‘The money can be a motivator, to me a little, but mostly PBF just helps me to do better in my job.’ An exploration of the motivational mechanisms of performance-based financing for health workers in Malawi

‘The money can be a motivator, to me a little, but mostly PBF just helps me to do better in my... Abstract Performance-based financing (PBF) is assumed to improve health care delivery by motivating health workers to enhance their work performance. However, the exact motivational mechanisms through which PBF is assumed to produce such changes are poorly understood to date. Although PBF is increasingly recognized as a complex health systems intervention, its motivational effect for individual health workers is still often reduced to financial ‘carrots and sticks’ in the literature and discourse. Aiming to contribute to the development of a more comprehensive understanding of the motivational mechanisms, we explored how PBF impacted health worker motivation in the context of the Malawian Results-based Financing for Maternal and Newborn Health (RBF4MNH) Initiative. We conducted in-depth interviews with 41 nurses, medical assistants and clinical officers from primary- and secondary-level health facilities 1 and 2 years after the introduction of RBF4MNH in 2013. Six categories of motivational mechanisms emerged: RBF4MNH motivated health workers to improve their performance (1) by acting as a periodic wake-up call to deficiencies in their day-to-day practice; (2) by providing direction and goals to work towards; (3) by strengthening perceived ability to perform successfully at work and triggering a sense of accomplishment; (4) by instilling feelings of recognition; (5) by altering social dynamics, improving team work towards a common goal, but also introducing social pressure; and (6) by offering a ‘nice to have’ opportunity to earn extra income. However, respondents also perceived weaknesses of the intervention design, implementation-related challenges and contextual constraints that kept RBF4MNH from developing its full motivating potential. Our results underline PBF’s potential to affect health workers’ motivation in ways which go far beyond the direct effects of financial rewards to individuals. We strongly recommend considering all motivational mechanisms more explicitly in future PBF design to fully exploit the approach’s capacity for enhancing health worker performance. Motivation, motivational mechanisms, health workers, performance-based financing, Malawi Key Messages PBF in Malawi impacted health worker motivation through various mechanisms. Particularly important were improvements in the working environment as a result of PBF which fostered health workers’ perceived ability to perform successfully on the job and created a new sense of accomplishment at work; the individual financial incentives, in contrast, seemed of limited importance. Various implementation-related challenges and contextual constraints kept the intervention from developing its full motivating potential. We strongly recommend considering all motivational mechanisms more explicitly in future PBF design to fully exploit the approach‘s capacity for enhancing health worker performance. Background Performance-based financing (PBF) has gained much attention among low- and middle-income country (LMIC) governments and international organizations as a means of strengthening health systems in recent years. PBF aims to overcome shortcomings in healthcare service delivery by motivating healthcare providers to better align their service provision behaviour with health system interests through performance contracts which financially reward the attainment of defined performance standards. A recent review of the literature indicates that PBF can indeed improve healthcare delivery in desired ways and underlines the importance attributed to motivation as a key element in bringing about this change (Renmans et al. 2016). However, much of the available literature remains unspecific regarding the precise motivational mechanisms involved in PBF at the level of the individual health workers. The review concludes that ‘more research is needed on the exact mechanisms through which not only incentives, but also ancillary components operate’ (Renmans et al. 2016, p. 1297). This statement alludes to the fact that although there is increasing recognition of PBF as a complex reform package, much of the literature and discourse on how PBF brings about change in health worker motivation and behaviour is focused on the individual incentives (Renmans et al. 2017). Specifically, in most currently operational PBF schemes, additional health facility revenue generated through PBF must partially be reinvested into the facility and can partially be disbursed to staff as incentive or reward payments (Fritsche et al. 2014). However, in addition to performance contracts and verification and reward payment activities, many PBF interventions include various other elements aimed at strengthening health system functions and promoting results orientation and entrepreneurial behaviour, such as a strengthening of performance monitoring and feedback systems and management structures, or capacity building measures (Witter et al. 2013; Renmans et al. 2016). These other elements likely also impact motivation, in addition to the financial reward component (Lohmann et al. 2016). Experiences from different settings indicate that PBF can induce powerful positive change in health workers’ working lives and activate various complex motivational mechanisms beyond the direct effects of financial incentives to individuals. For example, in Burundi, health workers reported that clearer tasks and objectives and more intensive support as a result of PBF reinforced feelings of professionalism (Bertone and Meessen 2013). In Rwanda, health workers experienced increased appreciation for their work, greater attention to their needs by managers, increased feelings of responsibility and improved team spirit (Kalk et al. 2010). In Tanzania, PBF fostered a competitive spirit between health facilities, motivating staff to work hard to be ‘winners’ (Chimhutu et al. 2014). In Nigeria, health workers reported to have been ‘awakened’ by PBF and motivated by improvements in their working conditions and their own performance (Bhatnagar and George 2016). However, there remains a lack of systematic and comprehensive explorations of PBF’s motivational mechanisms. We used the opportunity of the introduction of PBF in Malawi to contribute to filling this gap in knowledge. Our findings aim at informing the development of a comprehensive theory of change which will facilitate effective, efficient, and side effect-free future PBF planning. Methods Setting Malawi’s health system is characterized by a predominantly public health system which provides essential health services free of charge at point of service. The country has high utilization rates for essential health services (NSO 2016), but service quality is poor (MoH 2014) for a variety of reasons, including a severe shortage of mid-level healthcare personnel who shoulder the majority of primary health services, leading to high workload particularly for health workers in the maternity departments (Manafa et al. 2009; Bradley et al. 2015). Previous research has highlighted high levels of dissatisfaction with low income levels, a perceived lack of recognition of effort by the health system, and limited opportunities for in-service training (Manafa et al. 2009; Chimwaza et al. 2014). Health facility supervision, primarily task of the District Health Management Teams (DHMTs), happens regularly (MoH 2014), but is often unsupportive and of low quality (Manafa et al. 2009; Bradley et al. 2013). DHMTs are also in charge of procuring medicines and materials from central medical stores and allocating them to the public facilities in their districts, as those facilities do not manage their own budgets. As a result of management issues and the country’s macroeconomic situation, facilities have been experiencing stock-outs of drugs and supplies on a near regular basis in recent years (MoH 2014), a frustrating and demotivating situation for health workers (Chimwaza et al. 2014). The Results-Based Financing for Maternal and Newborn Health (RBF4MNH) Initiative In 2013, the Ministry of Health (MoH) introduced the RBF4MNH Initiative as a pilot PBF intervention in 14 primary and 4 secondary health facilities in the Balaka, Dedza, Ntcheu and Mchinji districts (Options 2012, 2014). In 2014, RBF4MNH was extended to 10 additional facilities. Aiming to reduce maternal and neonatal mortality, RBF4MNH combines PBF with conditional cash transfers (CCT) to pregnant women to increase the institutional delivery rate and improve the quality of delivery care services. The PBF component includes two sets of performance contracts, one targeting the DHMTs and one targeting health facilities. DHMTs are incentivized to increase institutional deliveries in their districts (removed end 2014), ensure availability of equipment, drugs and other commodities, and improve reporting of routine data. They receive an additional budget for supervisory activities. Within the four intervention districts, facilities were selected into the intervention based on several criteria including the ability to provide emergency obstetric care services. To enable facilities to do the latter, RBF4MNH provided substantial performance-unconditional start-up support to most selected facilities in the form of infrastructure upgrades, provision of essential equipment, refresher trainings and additional staff postings prior to or in the early stages of the intervention. Unlike many other PBF interventions (Renmans et al. 2016), RBF4MNH is not designed as a quality-adjusted fee-for-service scheme. Rather, RBF4MNH rewards the attainment of performance targets, reinforcing adherence to national treatment standards for maternal care (e.g. correct partograph use, HIV testing of pregnant women). Two targets related to increase in service volume were dropped at the end of 2014. All rewards are monetary. Maximal reward amounts by indicator are fixed and then discounted based on target attainment. In year 1, targets were absolute (e.g. minimum 80% of deliveries with partograph), with rewards only allocated if the target was attained. In year 2, this was changed to an achievement level-based approach (i.e. 75% of deliveries with partograph = 75% of maximum reward). Verification of facilities’ performance was initially done in a peer-to-peer arrangement every 6 months, but changed to verification by an external agency every 3 months at the end of 2014. Following each round of verification, results are communicated to all stakeholders, enabling districts and facilities to evaluate their performance in relation to the others. Facilities are required to invest 30% into the facility (‘facility portion’), and can distribute 70% to staff as bonus payments (‘staff portion’). They are autonomous in their decisions how to divide the staff portion between staff members and how to invest the facility portion. The latter is with the exception of drugs, which health facilities are not allowed to purchase but continue to request from the DHMTs. In all primary-level facilities, staff portions were effectively distributed to benefit everybody (including support staff), although to varying extent. At hospital level, maternity department staff were the primary beneficiaries of individual rewards. Table 1 shows individual reward amounts in relation to other sources of income. Table 1 Contribution of PBF rewards to health workers’ overall income in Malawi and elsewhere Cadre  Basic salary (gov’t), quarterly (MoH)  Unpublished income data collected in the context of the overall RBF4MNH impact evaluationa   n  Net income Mar–May ‘15, incl top-ups, per diems, locum, PBF  PBF rewards Jan–Mar 2015  Relative PBF contribution  Nurse/midwives  419–489  36  M = 615  M = 34.83  M: 5.8%  SD = 209  SD = 25.28  SD: 4.6%  Medical assistants  304–315  9  M = 453  M = 33.40  M: 7.0%  SD = 105  SD = 7.04  SD: 1.3%  Clinical officersb  772–894  –  –  –  –  Burundi (Rudasingwa and Uwizeye, 2017): PBF rewards in % of total salary  20–30%  Pakistan (Witter et al. 2011): PBF rewards in % of gross pay  13–16%  Philippines (Peabody et al. 2014): PBF rewards in % of total physician salary  5%  Rwanda (Basinga et al. 2011): Increase in staff salaries affected with PBF payments  38%  Sierra Leone (Bertone et al. 2016): PBF rewards in % of overall income  9–11%  Tanzania (Chimhutu et al. 2016): PBF rewards in % of salary  10%  Cadre  Basic salary (gov’t), quarterly (MoH)  Unpublished income data collected in the context of the overall RBF4MNH impact evaluationa   n  Net income Mar–May ‘15, incl top-ups, per diems, locum, PBF  PBF rewards Jan–Mar 2015  Relative PBF contribution  Nurse/midwives  419–489  36  M = 615  M = 34.83  M: 5.8%  SD = 209  SD = 25.28  SD: 4.6%  Medical assistants  304–315  9  M = 453  M = 33.40  M: 7.0%  SD = 105  SD = 7.04  SD: 1.3%  Clinical officersb  772–894  –  –  –  –  Burundi (Rudasingwa and Uwizeye, 2017): PBF rewards in % of total salary  20–30%  Pakistan (Witter et al. 2011): PBF rewards in % of gross pay  13–16%  Philippines (Peabody et al. 2014): PBF rewards in % of total physician salary  5%  Rwanda (Basinga et al. 2011): Increase in staff salaries affected with PBF payments  38%  Sierra Leone (Bertone et al. 2016): PBF rewards in % of overall income  9–11%  Tanzania (Chimhutu et al. 2016): PBF rewards in % of salary  10%  All amounts in USD (conversion rate 1 USD = 719 Malawi Kwacha). National minimum wage level in the study period: 79 USD (per 3 months) a At endline with a structured health worker survey among health workers in intervention facilities b Clinical officer subsample too small for valid estimates Study design We adopted an exploratory qualitative study design—embedded in the framework of a larger impact evaluation (Brenner et al. 2014)—to understand how PBF impacts health workers’ work motivation, which we define as the ‘willingness to exert and maintain an effort to succeed at work, achieve the organization’s goals or to help the team reach its goals’ (Franco et al. 2002, p. 1255). We conducted in-depth interviews with health workers directly involved in the intervention approximately 1 (2014) and 2 years (2015) after the start of the intervention. Sampling In alignment with the focus of the intervention, we interviewed primarily nurses and midwives, but also included some medical assistants and clinical officers. We purposely selected health facilities across all four districts to represent both primary and secondary levels of care, variation in facility size and variation in performance in RBF4MNH. We visited 12 facilities in 2014 and 14 facilities in 2015, of which 10 in both years. At each facility, we purposely selected one to four health workers according to availability of staff and facility size, and to represent both sexes as well as all age groups and seniority levels. To ensure sufficient intervention exposure, we only sampled health workers who had worked at the facility for at least 1 year. Data collection The first author conducted all interviews in English, using a semi-structured guide. We asked respondents to describe their views of and motivational and behavioural reactions to the various elements of the intervention, including changes they had perceived in their working environment and changes they had noticed in themselves (e.g. satisfaction, motivation, attitudes), probing specifically for causal links between these elements. Interviews started with an explanation of the interview purpose, reassurance on confidentiality and seeking of respondents’ written informed consent. All interviews were recorded and transcribed verbatim by trained transcribers. Analytical approach We analysed the transcribed material using a mixture of deductive and inductive coding, applying a series of codes partly defined a priori on the basis of the literature, themes in the interview guide, and main themes emerging from field notes. We allowed for additional codes to emerge as we proceeded through the material. Although we conducted interviews from an intervention perspective, along the different elements and consequences of PBF, we adopted an individual perspective at the level of analysis, exploring motivational mechanisms through the lens of health workers’ technical and psychosocial needs and experiences at work. We applied analyst triangulation; sub-portions of the material were coded independently by the first and the second author, with the two having previously worked together to identify a common analytical framework. The emerging interpretation was discussed among all authors. Data analysis was supported by QSR Nvivo10. Results We interviewed a total of 21 and 20 health workers in 2014 and 2015, respectively. Table 2 shows key sample characteristics. Table 2 Sample description   2014  2015  District      Balaka  6  5      Dedza  4  4      Mchinji  4  6      Ntcheu  7  5  Level of care      BEmOC  10  11      CEmOC  11  9  Sex      Female  11  11      Male  10  9  Cadre      Nurse/midwives  16  18      Medical assistants  2  1      Clinical officers  3  1  Age  mean = 34.7  mean = 36.8  min = 23  min = 25  max = 70  max = 60  Years at current health facility  mean = 3.9  mean = 5.3  min = 1  min = 1  max = 14  max = 14.5    2014  2015  District      Balaka  6  5      Dedza  4  4      Mchinji  4  6      Ntcheu  7  5  Level of care      BEmOC  10  11      CEmOC  11  9  Sex      Female  11  11      Male  10  9  Cadre      Nurse/midwives  16  18      Medical assistants  2  1      Clinical officers  3  1  Age  mean = 34.7  mean = 36.8  min = 23  min = 25  max = 70  max = 60  Years at current health facility  mean = 3.9  mean = 5.3  min = 1  min = 1  max = 14  max = 14.5  Six major categories of motivational mechanisms emerged from the analysis. The order in which the mechanisms are presented in the following does not reflect their relative importance, but was chosen for efficiency of presentation. Mechanism 1: RBF4MNH motivated health workers by acting as a periodic wake-up call Approximately half of the respondents spoke about how RBF4MNH had opened their eyes to the discrepancies between their day-to-day practice and what they had committed themselves to when joining the health care service. I have seen that previously we were killing our patients. The protocols were there, but we were not following them. (Nurse/midwife, 2014)This realization of the insufficiency of their practice, and the consequences of substandard performance for their patients, boosted health workers’ motivation to improve and step up to their role as health professionals in the future. We used to take some things for granted, like labour graphs not fully filled […]. So when the program rolled out, we were refreshed. It really helped us. (Nurse/midwife, 2014)Respondents mentioned many of the intervention elements as contributing to this ‘wake-up effect’, including initial refresher trainings, periodic performance feedback as part of the verification process, and improved and more frequent supportive supervision. Mechanism 2: RBF4MNH motivated health workers by giving them direction and goals to work towards Several health workers explained that prior to RBF4MNH, their enthusiasm and effort at work had been limited by a lack of focus, direction, and guidance. When I came here, we used to do things routinely, we had no direction. (Nurse/midwife, 2014)About half of the respondents described how RBF4MNH had increased their motivation to work hard by helping them be more focused, purposeful and efficient in their work. Several elements of RBF4MNH had contributed to this. Health workers described how the indicators and targets were constantly present for them, being displayed on the walls and constantly monitored both within facility teams and externally by DHMTs and the PBF verification process. Respondents expressed how this motivated them by serving as a constant reminder of the high quality standards they should strive to attain. [RBF4MNH] acts as a reminder to us that these are the things we are supposed to do as midwives, not necessarily for RBF but just for our patients in general. (Nurse/midwife, 2015)Important to mention in this context is that virtually all respondents strongly endorsed the intervention goals and the indicator set overall due to its perfect alignment with national treatment standards. The best part of it is that there are no new conditions to it. […] RBF4MNH is just coming to polish up things. (Medical assistant, 2014)The presence of work targets seemed to be a welcome challenge and a strong motivator for health workers, even independent of the rewards attached to target attainment. Many respondents described their satisfaction with how RBF4MNH had given them something to focus their effort on and work towards. When you are doing something and you don’t have a target, it’s like you don’t know where you are going, and if you don’t know where to go, it means any road can take you there. So to have targets, it‘s important because all your effort, you will be trying to reach that target. (Clinical officer, 2014)The financial reward attached to target attainment further propelled health workers’ inherent motivation to work hard towards achieving the targets. RBF4MNH not only gave health workers something to work towards, but also helped them develop strategies to reach their targets. Respondents described how RBF4MNH stimulated and allowed them to identify and set priorities in service delivery routines, reflect on and critically evaluate their own performance, identify areas in need of improvement, and develop solutions to challenges. They mentioned several of the intervention elements as important to this effect, including the constant performance feedback introduced by the intervention coupled with enhanced supportive supervision by the DHMT and the RBF4MNH management unit in the MoH (‘RBF4MNH secretariat’). It’s like the facility has been decentralized. Now, you can sit down and discuss, see your own problems and come up with solutions rather than waiting for somebody at the top level to see problems for you, discuss and say we will do this for you. We feel good because we see the problems right away and come up with solutions. And after coming up with solutions, we work according to the problems. So, it’s quite good. (Nurse/midwife, 2014)While generally supportive of the indicators, many respondents were frustrated with how the realities of their working conditions, particularly shortages in staffing and drugs, both beyond health facilities’ control, substantially hindered high levels of achievement. Most health workers expressed acceptance of this situation without apparent negative consequences for their work motivation, being able to focus on learning and small progress rather than on frustrations with non-attainment of targets. If it was not for the issues of staffing level, we would have really made a lot of progress by now. […] But we are far better now. I think we have really made progress. (Nurse/midwife, 2015)A few health workers, however, seemed to struggle with keeping up their motivation to work hard in light of their perceived inability to reach high performance levels. Some of the labour graphs are not filled because of shortage of staff. […] Seeing it clearly that you are losing some money because you did not fill all the partographs […] We feel bad, but we also feel that there is nothing we could do. (Nurse/midwife, 2015) Mechanism 3: RBF4MNH motivated health workers by strengthening their perceived ability to perform successfully in their job, giving them a new sense of accomplishment at work Virtually all respondents described how RBF4MNH had led to positive changes in their working environment. Such changes included improvements in infrastructure, equipment, and availability of material; improved skills due to refresher trainings and better on-the-job-training; improved management support; and—in certain facilities—increases in staffing levels. Many respondents indicated how they had previously often felt helpless and without purpose in a working environment that did not permit them to provide care to their patients in the way they would have wished, necessitating them to constantly improvise and find other ways to cope with client and health system expectations. Respondents described this situation as frustrating, physically and emotionally exhausting, and demotivating. The improved working conditions as a result of RBF4MNH alleviated such previous frustrations for many health workers, allowing them to more effectively translate their skills into practice, fostering feelings of self-efficacy, and making their work life generally easier and more comfortable. Respondents described how their general attitudes and motivation towards their job had improved as a result, and how they were motivated to work even harder towards achieving the PBF targets so that the next reward payment would allow them to improve their workplace even further. I feel very motivated. You know, the environment you work in matters. For instance, if you cannot provide a certain procedure because you lack equipment, you become demotivated. You know you could have helped the woman but you cannot give your best because you don’t have resources to do that. […] But because of the provision of the equipment we are now able to provide most of the services. (Nurse/midwife, 2015) We are being motivated with this RBF4MNH. When we work hard, we achieve the indicators for RBF4MNH, we receive more money, which helps us to buy more equipment for us to make our work easier. (Medical assistant, 2015)Most respondents perceived an increase in the quality of care delivered in their facility as a consequence of these improvements. About a third of respondents reported a perceived decrease in maternal and neonatal mortality and other positive changes in patient outcomes. This reignited a sense of accomplishment which positively impacted their work motivation. It feels very good and it is motivating us to see that we are no longer having maternal deaths or babies dying. (Nurse/midwife, 2014)While the intervention triggered improvements, many respondents made clear that substantial obstacles remained, keeping them from reaching truly high quality standards. Due to the combined effect of closer adherence to treatment protocols and increases in service utilization as a result of RBF4MNH, workload and resource consumption increased in many facilities. Respondents reported that this increase in workload and resource requirements—beyond already challenging pre-intervention levels—was not adequately met by improvements in staffing levels and resource availability. For a few respondents, this aggravated feelings of overburden and reduced self-efficacy rather than improved their perceived ability to provide care. Patients are not getting the care that they are supposed to get because of the workload. […] I feel that I am not delivering. I am not doing what I promised as a nurse that I will be doing. […] I feel as a failure. (Nurse/midwife, 2015)In general, health workers appeared torn between their need for rest and comfort at work, and their inherent desire to serve all patients in need and the joy of being better able to do so with RBF4MNH. For most respondents, the ability to serve more patients and provide better care outweighed the workload and fatigue associated with it. RBF4MNH brings a lot of workload but we are happy because we are improving the livelihood of women and children. (Medical assistant, 2014)In year 2, respondents were more critical due to additionally allocated staff leaving again and a general worsening of the resource situation in the health system. Mechanism 4: RBF4MNH motivated health workers by instilling feelings of recognition and appreciation of their effort About one-third of the respondents spoke about how the more frequent, intensive and tailored supervision and support by the DHMT and RBF4MNH secretariat made them feel more visible and appreciated in their contribution to the health system, including their effort and performance under difficult working conditions. In the past, you could do something good, nobody noticed. Now with this RBF4MNH, you are recognized that you have done something good. People can see that, ah, this man is working. (Nurse/midwife, 2014)A few respondents explicitly described how the financial rewards provided by RBF4MNH served as an expression or symbol of this enhanced recognition. When we are receiving this it’s like just like a congratulations to say carry on what you learned in school. (Nurse/midwife, 2015)Although the majority of respondents described positive ‘net’ changes in perceived recognition and appreciation and felt motivated by them, almost all also mentioned how implementation-related challenges attenuated these increases. Particularly in the first-year peer-to-peer verification model, many health workers felt unfairly evaluated by the verification teams. While most respondents stated that this perceived unfairness did not impact their work motivation much, five respondents described how it made them feel unappreciated rather than appreciated, demotivating rather than motivating them. It’s unfair. We work hard towards achieving these things, and then somebody just comes and says you didn’t do this, and yet the things were there. (Nurse/midwife, 2015)About one-third of the sample felt that the effort they made in the context of the intervention was not adequately reciprocated by RBF4MNH secretariat and DHMTs. For instance, they were frustrated with delays in various activities (infrastructure upgrade, verification) incurred by the RBF4MNH secretariat. Respondents further reported that DHMTs coped with the overall declining resource situation in the system by prioritizing non-RBF4MNH facilities in their resource allocation, effectively withdrawing support from RBF4MNH facilities and expecting them to support themselves with their RBF4MNH funds. A few respondents experienced this situation as a sign of disrespect, demotivating rather than motivating them. I feel like the District Health Officer has run away from his responsibilities because of the RBF4MNH. […] Sometimes I feel bad about it. (Medical assistant, 2015) It was a setback. Working with the intention that somebody will come to supervise your work, only to realize that they don’t come, you feel like, ahh, then I just worked for nothing? […] We wonder, up to this time they still have all those challenges, so I feel like [the RBF4MNH secretariat] somehow is not much serious. (Nurse/midwife, 2015)Finally, eight respondents indicated feeling disrespected by an intervention which they perceived as trying to improve health care coverage at all costs without adequate consideration of health workers’ constrained working conditions. This dampened their motivation to make an effort in the context of the intervention. Honestly, I feel like the project is there to bring a burden on us. They are just trying to get more customers in, but the staff and resources to attend to those customers are few. […] You know, as humans, sometimes emotions come in. So you may feel like you have been abused. (Nurse/midwife, 2015) Mechanism 5: RBF4MNH motivated health workers to improve their performance by altering social dynamics About half of the respondents described changes within their work teams and beyond which had in one way or another impacted their work motivation. Between districts and health facilities within districts, RBF4MNH triggered a mostly healthy sense of competition, the desire to be the best and outperform the others motivating health workers to work hard and improve their performance. Everybody is trying hard so that you win. This time you came number three, you want to be number two, the next time you want to be number one. (Nurse/midwife, 2014)Within health facilities, the desire to do well in RBF4MNH brought teams closer together as they worked towards this common objective. Respondents described this new team spirit and sense of coherence and cooperation as very positive and motivating. I’m very happy because things have changed drastically. […] Now we are working towards one goal and that is giving better services to our patients. (Medical assistant, 2014)At the same time, respondents acknowledged that RBF4MNH subjected them to additional pressure to perform up to standard from colleagues, managers, RBF4MNH secretariat, clients and other health system actors. Most respondents perceived this additional pressure as a positive and helpful motivation rather than as overly stressful and controlling. We have really changed. People are serious when doing their work because they know at the end of the day, somebody will ask:"Why didn’t you do this?" (Nurse/midwife, 2014)The above-mentioned high level of endorsement of the intervention, specifically the understanding that RBF4MNH only reinforces preexisting work responsibilities, seemed very important in this regard. With RBF4MNH, we are forced, I shouldn’t say forced, but we are being directed to do what we are supposed to do, what is required of us as nurses. (Nurse/midwife, 2015)While none of the respondents explicitly spoke about the additional social pressure as overburdening for them personally, several implied unfavourable motivational consequences for colleagues. Specifically, they described how certain coworkers would document in partographs even if they had not performed a service, so as not to appear low-performing and responsible for the team losing out on PBF rewards. People would still paint the picture to show that they had worked. But you will sometimes find that the care that is documented is not the care that was given to the patient. (Nurse/midwife, 2015)Although conducive to team spirit on the one hand, respondents described that RBF4MNH also introduced new interpersonal challenges, particularly between clinical and non-clinical staff. In many facilities, the autonomy in sharing the staff portion of the rewards led to substantial conflict as individuals or staff groups were dissatisfied with their share, which significantly dampened many respondents’ enthusiasm about the intervention and motivation to make an effort. Almost everybody called for fixed guidelines on how to share rewards to prevent further conflict. This RBF4MNH, it is bringing us together, but it is also driving us apart. (Nurse/midwife, 2015) Nurses who are putting direct impact towards implementation of the project are always disappointed or get setbacks. ′Why should I put all effort?′. Then at the end of the day, if you realize more, you still have equal shares with those colleagues who did not even put a direct impact. Aaah, then maybe […] I should better not put much effort towards implementing this. (Nurse/midwife, 2015) Mechanism 6: RBF4MNH motivated health workers to work hard by offering a ‘nice to have’ opportunity to earn extra income to improve their lifestyle Almost all respondents were appreciative of this opportunity. Only five respondents described the individual rewards as something they seriously and actively focused on and worked towards, however. We are human and become motivated when we see that there will be a reward, and you turn to work extra hard. (Medical assistant, 2014)The vast majority of respondents welcomed the additional income and felt encouraged to perform well by it, but at the same time made clear that the individual rewards were not the central motivating element of RBF4MNH for them, stressing that the improvements in the physical and interpersonal working environment are where the intervention really made a difference. Personally, the incentives are just an addition, but my spirit is to help people. Nursing is a calling, so incentives, no incentives, I do my work the same. But the money is good because it is not only given to the health workers, but it also assists the facility as a whole. (Nurse/midwife, 2014)Many qualified their generally positive feelings about the individual rewards by describing their wariness of the above-mentioned interpersonal conflict introduced by the incentives. Several respondents did not feel that their share of the staff portion was an adequate reflection of their contribution to their facilities’ performance in RBF4MNH, which they described as discouraging. Some health workers explained that the overall individual reward amount was too little to act as a real motivator, particularly at district hospital level where the large staff numbers led to many staff members only receiving very small absolute amounts. Seven respondents, all but one from district hospitals, stated that for them, these issues overshadowed positive aspects of the individual rewards to the extent that they acted as a demotivator rather than a motivator. With the [current] economy in Malawi, someone cannot motivate me with 7.600 Kwacha [≈USD 22.30] in six months.[…] But it is psychological torture to be told to work extra hard for something and that something is almost nothing. (Clinical officer, 2014) I would just make sure that there are enough resources, but incentives to the staff, I wouldn’t do that because I can see now it causes people to argue a lot because of the money. (Nurse/midwife, 2015) Discussion This study explored the mechanisms through which RBF4MNH in Malawi motivated health workers to perform better in their jobs. Our findings contribute to closing the important knowledge gap on the exact ‘how’ and ‘why’ PBF does or does not lead to health worker behaviour change and ultimately to more readily available and better health care services (Lohmann et al. 2016; Renmans et al. 2016). Our findings strongly support the notion that PBF motivates health workers with much more than the prospect of earning extra income, similar to what previous studies have suggested (see Table 3). We identified six major categories of motivational mechanisms, three of which were not directly related to the individual financial rewards. As observed in other countries (Renmans et al. 2016), perceived weaknesses of the intervention design, various implementation-related challenges, as well as contextual constraints fully or in part inhibited the activation of certain mechanisms for many respondents, keeping RBF4MNH from developing its full motivating potential. Table 3 Overview of RBF4MNH’s motivational mechanisms, contributory elements, challenges and previous studies with similar results Mechanism: RBF4MNH motivated health workers  Relation to individual rewards  Contributory PBF elements  Challenges  Previous research reporting similar findings  1  By acting as a periodic wake-up call to deficiencies in their day-to-day practice  Unrelated  Initial refresher trainings; improved performance feedback as part of the verification process and the improved supervision    Bertone et al. (2016) (Sierra Leone); Bhatnagar and George (2016) (Nigeria)  2  By providing direction and goals to work towards  Indirectly related  Performance targets; performance verification and feedback; improved supportive supervision; facility and individual rewards  Overly challenging targets; contextual constraints  Kalk et al. (2010) (Rwanda); Paul et al. (2014) (Benin)  3  By strengthening perceived ability to perform successfully at work and triggering a sense of accomplishment  Indirectly related  Initial refresher trainings; start-up support (infrastructure, equipment, staff); improved supportive supervision; facility rewards; CCT component  Improvements in the working environment inadequate in light of increased work demands  Bertone et al. (2016) (Sierra Leone); Kalk et al. (2010) (Rwanda); Paul et al. (2014) (Benin); Shen et al. (2017) (Zambia)  4  By instilling feelings of recognition  Directly related  Performance verification; improved supervision; facility and individual rewards  Perceived lack in fairness and reciprocity  Bhatnagar and George (2016) (Nigeria); Chimhutu et al. (2016) (Tanzania); Paul et al. (2014) (Benin);  5  By altering social dynamics, improving team work towards a common goal, but also introducing social pressure  Directly related  Performance targets; performance verification and feedback; facility and individual rewards  Within-team pressure to perform incentivizes undesired behaviour; conflict linked to distribution of individual rewards  Chimhutu et al. (2016) (Tanzania)  6  By offering a ‘nice to have’ opportunity to earn extra income  Directly related  Individual rewards  Low absolute/inadequate-to-effort amounts, particularly at health facilities with many staff; conflict linked to distribution of individual rewards  Bertone et al. (2016) (Sierra Leone); Bhatnagar and George (2016) (Nigeria); Chimhutu et al. (2016) (Tanzania); Paul et al. (2014) (Benin)  Mechanism: RBF4MNH motivated health workers  Relation to individual rewards  Contributory PBF elements  Challenges  Previous research reporting similar findings  1  By acting as a periodic wake-up call to deficiencies in their day-to-day practice  Unrelated  Initial refresher trainings; improved performance feedback as part of the verification process and the improved supervision    Bertone et al. (2016) (Sierra Leone); Bhatnagar and George (2016) (Nigeria)  2  By providing direction and goals to work towards  Indirectly related  Performance targets; performance verification and feedback; improved supportive supervision; facility and individual rewards  Overly challenging targets; contextual constraints  Kalk et al. (2010) (Rwanda); Paul et al. (2014) (Benin)  3  By strengthening perceived ability to perform successfully at work and triggering a sense of accomplishment  Indirectly related  Initial refresher trainings; start-up support (infrastructure, equipment, staff); improved supportive supervision; facility rewards; CCT component  Improvements in the working environment inadequate in light of increased work demands  Bertone et al. (2016) (Sierra Leone); Kalk et al. (2010) (Rwanda); Paul et al. (2014) (Benin); Shen et al. (2017) (Zambia)  4  By instilling feelings of recognition  Directly related  Performance verification; improved supervision; facility and individual rewards  Perceived lack in fairness and reciprocity  Bhatnagar and George (2016) (Nigeria); Chimhutu et al. (2016) (Tanzania); Paul et al. (2014) (Benin);  5  By altering social dynamics, improving team work towards a common goal, but also introducing social pressure  Directly related  Performance targets; performance verification and feedback; facility and individual rewards  Within-team pressure to perform incentivizes undesired behaviour; conflict linked to distribution of individual rewards  Chimhutu et al. (2016) (Tanzania)  6  By offering a ‘nice to have’ opportunity to earn extra income  Directly related  Individual rewards  Low absolute/inadequate-to-effort amounts, particularly at health facilities with many staff; conflict linked to distribution of individual rewards  Bertone et al. (2016) (Sierra Leone); Bhatnagar and George (2016) (Nigeria); Chimhutu et al. (2016) (Tanzania); Paul et al. (2014) (Benin)  In speaking about perceived changes in motivation, respondents described two different types of motivation. On the one hand, RBF4MNH appeared to have fostered specific motivation related to the targets incentivized by RBF4MNH. In an intervention targeting only a subset of services, this bears a risk of neglect of other services, referred to as ‘gaming’ in the PBF literature and observed in other PBF schemes (e.g. Kalk et al. 2010 in Rwanda, Chimhutu et al. 2014 in Tanzania). We did not specifically address gaming in our study. On the other hand, respondents made clear that RBF4MNH also affected their general motivation to work hard and perform well, beyond the specific services incentivized by PBF. Mechanisms 1, 3 and 4 played a particularly important role in fostering not only PBF-specific, but also general work motivation. Our results suggest that while all mechanisms were ‘pieces of the puzzle’, the increased perceived ability to perform successfully in the job and the new sense of accomplishment and purpose at work was where RBF4MNH had the most significant motivational impact for the respondents. Many respondents stressed their dedication to their profession and their innate desire to serve their patients well. Previous research has found challenging working conditions prohibiting the translation of this desire into practice a main demotivator for Malawian health workers (Manafa et al. 2009; Chimwaza et al. 2014). It is therefore not surprising that respondents felt strongly motivated by an alleviation of this demotivating situation. In this context, it is important to recall that the intensive start-up support made an important contribution to the positive changes in working conditions and went far beyond what would have been achievable with PBF rewards alone. However, favourable changes in the working environment emerged as a key contributor to changes in motivation in other PBF schemes as well, for instance in Nigeria (Bhatnagar and George 2016) and Sierra Leone (Bertone et al. 2016). In contrast, the individual rewards appeared to have a relatively weak motivational effect. Considering the importance attributed to them in the PBF discourse (Renmans et al. 2017), this is somewhat surprising, although not entirely unexpected based on previous research (Kalk et al. 2010; Paul et al. 2014; Bertone et al. 2016; Chimhutu et al. 2016; Shen et al. 2017). Their relative ineffectiveness can at least in part be explained by the diverse frustrations associated with them. RBF4MNH does not seem to be a singular case in this regard. Chimhutu et al. (2016) for instance described how in Tanzania, unfairness perceptions regarding the reward distribution process severely affected motivation and undermined social relationships. This raises the question as to whether performance-conditional rewards were really necessary, or whether otherwise effected improvements of working conditions might have achieved similar results, as some previous studies have implied (e.g. Shen et al. 2017). Our research design clearly does not allow for a conclusive answer to this question. However, our findings do indicate that the performance-conditionality of the additional resource inputs magnified motivational effects beyond what might have been achieved by unconditional inputs and isolated improvements of health systems functions. Specifically, some health workers reported to be motivated to work as hard as possible to maximize what their facility could gain in PBF rewards so as to be able to further improve their working conditions as much as possible. Performance-conditionality of rewards at the facility level thus appeared valuable, but the RBF4MNH experience calls into question the value of the individual reward component. Important in this context is that the relative contribution of PBF rewards to individual overall income appeared relatively low in international comparison (Table 1). Many health workers expressed their displeasure about the overall amounts which they found too small to have a serious motivating effect. Higher individual reward amounts might have been more powerful, although similar dissatisfaction has been documented in countries with higher amounts as well (e.g. Burundi, Pakistan, Tanzania). In interpreting the results, it is important to underline that our findings represent solely the experiences of clinical healthcare personnel, and at hospital level only from the maternity department. Other staff groups had much less positive motivational reactions to RBF4MNH. Further, we only interviewed health workers in intervention facilities. Although we probed respondents carefully for attribution of changes to RBF4MNH as opposed to other factors, the distinction was sometimes difficult. Interviews with health workers from non-intervention facilities would have helped to disentangle the motivational effects of PBF from the effects of PBF-unrelated changes in the health system. Third, most respondents wished for the intervention to continue despite the various challenges, and were therefore likely interested in portraying the intervention and its motivational effects positively. Although we do not believe that this affected our mapping of motivational effects in the sense that we missed important aspects, our findings might be slightly biased towards the positive. In judging the transferability of our findings, it is important to take into account that Malawi faced severe challenges in regards to most routine health systems functions pre-PBF, and continued to do so throughout the implementation period. Much of the motivational effect of RBF4MNH seems attributable to reinstating or reinforcing such health systems functions, and thus removing or alleviating previous demotivators. Our findings also need to be considered in light of the unusual PBF design based on target attainment rather than a quality-adjusted fees-for-service and including unconditional start-up support as well as CCTs. Health workers in contexts with a different PBF design or a less challenging pre-PBF situation might perceive a different relative importance of the mechanisms, or experience mechanisms that did not emerge in Malawi. Conclusion We conclude that PBF is clearly more than just ‘monetary carrots and sticks’, involving multiple motivational mechanisms that are closely, distantly, or not at all related to the individual reward payments. Health workers were particularly motivated by positive changes in their working environment, enabling them to more effectively translate their skills and desire to help their patients into practice. The individual rewards played a comparatively small role. Funding This work was funded by the United States Agency for International Development under Translating Research into Action [Cooperative Agreement No. GHS-A-00-09-00015-00]. This study is made possible by the support of the American People through the United States Agency for International Development (USAID). The study was further supported by the Norwegian Agency for Development Cooperation (NORAD) and by the Royal Norwegian Embassy in Lilongwe. The findings of this study are the sole responsibility of research teams at the University of Heidelberg and the College of Medicine of the University of Malawi and do not necessarily reflect the views of USAID, the United States Government, NORAD or the Royal Norwegian Embassy in Lilongwe. Ethical approval Ethical approval was granted by the Ethical Commission of the Medical Faculty of Heidelberg University, Germany (protocol S-256/2012) and the University of Malawi College of Medicine Research and Ethics Committee (protocol P.02/13/1338). We sought permission from MoH and DHMTs before data collection. All respondents gave their informed consent before being interviewed. Conflict of interest statement. None declared. References Basinga P, Gertler PJ, Binagwaho A, Soucat AL, Sturdy J, Vermeersch CM. 2011. Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet  377: 1421– 8. 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Witter S, Toonen J, Meessen B et al.   2013. Performance-based financing as a health system reform: mapping the key dimensions for monitoring and evaluation. BMC Health Services Research  13: 367. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Policy and Planning Oxford University Press

‘The money can be a motivator, to me a little, but mostly PBF just helps me to do better in my job.’ An exploration of the motivational mechanisms of performance-based financing for health workers in Malawi

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Abstract

Abstract Performance-based financing (PBF) is assumed to improve health care delivery by motivating health workers to enhance their work performance. However, the exact motivational mechanisms through which PBF is assumed to produce such changes are poorly understood to date. Although PBF is increasingly recognized as a complex health systems intervention, its motivational effect for individual health workers is still often reduced to financial ‘carrots and sticks’ in the literature and discourse. Aiming to contribute to the development of a more comprehensive understanding of the motivational mechanisms, we explored how PBF impacted health worker motivation in the context of the Malawian Results-based Financing for Maternal and Newborn Health (RBF4MNH) Initiative. We conducted in-depth interviews with 41 nurses, medical assistants and clinical officers from primary- and secondary-level health facilities 1 and 2 years after the introduction of RBF4MNH in 2013. Six categories of motivational mechanisms emerged: RBF4MNH motivated health workers to improve their performance (1) by acting as a periodic wake-up call to deficiencies in their day-to-day practice; (2) by providing direction and goals to work towards; (3) by strengthening perceived ability to perform successfully at work and triggering a sense of accomplishment; (4) by instilling feelings of recognition; (5) by altering social dynamics, improving team work towards a common goal, but also introducing social pressure; and (6) by offering a ‘nice to have’ opportunity to earn extra income. However, respondents also perceived weaknesses of the intervention design, implementation-related challenges and contextual constraints that kept RBF4MNH from developing its full motivating potential. Our results underline PBF’s potential to affect health workers’ motivation in ways which go far beyond the direct effects of financial rewards to individuals. We strongly recommend considering all motivational mechanisms more explicitly in future PBF design to fully exploit the approach’s capacity for enhancing health worker performance. Motivation, motivational mechanisms, health workers, performance-based financing, Malawi Key Messages PBF in Malawi impacted health worker motivation through various mechanisms. Particularly important were improvements in the working environment as a result of PBF which fostered health workers’ perceived ability to perform successfully on the job and created a new sense of accomplishment at work; the individual financial incentives, in contrast, seemed of limited importance. Various implementation-related challenges and contextual constraints kept the intervention from developing its full motivating potential. We strongly recommend considering all motivational mechanisms more explicitly in future PBF design to fully exploit the approach‘s capacity for enhancing health worker performance. Background Performance-based financing (PBF) has gained much attention among low- and middle-income country (LMIC) governments and international organizations as a means of strengthening health systems in recent years. PBF aims to overcome shortcomings in healthcare service delivery by motivating healthcare providers to better align their service provision behaviour with health system interests through performance contracts which financially reward the attainment of defined performance standards. A recent review of the literature indicates that PBF can indeed improve healthcare delivery in desired ways and underlines the importance attributed to motivation as a key element in bringing about this change (Renmans et al. 2016). However, much of the available literature remains unspecific regarding the precise motivational mechanisms involved in PBF at the level of the individual health workers. The review concludes that ‘more research is needed on the exact mechanisms through which not only incentives, but also ancillary components operate’ (Renmans et al. 2016, p. 1297). This statement alludes to the fact that although there is increasing recognition of PBF as a complex reform package, much of the literature and discourse on how PBF brings about change in health worker motivation and behaviour is focused on the individual incentives (Renmans et al. 2017). Specifically, in most currently operational PBF schemes, additional health facility revenue generated through PBF must partially be reinvested into the facility and can partially be disbursed to staff as incentive or reward payments (Fritsche et al. 2014). However, in addition to performance contracts and verification and reward payment activities, many PBF interventions include various other elements aimed at strengthening health system functions and promoting results orientation and entrepreneurial behaviour, such as a strengthening of performance monitoring and feedback systems and management structures, or capacity building measures (Witter et al. 2013; Renmans et al. 2016). These other elements likely also impact motivation, in addition to the financial reward component (Lohmann et al. 2016). Experiences from different settings indicate that PBF can induce powerful positive change in health workers’ working lives and activate various complex motivational mechanisms beyond the direct effects of financial incentives to individuals. For example, in Burundi, health workers reported that clearer tasks and objectives and more intensive support as a result of PBF reinforced feelings of professionalism (Bertone and Meessen 2013). In Rwanda, health workers experienced increased appreciation for their work, greater attention to their needs by managers, increased feelings of responsibility and improved team spirit (Kalk et al. 2010). In Tanzania, PBF fostered a competitive spirit between health facilities, motivating staff to work hard to be ‘winners’ (Chimhutu et al. 2014). In Nigeria, health workers reported to have been ‘awakened’ by PBF and motivated by improvements in their working conditions and their own performance (Bhatnagar and George 2016). However, there remains a lack of systematic and comprehensive explorations of PBF’s motivational mechanisms. We used the opportunity of the introduction of PBF in Malawi to contribute to filling this gap in knowledge. Our findings aim at informing the development of a comprehensive theory of change which will facilitate effective, efficient, and side effect-free future PBF planning. Methods Setting Malawi’s health system is characterized by a predominantly public health system which provides essential health services free of charge at point of service. The country has high utilization rates for essential health services (NSO 2016), but service quality is poor (MoH 2014) for a variety of reasons, including a severe shortage of mid-level healthcare personnel who shoulder the majority of primary health services, leading to high workload particularly for health workers in the maternity departments (Manafa et al. 2009; Bradley et al. 2015). Previous research has highlighted high levels of dissatisfaction with low income levels, a perceived lack of recognition of effort by the health system, and limited opportunities for in-service training (Manafa et al. 2009; Chimwaza et al. 2014). Health facility supervision, primarily task of the District Health Management Teams (DHMTs), happens regularly (MoH 2014), but is often unsupportive and of low quality (Manafa et al. 2009; Bradley et al. 2013). DHMTs are also in charge of procuring medicines and materials from central medical stores and allocating them to the public facilities in their districts, as those facilities do not manage their own budgets. As a result of management issues and the country’s macroeconomic situation, facilities have been experiencing stock-outs of drugs and supplies on a near regular basis in recent years (MoH 2014), a frustrating and demotivating situation for health workers (Chimwaza et al. 2014). The Results-Based Financing for Maternal and Newborn Health (RBF4MNH) Initiative In 2013, the Ministry of Health (MoH) introduced the RBF4MNH Initiative as a pilot PBF intervention in 14 primary and 4 secondary health facilities in the Balaka, Dedza, Ntcheu and Mchinji districts (Options 2012, 2014). In 2014, RBF4MNH was extended to 10 additional facilities. Aiming to reduce maternal and neonatal mortality, RBF4MNH combines PBF with conditional cash transfers (CCT) to pregnant women to increase the institutional delivery rate and improve the quality of delivery care services. The PBF component includes two sets of performance contracts, one targeting the DHMTs and one targeting health facilities. DHMTs are incentivized to increase institutional deliveries in their districts (removed end 2014), ensure availability of equipment, drugs and other commodities, and improve reporting of routine data. They receive an additional budget for supervisory activities. Within the four intervention districts, facilities were selected into the intervention based on several criteria including the ability to provide emergency obstetric care services. To enable facilities to do the latter, RBF4MNH provided substantial performance-unconditional start-up support to most selected facilities in the form of infrastructure upgrades, provision of essential equipment, refresher trainings and additional staff postings prior to or in the early stages of the intervention. Unlike many other PBF interventions (Renmans et al. 2016), RBF4MNH is not designed as a quality-adjusted fee-for-service scheme. Rather, RBF4MNH rewards the attainment of performance targets, reinforcing adherence to national treatment standards for maternal care (e.g. correct partograph use, HIV testing of pregnant women). Two targets related to increase in service volume were dropped at the end of 2014. All rewards are monetary. Maximal reward amounts by indicator are fixed and then discounted based on target attainment. In year 1, targets were absolute (e.g. minimum 80% of deliveries with partograph), with rewards only allocated if the target was attained. In year 2, this was changed to an achievement level-based approach (i.e. 75% of deliveries with partograph = 75% of maximum reward). Verification of facilities’ performance was initially done in a peer-to-peer arrangement every 6 months, but changed to verification by an external agency every 3 months at the end of 2014. Following each round of verification, results are communicated to all stakeholders, enabling districts and facilities to evaluate their performance in relation to the others. Facilities are required to invest 30% into the facility (‘facility portion’), and can distribute 70% to staff as bonus payments (‘staff portion’). They are autonomous in their decisions how to divide the staff portion between staff members and how to invest the facility portion. The latter is with the exception of drugs, which health facilities are not allowed to purchase but continue to request from the DHMTs. In all primary-level facilities, staff portions were effectively distributed to benefit everybody (including support staff), although to varying extent. At hospital level, maternity department staff were the primary beneficiaries of individual rewards. Table 1 shows individual reward amounts in relation to other sources of income. Table 1 Contribution of PBF rewards to health workers’ overall income in Malawi and elsewhere Cadre  Basic salary (gov’t), quarterly (MoH)  Unpublished income data collected in the context of the overall RBF4MNH impact evaluationa   n  Net income Mar–May ‘15, incl top-ups, per diems, locum, PBF  PBF rewards Jan–Mar 2015  Relative PBF contribution  Nurse/midwives  419–489  36  M = 615  M = 34.83  M: 5.8%  SD = 209  SD = 25.28  SD: 4.6%  Medical assistants  304–315  9  M = 453  M = 33.40  M: 7.0%  SD = 105  SD = 7.04  SD: 1.3%  Clinical officersb  772–894  –  –  –  –  Burundi (Rudasingwa and Uwizeye, 2017): PBF rewards in % of total salary  20–30%  Pakistan (Witter et al. 2011): PBF rewards in % of gross pay  13–16%  Philippines (Peabody et al. 2014): PBF rewards in % of total physician salary  5%  Rwanda (Basinga et al. 2011): Increase in staff salaries affected with PBF payments  38%  Sierra Leone (Bertone et al. 2016): PBF rewards in % of overall income  9–11%  Tanzania (Chimhutu et al. 2016): PBF rewards in % of salary  10%  Cadre  Basic salary (gov’t), quarterly (MoH)  Unpublished income data collected in the context of the overall RBF4MNH impact evaluationa   n  Net income Mar–May ‘15, incl top-ups, per diems, locum, PBF  PBF rewards Jan–Mar 2015  Relative PBF contribution  Nurse/midwives  419–489  36  M = 615  M = 34.83  M: 5.8%  SD = 209  SD = 25.28  SD: 4.6%  Medical assistants  304–315  9  M = 453  M = 33.40  M: 7.0%  SD = 105  SD = 7.04  SD: 1.3%  Clinical officersb  772–894  –  –  –  –  Burundi (Rudasingwa and Uwizeye, 2017): PBF rewards in % of total salary  20–30%  Pakistan (Witter et al. 2011): PBF rewards in % of gross pay  13–16%  Philippines (Peabody et al. 2014): PBF rewards in % of total physician salary  5%  Rwanda (Basinga et al. 2011): Increase in staff salaries affected with PBF payments  38%  Sierra Leone (Bertone et al. 2016): PBF rewards in % of overall income  9–11%  Tanzania (Chimhutu et al. 2016): PBF rewards in % of salary  10%  All amounts in USD (conversion rate 1 USD = 719 Malawi Kwacha). National minimum wage level in the study period: 79 USD (per 3 months) a At endline with a structured health worker survey among health workers in intervention facilities b Clinical officer subsample too small for valid estimates Study design We adopted an exploratory qualitative study design—embedded in the framework of a larger impact evaluation (Brenner et al. 2014)—to understand how PBF impacts health workers’ work motivation, which we define as the ‘willingness to exert and maintain an effort to succeed at work, achieve the organization’s goals or to help the team reach its goals’ (Franco et al. 2002, p. 1255). We conducted in-depth interviews with health workers directly involved in the intervention approximately 1 (2014) and 2 years (2015) after the start of the intervention. Sampling In alignment with the focus of the intervention, we interviewed primarily nurses and midwives, but also included some medical assistants and clinical officers. We purposely selected health facilities across all four districts to represent both primary and secondary levels of care, variation in facility size and variation in performance in RBF4MNH. We visited 12 facilities in 2014 and 14 facilities in 2015, of which 10 in both years. At each facility, we purposely selected one to four health workers according to availability of staff and facility size, and to represent both sexes as well as all age groups and seniority levels. To ensure sufficient intervention exposure, we only sampled health workers who had worked at the facility for at least 1 year. Data collection The first author conducted all interviews in English, using a semi-structured guide. We asked respondents to describe their views of and motivational and behavioural reactions to the various elements of the intervention, including changes they had perceived in their working environment and changes they had noticed in themselves (e.g. satisfaction, motivation, attitudes), probing specifically for causal links between these elements. Interviews started with an explanation of the interview purpose, reassurance on confidentiality and seeking of respondents’ written informed consent. All interviews were recorded and transcribed verbatim by trained transcribers. Analytical approach We analysed the transcribed material using a mixture of deductive and inductive coding, applying a series of codes partly defined a priori on the basis of the literature, themes in the interview guide, and main themes emerging from field notes. We allowed for additional codes to emerge as we proceeded through the material. Although we conducted interviews from an intervention perspective, along the different elements and consequences of PBF, we adopted an individual perspective at the level of analysis, exploring motivational mechanisms through the lens of health workers’ technical and psychosocial needs and experiences at work. We applied analyst triangulation; sub-portions of the material were coded independently by the first and the second author, with the two having previously worked together to identify a common analytical framework. The emerging interpretation was discussed among all authors. Data analysis was supported by QSR Nvivo10. Results We interviewed a total of 21 and 20 health workers in 2014 and 2015, respectively. Table 2 shows key sample characteristics. Table 2 Sample description   2014  2015  District      Balaka  6  5      Dedza  4  4      Mchinji  4  6      Ntcheu  7  5  Level of care      BEmOC  10  11      CEmOC  11  9  Sex      Female  11  11      Male  10  9  Cadre      Nurse/midwives  16  18      Medical assistants  2  1      Clinical officers  3  1  Age  mean = 34.7  mean = 36.8  min = 23  min = 25  max = 70  max = 60  Years at current health facility  mean = 3.9  mean = 5.3  min = 1  min = 1  max = 14  max = 14.5    2014  2015  District      Balaka  6  5      Dedza  4  4      Mchinji  4  6      Ntcheu  7  5  Level of care      BEmOC  10  11      CEmOC  11  9  Sex      Female  11  11      Male  10  9  Cadre      Nurse/midwives  16  18      Medical assistants  2  1      Clinical officers  3  1  Age  mean = 34.7  mean = 36.8  min = 23  min = 25  max = 70  max = 60  Years at current health facility  mean = 3.9  mean = 5.3  min = 1  min = 1  max = 14  max = 14.5  Six major categories of motivational mechanisms emerged from the analysis. The order in which the mechanisms are presented in the following does not reflect their relative importance, but was chosen for efficiency of presentation. Mechanism 1: RBF4MNH motivated health workers by acting as a periodic wake-up call Approximately half of the respondents spoke about how RBF4MNH had opened their eyes to the discrepancies between their day-to-day practice and what they had committed themselves to when joining the health care service. I have seen that previously we were killing our patients. The protocols were there, but we were not following them. (Nurse/midwife, 2014)This realization of the insufficiency of their practice, and the consequences of substandard performance for their patients, boosted health workers’ motivation to improve and step up to their role as health professionals in the future. We used to take some things for granted, like labour graphs not fully filled […]. So when the program rolled out, we were refreshed. It really helped us. (Nurse/midwife, 2014)Respondents mentioned many of the intervention elements as contributing to this ‘wake-up effect’, including initial refresher trainings, periodic performance feedback as part of the verification process, and improved and more frequent supportive supervision. Mechanism 2: RBF4MNH motivated health workers by giving them direction and goals to work towards Several health workers explained that prior to RBF4MNH, their enthusiasm and effort at work had been limited by a lack of focus, direction, and guidance. When I came here, we used to do things routinely, we had no direction. (Nurse/midwife, 2014)About half of the respondents described how RBF4MNH had increased their motivation to work hard by helping them be more focused, purposeful and efficient in their work. Several elements of RBF4MNH had contributed to this. Health workers described how the indicators and targets were constantly present for them, being displayed on the walls and constantly monitored both within facility teams and externally by DHMTs and the PBF verification process. Respondents expressed how this motivated them by serving as a constant reminder of the high quality standards they should strive to attain. [RBF4MNH] acts as a reminder to us that these are the things we are supposed to do as midwives, not necessarily for RBF but just for our patients in general. (Nurse/midwife, 2015)Important to mention in this context is that virtually all respondents strongly endorsed the intervention goals and the indicator set overall due to its perfect alignment with national treatment standards. The best part of it is that there are no new conditions to it. […] RBF4MNH is just coming to polish up things. (Medical assistant, 2014)The presence of work targets seemed to be a welcome challenge and a strong motivator for health workers, even independent of the rewards attached to target attainment. Many respondents described their satisfaction with how RBF4MNH had given them something to focus their effort on and work towards. When you are doing something and you don’t have a target, it’s like you don’t know where you are going, and if you don’t know where to go, it means any road can take you there. So to have targets, it‘s important because all your effort, you will be trying to reach that target. (Clinical officer, 2014)The financial reward attached to target attainment further propelled health workers’ inherent motivation to work hard towards achieving the targets. RBF4MNH not only gave health workers something to work towards, but also helped them develop strategies to reach their targets. Respondents described how RBF4MNH stimulated and allowed them to identify and set priorities in service delivery routines, reflect on and critically evaluate their own performance, identify areas in need of improvement, and develop solutions to challenges. They mentioned several of the intervention elements as important to this effect, including the constant performance feedback introduced by the intervention coupled with enhanced supportive supervision by the DHMT and the RBF4MNH management unit in the MoH (‘RBF4MNH secretariat’). It’s like the facility has been decentralized. Now, you can sit down and discuss, see your own problems and come up with solutions rather than waiting for somebody at the top level to see problems for you, discuss and say we will do this for you. We feel good because we see the problems right away and come up with solutions. And after coming up with solutions, we work according to the problems. So, it’s quite good. (Nurse/midwife, 2014)While generally supportive of the indicators, many respondents were frustrated with how the realities of their working conditions, particularly shortages in staffing and drugs, both beyond health facilities’ control, substantially hindered high levels of achievement. Most health workers expressed acceptance of this situation without apparent negative consequences for their work motivation, being able to focus on learning and small progress rather than on frustrations with non-attainment of targets. If it was not for the issues of staffing level, we would have really made a lot of progress by now. […] But we are far better now. I think we have really made progress. (Nurse/midwife, 2015)A few health workers, however, seemed to struggle with keeping up their motivation to work hard in light of their perceived inability to reach high performance levels. Some of the labour graphs are not filled because of shortage of staff. […] Seeing it clearly that you are losing some money because you did not fill all the partographs […] We feel bad, but we also feel that there is nothing we could do. (Nurse/midwife, 2015) Mechanism 3: RBF4MNH motivated health workers by strengthening their perceived ability to perform successfully in their job, giving them a new sense of accomplishment at work Virtually all respondents described how RBF4MNH had led to positive changes in their working environment. Such changes included improvements in infrastructure, equipment, and availability of material; improved skills due to refresher trainings and better on-the-job-training; improved management support; and—in certain facilities—increases in staffing levels. Many respondents indicated how they had previously often felt helpless and without purpose in a working environment that did not permit them to provide care to their patients in the way they would have wished, necessitating them to constantly improvise and find other ways to cope with client and health system expectations. Respondents described this situation as frustrating, physically and emotionally exhausting, and demotivating. The improved working conditions as a result of RBF4MNH alleviated such previous frustrations for many health workers, allowing them to more effectively translate their skills into practice, fostering feelings of self-efficacy, and making their work life generally easier and more comfortable. Respondents described how their general attitudes and motivation towards their job had improved as a result, and how they were motivated to work even harder towards achieving the PBF targets so that the next reward payment would allow them to improve their workplace even further. I feel very motivated. You know, the environment you work in matters. For instance, if you cannot provide a certain procedure because you lack equipment, you become demotivated. You know you could have helped the woman but you cannot give your best because you don’t have resources to do that. […] But because of the provision of the equipment we are now able to provide most of the services. (Nurse/midwife, 2015) We are being motivated with this RBF4MNH. When we work hard, we achieve the indicators for RBF4MNH, we receive more money, which helps us to buy more equipment for us to make our work easier. (Medical assistant, 2015)Most respondents perceived an increase in the quality of care delivered in their facility as a consequence of these improvements. About a third of respondents reported a perceived decrease in maternal and neonatal mortality and other positive changes in patient outcomes. This reignited a sense of accomplishment which positively impacted their work motivation. It feels very good and it is motivating us to see that we are no longer having maternal deaths or babies dying. (Nurse/midwife, 2014)While the intervention triggered improvements, many respondents made clear that substantial obstacles remained, keeping them from reaching truly high quality standards. Due to the combined effect of closer adherence to treatment protocols and increases in service utilization as a result of RBF4MNH, workload and resource consumption increased in many facilities. Respondents reported that this increase in workload and resource requirements—beyond already challenging pre-intervention levels—was not adequately met by improvements in staffing levels and resource availability. For a few respondents, this aggravated feelings of overburden and reduced self-efficacy rather than improved their perceived ability to provide care. Patients are not getting the care that they are supposed to get because of the workload. […] I feel that I am not delivering. I am not doing what I promised as a nurse that I will be doing. […] I feel as a failure. (Nurse/midwife, 2015)In general, health workers appeared torn between their need for rest and comfort at work, and their inherent desire to serve all patients in need and the joy of being better able to do so with RBF4MNH. For most respondents, the ability to serve more patients and provide better care outweighed the workload and fatigue associated with it. RBF4MNH brings a lot of workload but we are happy because we are improving the livelihood of women and children. (Medical assistant, 2014)In year 2, respondents were more critical due to additionally allocated staff leaving again and a general worsening of the resource situation in the health system. Mechanism 4: RBF4MNH motivated health workers by instilling feelings of recognition and appreciation of their effort About one-third of the respondents spoke about how the more frequent, intensive and tailored supervision and support by the DHMT and RBF4MNH secretariat made them feel more visible and appreciated in their contribution to the health system, including their effort and performance under difficult working conditions. In the past, you could do something good, nobody noticed. Now with this RBF4MNH, you are recognized that you have done something good. People can see that, ah, this man is working. (Nurse/midwife, 2014)A few respondents explicitly described how the financial rewards provided by RBF4MNH served as an expression or symbol of this enhanced recognition. When we are receiving this it’s like just like a congratulations to say carry on what you learned in school. (Nurse/midwife, 2015)Although the majority of respondents described positive ‘net’ changes in perceived recognition and appreciation and felt motivated by them, almost all also mentioned how implementation-related challenges attenuated these increases. Particularly in the first-year peer-to-peer verification model, many health workers felt unfairly evaluated by the verification teams. While most respondents stated that this perceived unfairness did not impact their work motivation much, five respondents described how it made them feel unappreciated rather than appreciated, demotivating rather than motivating them. It’s unfair. We work hard towards achieving these things, and then somebody just comes and says you didn’t do this, and yet the things were there. (Nurse/midwife, 2015)About one-third of the sample felt that the effort they made in the context of the intervention was not adequately reciprocated by RBF4MNH secretariat and DHMTs. For instance, they were frustrated with delays in various activities (infrastructure upgrade, verification) incurred by the RBF4MNH secretariat. Respondents further reported that DHMTs coped with the overall declining resource situation in the system by prioritizing non-RBF4MNH facilities in their resource allocation, effectively withdrawing support from RBF4MNH facilities and expecting them to support themselves with their RBF4MNH funds. A few respondents experienced this situation as a sign of disrespect, demotivating rather than motivating them. I feel like the District Health Officer has run away from his responsibilities because of the RBF4MNH. […] Sometimes I feel bad about it. (Medical assistant, 2015) It was a setback. Working with the intention that somebody will come to supervise your work, only to realize that they don’t come, you feel like, ahh, then I just worked for nothing? […] We wonder, up to this time they still have all those challenges, so I feel like [the RBF4MNH secretariat] somehow is not much serious. (Nurse/midwife, 2015)Finally, eight respondents indicated feeling disrespected by an intervention which they perceived as trying to improve health care coverage at all costs without adequate consideration of health workers’ constrained working conditions. This dampened their motivation to make an effort in the context of the intervention. Honestly, I feel like the project is there to bring a burden on us. They are just trying to get more customers in, but the staff and resources to attend to those customers are few. […] You know, as humans, sometimes emotions come in. So you may feel like you have been abused. (Nurse/midwife, 2015) Mechanism 5: RBF4MNH motivated health workers to improve their performance by altering social dynamics About half of the respondents described changes within their work teams and beyond which had in one way or another impacted their work motivation. Between districts and health facilities within districts, RBF4MNH triggered a mostly healthy sense of competition, the desire to be the best and outperform the others motivating health workers to work hard and improve their performance. Everybody is trying hard so that you win. This time you came number three, you want to be number two, the next time you want to be number one. (Nurse/midwife, 2014)Within health facilities, the desire to do well in RBF4MNH brought teams closer together as they worked towards this common objective. Respondents described this new team spirit and sense of coherence and cooperation as very positive and motivating. I’m very happy because things have changed drastically. […] Now we are working towards one goal and that is giving better services to our patients. (Medical assistant, 2014)At the same time, respondents acknowledged that RBF4MNH subjected them to additional pressure to perform up to standard from colleagues, managers, RBF4MNH secretariat, clients and other health system actors. Most respondents perceived this additional pressure as a positive and helpful motivation rather than as overly stressful and controlling. We have really changed. People are serious when doing their work because they know at the end of the day, somebody will ask:"Why didn’t you do this?" (Nurse/midwife, 2014)The above-mentioned high level of endorsement of the intervention, specifically the understanding that RBF4MNH only reinforces preexisting work responsibilities, seemed very important in this regard. With RBF4MNH, we are forced, I shouldn’t say forced, but we are being directed to do what we are supposed to do, what is required of us as nurses. (Nurse/midwife, 2015)While none of the respondents explicitly spoke about the additional social pressure as overburdening for them personally, several implied unfavourable motivational consequences for colleagues. Specifically, they described how certain coworkers would document in partographs even if they had not performed a service, so as not to appear low-performing and responsible for the team losing out on PBF rewards. People would still paint the picture to show that they had worked. But you will sometimes find that the care that is documented is not the care that was given to the patient. (Nurse/midwife, 2015)Although conducive to team spirit on the one hand, respondents described that RBF4MNH also introduced new interpersonal challenges, particularly between clinical and non-clinical staff. In many facilities, the autonomy in sharing the staff portion of the rewards led to substantial conflict as individuals or staff groups were dissatisfied with their share, which significantly dampened many respondents’ enthusiasm about the intervention and motivation to make an effort. Almost everybody called for fixed guidelines on how to share rewards to prevent further conflict. This RBF4MNH, it is bringing us together, but it is also driving us apart. (Nurse/midwife, 2015) Nurses who are putting direct impact towards implementation of the project are always disappointed or get setbacks. ′Why should I put all effort?′. Then at the end of the day, if you realize more, you still have equal shares with those colleagues who did not even put a direct impact. Aaah, then maybe […] I should better not put much effort towards implementing this. (Nurse/midwife, 2015) Mechanism 6: RBF4MNH motivated health workers to work hard by offering a ‘nice to have’ opportunity to earn extra income to improve their lifestyle Almost all respondents were appreciative of this opportunity. Only five respondents described the individual rewards as something they seriously and actively focused on and worked towards, however. We are human and become motivated when we see that there will be a reward, and you turn to work extra hard. (Medical assistant, 2014)The vast majority of respondents welcomed the additional income and felt encouraged to perform well by it, but at the same time made clear that the individual rewards were not the central motivating element of RBF4MNH for them, stressing that the improvements in the physical and interpersonal working environment are where the intervention really made a difference. Personally, the incentives are just an addition, but my spirit is to help people. Nursing is a calling, so incentives, no incentives, I do my work the same. But the money is good because it is not only given to the health workers, but it also assists the facility as a whole. (Nurse/midwife, 2014)Many qualified their generally positive feelings about the individual rewards by describing their wariness of the above-mentioned interpersonal conflict introduced by the incentives. Several respondents did not feel that their share of the staff portion was an adequate reflection of their contribution to their facilities’ performance in RBF4MNH, which they described as discouraging. Some health workers explained that the overall individual reward amount was too little to act as a real motivator, particularly at district hospital level where the large staff numbers led to many staff members only receiving very small absolute amounts. Seven respondents, all but one from district hospitals, stated that for them, these issues overshadowed positive aspects of the individual rewards to the extent that they acted as a demotivator rather than a motivator. With the [current] economy in Malawi, someone cannot motivate me with 7.600 Kwacha [≈USD 22.30] in six months.[…] But it is psychological torture to be told to work extra hard for something and that something is almost nothing. (Clinical officer, 2014) I would just make sure that there are enough resources, but incentives to the staff, I wouldn’t do that because I can see now it causes people to argue a lot because of the money. (Nurse/midwife, 2015) Discussion This study explored the mechanisms through which RBF4MNH in Malawi motivated health workers to perform better in their jobs. Our findings contribute to closing the important knowledge gap on the exact ‘how’ and ‘why’ PBF does or does not lead to health worker behaviour change and ultimately to more readily available and better health care services (Lohmann et al. 2016; Renmans et al. 2016). Our findings strongly support the notion that PBF motivates health workers with much more than the prospect of earning extra income, similar to what previous studies have suggested (see Table 3). We identified six major categories of motivational mechanisms, three of which were not directly related to the individual financial rewards. As observed in other countries (Renmans et al. 2016), perceived weaknesses of the intervention design, various implementation-related challenges, as well as contextual constraints fully or in part inhibited the activation of certain mechanisms for many respondents, keeping RBF4MNH from developing its full motivating potential. Table 3 Overview of RBF4MNH’s motivational mechanisms, contributory elements, challenges and previous studies with similar results Mechanism: RBF4MNH motivated health workers  Relation to individual rewards  Contributory PBF elements  Challenges  Previous research reporting similar findings  1  By acting as a periodic wake-up call to deficiencies in their day-to-day practice  Unrelated  Initial refresher trainings; improved performance feedback as part of the verification process and the improved supervision    Bertone et al. (2016) (Sierra Leone); Bhatnagar and George (2016) (Nigeria)  2  By providing direction and goals to work towards  Indirectly related  Performance targets; performance verification and feedback; improved supportive supervision; facility and individual rewards  Overly challenging targets; contextual constraints  Kalk et al. (2010) (Rwanda); Paul et al. (2014) (Benin)  3  By strengthening perceived ability to perform successfully at work and triggering a sense of accomplishment  Indirectly related  Initial refresher trainings; start-up support (infrastructure, equipment, staff); improved supportive supervision; facility rewards; CCT component  Improvements in the working environment inadequate in light of increased work demands  Bertone et al. (2016) (Sierra Leone); Kalk et al. (2010) (Rwanda); Paul et al. (2014) (Benin); Shen et al. (2017) (Zambia)  4  By instilling feelings of recognition  Directly related  Performance verification; improved supervision; facility and individual rewards  Perceived lack in fairness and reciprocity  Bhatnagar and George (2016) (Nigeria); Chimhutu et al. (2016) (Tanzania); Paul et al. (2014) (Benin);  5  By altering social dynamics, improving team work towards a common goal, but also introducing social pressure  Directly related  Performance targets; performance verification and feedback; facility and individual rewards  Within-team pressure to perform incentivizes undesired behaviour; conflict linked to distribution of individual rewards  Chimhutu et al. (2016) (Tanzania)  6  By offering a ‘nice to have’ opportunity to earn extra income  Directly related  Individual rewards  Low absolute/inadequate-to-effort amounts, particularly at health facilities with many staff; conflict linked to distribution of individual rewards  Bertone et al. (2016) (Sierra Leone); Bhatnagar and George (2016) (Nigeria); Chimhutu et al. (2016) (Tanzania); Paul et al. (2014) (Benin)  Mechanism: RBF4MNH motivated health workers  Relation to individual rewards  Contributory PBF elements  Challenges  Previous research reporting similar findings  1  By acting as a periodic wake-up call to deficiencies in their day-to-day practice  Unrelated  Initial refresher trainings; improved performance feedback as part of the verification process and the improved supervision    Bertone et al. (2016) (Sierra Leone); Bhatnagar and George (2016) (Nigeria)  2  By providing direction and goals to work towards  Indirectly related  Performance targets; performance verification and feedback; improved supportive supervision; facility and individual rewards  Overly challenging targets; contextual constraints  Kalk et al. (2010) (Rwanda); Paul et al. (2014) (Benin)  3  By strengthening perceived ability to perform successfully at work and triggering a sense of accomplishment  Indirectly related  Initial refresher trainings; start-up support (infrastructure, equipment, staff); improved supportive supervision; facility rewards; CCT component  Improvements in the working environment inadequate in light of increased work demands  Bertone et al. (2016) (Sierra Leone); Kalk et al. (2010) (Rwanda); Paul et al. (2014) (Benin); Shen et al. (2017) (Zambia)  4  By instilling feelings of recognition  Directly related  Performance verification; improved supervision; facility and individual rewards  Perceived lack in fairness and reciprocity  Bhatnagar and George (2016) (Nigeria); Chimhutu et al. (2016) (Tanzania); Paul et al. (2014) (Benin);  5  By altering social dynamics, improving team work towards a common goal, but also introducing social pressure  Directly related  Performance targets; performance verification and feedback; facility and individual rewards  Within-team pressure to perform incentivizes undesired behaviour; conflict linked to distribution of individual rewards  Chimhutu et al. (2016) (Tanzania)  6  By offering a ‘nice to have’ opportunity to earn extra income  Directly related  Individual rewards  Low absolute/inadequate-to-effort amounts, particularly at health facilities with many staff; conflict linked to distribution of individual rewards  Bertone et al. (2016) (Sierra Leone); Bhatnagar and George (2016) (Nigeria); Chimhutu et al. (2016) (Tanzania); Paul et al. (2014) (Benin)  In speaking about perceived changes in motivation, respondents described two different types of motivation. On the one hand, RBF4MNH appeared to have fostered specific motivation related to the targets incentivized by RBF4MNH. In an intervention targeting only a subset of services, this bears a risk of neglect of other services, referred to as ‘gaming’ in the PBF literature and observed in other PBF schemes (e.g. Kalk et al. 2010 in Rwanda, Chimhutu et al. 2014 in Tanzania). We did not specifically address gaming in our study. On the other hand, respondents made clear that RBF4MNH also affected their general motivation to work hard and perform well, beyond the specific services incentivized by PBF. Mechanisms 1, 3 and 4 played a particularly important role in fostering not only PBF-specific, but also general work motivation. Our results suggest that while all mechanisms were ‘pieces of the puzzle’, the increased perceived ability to perform successfully in the job and the new sense of accomplishment and purpose at work was where RBF4MNH had the most significant motivational impact for the respondents. Many respondents stressed their dedication to their profession and their innate desire to serve their patients well. Previous research has found challenging working conditions prohibiting the translation of this desire into practice a main demotivator for Malawian health workers (Manafa et al. 2009; Chimwaza et al. 2014). It is therefore not surprising that respondents felt strongly motivated by an alleviation of this demotivating situation. In this context, it is important to recall that the intensive start-up support made an important contribution to the positive changes in working conditions and went far beyond what would have been achievable with PBF rewards alone. However, favourable changes in the working environment emerged as a key contributor to changes in motivation in other PBF schemes as well, for instance in Nigeria (Bhatnagar and George 2016) and Sierra Leone (Bertone et al. 2016). In contrast, the individual rewards appeared to have a relatively weak motivational effect. Considering the importance attributed to them in the PBF discourse (Renmans et al. 2017), this is somewhat surprising, although not entirely unexpected based on previous research (Kalk et al. 2010; Paul et al. 2014; Bertone et al. 2016; Chimhutu et al. 2016; Shen et al. 2017). Their relative ineffectiveness can at least in part be explained by the diverse frustrations associated with them. RBF4MNH does not seem to be a singular case in this regard. Chimhutu et al. (2016) for instance described how in Tanzania, unfairness perceptions regarding the reward distribution process severely affected motivation and undermined social relationships. This raises the question as to whether performance-conditional rewards were really necessary, or whether otherwise effected improvements of working conditions might have achieved similar results, as some previous studies have implied (e.g. Shen et al. 2017). Our research design clearly does not allow for a conclusive answer to this question. However, our findings do indicate that the performance-conditionality of the additional resource inputs magnified motivational effects beyond what might have been achieved by unconditional inputs and isolated improvements of health systems functions. Specifically, some health workers reported to be motivated to work as hard as possible to maximize what their facility could gain in PBF rewards so as to be able to further improve their working conditions as much as possible. Performance-conditionality of rewards at the facility level thus appeared valuable, but the RBF4MNH experience calls into question the value of the individual reward component. Important in this context is that the relative contribution of PBF rewards to individual overall income appeared relatively low in international comparison (Table 1). Many health workers expressed their displeasure about the overall amounts which they found too small to have a serious motivating effect. Higher individual reward amounts might have been more powerful, although similar dissatisfaction has been documented in countries with higher amounts as well (e.g. Burundi, Pakistan, Tanzania). In interpreting the results, it is important to underline that our findings represent solely the experiences of clinical healthcare personnel, and at hospital level only from the maternity department. Other staff groups had much less positive motivational reactions to RBF4MNH. Further, we only interviewed health workers in intervention facilities. Although we probed respondents carefully for attribution of changes to RBF4MNH as opposed to other factors, the distinction was sometimes difficult. Interviews with health workers from non-intervention facilities would have helped to disentangle the motivational effects of PBF from the effects of PBF-unrelated changes in the health system. Third, most respondents wished for the intervention to continue despite the various challenges, and were therefore likely interested in portraying the intervention and its motivational effects positively. Although we do not believe that this affected our mapping of motivational effects in the sense that we missed important aspects, our findings might be slightly biased towards the positive. In judging the transferability of our findings, it is important to take into account that Malawi faced severe challenges in regards to most routine health systems functions pre-PBF, and continued to do so throughout the implementation period. Much of the motivational effect of RBF4MNH seems attributable to reinstating or reinforcing such health systems functions, and thus removing or alleviating previous demotivators. Our findings also need to be considered in light of the unusual PBF design based on target attainment rather than a quality-adjusted fees-for-service and including unconditional start-up support as well as CCTs. Health workers in contexts with a different PBF design or a less challenging pre-PBF situation might perceive a different relative importance of the mechanisms, or experience mechanisms that did not emerge in Malawi. Conclusion We conclude that PBF is clearly more than just ‘monetary carrots and sticks’, involving multiple motivational mechanisms that are closely, distantly, or not at all related to the individual reward payments. Health workers were particularly motivated by positive changes in their working environment, enabling them to more effectively translate their skills and desire to help their patients into practice. The individual rewards played a comparatively small role. Funding This work was funded by the United States Agency for International Development under Translating Research into Action [Cooperative Agreement No. GHS-A-00-09-00015-00]. This study is made possible by the support of the American People through the United States Agency for International Development (USAID). The study was further supported by the Norwegian Agency for Development Cooperation (NORAD) and by the Royal Norwegian Embassy in Lilongwe. The findings of this study are the sole responsibility of research teams at the University of Heidelberg and the College of Medicine of the University of Malawi and do not necessarily reflect the views of USAID, the United States Government, NORAD or the Royal Norwegian Embassy in Lilongwe. Ethical approval Ethical approval was granted by the Ethical Commission of the Medical Faculty of Heidelberg University, Germany (protocol S-256/2012) and the University of Malawi College of Medicine Research and Ethics Committee (protocol P.02/13/1338). We sought permission from MoH and DHMTs before data collection. All respondents gave their informed consent before being interviewed. Conflict of interest statement. None declared. References Basinga P, Gertler PJ, Binagwaho A, Soucat AL, Sturdy J, Vermeersch CM. 2011. Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet  377: 1421– 8. 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Health Policy and PlanningOxford University Press

Published: Mar 1, 2018

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