Motivating health workers up to a limit: partial effects of performance-based financing on working environments in Nigeria

Abstract

Background: In 2012, the Nigerian government launched performance-based financing (PBF) in three districts providing financial incentives to health workers based on the quantity and quality of service provision. They were given autonomy to use funds for operational costs and performance bonuses. This study aims to understand changes in perceived motivation among health workers with the introduction of PBF in Wamba district, Nigeria. Methods: The study used a qualitative research design to compare perceptions of health workers in facilities receiving PBF payments in the pilot district of Wamba to those that were not. In-depth semi-structured interviews (n ¼ 39) were conducted with health workers from PBF and non-PBF facilities along with managers of the PBF project. Framework analysis was used to identify patterns and variations in responses. Facility records were collated and triangulated with qualitative data. Findings: Health workers receiving PBF payments reported to be 'awakened' by performance bonuses and improved working environments including routine supportive supervision and availability of essential drugs. They recounted being more punctual, hard working and proud of providing better services to their communities. In comparison, health workers in non-PBF facilities complained about the dearth of basic equipment and lack of motivating strategies. However, health workers from both sets of facilities considered there to be a severe shortage of manpower resulting in excessive workload, fatigue and general dissatisfaction. Conclusions: PBF strategies can succeed in motivating health workers by bringing about a change in incentives and working conditions. However, such programmes need to be aligned with human resource reforms including timely recruitment and appropriate distribution of health workers to prevent burn out and attrition. As people working on the frontline of constrained health systems, health workers are responsive to improved incentives and working conditions, but need more comprehensive support.

Effects in spite of tough constraints - A theory of change based investigation of contextual and implementation factors affecting the results of a performance based financing scheme extended to malnutrition in Burundi

“…The effects of PBF-N have been partly determined by problems at the level of these other interventions. This dependence upon the whole health system has been documented in many PBF studies; barriers vary across experiences, but several of those reported in this study (competencies of human resources at the facility level, skills of supervisors, supply of inputs and delays in payment) have been reported in other experiences [50][51][52][53][54][55][56][57][58][59][60]. Such a dependence confirms the systemic nature of PBF [61], but at short term, it has an impact on the effectiveness of the strategy.…”

Key challenges of health care workers in implementing the integrated management of childhood illnesses (IMCI) program: a scoping review

“…Indeed evidence from other systematic reviews and global health studies confirms that the performance, attrition and retention of frontline HCWs are linked to intrinsic and extrinsic motivational factors such as being proud of their contributions to communities, opportunities for skills improvement and self-development, supportive supervision, proper remuneration, and healthy organizational cultures and work environments [48][49][50]. Some recent studies, for example, highlight opportunities to motivate health care providers in terms of performance-based incentives [51,52] and team-based goals and incentives model [50].…”

Brazilian Payment for Performance (PMAQ) Seen From a Global Health and Public Policy Perspective

“…Researchers also question whether this benefit has affected the quality of care in other areas not targeted by the program, whether it has been effective to improve performance or can be considered essential for the maintenance of the quality of care itself. In different ways, these questions are made in both high income (Forbes, Marchand, & Peckham, 2016;Peckham & Wallace 2010;Roland & Guthrie, 2016) and middle and low income countries (Bhatnagar & George, 2016;Lee et al, 2012). Findings have also revealed, in this case related (possibly) more to middle and low income countries, that workers and managers were not fully aware of performance indicators and standards.…”