What Happens When Donors Pull Out? Examining Differences in Motivation Between Health Workers Who Recently Had Performance-Based Financing (PBF) Withdrawn With Workers Who Never Received PBF in the Democratic Republic of Congo

Document Type: Original Article

Authors

1 Faculty of Public Health Policy, London School of Hygiene and Tropical Medicine, London, UK

2 Faculty of Medicine, Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany

3 School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA

Abstract

Background
A motivated workforce is necessary to ensure the delivery of high quality health services. In developing countries, performance-based financing (PBF) is often employed to increase motivation by providing financial incentives linked to performance. However, given PBF schemes are usually funded by donors, their long-term financing is not always assured, and the effects of withdrawing PBF on motivation are largely unknown. This cross-sectional study aimed to identify differences in motivation between workers who recently had donor-funded PBF withdrawn, with workers who had not received PBF.
 
Methods
Quantitative data were collected from 485 health workers in 5 provinces using a structured survey containing questions on motivation which were based on an established motivation framework. Confirmatory factor analysis was used to verify dimensions of motivation, and multiple regression to assess differences in motivation scores between workers who had previously received PBF and those who never had. Qualitative interviews were also carried out in Kasai Occidental province with 16 nurses who had previously or never received PBF.
 
Results
The results indicated that workers in facilities where PBF had been removed scored significantly lower on most dimensions of motivation compared to workers who had never received PBF. The removal of the PBF scheme was blamed for an exodus of staff due to the dramatic reduction in income, and negatively impacted on relationships between staff and the local community.
 
Conclusion
Donors and governments unable to sustain PBF or other donor-payments should have clear exit strategies and institute measures to mitigate any adverse effects on motivation following withdrawal.

Highlights

Supplementary File 1 (Download)

Supplementary File 2 (Download)

Supplementary File 3 (Download)

Supplementary File 4 (Download)

Keywords

Main Subjects


  1. World Health Organization (WHO). The world health report: working together for health. WHO; 2006. https://www.who.int/whr/2006/en/. Accessed 1 September, 2018.
  2. Pembe AB, Carlstedt A, Urassa DP, Lindmark G, Nystrom L, Darj E. Quality of antenatal care in rural Tanzania: counselling on pregnancy danger signs. BMC Pregnancy Childbirth. 2010;10:35. doi:10.1186/1471-2393-10-35
  3. Eriksen J, Tomson G, Mujinja P, Warsame MY, Jahn A, Gustafsson LL. Assessing health worker performance in malaria case management of underfives at health facilities in a rural Tanzanian district. Trop Med Int Health. 2007;12(1):52-61. doi:10.1111/j.1365-3156.2006.01753.x
  4. Maestad O, Torsvik G. Improving the quality of health care when health workers are in short supply. Bergen: Chr. Michelsen institute (CMI); 2008:12:25.
  5. Leonard KL, Masatu MC. Professionalism and the know-do gap: exploring intrinsic motivation among health workers in Tanzania. Health Econ. 2010;19(12):1461-1477. doi:10.1002/hec.1564
  6. Franco LM, Bennett S, Kanfer R. Health sector reform and public sector health worker motivation: a conceptual framework. Soc Sci Med. 2002;54(8):1255-1266.
  7. Hongoro C, McPake B. How to bridge the gap in human resources for health. Lancet. 2004;364(9443):1451-1456. doi:10.1016/s0140-6736(04)17229-2
  8. Mathauer I, Imhoff I. Health worker motivation in Africa: the role of non-financial incentives and human resource management tools. Hum Resour Health. 2006;4:24. doi:10.1186/1478-4491-4-24
  9. Janovsky K, Peters D, Arur A, Sundaram S. Improving health services and strengthening health systems: adopting and implementing innovative strategies: an exploratory review in twelve countries. Department of Health Policy, Development and Services, Evidence and Information for Policy. Geneva: World Health Organization; 2006.
  10. Lemiere C, Herbst CH, Jahanshahi N, Smith E. Reducing geographical imbalances of health workers in sub-Saharan Africa: a labor market prospective on what works, what does not, and why. World Bank; 2011. https://elibrary.worldbank.org/doi/abs/10.1596/978-0-8213-8599-9. Accessed 1 September, 2018.
  11. Dieleman M, Cuong PV, Anh LV, Martineau T. Identifying factors for job motivation of rural health workers in North Viet Nam. Hum Resour Health. 2003;1(1):10. doi:10.1186/1478-4491-1-10
  12. Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D, Ditlopo P. Motivation and retention of health workers in developing countries: a systematic review. BMC Health Serv Res. 2008;8:247. doi:10.1186/1472-6963-8-247
  13. Stilwell B, Diallo K, Zurn P, Vujicic M, Adams O, Dal Poz M. Migration of health-care workers from developing countries: strategic approaches to its management. Bull World Health Organ. 2004;82(8):595-600. doi:10.1590/S0042-96862004000800009
  14. Dieleman M, Harnmeijer JW. Improving health worker performance: in search of promising practices. Geneva: World Health Organization; 2006.
  15. Kalk A, Paul FA, Grabosch E. 'Paying for performance' in Rwanda: does it pay off? Trop Med Int Health. 2010;15(2):182-190. doi:10.1111/j.1365-3156.2009.02430.x
  16. Huillery E, Seban J. Financial incentives are counterproductive in non-profit sectors: evidence from a health experiment. Sciences Po; 2015
  17. Engineer CY, Dale E, Agarwal A, et al. Effectiveness of a pay-for-performance intervention to improve maternal and child health services in Afghanistan: a cluster-randomized trial. Int J Epidemiol. 2016;45(2):451-459. doi:10.1093/ije/dyv362
  18. Lohmann J, Wilhelm D, Kambala C, Brenner S, Muula AS, De Allegri M. 'The money can be a motivator, to me a little, but mostly PBF just helps me to do better in my job.' An exploration of the motivational mechanisms of performance-based financing for health workers in Malawi. Health Policy Plan. 2018;33(2):183-191. doi:10.1093/heapol/czx156
  19. Lohmann J, Muula AS, Houlfort N, De Allegri M. How does performance-based financing affect health workers' intrinsic motivation? A Self-Determination Theory-based mixed-methods study in Malawi. Soc Sci Med. 2018;208:1-8. doi:10.1016/j.socscimed.2018.04.053
  20. World Bank. RBF Health. 2017; www.rbfhealth.org/. Accessed 20th November 2017, 2017.
  21. World Health Organization (WHO). Success stories of health financing reforms for universal coverage. Burundi: WHO; 2011.
  22. World Bank. CG Rep. Health Sector Project. 2017; http://projects.worldbank.org/P143849/health-sector-project?lang=en&tab=overview. Accessed 20th November 2017, 2017.
  23. Rusa L, Schneidman M, Fritsche G, Musango L. Rwanda: performance-based financing in the public sector Performance incentives for global health: potentials and pitfalls 2009; http://www.cgdev.org/sites/default/files/9781933286297-Levine-performance-incentives.pdf. Accessed 20th November 2011, 2017.
  24. Coghlan B, Brennan RJ, Ngoy P, et al. Mortality in the Democratic Republic of Congo: a nationwide survey. Lancet. 2006;367(9504):44-51. doi:10.1016/s0140-6736(06)67923-3
  25. Bertone MP, Lurton G, Mutombo PB. Investigating the remuneration of health workers in the DR Congo: implications for the health workforce and the health system in a fragile setting. Health Policy Plan. 2016;31(9):1143-1151. doi:10.1093/heapol/czv131
  26. Fox S, Witter S, Wylde E, Mafuta E, Lievens T. Paying health workers for performance in a fragmented, fragile state: reflections from Katanga Province, Democratic Republic of Congo. Health Policy Plan. 2014;29(1):96-105. doi:10.1093/heapol/czs138
  27. Soeters R, Peerenboom PB, Mushagalusa P, Kimanuka C. Performance-based financing experiment improved health care in the Democratic Republic of Congo. Health Aff (Millwood). 2011;30(8):1518-1527. doi:10.1377/hlthaff.2009.0019
  28. Latham GP, Pinder CC. Work motivation theory and research at the dawn of the twenty-first century. Annu Rev Psychol. 2005;56:485-516. doi:10.1146/annurev.psych.55.090902.142105
  29. Porter LW, Lawler EE. Managerial attitudes and performance. Homewood, Ill: RD Irwin; 1968.
  30. Hackman JR, Oldham GR. Motivation through the design of work: test of a theory. Organizational Behavior and Human Performance. 1976;16(2):250-279. doi:10.1016/0030-5073(76)90016-7
  31. Ryan RM, Deci EL. Self-determination theory: Basic psychological needs in motivation, development, and wellness. Guilford Publications; 2017.
  32. Toure-Tillery M, Fishbach A. How to measure motivation: A guide for the experimental social psychologist. Soc Personal Psychol Compass. 2014;8(7):328-341. doi:10.1111/spc3.12110
  33. Borghi J, Lohmann J, Dale E, et al. How to do (or not to do)... Measuring health worker motivation in surveys in low- and middle-income countries. Health Policy Plan. 2018;33(2):192-203. doi:10.1093/heapol/czx153
  34. Hotchkiss DR, Banteyerga H, Tharaney M. Job satisfaction and motivation among public sector health workers: evidence from Ethiopia. Hum Resour Health. 2015;13:83. doi:10.1186/s12960-015-0083-6
  35. Lohmann J, Houlfort N, De Allegri M. Crowding out or no crowding out? A Self-Determination Theory approach to health worker motivation in performance-based financing. Soc Sci Med. 2016;169:1-8. doi:10.1016/j.socscimed.2016.09.006
  36. Lohmann J, Souares A, Tiendrebeogo J, et al. Measuring health workers' motivation composition: validation of a scale based on Self-Determination Theory in Burkina Faso. Hum Resour Health. 2017;15(1):33. doi:10.1186/s12960-017-0208-1
  37. Alhassan RK, Spieker N, van Ostenberg P, Ogink A, Nketiah-Amponsah E, de Wit TF. Association between health worker motivation and healthcare quality efforts in Ghana. Hum Resour Health. 2013;11:37. doi:10.1186/1478-4491-11-37
  38. Bonenberger M, Aikins M, Akweongo P, Wyss K. The effects of health worker motivation and job satisfaction on turnover intention in Ghana: a cross-sectional study. Hum Resour Health. 2014;12:43. doi:10.1186/1478-4491-12-43
  39. Mutale W, Ayles H, Bond V, Mwanamwenge MT, Balabanova D. Measuring health workers' motivation in rural health facilities: baseline results from three study districts in Zambia. Hum Resour Health. 2013;11:8. doi:10.1186/1478-4491-11-8
  40. Franco LM, Bennett S, Kanfer R, Stubblebine P. Determinants and consequences of health worker motivation in hospitals in Jordan and Georgia. Soc Sci Med. 2004;58(2):343-355.
  41. Chandler CI, Chonya S, Mtei F, Reyburn H, Whitty CJ. Motivation, money and respect: a mixed-method study of Tanzanian non-physician clinicians. Soc Sci Med. 2009;68(11):2078-2088. doi:10.1016/j.socscimed.2009.03.007
  42. Creswell JW, Klassen AC, Plano Clark VL, Smith KC. Best practices for mixed methods research in the health sciences. Bethesda, MD: National Institutes of Health. 2011;2013:541-545.
  43. Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. Sage Publications; 2017.
  44. Bennett S, Franco LM, Kanfer R, Stubblebine P. The Development of Tools to Measure the Determinants and Consequences of Health Worker Motivation in Developing Countries. Bethesda, MD: Partnerships for Health Reform Project, Abt Associates Inc;2000.
  45. Prytherch H, Kagone M, Aninanya GA, et al. Motivation and incentives of rural maternal and neonatal health care providers: a comparison of qualitative findings from Burkina Faso, Ghana and Tanzania. BMC Health Serv Res. 2013;13:149. doi:10.1186/1472-6963-13-149
  46. Mbindyo PM, Blaauw D, Gilson L, English M. Developing a tool to measure health worker motivation in district hospitals in Kenya. Hum Resour Health. 2009;7:40. doi:10.1186/1478-4491-7-40
  47. Faye A, Fournier P, Diop I, Philibert A, Morestin F, Dumont A. Developing a tool to measure satisfaction among health professionals in sub-Saharan Africa. Hum Resour Health. 2013;11:30. doi:10.1186/1478-4491-11-30
  48. Agyepong IA, Anafi P, Asiamah E, Ansah EK, Ashon DA, Narh-Dometey C. Health worker (internal customer) satisfaction and motivation in the public sector in Ghana. Int J Health Plann Manage. 2004;19(4):319-336. doi:10.1002/hpm.770
  49. Penn-Kekana L, Blaauw D, Tint KS, Monareng D, Chege J. Nursing staff dynamics and implications for maternal health provision in public health facilities in the context of HIV/AIDS. Frontiers in Reproductive Health; 2005.
  50. Peters DH, Chakraborty S, Mahapatra P, Steinhardt L. Job satisfaction and motivation of health workers in public and private sectors: cross-sectional analysis from two Indian states. Hum Resour Health. 2010;8:27. doi:10.1186/1478-4491-8-27
  51. Yami A, Hamza L, Hassen A, Jira C, Sudhakar M. Job satisfaction and its determinants among health workers in jimma university specialized hospital, southwest ethiopia. Ethiop J Health Sci. 2011;21(Suppl 1):19-27.
  52. Blaauw D, Ditlopo P, Maseko F, et al. Comparing the job satisfaction and intention to leave of different categories of health workers in Tanzania, Malawi, and South Africa. Glob Health Action. 2013;6:19287. doi:10.3402/gha.v6i0.19287
  53. Khan MM, Hotchkiss DR, Dmytraczenko T, Zunaid Ahsan K. Use of a Balanced Scorecard in strengthening health systems in developing countries: an analysis based on nationally representative Bangladesh Health Facility Survey. Int J Health Plann Manage. 2013;28(2):202-215. doi:10.1002/hpm.2136
  54. Laokri S, Soelaeman R, Hotchkiss DR. Assessing out-of-pocket expenditures for primary health care: how responsive is the Democratic Republic of Congo health system to providing financial risk protection? BMC Health Serv Res. 2018;18(1):451. doi:10.1186/s12913-018-3211-x
  55. Bertone MP, Lagarde M, Witter S. Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone. BMC Health Serv Res. 2016;16:286. doi:10.1186/s12913-016-1546-8
  56. Paul E, Sossouhounto N, Eclou DS. Local stakeholders' perceptions about the introduction of performance-based financing in Benin: a case study in two health districts. Int J Health Policy Manag. 2014;3(4):207-214. doi:10.15171/ijhpm.2014.93
  57. Deci EL, Koestner R, Ryan RM. A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychol Bull. 1999;125(6):627-668; discussion 692-700.
  58. nmans D, Holvoet N, Orach CG, Criel B. Opening the 'black box' of performance-based financing in low- and lower middle-income countries: a review of the literature. Health Policy Plan. 2016;31(9):1297-1309. doi:10.1093/heapol/czw045
  59. Bertone MP, Meessen B. Studying the link between institutions and health system performance: a framework and an illustration with the analysis of two performance-based financing schemes in Burundi. Health Policy Plan. 2013;28(8):847-857. doi:10.1093/heapol/czs124
  60. Binyaruka P, Patouillard E, Powell-Jackson T, Greco G, Maestad O, Borghi J. Effect of paying for performance on utilisation, quality, and user costs of health services in Tanzania: a controlled before and after study. PLoS One. 2015;10(8):e0135013. doi:10.1371/journal.pone.0135013
  61. Basinga P, Mayaka S, Condo J. Performance-based financing: the need for more research. Bull World Health Organ. 2011;89(9):698-699. doi:10.2471/blt.11.089912
  62. Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does pay-for-performance improve the quality of health care? Ann Intern Med. 2006;145(4):265-272. doi:10.7326/0003-4819-145-4-200608150-00006
  63. Schuster RC, de Sousa O, Reme AK, et al. Performance-based financing empowers health workers delivering prevention of vertical transmission of HIV services and decreases desire to leave in Mozambique. Int J Health Policy Manag. 2018;7(7):630-644. doi:10.15171/ijhpm.2017.137
  64. Paul E, Lamine Drame M, Kashala JP, et al. Performance-Based Financing to Strengthen the Health System in Benin: Challenging the Mainstream Approach. Int J Health Policy Manag. 2017;7(1):35-47. doi:10.15171/ijhpm.2017.42
  65. Lannes L. Improving health worker performance: The patient-perspective from a PBF program in Rwanda. Soc Sci Med. 2015;138:1-11. doi:10.1016/j.socscimed.2015.05.033
  66. Stremmel AJ. Predictors of intention to leave child care work. Early Child Res Q. 1991;6(2):285-298. doi:10.1016/0885-2006(91)90013-B
  67. Rosse JG, Miller HE. Relationship between absenteeism and other employee behaviors. Absenteeism, 1. 1984:194-228.
  68. Pool J, Meeuwsen E, Michels K. Turnover and management of turnover. Personeelsmanagement in De Gezondheidszorg. 1992:77-94.
  69. Vandenberg RJ, Lance CE. A review and synthesis of the measurement invariance literature: Suggestions, practices, and recommendations for organizational research. Organ Res Methods. 2000;3(1):4-70. doi:10.1177/109442810031002
  70. Maini R, Hotchkiss DR, Borghi J. A cross-sectional study of the income sources of primary care health workers in the Democratic Republic of Congo. Hum Resour Health. 2017;15(1):17. doi:10.1186/s12960-017-0185-4
  71. Boyatzis RE. Transforming qualitative information: Thematic analysis and code development. Thousand Oaks, CA: Sage; 1998.
  72. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
  73. Frey BS, Jegen R. Motivation crowding theory. J Econ Surv. 2001;15(5):589-611. doi:10.1111/1467-6419.00150
  74. Benzer JK, Young GJ, Burgess JF, Jr., et al. Sustainability of quality improvement following removal of pay-for-performance incentives. J Gen Intern Med. 2014;29(1):127-132. doi:10.1007/s11606-013-2572-4
  75. Kontopantelis E, Springate D, Reeves D, Ashcroft DM, Valderas JM, Doran T. Withdrawing performance indicators: retrospective analysis of general practice performance under UK Quality and Outcomes Framework. BMJ. 2014;348:g330. doi:10.1136/bmj.g330
  76. Soucat A, Dale E, Mathauer I, Kutzin J. Pay-for-performance debate: not seeing the forest for the trees. Health Systems & Reform. 2017;3(2):74-79. doi:10.1080/23288604.2017.1302902
  77. Maini R, Mounier-Jack S, Borghi J. Performance-based financing versus improving salary payments to workers: insights from the Democratic Republic of Congo. BMJ Glob Health. 2018;3(5):e000958. doi:10.1136/bmjgh-2018-000958
  78. Creswell JW. Qualitative inquiry and research design: Choosing among five approaches. Thousand Oaks, CA: Sage; 1998.
  79. Morse JM. Designing funded qualitative research. In: Denzin NK, Lincoln YS, eds. Handbook of qualitative research. 2nd ed. Thousand Oaks, CA: Sage; 1994:220-235.