How does performance-based financing affect health workers' intrinsic motivation? A Self-Determination Theory-based mixed-methods study in Malawi

What Factors Explain Low Adoption of Digital Technologies for Health Financing in an Insurance Setting? Novel Evidence From a Quantitative Panel Study on IMIS in Tanzania

BACKGROUND

Digital information management systems for health financing are implemented on the assumption thatdigitalization, among other things, enables strategic purchasing. However, little is known about the extent to which thesesystems are adopted as planned to achieve desired results. This study assesses the levels of, and the factors associated withthe adoption of the Insurance Management Information System (IMIS) by healthcare providers in Tanzania.

METHODS

Combining multiple data sources, we estimated IMIS adoption levels for 365 first-line health facilities in2017 by comparing IMIS claim data (verified claims) with the number of expected claims. We defined adoption as abinary outcome capturing underreporting (verified

RESULTS

We found a median (interquartile range [IQR]) difference of 77.8% (32.7-100) between expected and verifiedclaims, showing a consistent pattern of underreporting across districts, regions, and months. Levels of underreportingvaried across regions (ANOVA: F=7.24, P<.001) and districts (ANOVA: F=4.65, P<.001). Logistic regression resultsshowed that higher service volume, share of people insured, and greater distance to district headquarter were associatedwith a higher probability of underreporting.

CONCLUSION

Our study shows that the adoption of IMIS in Tanzania may be sub-optimal and far from policy-makers'expectations, limiting its capacity to provide the necessary information to enhance strategic purchasing in the healthsector. Countries and agencies adopting digital interventions such as openIMIS to foster health financing reform areadvised to closely track their implementation efforts to make sure the data they rely on is accurate. Further, our studysuggests organizational and infrastructural barriers beyond the software itself hamper effective adoption.

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Key Words

• Adoption
• Digital Health Intervention
• Health Financing
• Health Insurance
• Strategic Purchasing
• Tanzania

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MESH Headings

• Humans
• Tanzania
• Healthcare Financing
• Digital Technology
• Insurance, Health
• Universal Health Insurance

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Affiliation(s)

Leon Schuetze Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
Siddharth Srivastava Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland University of Basel, Basel, Switzerland
Naasegnibe Kuunibe Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany Faculty of Integrated Development Studies, University for Development Studies, Wa, Ghana
Elizeus Josephat Rwezaula Health Promotion and System Strengthening Project (HPSS), Dodoma, Tanzania
Abdallah Missenye Kongwa District Council, Dodoma, Tanzania
Manfred Stoermer Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland University of Basel, Basel, Switzerland
Manuela De Allegri Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany

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Do Incentives Crowd Out Motivation? A Feasibility Study of a Community Vector-Control Campaign in Peru

Incentives are a useful tool in encouraging healthy behavior as part of public health initiatives. However, there remains concern about motivation crowd out-a decline in levels of motivation to undertake a behavior to below baseline levels after incentives have been removed-and few public health studies have assessed for motivation crowd out. Here, we assess the feasibility of identifying motivation crowd out following a lottery to promote participation in a Chagas disease vector control campaign. We look for evidence of crowd out in subsequent participation in the same behavior, a related behavior, and an unrelated behavior. We identified potential motivation crowd out for the same behavior, but not for related behavior or unrelated behaviors after lottery incentives are removed. Despite some limitations, we conclude that motivation crowd out is feasible to assess in large-scale trials of incentives.

Reviewing the evidence on health financing for effective coverage: do financial incentives work?

The widening gap between improving healthcare coverage rates and stagnating health outcomes across low-income and middle-income countries highlights the need for investments in quality of care, in addition to access. New research, presented in a World Bank report, examines one type of relevant policy reform: performance-based financing (PBF), which is a package reform that always includes performance pay to front-line health workers and often also provides facility autonomy, transparency and community engagement. A large body of rigorous studies and new analysis show that in under-resourced, centralised health systems, PBF can result in gains to service utilisation, but only has limited impacts on quality. Even the relative benefits of PBF on service utilisation are less clear when compared with (1) direct facility financing which provides front-line facilities with operating budgets and provider autonomy, but not performance pay and (2) demand-side financial support for health services (ie, conditional cash transfers and vouchers). Thus, the central component of PBF—the performance pay—appears to add little value over flexible payment systems and provider autonomy. The analysis shows that this lack of impact is unsurprising because most of the constraints to improving quality do not lie with the health worker in these settings. While PBF was conceived as a complex package ‘blueprint’, we review the evidence to conclude that only some elements seem to make sense. To improve quality of care, health financing should pivot from performance pay while retaining the elements of direct facility financing, autonomy, transparency and community engagement.

How much does it cost to combine supply-side and demand-side RBF approaches in a single intervention? Full cost analysis of the Results Based Financing for Maternal and Newborn Health Initiative in Malawi

OBJECTIVE

To estimate the economic cost associated with implementing the Results Based Financing for Maternal and Newborn Health (RBF4MNH) Initiative in Malawi. No specific hypotheses were formulated ex-ante.

SETTING

Primary and secondary delivery facilities in rural Malawi.

PARTICIPANTS

Not applicable. The study relied almost exclusively on secondary financial data.

INTERVENTION

The RBF4MNH Initiative was a results-based financing (RBF) intervention including both a demand and a supply-side component.

PRIMARY AND SECONDARY OUTCOME MEASURES

Cost per potential and for actual beneficiaries.

RESULTS

The overall economic cost of the Initiative during 2011-2016 amounted to €12 786 924, equivalent to €24.17 per pregnant woman residing in the intervention districts. The supply side activity cluster absorbed over 40% of all resources, half of which were spent on infrastructure upgrading and equipment supply, and 10% on incentives. Costs for the demand side activity cluster and for verification were equivalent to 14% and 6%, respectively of the Initiative overall cost.

CONCLUSION

Carefully tracing resource consumption across all activities, our study suggests that the full economic cost of implementing RBF interventions may be higher than what was previously reported in published cost-effectiveness studies. More research is urgently needed to carefully trace the costs of implementing RBF and similar health financing innovations, in order to inform decision-making in low-income and middle-income countries around scaling up RBF approaches.

Is Performance-Based Financing A Pathway to Strategic Purchasing in Sub-Saharan Africa? A Synthesis of the Evidence

Many countries in sub-Saharan Africa have implemented performance-based financing (PBF) to improve health system performance. Much of the debate and analysis relating to PBF has focused on whether PBF "works"-that is, whether it leads to improvements in indicators tied to incentive-based payments. Because PBF schemes embody key elements of strategic health purchasing, this study examines the question of whether and how PBF programs in sub-Saharan Africa influence strategic purchasing more broadly within country health financing arrangements. We searched PubMed, Scopus, EconLit, Cochrane Database of Systematic Reviews, Google Scholar, Google, and the World Health Organization and World Bank's repositories for studies that focused on the implementation experience or effects of PBF in sub-Saharan African and published in English from 2000 to 2020. We identified 44 papers and used framework analysis to analyze the data and generate key findings. The evidence we reviewed shows that PBF has the potential to raise awareness about strategic purchasing, improve governance and institutional arrangements, and strengthen strategic purchasing functions. However, these effects are minimal in practice because PBF has been introduced as narrow, often pilot, projects that run parallel to and have little integration with the mainstream health financing system. We concluded that PBF has not systematically transformed health purchasing in countries in sub-Saharan Africa but that the experience with PBF can provide valuable lessons for how system-wide strategic purchasing can be implemented most effectively in that region-either in countries that currently have PBF schemes and aim to integrate them into broader purchasing systems, or in countries that are not currently implementing PBF. We also concluded that for countries to pursue more holistic approaches to strategic health purchasing and achieve better health outcomes, they need to implement health financing reforms within or aligned with existing financing systems.

Long-term effects of payment for performance on maternal and child health outcomes: evidence from Tanzania

BACKGROUND

The success of payment for performance (P4P) schemes relies on their ability to generate sustainable changes in the behaviour of healthcare providers. This paper examines short-term and longer-term effects of P4P in Tanzania and the reasons for these changes.

METHODS

We conducted a controlled before and after study and an embedded process evaluation. Three rounds of facility, patient and household survey data (at baseline, after 13 months and at 36 months) measured programme effects in seven intervention districts and four comparison districts. We used linear difference-in-difference regression analysis to determine programme effects, and differential effects over time. Four rounds of qualitative data examined evolution in programme design, implementation and mechanisms of change.

RESULTS

Programme effects on the rate of institutional deliveries and antimalarial treatment during antenatal care reduced overtime, with stock out rates of antimalarials increasing over time to baseline levels. P4P led to sustained improvements in kindness during deliveries, with a wider set of improvements in patient experience of care in the longer term. A change in programme management and funding delayed incentive payments affecting performance on some indicators. The verification system became more integrated within routine systems over time, reducing the time burden on managers and health workers. Ongoing financial autonomy and supervision sustained motivational effects in those aspects of care giving not reliant on funding.

CONCLUSION

Our study adds to limited and mixed evidence documenting how P4P effects evolve over time. Our findings highlight the importance of undertaking ongoing assessment of effects over time.

The effects of performance-based financing on neonatal health outcomes in Burundi, Lesotho, Senegal, Zambia and Zimbabwe

Maternal and newborn care has been a primary focus of performance-based financing (PBF) projects, which have been piloted or implemented in 21 countries in sub-Saharan Africa since 2007. Several evaluations of PBF have demonstrated improvements to facility delivery or quality of care. However, no studies have measured the impact of PBF programmes directly on neonatal health outcomes in Africa, nor compared PBF programmes against another. We assess the impact of PBF on early neonatal health outcomes and associated health care utilization and quality in Burundi, Lesotho, Senegal, Zambia and Zimbabwe. We pooled Demographic and Health Surveys and Multiple Indicator Cluster Surveys and apply difference-in-differences analysis to estimate the effect of PBF projects supported by the World Bank on early neonatal mortality and low birthweight. We also assessed the effect of PBF on intermediate outputs that are frequently explicitly incentivized in PBF projects, including facility delivery and antenatal care utilization and quality, and caesarean section. Finally, we examined the impact among births to poor or high-risk women. We found no statistically significant impact of PBF on neonatal health outcomes, health care utilization or quality in a pooled sample. PBF was also not associated with better health outcomes in each country individually, though in some countries and among poor women PBF improved facility delivery, antenatal care utilization or antenatal care quality. There was no improvement on the health outcomes among poor or high-risk women in the five countries. PBF had no impact on early neonatal health outcomes in the five African countries studied and had limited and variable effects on the utilization and quality of neonatal health care. These findings suggest that there is a need for both a deeper assessment of PBF and for other strategies to make meaningful improvements to neonatal health outcomes.

Performance management in complex adaptive systems: a conceptual framework for health systems

Existing performance management approaches in health systems in low-income and middle-income countries are generally ineffective at driving organisational-level and population-level outcomes. They are largely directive: they try to control behaviour using targets, performance monitoring, incentives and answerability to hierarchies. In contrast, enabling approaches aim to leverage intrinsic motivation, foster collective responsibility, and empower teams to self-organise and use data for shared sensemaking and decision-making.The current evidence base is too limited to guide reforms to strengthen performance management in a particular context. Further, existing conceptual frameworks are undertheorised and do not consider the complexity of dynamic, multilevel health systems. As a result, they are not able to guide reforms, particularly on the contextually appropriate balance between directive and enabling approaches. This paper presents a framework that attempts to situate performance management within complex adaptive systems. Building on theoretical and empirical literature across disciplines, it identifies interdependencies between organisational performance management, organisational culture and software, system-level performance management, and the system-derived enabling environment. It uses these interdependencies to identify when more directive or enabling approaches may be more appropriate. The framework is intended to help those working to strengthen performance management to achieve greater effectiveness in organisational and system performance. The paper provides insights from the literature and examples of pitfalls and successes to aid this thinking. The complexity of the framework and the interdependencies it describes reinforce that there is no one-size-fits-all blueprint for performance management, and interventions must be carefully calibrated to the health system context.

Paying for performance to improve the delivery of health interventions in low- and middle-income countries

BACKGROUND

There is growing interest in paying for performance (P4P) as a means to align the incentives of healthcare providers with public health goals. Rigorous evidence on the effectiveness of these strategies in improving health care and health in low- and middle-income countries (LMICs) is lacking; this is an update of the 2012 review on this topic.

OBJECTIVES

To assess the effects of paying for performance on the provision of health care and health outcomes in low- and middle-income countries.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and 10 other databases between April and June 2018. We also searched two trial registries, websites, online resources of international agencies, organizations and universities, and contacted experts in the field. Studies identified from rerunning searches in 2020 are under 'Studies awaiting classification.'

SELECTION CRITERIA

We included randomized or non-randomized trials, controlled before-after studies, or interrupted time series studies conducted in LMICs (as defined by the World Bank in 2018). P4P refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: patient health outcomes, changes in targeted measures of provider performance (such as the delivery of healthcare services), unintended effects, or changes in resource use.

DATA COLLECTION AND ANALYSIS

We extracted data as per original review protocol and narratively synthesised findings. We used standard methodological procedures expected by Cochrane. Given diversity and variability in intervention types, patient populations, analyses and outcome reporting, we deemed meta-analysis inappropriate. We noted the range of effects associated with P4P against each outcome of interest. Based on intervention descriptions provided in documents, we classified design schemes and explored variation in effect by scheme design.

MAIN RESULTS

We included 59 studies: controlled before-after studies (19), non-randomized (16) or cluster randomized trials (14);  and interrupted time-series studies (9). One study included both an interrupted time series and a controlled before-after study. Studies focused on a wide range of P4P interventions, including target payments and payment for outputs as modified by quality (or quality and equity assessments). Only one study assessed results-based aid. Many schemes were funded by national governments (23 studies) with the World Bank funding most externally funded schemes (11 studies). Targeted services varied; however, most interventions focused on reproductive, maternal and child health indicators. Participants were predominantly located in public or in a mix of public, non-governmental and faith-based facilities (54 studies). P4P was assessed predominantly at health facility level, though districts and other levels were also involved. Most studies assessed the effects of P4P against a status quo control (49 studies); however, some studies assessed effects against comparator interventions (predominantly enhanced financing intended to match P4P funds (17 studies)). Four studies reported intervention effects against both comparator and status quo. Controlled before-after studies were at higher risk of bias than other study designs. However, some randomised trials were also downgraded due to risk of bias. The interrupted time-series studies provided insufficient information on other concurrent changes in the study context. P4P compared to a status quo control For health services that are specifically targeted, P4P may slightly improve health outcomes (low certainty evidence), but few studies assessed this. P4P may also improve service quality overall (low certainty evidence); and probably increases the availability of health workers, medicines and well-functioning infrastructure and equipment (moderate certainty evidence). P4P may have mixed effects on the delivery and use of services (low certainty evidence) and may have few or no distorting unintended effects on outcomes that were not targeted (low-certainty evidence), but few studies assessed these. For secondary outcomes, P4P may make little or no difference to provider absenteeism, motivation or satisfaction (low certainty evidence); but may improve patient satisfaction and acceptability (low certainty evidence); and may positively affect facility managerial autonomy (low certainty evidence). P4P probably makes little to no difference to management quality or facility governance (low certainty evidence). Impacts on equity were mixed (low certainty evidence). For health services that are untargeted, P4P probably improves some health outcomes (moderate certainty evidence); may improve the delivery, use and quality of some health services but may make little or no difference to others (low certainty evidence); and may have few or no distorting unintended effects (low certainty evidence). The effects of P4P on the availability of medicines and other resources are uncertain (very low certainty evidence). P4P compared to other strategies For health outcomes and services that are specifically targeted, P4P may make little or no difference to health outcomes (low certainty evidence), but few studies assessed this. P4P may improve service quality (low certainty evidence); and may have mixed effects on the delivery and use of health services and on the availability of equipment and medicines (low certainty evidence). For health outcomes and services that are untargeted, P4P may make little or no difference to health outcomes and to the delivery and use of health services (low certainty evidence). The effects of P4P on service quality, resource availability and unintended effects are uncertain (very low certainty evidence). Findings of subgroup analyses Results-based aid, and schemes using payment per output adjusted for service quality, appeared to yield the greatest positive effects on outcomes. However, only one study evaluated results-based aid, so the effects may be spurious. Overall, schemes adjusting both for quality of service and rewarding equitable delivery of services appeared to perform best in relation to service utilization outcomes.

AUTHORS' CONCLUSIONS

The evidence base on the impacts of P4P schemes has grown considerably, with study quality gradually increasing. P4P schemes may have mixed effects on outcomes of interest, and there is high heterogeneity in the types of schemes implemented and evaluations conducted. P4P is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention (e.g., who receives payments ), the amount of additional funding,  ancillary components (such as technical support) and contextual factors (including organizational context).

Sustainability determinants of the Burkinabe performance-based financing project

PURPOSE

A performance-based financing (PBF) pilot project was implemented in 2011 in Burkina Faso. After more than five years of implementation (data collection in 2016), the project's sustainability was not guaranteed. This study's objective is to assess this project's sustainability in 2016 by identifying the presence/absence of different determinants of sustainability according to the conceptual framework of Seppey et al. (2017).

DESIGN/METHODOLOGY/APPROACH

It uses a case study approach using in-depth interviews with various actors at the local, district/regional and national levels. Participants (n = 37) included health practitioners, management team members, implementers and senior members of health directions. A thematic analysis based on the conceptual framework was conducted, as well as an inductive analysis.

FINDINGS

Results show the project's sustainability level was weak according to an unequal presence of sustainability's determinants; some activities are being maintained but not fully routinised. Discrepancies between the project and the context's values appeared to be important barriers towards sustainability. Project's ownership by key stakeholders also seemed superficial despite the implementers' leadership towards its success. The project's objective towards greater autonomy for health centres was also directly confronting the Burkinabe's hierarchical health system.

ORIGINALITY/VALUE

This study reveals many fits and misfits between a PBF project and its context affecting its ability to sustain activities through time. It also underlines the importance of using a conceptual framework in implementing and evaluating interventions. These results could be interesting for decision-makers and implementers in further assessing PBF projects elsewhere.

What theories underpin performance-based financing? A scoping review

PURPOSE

The study aims to explore the theoretical bases justifying the use of performance-based financing (PBF) in the health sector in low- and middle-income countries (LMICs).

DESIGN/METHODOLOGY/APPROACH

The authors conducted a scoping review of the literature on PBF so as to identify the theories utilized to underpin it and analyzed its theoretical justifications.

FINDINGS

Sixty-four studies met the inclusion criteria. Economic theories were predominant, with the principal-agent theory being the most commonly-used theory, explicitly referred to by two-thirds of included studies. Psychological theories were also common, with a wide array of motivation theories. Other disciplines in the form of management or organizational science, political and social science and systems approaches also contributed. However, some of the theories referred to contradicted each other. Many of the studies included only casually alluded to one or more theories, and very few used these theories to justify or support PBF. No theory emerged as a dominant, consistent and credible justification of PBF, perhaps except for the principal-agent theory, which was often inappropriately applied in the included studies, and when it included additional assumptions reflecting the contexts of the health sector in LMICs, might actually warn against adopting PBF.

PRACTICAL IMPLICATIONS

Overall, this review has not been able to identify a comprehensive, credible, consistent, theoretical justification for using PBF rather than alternative approaches to health system reforms and healthcare providers' motivation in LMICs.

ORIGINALITY/VALUE

The theoretical justifications of PBF in the health sector in LMICs are under-documented. This review is the first of this kind and should encourage further debate and theoretical exploration of the justifications of PBF.

Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol

In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes.  Our programme theory is an expression of our assumptions about what actions will be both useful and feasible.  It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.

Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol

In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes.  Our programme theory is an expression of our assumptions about what actions will be both useful and feasible.  It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.

An Investigation of Healthcare Professionals' Motivation in Public and Mission Hospitals in Meru County, Kenya

Strengthening health systems in developing countries such as Kenya is required to achieve the third United Nations’ Sustainable Development Goal of health for all, at all ages. However, Kenya is experiencing a “brain drain” and a critical shortage of healthcare professionals. There is a need to identify the factors that motivate healthcare workers to work in the health sector in rural and marginalized areas. This cross-sectional study aims to investigate the factors associated with the level and types of motivation among healthcare professionals in public and mission hospitals in Meru county, Kenya. Data were collected from 24 public and mission hospitals using a self-administered structured questionnaire. A total of 553 healthcare professionals participated in this study; 78.48% from public hospitals and 21.52% from mission hospitals. Hospital ownership was statistically nonsignificant in healthcare professionals’ overall motivation (p > 0.05). The results showed that sociodemographic and work-environment factors explained 29.95% of the variation in overall motivation scores among participants. Findings indicate there are more similarities than disparities among healthcare professionals’ motivation factors, regardless of hospital ownership; therefore, motivation strategies should be developed and applied in both public and private not-for-profit hospitals to ensure an effective healthcare workforce and strengthen healthcare systems in Kenya.

'Our village is dependent on us. That's why we can't leave our work'. Characterizing mechanisms of motivation to perform among Accredited Social Health Activists (ASHA) in Bihar

Community health workers (CHWs) play major roles in delivering primary healthcare services, linking communities to the formal health system and addressing the social determinants of health. Available evidence suggests that the performance of CHW programmes in low- and middle-income countries can be influenced by context-dependent causal mechanisms such as motivation to perform. There are gaps regarding what these mechanisms are, and what their contribution is to CHW performance. We used a theory-driven case study to characterize motivational mechanisms among Accredited Social Health Activists (ASHAs) in Bihar, India. Data were collected through semi-structured interviews with CHWs and focus group discussions with beneficiary women. Data were coded using a combined deductive and inductive approach. We found that ASHAs were motivated by a sense of autonomy and self-empowerment; a sense of competence, connection and community service; satisfaction of basic financial needs; social recognition; and feedback and answerability. Findings highlight the potential of ASHAs' intrinsic motivation to increase their commitment to communities and identification with the health system and of programme implementation and management challenges as sources of work dissatisfaction. Efforts to nurture and sustain ASHAs' intrinsic motivation while addressing these challenges are necessary for improving the performance of Bihar's ASHA programme. Further research is needed to characterize the dynamic interactions between ASHAs' motivation, commitment, job satisfaction and overall performance; also, to understand how work motivation is sustained or lost through time. This can inform policy and managerial reforms to improve ASHA programme's performance.

Exploiting the emergent nature of mixed methods designs: insights from a mixed methods impact evaluation in Malawi

The application of mixed methods in Health Policy and Systems Research (HPSR) has expanded remarkably. Nevertheless, a recent review has highlighted how many mixed methods studies do not conceptualize the quantitative and the qualitative component as part of a single research effort, failing to make use of integrated approaches to data collection and analysis. More specifically, current mixed methods studies rarely rely on emergent designs as a specific feature of this methodological approach. In our work, we postulate that explicitly acknowledging the emergent nature of mixed methods research by building on a continuous exchange between quantitative and qualitative strains of data collection and analysis leads to a richer and more informative application in the field of HPSR. We illustrate our point by reflecting on our own experience conducting the mixed methods impact evaluation of a complex health system intervention in Malawi, the Results Based Financing for Maternal and Newborn Health Initiative. We describe how in the light of a contradiction between the initial set of quantitative and qualitative findings, we modified our design multiple times to include additional sources of quantitative and qualitative data and analytical approaches. To find an answer to the initial riddle, we made use of household survey data, routine health facility data, and multiple rounds of interviews with both healthcare workers and service users. We highlight what contextual factors made it possible for us to maintain the high level of methodological flexibility that ultimately allowed us to solve the riddle. This process of constant reiteration between quantitative and qualitative data allowed us to provide policymakers with a more credible and comprehensive picture of what dynamics the intervention had triggered and with what effects, in a way that we would have never been able to do had we kept faithful to our original mixed methods design.

Spatial Inequality Hides the Burden of Dog Bites and the Risk of Dog-Mediated Human Rabies

Since its reintroduction in 2015, rabies has been established as an enzootic disease among the dog population of Arequipa, Peru. Given the unknown rate of dog bites, the risk of human rabies transmission is concerning. Our objective was to estimate the rate of dog bites in the city and to identify factors associated with seeking health care in a medical facility for wound care and rabies prevention follow-up. To this end, we conducted a door-to-door survey with 4,370 adults in 21 urban and 21 peri-urban communities. We then analyzed associations between seeking health care following dog bites and various socioeconomic factors, stratifying by urban and peri-urban localities. We found a high annual rate of dog bites in peri-urban communities (12.4%), which was 2.6 times higher than that in urban areas (4.8%). Among those who were bitten, the percentage of people who sought medical treatment was almost twice as high in urban areas (39.1%) as in peri-urban areas (21.4%).

iSAY (incentives for South African youth): Stated preferences of young people living with HIV

High adherence to antiretroviral therapy (ART) is essential for achieving viral suppression and preventing HIV transmission. Yet adherence is suboptimal among adolescents who face unique adherence challenges. Little is known about the role of conditional economic incentives (CEIs) for increasing ART adherence in this population. During 2017-2019, we conducted a mixed-methods discrete choice experiment in Cape Town, South Africa to inform the optimal design of a CEI intervention for ART adherence among youth. In-depth interviews were conducted with n = 35 adolescents (10-19 years old) living with HIV and prescribed ART, to identify attributes of a youth-centered CEI intervention for ART adherence. A discrete choice experiment was subsequently conducted with N = 168 adolescents to elicit preferences for intervention components. A rank-ordered mixed logit model was used for main results; marginal willingness-to-accept (mWTA) was then estimated. Five attributes emerged from the qualitative research as important for a CEI-based intervention for youth ART adherence: (1) incentive amount, (2) incentive format, (3) incentive recipient, (4) delivery mode, and (5) program participants. Youth had a high probability of acceptance of any incentives program (88-100%), yet they did not have a strong preference of a quarterly over a monthly program. From a maximum incentive amount of R1920 (~US$115), youth were willing to forgo up to R126 per year (~US$9) if the incentive was given in cash (versus fashion vouchers); R274 (~US$19.6) if it was open to both previously adherent and non-adherent youth (instead of non-adherent only); and up to R91 (~US$6.5) to receive incentives at a clinic setting (instead of electronically). The use of incentives over the short term during the critical age- and developmental-transition, when adolescents begin to take sole responsibility for their medication-taking behaviors, holds great promise for habituating adherence into adulthood.

Meeting the challenges posed by per diem in development projects in southern countries: a scoping review

PURPOSE

This study presents the results of a review whose goal is to generate knowledge on the possible levers of action concerning per diem practices in southern countries in order to propose reforms to the existing schemes.

METHODOLOGY

A synthesis of available knowledge was performed using scoping review methodology: a literature search was conducted using several databases (Medline, Cinahl, Embase, PubMed, Google Scholar, ProQuest) and grey literature. A total of 26 documents were included in the review. Furthermore, interviews were conducted with the authors of the selected articles to determine whether the proposed recommendations had been implemented and to identify any outcomes.

RESULTS

For the most part, the results of this review are recommendations supporting per diem reform. In terms of strategy, the recommendations call for a redefinition of per diems by limiting their appeal. Issued recommendations include reducing daily allowance rates, paying per diem only in exchange for actual work, increasing control mechanisms or harmonizing rates across organizations. In terms of operations, the recommendations call for the implementation of concrete actions to reduce instances of abuse, including not paying advances or introducing reasonable flat-rate per diem. That said, the authors contacted stated that few per diem reforms had been implemented as a result of the issued recommendations.

CONCLUSION

The results of the study clearly identify possible levers of action. Such levers could make up the groundwork for further reflection on context and country-specific reforms that are carried out using a dynamic, participatory and consensual approach.

The cost-effectiveness of using results-based financing to reduce maternal and perinatal mortality in Malawi

INTRODUCTION

Results-based financing (RBF) is being promoted to increase coverage and quality of maternal and perinatal healthcare in sub-Saharan Africa (SSA) countries. Evidence on the cost-effectiveness of RBF is limited. We assessed the cost-effectiveness within the context of an RBF intervention, including performance-based financing and conditional cash transfers, in rural Malawi.

METHODS

We used a decision tree model to estimate expected costs and effects of RBF compared with status quo care during single pregnancy episodes. RBF effects on maternal case fatality rates were modelled based on data from a maternal and perinatal programme evaluation in Zambia and Uganda. We obtained complementary epidemiological information from the published literature. Service utilisation rates for normal and complicated deliveries and associated costs of care were based on the RBF intervention in Malawi. Costs were estimated from a societal perspective. We estimated incremental cost-effectiveness ratios per disability adjusted life year (DALY) averted, death averted and life-year gained (LYG) and conducted sensitivity analyses to how robust results were to variations in key model parameters.

RESULTS

Relative to status quo, RBF implied incremental costs of US$1122, US$26 220 and US$987 per additional DALY averted, death averted and LYG, respectively. The share of non-RBF facilities that provide quality care, life expectancy of mothers at time of delivery and the share of births in non-RBF facilities strongly influenced cost-effectiveness values. At a willingness to pay of US$1485 (3 times Malawi gross domestic product per capita) per DALY averted, RBF has a 77% probability of being cost-effective.

CONCLUSIONS

At high thresholds of wiliness-to-pay, RBF is a cost-effective intervention to improve quality of maternal and perinatal healthcare and outcomes, compared with the non-RBF based approach. More RBF cost-effectiveness analyses are needed in the SSA region to complement the few published studies and narrow the uncertainties surrounding cost-effectiveness estimates.

Predicting Students’ Behavioral Intention to Use Open Source Software: A Combined View of the Technology Acceptance Model and Self-Determination Theory

This study focuses on students’ behavioral intention to use Open Source Software (OSS). The article examines how students, who were trained in OSS, are motivated to continue using it. A conceptual model based on Self-Determination Theory and the Technological Acceptance Model (TAM) was defined in order to test the behavioral intention to use OSS, comprising six constructs: (1) autonomy, (2) competence, (3) relatedness, (4) perceived ease of use, (5) perceived usefulness and (6) behavioral intention to use. A survey was designed for data collection. The participants were recent secondary school graduates, and all of them had received mandatory OSS training. A total of 352 valid responses were used to test the proposed structural model, which was performed using the Lisrel software. The results clearly confirmed the positive influence of the intrinsic motivations; autonomy and relatedness, to improve perceptions regarding the usefulness and ease of use of OSS, and; therefore, on behavioral intention to use OSS. In addition, the implications and limitations of this study are considered.

Unravelling the role of leadership in motivation of health workers in a Moroccan public hospital: a realist evaluation

OBJECTIVES

This study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco.

DESIGN

We adopted the realist evaluation approach and used the case study design to test the initial programme theory we formulated on the basis of a scoping review on complex leadership. We used the Intervention-Context-Actors-Mechanism-Outcome Configuration as a heuristic tool to identify plausible causal configurations.

SETTINGS

Since 2000, the Ministry of Health in Morocco initiated many reforms in the frame of the governmental deconcentration process called 'advanced regionalisation'. The implementation of these reforms is hampered by inadequate human resource management capacities of local health system managers. Yet, the National 'Concours Qualité', a national quality assurance programme implemented since 2007, demonstrated that there are many islands of excellence. We explore how leadership may play a role in explaining these islands of excellence.

PARTICIPANTS

We carried out a document review, 18 individual interviews and 3 group discussions (with doctors, administrators and nurses), and non-participant observations during a 2-week field visit in January-February 2018.

RESULTS

We confirmed that effective leaders adopt an appropriate mix of transactional, transformational and distributed leadership styles that fits the mission, goals, organisational culture and nature of tasks of the organisation and the individual characteristics of the personnel when organisational culture is conducive. Leadership effectiveness is conditioned by the degree of responsiveness to the basic psychological needs of autonomy, competence and relatedness, perceived organisational support and perceived supervisor support. Transactional and overcontrolling leadership behaviour decreased the satisfaction of the need for autonomy and mutual respect. By distributing leadership responsibilities, complex leaders create an enabling environment for collective efficacy and creative problem solving.

CONCLUSIONS

We found indications that in the Moroccan context, well-performing hospitals could be characterised by a good fit between leadership styles, organisational characteristics and individual staff attributes.

Psychological wellbeing in a resource-limited work environment: examining levels and determinants among health workers in rural Malawi

BACKGROUND

A competent, responsive, and productive health workforce is central to a well-performing health system capable of providing universal access to high-quality care. Ensuring health workers' psychological wellbeing is critical to sustaining their availability and productivity. This is particularly true in heavily constrained health systems in low- and lower-middle-income countries. Research on the issue, however, is scarce. This study aimed to contribute to filling the gap in knowledge by investigating levels of and factors associated with psychological wellbeing of mid-level health workers in Malawi.

METHODS

The study relied on a cross-sectional sample of 174 health workers from 33 primary- and secondary-level health facilities in four districts of Malawi. Psychological wellbeing was measured using the WHO-5 Wellbeing Index. Data were analyzed using linear and logistic regression models.

RESULTS

Twenty-five percent of respondents had WHO-5 scores indicative of poor psychological wellbeing. Analyses of factors related to psychological wellbeing showed no association with sex, cadre, having dependents, supervision, perceived coworker support, satisfaction with the physical work environment, satisfaction with remuneration, and motivation; a positive association with respondents' satisfaction with interpersonal relationships at work; and a negative association with having received professional training recently. Results were inconclusive in regard to personal relationship status, seniority and responsibility at the health facility, clinical knowledge, perceived competence, perceived supervisor support, satisfaction with job demands, health facility level, data collection year, and exposure to performance-based financing.

CONCLUSIONS

The high proportion of health workers with poor wellbeing scores is concerning in light of the general health workforce shortage in Malawi and strong links between wellbeing and work performance. While more research is needed to draw conclusions and provide recommendations as to how to enhance wellbeing, our results underline the importance of considering this as a key concern for human resources for health.

What Happens When Donors Pull Out? Examining Differences in Motivation Between Health Workers Who Recently Had Performance-Based Financing (PBF) Withdrawn With Workers Who Never Received PBF in the Democratic Republic of Congo

Background: A motivated workforce is necessary to ensure the delivery of high quality health services. In developing countries, performance-based financing (PBF) is often employed to increase motivation by providing financial incentives linked to performance. However, given PBF schemes are usually funded by donors, their long-term financing is not always assured, and the effects of withdrawing PBF on motivation are largely unknown. This cross-sectional study aimed to identify differences in motivation between workers who recently had donor-funded PBF withdrawn, with workers who had not received PBF.

Methods: Quantitative data were collected from 485 health workers in 5 provinces using a structured survey containing questions on motivation which were based on an established motivation framework. Confirmatory factor analysis was used to verify dimensions of motivation, and multiple regression to assess differences in motivation scores between workers who had previously received PBF and those who never had. Qualitative interviews were also carried out in Kasai Occidental province with 16 nurses who had previously or never received PBF.

Results: The results indicated that workers in facilities where PBF had been removed scored significantly lower on most dimensions of motivation compared to workers who had never received PBF. The removal of the PBF scheme was blamed for an exodus of staff due to the dramatic reduction in income, and negatively impacted on relationships between staff and the local community.

Conclusion: Donors and governments unable to sustain PBF or other donor-payments should have clear exit strategies and institute measures to mitigate any adverse effects on motivation following withdrawal.

Conditional economic incentives to improve HIV prevention and treatment in low-income and middle-income countries

New and innovative approaches are needed to improve the prevention, diagnosis, and treatment of HIV in low-income and middle-income countries. Several trials use conditional economic incentives (CEIs) to improve HIV outcomes. Most CEI interventions use a traditional economic theory approach, although some interventions incorporate behavioural economics, which combines traditional economics with insights from psychology. Incentive interventions that are appropriately implemented can increase HIV testing rates and voluntary male circumcision, and they can improve other HIV prevention and treatment outcomes in certain settings in the short term. More research is needed to uncover theory-based mechanisms that increase the duration of incentive effects and provide strategies for susceptible individuals, which will help to address common constraints and biases that can influence health-related decisions.

Effect of results-based financing on facility-based maternal mortality at birth: an interrupted time-series analysis with independent controls in Malawi

INTRODUCTION

The aim of this study was to assess the impact of a results-based financing (RBF) programme on the reduction of facility-based maternal mortality at birth. Malawi is a low-income country with high maternal mortality. The Results-Based Financing For Maternal and Newborn Health (RBF4MNH) Initiative was introduced at obstetric care facilities in four districts to improve quality and utilisation of maternal and newborn health services. The RBF4MNH Initiative was launched in April 2013 as a combined supply-side and demand-side RBF. Programme expansion occurred in October 2014.

METHODS

Controlled interrupted time series was used to estimate the effect of the RBF4MNH on reducing facility-based maternal mortality at birth. The study sample consisted of all obstetric care facilities in 4 intervention and 19 control districts, which constituted all non-urban mainland districts in Malawi. Data for obstetric care facilities were extracted from the Malawi Health Management Information System. Facility-based maternal mortality at birth was calculated as the number of maternal deaths per all deliveries at a facility in a given time period.

RESULTS

The RBF4MNH effectively reduced facility-based maternal mortality by 4.8 (-10.3 to 0.7, p<0.1) maternal deaths/100 000 facility-based deliveries/month after reaching full operational capacity in October 2014. Immediate effects (changes in level rather than slope) attributable to the RBF4MNH were not statistically significant.

CONCLUSION

This is the first study evaluating the effect of a combined supply-side and demand-side RBF on maternal mortality outcomes and demonstrates the positive role financial incentives can play in improving health outcomes. This study further shows that timeframes spanning several years might be necessary to fully evaluate the impact of health-financing programmes on health outcomes. Further research is needed to assess the extent to which the observed reduction in facility-based mortality at birth contributes to all-cause maternal mortality in the country.

Stunted scale-up of a performance-based financing program on HIV and maternal-child health services in Mozambique - a policy analysis

OBJECTIVE

A performance-based financing (PBF) program was implemented for services for HIV, prevention of mother-to-child transmission (PMTCT) and maternal/child health (MCH) in two provinces of Mozambique. This study investigates the determinants of policy scale-up to help accelerate the expansion of PBF in Mozambique and globally from pilot projects to national policies.

METHODS

A retrospective policy programme analysis was carried out using in-depth key informant interviews. A total of 24 interviews were conducted with stakeholders from donor agencies, the implementing NGO, district and provincial health offices, and the Ministry of Health.

RESULTS

Stakeholders reported that the scale-up process of PBF was influenced by three key determinants: political power, financial sustainability, and available capacity and evidence. In Mozambique, PBF scaled-up provincially but not nationally due to these determinants. The adoption of PBF in Mozambique involved a restricted range of policy actors at the central level and was strongly driven by the donor and a PBF champion. Provincial scale-up was fostered by political support and increasing capacity over time.

CONCLUSION

There was a generalised ambivalence and lack of incentive to scale-up PBF from the implementing NGO. Coupled with the lack of evidence of a positive effect, and of cost-effectiveness in comparison with other models to improve health service delivery and health system strengthening, it is difficult to argue for the need to scale up the PBF programme studied. Care needs to be taken to base the adoption of health policies, including PBF, on a situational analysis and on evidence of intervention effectiveness, cost-benefits and contextual fit.

The Importance of Leadership and Organizational Capacity in Shaping Health Workers' Motivational Reactions to Performance-Based Financing: A Multiple Case Study in Burkina Faso

BACKGROUND

Performance-based financing (PBF) is currently tested in many low- and middle-income countries as a health system strengthening strategy. One of the main mechanisms through which PBF is assumed to effect change is by motivating health workers to improve their service delivery performance. This article aims at a better understanding of such motivational effects of PBF. In particular, the study focused on organizational context factors and health workers' perceptions thereof as moderators of the motivational effects of PBF, which to date has been little explored.

METHODS

We conducted a multiple case study in 2 district hospitals and 16 primary health facilities across three districts. Health facilities were purposely sampled according to pre-PBF performance levels. Within sampled facilities, 82 clinical skilled healthcare workers were in-depth interviewed one year after the start of the PBF intervention. Data were analyzed using a blended deductive and inductive process, using self-determination theory (SDT) as an analytical framework.

RESULTS

Results show that the extent to which PBF contributed to positive, sustainable forms of motivation depended on the "ground upon which PBF fell," beyond health workers' individual personalities and disposition. In particular, health workers described three aspects of the organizational context in which PBF was implemented: the extent to which existing hierarchies fostered as opposed to hindered participation and transparency; managers' handling of the increased performance feedback inherent in PBF; and facility's pre-PBF levels in regards to infrastructure, equipment, and human resources.

CONCLUSION

Our results underline the importance of leadership styles and pre-implementation performance levels in shaping health workers' motivational reactions to PBF. Ancillary interventions aimed at fostering participatory as opposed to directional leadership or start-up support to low-performing health facilities will likely boost PBF effects in regards to the development of valuable motivational capacities.