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BackgroundPolicies generate accountability in that they offer a standard against which government performance can be assessed. A central question of this study is whether ideological imprint left by policy is realized in the time following its adoption. National mental health policy expressly promotes the notion of deinstitutionalization, which mandates that individuals be cared for in the community rather than in institutional environments.MethodsWe investigate whether mental health policy adoption induced a transformation in the structure of mental health systems, namely psychiatric beds, using panel data on 193 countries between 2001 and 2011.ResultsOur striking regression results demonstrate that late-adopters of mental health policy are more likely to reduce psychiatric beds in mental hospitals and other biomedical settings than innovators, whereas they are less likely than non-adopters to reduce psychiatric beds in general hospitals.ConclusionsIt can be inferred late adopters are motivated to implement deinstitutionalization for technical efficiency rather than social legitimacy reasons.Electronic supplementary materialThe online version of this article (doi:10.1186/1752-4458-8-47) contains supplementary material, which is available to authorized users.

BackgroundPerformance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers’ job satisfaction, motivation, and attrition in Zambia. It uses a randomized intervention/control design to evaluate before–after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group.MethodsMixed methods are employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion seeks to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program.ResultsEconometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centers were staffed with qualified personnel and the personnel had role clarity.ConclusionsIn Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.Electronic supplementary materialThe online version of this article (doi:10.1186/s12960-017-0179-2) contains supplementary material, which is available to authorized users.