Centre for International Health, University of Bergen, P.O. Box 7804, Bergen 5020, Norway.
Global Health. 2012 Sep 10;8:33. doi: 10.1186/1744-8603-8-33.
Health workers' motivation is a key determinant of the quality of health services, and poor motivation has been found to be an obstacle to service delivery in many low-income countries. In order to increase the quality of service delivery in the public sector in Tanzania, the Open Performance Review and Appraisal System (OPRAS) has been implemented, and a new results-based payment system, Payment for performance (P4P) is introduced in the health sector. This article addresses health workers' experiences with OPRAS, expectations towards P4P and how lessons learned from OPRAS can assist in the implementation of P4P. The broader aim is to generate knowledge on health workers' motivation in low-income contexts.
A qualitative study design has been employed to elicit data on health worker motivation at a general level and in relation to OPRAS and P4P in particular. Focus group discussions (FGDs) and in-depth interviews (IDIs) have been conducted with nursing staff, clinicians and administrators in the public health sector in a rural district in Tanzania. The study has an ethnographic backdrop based on earlier long-term fieldwork in Tanzania.
Health workers evaluated OPRAS and P4P in terms of the benefits experienced or expected from complying with the tools. The study found a general reluctance towards OPRAS as health workers did not see OPRAS as leading to financial gains nor did it provide feedback on performance. Great expectations were expressed towards P4P due to its prospects of topping up salaries, but the links between the two performance enhancing tools were unclear.
Health workers respond to performance enhancing tools based on whether the tools are found appropriate or yield any tangible benefits. The importance placed on salary and allowances forms the setting in which OPRAS operates. The expected addition to the salary through P4P has created a vigorous discourse among health workers attesting to the importance of the salary for motivation. Lessons learned from OPRAS can be utilized in the implementation of P4P and can enhance our knowledge on motivation and performance in the health services in low-income contexts such as Tanzania.
卫生工作者的激励是医疗服务质量的关键决定因素，在许多低收入国家，激励不足被发现是服务提供的障碍。为了提高坦桑尼亚公共部门的服务质量，已经实施了公开绩效审查和评估系统（OPRAS），并在卫生部门引入了新的基于成果的支付系统，即绩效支付（P4P）。本文探讨了卫生工作者对 OPRAS 的体验、对 P4P 的期望，以及从 OPRAS 中吸取的经验教训如何有助于 P4P 的实施。更广泛的目标是在低收入背景下生成有关卫生工作者激励的知识。
采用定性研究设计，从一般层面以及特别是 OPRAS 和 P4P 方面，收集卫生工作者激励方面的数据。在坦桑尼亚农村地区的公共卫生部门，对护理人员、临床医生和管理人员进行了焦点小组讨论（FGD）和深入访谈（IDI）。该研究基于在坦桑尼亚的早期长期实地工作，具有民族志背景。
卫生工作者根据遵守这些工具所带来的已体验到或预期的好处来评估 OPRAS 和 P4P。研究发现，卫生工作者普遍不愿意接受 OPRAS，因为他们认为 OPRAS 不会带来经济收益，也不会提供绩效反馈。由于 P4P 有望增加工资，他们对 P4P 寄予厚望，但这两种提高绩效的工具之间的联系尚不清楚。
卫生工作者根据工具是否合适或是否产生任何实际收益来回应提高绩效的工具。对工资和津贴的重视构成了 OPRAS 运作的背景。通过 P4P 增加工资的预期，引起了卫生工作者的激烈讨论，证明了工资对激励的重要性。从 OPRAS 中吸取的经验教训可用于 P4P 的实施，并增强我们在像坦桑尼亚这样的低收入环境中对卫生服务的激励和绩效的知识。
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