IMPACT OF RESULTS-BASED FINANCING ON HEALTH WORKER SATISFACTION AND MOTIVATION IN ZIMBABWE Implications for program design and implementation

Provider incentives are targeted to improve health worker outcomes, yet the evidence captures their effect more in terms of utilization of services (and quality of care to some extent). This paper assesses the impact of a Results-based Financing (RBF) program in Zimbabwe on health worker satisfaction and motivation using a difference-in-differences method and health facility survey data. It also tries to underpin the causal pathways of these observed outcomes with qualitative information. Quantitative results show that health workers in RBF facilities had higher overall job satisfaction, particularly for compensation (8.436 points, on a maximum scale of 100; p<0.05). They reflected less motivation, specifically for teamwork, recognition, and facility leadership. Qualitative data, on the other hand, reveal a rather positive picture: in general, health workers were motivated with bonus from RBF, and beyond that, they expressed a sense of satisfaction for being better able to serve the community. Although the overall impact evaluation indicated that the Zimbabwe RBF is high performing, certain design features of the program and their interaction with contextual factors could have explained these puzzling outcomes. Staff expressed their dissatisfaction over the following: reduced unit prices of incentivized services; the relative proportion of incentive amount to their tasks and that of peers; inadequate living accommodation; limited capacity of supervisors; restricted leadership ability of the head of facility; and ‘burn-out’ due to increased patient load. Conversely, they were positively motivated by improvements in working conditions and facility autonomy. To enable the RBF program to have a greater positive impact on human resources for health outcomes, some larger health system issues are important, such as availability of skilled workers. Within the control span of the program, scope for improvement includes revisiting the unit prices of services and allocation criteria of incentives in a context-specific and consensual

[1]  Eric de Roodenbeke,et al.  Performance incentives for health care providers , 2017 .

[2]  G. Tamburlini,et al.  Correction: Assessing Coverage, Equity and Quality Gaps in Maternal and Neonatal Care in Sub-Saharan Africa: An Integrated Approach , 2015, PloS one.

[3]  Jean Christophe Fotso,et al.  Psychosocial support and resilience building among health workers in Sierra Leone: interrelations between coping skills, stress levels, and interpersonal relationships , 2015, BMC Health Services Research.

[4]  A. Binagwaho,et al.  Using Provider Performance Incentives to Increase HIV Testing and Counseling Services in Rwanda , 2013, Journal of health economics.

[5]  E. van Doorslaer,et al.  Introduction of performance-based financing in burundi was associated with improvements in care and quality. , 2014, Health affairs.

[6]  M. Rezaeian,et al.  Factors Affecting Job Motivation among Health Workers: A Study From Iran , 2014, Global journal of health science.

[7]  Jordan D. Jarvis,et al.  Factors affecting motivation and retention of primary health care workers in three disparate regions in Kenya , 2014, Human Resources for Health.

[8]  Élise Huillery,et al.  Pay-for-Performance, Motivation and Final Output in the Health Sector: Experimental Evidence from the Democratic Republic of Congo , 2014 .

[9]  M. English,et al.  Absenteeism amongst health workers – developing a typology to support empiric work in low-income countries and characterizing reported associations , 2013, Human Resources for Health.

[10]  R. Sauerborn,et al.  Motivation and incentives of rural maternal and neonatal health care providers: a comparison of qualitative findings from Burkina Faso, Ghana and Tanzania , 2013, BMC Health Services Research.

[11]  Grant Miller,et al.  Pay-for-Performance Incentives in Low- and Middle-Income Country Health Programs , 2013 .

[12]  Carinne Brody,et al.  The impact of vouchers on the use and quality of health care in developing countries: A systematic review , 2013, Global public health.

[13]  A. Soucat,et al.  Towards Interventions in Human Resources for Health in Ghana : Evidence for Health Workforce Planning and Results , 2013 .

[14]  H. Ayles,et al.  Measuring health workers’ motivation in rural health facilities: baseline results from three study districts in Zambia , 2013, Human Resources for Health.

[15]  Nils Gunnar Songstad.  Health worker motivation in a low-income context The case of rural health services in Tanzania , 2012 .

[16]  Nicholas Steel,et al.  Pay-for-Performance in the United Kingdom: Impact of the Quality and Outcomes Framework—A Systematic Review , 2012, The Annals of Family Medicine.

[17]  S. Mtenga,et al.  Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania , 2012, BMJ Open.

[18]  M. Fesharaki,et al.  Reliability and validity of "Job Satisfaction Survey " questionnaire in military health care workers , 2012 .

[19]  Maria Paola Bertone,et al.  The sudden removal of user fees: the perspective of a frontline manager in Burundi. , 2011, Health policy and planning.

[20]  L. Gilson,et al.  Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries. , 2011, Health policy and planning.

[21]  A. Scott,et al.  The effect of financial incentives on the quality of health care provided by primary care physicians. , 2011, The Cochrane database of systematic reviews.

[22]  A. Binagwaho,et al.  Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation , 2011, The Lancet.

[23]  D. Nambiar.  Performance incentives for global health: Potential and pitfalls , 2011 .

[24]  S. Kane,et al.  Realist review and synthesis of retention studies for health workers in rural and remote areas , 2011 .

[25]  F. Morestin,et al.  A scoping review of the literature on the abolition of user fees in health care services in Africa. , 2011, Health policy and planning.

[26]  K. Leonard,et al.  Professionalism and the know-do gap: exploring intrinsic motivation among health workers in Tanzania. , 2010, Health economics.

[27]  M. Deming,et al.  The rise and fall of supervision in a project designed to strengthen supervision of Integrated Management of Childhood Illness in Benin. , 2010, Health policy and planning.

[28]  M. English,et al.  Contextual influences on health worker motivation in district hospitals in Kenya , 2009, Implementation science : IS.

[29]  M. English,et al.  Developing a tool to measure health worker motivation in district hospitals in Kenya , 2009, Human Resources for Health.

[30]  M. Dieleman,et al.  Human resource management interventions to improve health workers' performance in low and middle income countries: a realist review , 2009, Health research policy and systems.

[31]  T. Martineau,et al.  Does decentralisation improve human resource management in the health sector? A case study from China. , 2006, Social Science & Medicine (1967).

[32]  Laura Petersen,et al.  Does Pay-for-Performance Improve the Quality of Health Care? , 2006, Annals of Internal Medicine.

[33]  M. Dieleman,et al.  Improving health worker performance : in search of promising practices , 2006 .

[34]  M. Qayad.  Competence of maternal and child health clinic workers in detecting malnutrition in Somalia. , 2005, African health sciences.

[35]  Stephen O. Ogunlana,et al.  Testing Herzberg’s two‐factor theory in the Thai construction industry , 2003 .

[36]  Mark C. Ellickson,et al.  Determinants of Job Satisfaction of Municipal Government Employees , 2001 .

[37]  Paul E. Spector.  Job satisfaction: application, assessment, cause, and consequences , 1997 .

[38]  Teresa M. Amabile,et al.  "The Work Preference Inventory: Assessing intrinsic and extrinsic motivational orientations": Correction. , 1995 .

[39]  L. Gilson,et al.  The structural quality of Tanzanian primary health facilities. , 1995, Bulletin of the World Health Organization.

[40]  Gill Christy,et al.  Management and Organisational Behaviour , 1985 .

[41]  J. Schermerhorn.  Management for Productivity , 1984 .