Paying health workers for performance in Battagram district, Pakistan

Abstract

BackgroundThere is a growing interest in using pay-for-performance mechanisms in low and middle-income countries in order to improve the performance of health care providers. However, at present there is a dearth of independent evaluations of such approaches which can guide understanding of their potential and risks in differing contexts. This article presents the results of an evaluation of a project managed by an international non-governmental organisation in one district of Pakistan. It aims to contribute to learning about the design and implementation of pay-for-performance systems and their impact on health worker motivation.MethodsQuantitative analysis was conducted of health management information system (HMIS) data, financial records, and project documents covering the period 2007-2010. Key informant interviews were carried out with stakeholders at all levels. At facility level, in-depth interviews were held, as were focus group discussions with staff and community members.ResultsThe wider project in Battagram had contributed to rebuilding district health services at a cost of less than US$4.5 per capita and achieved growth in outputs. Staff, managers and clients were appreciative of the gains in availability and quality of services. However, the role that the performance-based incentive (PBI) component played was less clear--PBI formed a relatively small component of pay, and did not increase in line with outputs. There was little evidence from interviews and data that the conditional element of the PBIs influenced behaviour. They were appreciated as a top-up to pay, but remained low in relative terms, and only slightly and indirectly related to individual performance. Moreover, they were implemented independently of the wider health system and presented a clear challenge for longer term integration and sustainability.ConclusionsChallenges for performance-based pay approaches include the balance of rewarding individual versus team efforts; reflecting process and outcome indicators; judging the right level of incentives; allowing for very different starting points and situations; designing a system which is simple enough for participants to comprehend; and the tension between independent monitoring and integration in a national system. Further documentation of process and cost-effectiveness, and careful examination of the wider impacts of paying for performance, are still needed.

Leaders’ experiences and perceptions implementing activity-based funding and pay-for-performance hospital funding models: A systematic review

“…Full manuscripts were retrieved for all potentially eligible citations and similarly screened. Additional manuscripts [48][49][50][51][52][53][54][55] were excluded during data extraction if, upon review of the full text of the article, they were evaluated as not meeting inclusion criteria.…”

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

“…Similarly, in other countries health workers were frustrated by irregularities in payment (Morgan 2010;Ssengooba et al 2012;Fox et al 2013;Population Council 2013) and the relatively low incentives provided as compared with increased workloads undertaken (Witter et al 2011;Fox et al 2013). Moreover, PBF payments were found to be de-motivating in cases where the distribution was not transparent and perceived to be inequitable (Kalk et al 2010;Witter et al 2011;Fox et al 2013). Finally, in Nepal and Democratic Republic of Congo, bonus payments were found to create conflict among health workers (PowellJackson et al 2008;Huillery and Seban 2013).…”

“…Based on lessons learnt from other settings (Witter et al 2011;Ssengooba et al 2012), planners and policy makers in Nigeria need to be cognizant about effects of delays in payment and inconsistent design of PBF on health worker motivation and performance. Most health workers were dismayed by the reduction in their bonus amounts due to an unexpected, mid-point change of prices of their services and agitated by delays in payments.…”

Research gaps in routine health information system design barriers to data quality and use in low‐ and middle‐income countries: A literature review

“…Review of all 316 abstracts showed that 53 did not focus on data quality or data use barriers pertaining to RHIS or HMIS. These publications were focused on vertical disease programs, including estimation of malaria incidence; access to malaria rapid diagnostic tests; health systems research; maternal death reviews; and different aspects of malaria, maternal health, uptake of mental health services, and health worker performance …”

“…health systems research 12 ; maternal death reviews 13 ; and different aspects of malaria, 14,15 maternal health, 16,17 uptake of mental health services, 18 and health worker performance. 19 The publications described the review, synthesis, analysis, and interpretation of data to answer a research question, but data use was not aligned with decision making. Even though these publications did not explicitly discuss system design barriers, they explained issues related to data integration, data flow, data entry, and data analytics.…”