London School of Hygiene & Tropical Medicine, London, UK.
Institute of Global Health, Heidelberg University Hospital and Medical Faculty, Heidelberg, Germany.
Int J Health Policy Manag. 2021 Aug 1;10(8):483-494. doi: 10.34172/ijhpm.2020.61.
Evidence emerging from qualitative studies suggests the existence of substantial variation in how health workers experience performance-based financing (PBF) within the same setting. To date, however, no study has quantified or systematically explored this within-setting heterogeneity. Considering that differences in health workers' affective reactions to PBF likely constitute an important element mediating the effectiveness of PBF in improving health service delivery, systematic and tangible information will be highly valuable to policy-makers and program managers who aim to maximize positive impacts of PBF. Our study aimed at contributing to filling this gap in knowledge by quantifying health workers' knowledge of, satisfaction with, and perceptions of PBF in Burkina Faso, and exploring factors associated with heterogeneity therein.
The study employed a post-intervention cross-sectional explanatory mixed methods study design with a dominant quantitative component - a structured survey to a total of 1314 health workers from 396 intervention health facilities - and a small and focused qualitative component - key informant interviews with 5 program managers - to triangulate and further elucidate the quantitative findings. Quantitative data were analyzed descriptively as well as using 3-level mixed-effects models. Qualitative data were analyzed in a largely deductive process along the quantitative variables and results.
Health workers were on average moderately satisfied with PBF overall, with a slight tendency towards the positive and large variation between individuals. Two-thirds of health workers did not have adequate basic knowledge of key PBF elements. Perceived fairness of the performance evaluation process, of the bonus distribution process, and satisfaction with the individual financial bonuses varied dramatically between respondents. Factors associated with heterogeneity in knowledge, satisfaction, and fairness perceptions included responsibility at the facility, general work attitudes, management factors, and training in and length of exposure to PBF.
Findings imply that investments into staff training on PBF and manager training on organizational change processes might be beneficial to positive staff attitudes towards PBF, which in turn would likely contribute to improving the effectiveness of PBF.
来自定性研究的证据表明，在同一环境中，卫生工作者对基于绩效的融资（PBF）的体验存在很大差异。然而，迄今为止，尚无研究对这种环境内异质性进行量化或系统探索。考虑到卫生工作者对 PBF 的情感反应差异可能构成影响 PBF 改善卫生服务提供效果的一个重要因素，为政策制定者和项目管理者提供系统且切实的信息将具有很高的价值，他们旨在最大限度地提高 PBF 的积极影响。我们的研究旨在通过量化布基纳法索卫生工作者对 PBF 的了解、满意度和看法，并探索其中存在差异的相关因素，为填补这一知识空白做出贡献。
该研究采用了一种干预后横截面解释性混合方法研究设计，其中主要部分是定量部分，即对来自 396 个干预卫生机构的 1314 名卫生工作者进行的一项结构化调查，以及一个小型而重点突出的定性部分，即对 5 名项目管理者进行的关键知情人访谈，以对定量结果进行三角剖分和进一步阐明。定量数据进行了描述性分析以及使用 3 级混合效应模型进行了分析。定性数据主要按照定量变量和结果进行演绎式分析。
卫生工作者对 PBF 的总体满意度中等偏上，略有积极倾向，个体之间差异较大。三分之二的卫生工作者对关键 PBF 要素没有足够的基本了解。绩效评估过程、奖金分配过程的公平性以及对个人奖金的满意度在受访者之间存在显著差异。与知识、满意度和公平感异质性相关的因素包括机构责任、一般工作态度、管理因素以及 PBF 的培训和接触时间。
研究结果表明，对 PBF 员工培训和管理人员组织变革培训的投资可能有助于提高员工对 PBF 的积极态度，这反过来可能有助于提高 PBF 的有效性。
