Crowding out or no crowding out? A Self-Determination Theory approach to health worker motivation in performance-based financing

Abstract

Performance-based financing (PBF) is a common health system reform approach in low and middle income countries at present. Although increasing evidence on the effectiveness of PBF and knowledge of principles of good design are available, research is still lacking in regards to other aspects. Among these are a yet limited understanding of the complex role of health worker motivation in PBF and of potential side effects, for instance on intrinsic motivation. Our article aims to support meaningful future research by advancing the theoretical discussion around health worker motivation and PBF. We argue that an in-depth understanding of the motivational mechanisms and consequences of PBF at health worker level are of high practical relevance and should be at the heart of the PBF research agenda, and that predominant unidimensional conceptualizations of health worker motivation and descriptive rather than explanatory research approaches are insufficient to fully understand whether, how, and why PBF schemes alter health workers' motivational structures, mindsets, affect, and behavior. We introduce and apply Self-Determination Theory to the context of PBF as a valuable theoretical framework for future empirical exploration. From this, we conclude that PBF interventions are unlikely to have a generally adverse effect on intrinsic motivation as feared by parts of the PBF community. Rather, we posit that PBF can have positive and negative effects on both intrinsic and extrinsic motivation, to varying degrees depending on the specific design, implementation, and results of a particular intervention and on health workers' perceptions and evaluations of it.

Measuring health workers’ motivation composition: validation of a scale based on Self-Determination Theory in Burkina Faso

“…However, the few studies from LMIC (non-healthcare) settings [18] and the (non-SDT-based) literature on health worker motivation in LMICs suggest its validity in LMIC healthcare contexts as well. Specifically, sources of motivation identified by the latter correspond well to the five dimensions differentiated by the SDT taxonomy (e.g., [4, 7, 8, 10–13, 19–25]). For a theoretical application of SDT and the taxonomy to LMIC healthcare settings, see [4].…”

“…The scale will be useful for researchers who want to not only investigate overall levels of work motivation (“motivation intensity”) but also study how motivation of different origin and characteristics contribute to these overall levels (“motivation composition”) to understand how different “motivation profiles” relate to outcomes of interest [4]. …”

“…Despite the attention such interventions are receiving, gaps in understanding remain. In particular, the mechanisms through which interventions bring about motivational changes and potential side effects thereof remain poorly understood [4–8]. For instance, there is an ongoing debate around whether the monetary incentives involved in PBF undermine intrinsic motivation (“crowding out effect”) [5].…”

“…Research on health worker motivation in LMICs has mostly focused on the overall amount or on determinants and outcomes of motivation, leaving other relevant dimensions discussed in the psychological literature such as motivation composition relatively unexplored [4, 9]. Corresponding quantitative measurement tools (e.g., [10–13]), while without doubt useful to answer many research questions, are not suited to others, including that around the crowding out effect which deals with a shift in motivation composition from intrinsic to extrinsic forms.…”

“…We define motivation composition as the extent to which motivation of different origin within and outside a person contributes to their overall work motivation. The scale is theoretically grounded in Deci and Ryan’s Self-Determination Theory (SDT) [4, 14] and was developed for use in questionnaires or structured interviews. It assesses general motivation towards work rather than task- or situation-specific motivation.…”