School of Public Health, University of Montreal, Montreal, QC, Canada.
Heidelberg Institute of Global Health, Faculty of Medicine, Heidelberg University, Heidelberg, Germany.
Int J Health Policy Manag. 2019 May 1;8(5):272-279. doi: 10.15171/ijhpm.2018.133.
BACKGROUND: Performance-based financing (PBF) is currently tested in many low- and middle-income countries as a health system strengthening strategy. One of the main mechanisms through which PBF is assumed to effect change is by motivating health workers to improve their service delivery performance. This article aims at a better understanding of such motivational effects of PBF. In particular, the study focused on organizational context factors and health workers' perceptions thereof as moderators of the motivational effects of PBF, which to date has been little explored. METHODS: We conducted a multiple case study in 2 district hospitals and 16 primary health facilities across three districts. Health facilities were purposely sampled according to pre-PBF performance levels. Within sampled facilities, 82 clinical skilled healthcare workers were in-depth interviewed one year after the start of the PBF intervention. Data were analyzed using a blended deductive and inductive process, using self-determination theory (SDT) as an analytical framework. RESULTS: Results show that the extent to which PBF contributed to positive, sustainable forms of motivation depended on the "ground upon which PBF fell," beyond health workers' individual personalities and disposition. In particular, health workers described three aspects of the organizational context in which PBF was implemented: the extent to which existing hierarchies fostered as opposed to hindered participation and transparency; managers' handling of the increased performance feedback inherent in PBF; and facility's pre-PBF levels in regards to infrastructure, equipment, and human resources. CONCLUSION: Our results underline the importance of leadership styles and pre-implementation performance levels in shaping health workers' motivational reactions to PBF. Ancillary interventions aimed at fostering participatory as opposed to directional leadership or start-up support to low-performing health facilities will likely boost PBF effects in regards to the development of valuable motivational capacities.
背景：绩效激励型支付（PBF）目前在许多中低收入国家作为一项加强卫生系统的战略正在进行测试。PBF 被认为可以通过激励卫生工作者提高服务提供绩效来实现改变的主要机制之一。本文旨在更深入地了解 PBF 的这种激励效应。特别是，该研究侧重于组织背景因素和卫生工作者对这些因素的看法，作为 PBF 激励效应的调节因素，而这一点迄今为止还很少被探讨。
方法：我们在三个地区的 2 家区医院和 16 家基层卫生机构进行了一项多案例研究。根据 PBF 实施前的绩效水平，有针对性地对卫生机构进行了抽样。在抽样的医疗机构中，在 PBF 干预开始一年后对 82 名临床熟练医护人员进行了深入访谈。数据分析采用了演绎和归纳相结合的混合方法，以自我决定理论（SDT）为分析框架。
结果：结果表明，PBF 对积极、可持续的激励形式的贡献程度取决于“PBF 落地的基础”，而不仅仅是卫生工作者的个人性格和倾向。具体而言，卫生工作者描述了 PBF 实施的组织背景的三个方面：现有层级结构在促进还是阻碍参与和透明度方面的程度；管理者对 PBF 固有的绩效反馈增加的处理方式；以及医疗机构在基础设施、设备和人力资源方面实施 PBF 之前的水平。
结论：我们的研究结果强调了领导风格和实施前的绩效水平在塑造卫生工作者对 PBF 的激励反应方面的重要性。旨在培养参与式而不是指导性领导风格或为低绩效卫生机构提供启动支持的辅助干预措施，可能会增强 PBF 在发展有价值的激励能力方面的效果。
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