist evaluation can help prioritize policy-relevant research and enhance the design and evaluation of large-scale performance reforms in primary care systems in low- and middle-income settings.
Highlights
Calls have been made for acquiring a better understanding of the ways in which various policy and management interventions contribute to improving the performance of primary care delivery systems, in low- and middle-income countries (LMIC) where such improvements might be necessary conditions for the achievement of universal health coverage in the age of the Sustainable Development Goals[1,2]
A randomized-controlled trial to evaluate the impact of the in-kind incentives measured Community Health Teams (CHTs) performance
Context Based on the evidence from the achievement in the four high-performance CHTs sampled, several contextual factors appear to have been conducive to the successful implementation of Salud Mesoamerica Initiative (SMI) in El Salvador
Summary
Calls have been made for acquiring a better understanding of the ways in which various policy and management interventions contribute to improving the performance of primary care delivery systems, in low- and middle-income countries (LMIC) where such improvements might be necessary conditions for the achievement of universal health coverage in the age of the Sustainable Development Goals[1,2]. Experimental studies infrequently address the role of context in moderating the motivational effects of PMM interventions in the public-sector in general[17,18,19,20], and in LMIC primary care systems in particular[21,22]. We study the role of individual and team-level motivation in explaining large-scale primary care performance improvements in El Salvador, one of the top-performing countries in the Salud Mesoamerica Initiative. Closeness to communities creates strong emotional linkages among team members that further increases collective efficacy and social identity Such changes in individuals, team, and organizational behaviors can contribute to improved delivery of primary care services and explain the gains in performance demonstrated by the program. In my view it deserves an additional step which provides more clarity of results and thereby can improve meaning and impact substantially
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