Abstract
Background: Performance-based financing (PBF) is currently tested in many low- and middle-income countries as a health system strengthening strategy. One of the main mechanisms through which PBF is assumed to effect change is by motivating health workers to improve their service delivery performance. This article aims at a better understanding of such motivational effects of PBF. In particular, the study focused on organizational context factors and health workers’ perceptions thereof as moderators of the motivational effects of PBF, which to date has been little explored. Methods: We conducted a multiple case study in 2 district hospitals and 16 primary health facilities across three districts. Health facilities were purposely sampled according to pre-PBF performance levels. Within sampled facilities, 82 clinical skilled healthcare workers were in-depth interviewed one year after the start of the PBF intervention. Data were analyzed using a blended deductive and inductive process, using self-determination theory (SDT) as an analytical framework. Results: Results show that the extent to which PBF contributed to positive, sustainable forms of motivation depended on the "ground upon which PBF fell," beyond health workers’ individual personalities and disposition. In particular, health workers described three aspects of the organizational context in which PBF was implemented: the extent to which existing hierarchies fostered as opposed to hindered participation and transparency; managers’ handling of the increased performance feedback inherent in PBF; and facility’s pre-PBF levels in regards to infrastructure, equipment, and human resources. Conclusion: Our results underline the importance of leadership styles and pre-implementation performance levels in shaping health workers’ motivational reactions to PBF. Ancillary interventions aimed at fostering participatory as opposed to directional leadership or start-up support to low-performing health facilities will likely boost PBF effects in regards to the development of valuable motivational capacities.
Highlights
Performance-based financing (PBF) aims to improve quality of and access to healthcare services by giving “healthcare providers financial payments based on the achievement of predetermined targets, goals or outputs after being verified for quality” (p. 861).[1]
PBF: A Means to Get Health Workers to Work More and Better? Approximately 1 year after the start of PBF, the majority of health workers expressed a sense of increased motivation and effort due to PBF and the individual reward component
For the case of Burkina Faso and similar contexts with a strong presence of hierarchical leadership styles, our results imply that leadership support and training in the context of PBF or similar health system interventions might be highly conducive to the development of positive and lasting forms of work motivation
Summary
Performance-based financing (PBF) aims to improve quality of and access to healthcare services by giving “healthcare providers (facilities or health workers) financial payments based on the achievement of predetermined targets, goals or outputs after being verified for quality” (p. 861).[1]. Performance-based financing (PBF) aims to improve quality of and access to healthcare services by giving “healthcare providers (facilities or health workers) financial payments based on the achievement of predetermined targets, goals or outputs after being verified for quality” 861).[1] Usually explained in agency theory terms, PBF thereby aims to motivate healthcare providers to align their service provision behavior in the interest of the Ministry of Health, in order to maximize quality of and access to care for the population they serve.[1,2]. PBF has traditionally been thought to exert its motivating effect primarily through the individual financial rewards to health workers, recent research from various settings points at more complex, multifaceted, positive and negative motivational mechanisms. While there is a growing recognition of the importance of the implementation context in determining PBF success in the literature and applied discourse, research is yet scarce.[6,7,8] In regards to health worker motivation, research points at rigid procurement channels and human resources shortages as demotivators in the context of PBF.[3,9,10] there are no studies explicitly investigating how the implementation context shapes health workers’ motivational reactions to PBF yet
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