Does the gap between health workers’ expectations and the realities of implementing a Performance-Based Financing project in Mali create frustration?

doi:10.21203/rs.3.rs-54170/v3

Download PDF

Research

Does the gap between health workers’ expectations and the realities of implementing a Performance-Based Financing project in Mali create frustration?

https://doi.org/10.21203/rs.3.rs-54170/v3

This work is licensed under a CC BY 4.0 License

Journal Publication

published 02 Feb, 2021

Read the published version in Global Health Research and Policy →

You are reading this older preprint version

Read the latest preprint version →

Background: Low-and middle-income countries (LMICs) have seen a shift in the health financing architecture in recent years, particularly in Africa. Performance-Based Financing (PBF) is one of these recent initiatives. Motivating health workers is one of the mechanisms through which PBF is assumed to improve the quality of care. Our study therefore offers a unique opportunity to identify and understand how health workers’ expectations related to their experiences of the first cycle of payment of PBF subsidies, and how this affected their motivation and sentiments towards the intervention.

Methods: We adopted a qualitative approach using multiple case studies. For our study, we chose three district hospitals (DH 1, 2 and 3) in three health districts (district 1, 2 and 3) among the ten in the Koulikoro region. Our cases correspond to the three DHs. We followed the principle of data source triangulation. The different data sources used are: 53 semi-directive interviews conducted with health workers, following the principle of saturation; field notes and documents relating to the distribution grids of subsidies for each DH. Data was analyzed in a mixed deductive and inductive manner.

Results: The results show that the PBF subsidies led to health workers feeling more motivated to perform their tasks overall. Beyond financial motivation, this was primarily due to PBF allowing them to work better. However, respondents perceived a discrepancy between the efforts made and the subsidies received. The fact that their expectations were not met led to a sense of frustration and disappointment. Similarly, the way in which the subsidies were distributed and the lack of transparency in the distribution process led to feelings of unfairness among the vast majority of respondents. The results show that frustrations can build up in the early days of the intervention.

Conclusion: The PBF implementation in Mali left health workers frustrated. The short overall implementation period did not allow actors to adjust their initial expectations and motivational responses, neither positive nor negative. This underlines how short-term interventions might not just lack impact, but instil negative sentiments likely to carry on into the future.

Health Policy

Motivation of health workers

Performance-Based Financing

district hospital

expectations

Frustration

Mali

The performance of health workers is a determining factor in the provision of health care. It influences the quality of the health services offered and the level of health of the population [1; 2]. Several factors influence the performance of health workers in low- and middle-income countries (LMICs): financial and non-financial incentives, career development, continuing education, the state of infrastructure, the availability of human and material resources, the management and leadership skills of managers, and job satisfaction [3].

Despite the fact that motivation is one of the key factors in job performance, it remains a challenge in LMICs. There are several theories about motivation at work [4;5]. Ryan and Deci define motivation as the drive or energy to act towards an objective [6]. In Mali, the Ministry of Health postulates that health workers working in the public system are very poorly motivated, regardless of whether they work in rural or urban areas [7]. Reasons for their lack of motivation are diverse: insufficient remuneration, poor physical working conditions, lack of professional training, lack of consideration, and poor organization and distribution of work [7;8].

In LMICs, several pilot projects of performance-based financing (PBF) have been implemented with the aim of improving health service provision. One assumed mechanisms is that by linking financial rewards to predefined performance objectives, health workers would be more motivated to perform well [9]. Over the past several years, the architecture of health financing in LMICs has evolved significantly in Africa [10;11], with PBF being one of the most important, but not the only new introduction to the health financing landscape. Theoretically, the PBF aims to strengthen the capacity of health systems in a sustainable manner. However, in reality this is not always the case [12;13]. Many initiatives financed by international donors are short-term interventions with the desire to have a rapid impact to the detriment of medium- and long-term interventions [10;14;15].

A number of studies have looked into the effects of PBF on health worker motivation in Africa [12;16;17;18;19;20]. However, there is not yet scientific consensus on these effects, neither on their direction and strength, nor their exact mechanisms, nor on developments over time [20;21;22;23;24;25]. In regards to the latter, the majority of existing studies were carried out fairly long after the start of implementation (12 months in Burkina Faso, [17], 18 months in Nigeria [26], 24 months in Malawi [20]). Studies suggest that the initial months of implementation were particularly crucial in shaping expectations and sentiments towards PBF that would carry through the entire implementation period. However, the long recall periods over an extensive implementation period likely distorted memories particularly in relation to the early implementation days.

To our knowledge, in Africa, the gap between what health workers expect from the PBF and the reality is very little studied, especially in relation to the early days of implementation. In Mali, PBF was only implemented for eight months in total. Our study therefore offers a unique opportunity to identify and understand how health workers’ expectations related to their experiences of the first cycle of payment of PBF subsidies, and how this affected their motivation and sentiments towards the intervention.

Study setting

Mali is a country in West Africa with an estimated population of 19 658 031 inhabitants in 2019 [27]. It is subdivided into eight regions and the district of Bamako. In 2012, the country experienced a political, security and institutional crisis following the occupation of the northern regions by armed groups, and the coup d’état of March 22 [28].

Description of the PBF intervention in Mali

A PBF pilot project took place in ten health districts in Mali’s Koulikoro region between June 2016 and February 2017, as one of the sub-components of the Ministry of Health’s Strengthening Reproductive Health Project, funded by the World Bank. This project supports the strengthening of the health system through three components: (i) strengthening the supply and quality of reproductive health services, (ii) increasing the demand for reproductive health services, and (iii) strengthening social responsibility, project management, and monitoring-evaluation.

The objective of the pilot PBF project nested within this overall project was to increase the use of quality reproductive health services by increasing the motivation, responsibility, and accountability of service providers to achieve results [29]. For the implementation of the project, the Ministry of Health entered into a service contract with a specialized PBF agency, referred to as the Consortium (Royal Tropical Institute, Clinique de Gestion et d'Innovation des Connaissances, and Cordaid). Initially, the project was planned for two years [30]. For politico-administrative reasons, however, it ultimately only ran for eight months. Several activities were carried out during its short implementation: training of actors, development of results plans, signing of contracts, production of results by health centers, reporting, and verification of results in terms of quantity and quality of care, community verification, measurement of user satisfaction, and payment for results of one three-month cycle [31].

Mali's health system is pyramidal at three levels (peripheral, intermediate, and central). At the central level, there are national hospitals and university hospitals. At the intermediate level are reference health centers (Centre de santé de reference [CSRéf]) or district hospitals (DH). At peripheral level, community health centres (Centres de santé communautaires [CSCom]) provide primary-level care. This PBF pilot project concerned only DHs and community health centres in the Koulikoro region. The DHs and community health centres were to be paid on the basis of results concerning reproductive health indicators (family planning, delivery by qualified personnel, pre- and post-natal care) [29]. Verification of results in terms of quantity and quality to enable the payment of subsidies (which is the term locally used for the PBF payment, synonymous to incentives or bonuses) were supposed to be carried out on a monthly basis. However, this schedule was not adhered to in practice, with verification activities delayed by five to six months depending on the hospital. Community verification (CV) was carried out by local NGOs in the last month of implementation (February 2017), and factored into the one payment made into facilities’ bank accounts in February 2017.

In the DHs, at least 40% of the total amount of subsidies was reserved for investments and purchase of equipment, and a maximum of 60% could be used as individual subsidies for health workers. In community health centres, at least 60% of the total subsidies had to be invested or used for purchasing equipment, and 40% could be used as individual subsidies for health workers.

In regards to the latter, a fixed portion of 28% was to be distributed according to the socio-professional category of the health workers, and a variable portion of 72% according to individual performance over a three-month period [32]. The calculation of the performance percentage is made on the basis of the tasks recorded in each individual’s engagement form [32]. The fixed portion was calculated on the basis of each health workers’ salary category. For health workers whose wages were lower than the guaranteed minimum interprofessional wage, the amount was calculated by dividing the net monthly wage by an index value of 335 CFA francs (US $0.56) [32]. PBF provided an excel spreadsheet to facilitate calculation of the total amounts to be received by each facility staff.

Important discrepancies existed between what was foreseen at the outset of implementation and stipulated in the procedures manual and what was actually implemented. Most importantly, only one cycle (3 months) of service purchasing (incl. verification and payment) was completed during the eight months of implementation while two cycles were planned.

Study design

We adopted a qualitative approach, based on an estimate of multiple case studies [33]. Our study is part of a larger research program in the context of which the cases were selected. For our study, we chose three DHs (DH 1, 2 and 3) in three health districts (district 1, 2 and 3) among the ten in the Koulikoro region. Our cases correspond to the three DHs. District 1 has a more rural character, and had participated in the PBF pre-pilot project from February 2012 to December 2013, unlike districts 2 and 3. District 2 was chosen because it is more urban than the other two districts. District 3 was selected because it was envisioned to link PBF with the community-based health insurance existing in this district. These numbers of cases take into account our resource constraints, but provide sufficient representation of the diversity of contextual situations conducive to the analytical generalization specific to the case studies [34].

Sampling of participants

Participants were purposively selected to reflect all socio-professional categories and sub-profiles working at the DH, and thereby achieve maximum variation in opinions and experiences of PBF. Once in the field, TZ selected the respondents in a purposive manner to represent all stakeholder groups (Table 1) and in consideration of their availability at the time of the survey. Once he had reached saturation at a study site, TZ proceeded with data collection at the next district hospital. Of the resulting sample of 53 respondents, 34 were male and 19 female.

Table 1: Respondents in the study

Respondents		DH1	DH2	DH3	Total
Socio-professional category	Profiles	DH1	DH2	DH3	Total
A	Specialist doctor	1	1	0	2
	General physician	0	2	2	4
	Pharmacist	1	0	0	1
	Medical Assistant	3	1	1	5
B	Senior Health Technician	5	1	4	10
	Health technician	4	3	0	7
	State nurse	2	1	3	6
	Midwife	2	1	2	5
	Financial Controller	0	1	1	2
C	Obstetrician Nurse	2	1	0	3
C	Executive Secretary	0	1	0	1
D	Ambulance driver	0	2	2	4
E	Hygienist	0	1	0	1
E	Security guard	0	0	2	2
Total		20	16	17	53

Data collection and analysis framework

We used Paul and Robinson's classification of motivation types [35]. According to this classification, health worker motivation can be broadly categorized into three types (Table 2).

Table 2: Paul and Robinson's classification of health worker motivation types

Types of Motivations	Description
Financial motivation	Performance driven by desire to obtain subsidies/bonuses, salary, or other financial benefits.
Social motivation	Performance driven by social relationships in the workplace that promote feeling of approval and/or acceptance of others, which are related to the need to identify with a group, to adhere to standards. The concept of a sense of justice in the sense of fair treatment is central.
Internal motivation	Performance is driven by desire to act in accordance with one's values and beliefs, independently of personal benefits, in order to feel that one's behaviour has meaning and/or to enjoy doing one's job on a daily basis, the various tasks related to that job, having an interest in those tasks in itself.

The PBF pilot project ended in February 2017. According to DHs, the payment of the first and only round of PBF subsidies was made approximately five to six months (July to August 2017) after the end of the project. From October 2, 2017 to November 20, 2017, TZ conducted 53 semi-structured interviews with health workers in three DHs in the Koulikoro region, about two months after the payment of subsidies. The data collection tools were developed by TZ, AC, AF, JL and VR. Two semi-structured interviews guides were used, one for the District Health Manager and another for the rest of the staff. We followed the principle of triangulation advocated in the case studies by using multiple lines of evidence [33]. The different data sources used were: the 53 semi-directive interviews conducted with the different groups of actors, the TZ field notes, and documents relating to the distribution grids of subsidies for each DH. Subsidy distribution grids were used to triangulate respondents' information on the amount of subsidies obtained and the criteria taken into account when calculating subsidies in each DHs.

Data processing and analysis

The data were verbatim transcribed by research assistants, with quality monitored by the research team. Data coding was performed by TZ using a code tree constructed by TZ, AC, AF, JL, and VR along Paul and Robinson's classification of motivation types [35]. We followed a mixed deductive-inductive approach to content analysis based primarily on the predefined code tree, but allowing a few additional codes to emerge from the data as we went through the material. QDA Miner Lite was used for data coding. All authors discussed the resulting coding and agreed on the emerging interpretation.

This section presents the main findings on the modalities and process of distribution of the first round of PBF subsidy payments, and its effects on the motivation of health workers.

Motivation of health workers before the arrival of the PBF

The vast majority of respondents said they chose their profession out of vocation or love for their job, and that they loved working in their job before the arrival of PBF. In their view, being a health care worker is considered a noble profession in society. For health workers, contact with patients on a daily basis and the care they provide is a great source of inner satisfaction (internal motivation). In spite of this, respondents noted difficulties in their working conditions (low salary, lack of equipment, retraining, and human resources). For them, these difficulties hinder their effectiveness in providing quality care to the population, which negatively affected their motivation at times.

Positive PBF effects on health worker motivation

Prior to the implementation of the PBF, the vast majority of health workers did not receive individual subsidies or other bonus payments. Respondents recognized that there was a change in their attitudes when their work started being valued by a financial subsidy (financial motivation). The majority of respondents equated receiving subsidies with both encouragement and incentives to do their job better. In addition, they perceived individual and hospital subsidies as a means to improving their difficult working conditions:

''When there are (individual) subsidies, it changes people's behaviour. In spite of the willingness, i.e. the willingness to work well, when there is money it always supports that. No matter what people say, money is a source of motivation. Today in a structure like the district hospital, it is the subsidies that can motivate the staff to do well. I don't see anything else'' [Specialist doctor, HD 2]

In allowing them to work better, it was not only the financial aspect of the PBF that made a difference for their motivation, but PBF also contributed to better internal motivation.

''When you do a good job, you feel in yourself that you've done a good job, there's satisfaction, that's not material, but it makes you feel comfortable inside'' [Senior Health Technician, HD1]

According to some respondents, improved recognition of their work by their superiors was another factor contributing to their job satisfaction (internal motivation). Moreover, according to some respondents, the PBF made it possible to better describe and distribute work tasks between health workers, contributing to better planning and organization of daily work.

Development process of health workers' expectations regarding subsidies

The vast majority of health workers were happy when the subsidies were announced upon introduction of PBF. However, after receiving their first PBF subsidies, respondents felt disappointed because they perceived a huge gap between the amounts hoped for and those received. Most respondents found the amount of individual subsidy received too low in absolute terms and therefore not motivating. In addition, they perceived a discrepancy between the efforts made and the amount obtained (financial motivation). Disappointment with the subsidy amount varied from one socio-professional category to another. Specifically, disappointment was greater among health workers in lower-level categories C, D and E, because they placed more hope in the amount of the subsidies than those in higher-level categories A and B. For example, in the three HDs, health workers in socio-professional categories A and B (doctors, pharmacists, and administrative staff) obtained between 20,000 CFA francs (US $32.99) and 30,000 CFA francs (US $49.49) as an individual subsidy for the one paid cycle, which corresponds to three months of the PBF. Those in categories C, D and E (hygienist, ambulance driver, security guard, etc.) had individual subsidy ranging from 3,500 CFA francs (US $5.77) to 15,000 CFA francs (US $24.74):

''I know of Hygienist who went into debt because they said there's PBF subsidies ... they got 3,500 CFA francs (US $5.85) as a subsidies... (Laughing) . they were really discouraged." [Ambulance man, HD2]

''I felt a little discouraged about what I was given as payment. I told myself that I actually worked for three months and at the end of my effort I only received 24,000 CFA francs (US $40.14). For this reason, I planned to eventually do another activity, and leave the PBF for the benefit of this activity. For example, if I had a mission within the district, I will forcibly leave the follow-up here, because I know that in two or three days I will have 40,000 CFA francs (US $66.90). Because everyone is chasing after profit. Here I don't think if someone has exceeded 30,000 CFA francs (US $50.17) or 40,000 CFA francs (US $66.90)" [Senior Health Technician, HD1].

DH 1 health workers who had already participated in the PBF pre-pilot project were more disappointed with the amount of individual subsidy received compared to DH 2 and 3, as the majority of them hoped for an amount on average equal to those they obtained during the PBF pre-pilot project, where higher subsidies had been paid.

Effects of PBF implementation difficulties on the motivation of health workers

According to DHs, a delay of six to seven months was observed in the distribution of subsidies. There are two reasons for this delay: administrative delays due to the complexity of the PBF process and errors in bank processing. Respondents stated that they had not received any formal information on the reasons for the delay. In their view, this facilitated the circulation of rumors accusing those responsible of having embezzled subsidies. Some health workers felt that if subsidies are delayed, officials need to communicate the reasons better.

Health workers' suspicions of their managers reveal a lack of confidence in their management of finances. In addition to creating a lack of confidence in the PBF mechanism among health workers, the delay in the disbursement of subsidies and its distribution also led to a lack of motivation among the workers. Health workers were informed individually by the hospital accounting department when the subsidies arrived. However, there was no meeting to inform the health workers about the overall amount of subsidies, individual subsidies, and hospital investment subsidies. A significant number of respondents stated that the subsidy sharing process was not transparent, which caused demotivation (social motivation):

''When they call you just to give you a sum of money, I can even say that the district hospital got billions and they only gave me 20,000 CFA francs (US $33.95) when that's not it, you have to be transparent because that's the best way'' [Medical Assistant, HD1].

Prior to the start of the project, the PBF agency established a key for the distribution of subsidies with several criteria to be used for the calculation of subsidies. Apart from the members of the district health management team (district health manager, manager, and unit heads), most health workers had only partial knowledge of these criteria. Respondents stated that details of the distribution of subsidies were not discussed in depth during the training sessions. The managers of DH 1 had a better grasp of how subsidies were distributed compared to those of DH 2 and 3.This was due to the fact that they had already participated in the PBF pre-pilot project. Beyond knowledge, In the two DHs, most of the distribution criteria were not applied when the subsidies were distributed. For example, in DH 2, some volunteer trainees and members of the management committee had received subsidies, although this was not foreseen. Similarly, individual performance was not considered in two of the three DHs (DH 2 and 3), possibly because the evaluation of individual performance had not been carried out. According to some hospital officials, since the PBF project had already ended, there was no longer a point in evaluating the health workers, and doing so would only create tensions within the teams. In contrast to this judgement, DH 1 health workers, where individual performance evaluation had taken place, stressed the importance of knowing their individual performance rating as an important element for morale:

''If I don't even know the grade I've got, I can really get an idea that somewhere they've taken something off, ... I can get fuzzy ideas.'' [Senior Health Technician, DH 1]

In result of the above issues, the vast majority of health workers felt that the subsidies were not well shared (social motivation). In addition, they felt that the criteria considered when calculating the subsidies did not reflect everyone's effort. Indeed, in the absence of individual performance evaluations in DHs 2 and 3, there was a divergence of views among the different actors with regard to the criteria that should have been considered for the sharing of subsidies. Ideas varied in relation to the socio-professional category of health workers. In particular, for the majority of category C, D, and E health workers, subsidies should have been shared equally among all health workers without distinction of socio-professional category. However, the majority of category A and B health workers were against this egality principle. In their opinion, only the socio-professional category should have been considered, not individual performance. This difference of views among health workers sometimes led to tensions. Some health workers of socio-professional categories C, D, and E reported that they work more than those of higher categories A and B, and therefore should have received the same or higher amounts. In consequence, for example, in DH 2, a health worker refused to receive his subsidies because he considered the amount inadequate in relation to the effort made. Nevertheless, it appears that the vast majority of health workers did not openly express their dissatisfaction:

''the way we did it (the distribution of subsidies), even if they don't tell us we know there's frustration'' [General physician, DH2]

Our study is the first in Mali to explore the expectations of health workers with regard to the first cycle of PBF subsidies payment, and their effects on their motivation. It is one of the few publications in French-speaking West Africa on the subject, and the first to explore dynamics in the initial days of PBF in an isolated manner.

PBF motivates but can also demotivate, a "double-edged sword”?

Our findings show that PBF can motivate health workers to make an effort at work. However, our findings also show that if it is poorly adapted to the implementation context or poorly implemented, it can become a source of demotivation and thus produce the opposite effect to that initially intended. Our results show that the principle of the PBF mechanism is well received by health workers. For them, the fact that they benefitted from subsidies under PBF motivated them to improve their performance. However, difficulties in implementation had a negative impact on their motivation. The delay of PBF subsidies led to a lack of confidence among health workers both in the PBF mechanism and in their managers. Stakeholder confidence in the health system is an important factor and is indicative of interpersonal relationships within the organization [36;37]. In South Africa, Gilson et al. showed that health providers' trust in their manager and the employing organization are important factors influencing performance [38]. Within the framework of the implementation of the PBF in Mali, preserving trust of the providers towards the PBF and those in charge would have required more effective communication and transparency in the organizational and financial management of the hospitals.

Two of the DHs had not applied staff performance evaluation as a criterion for calculating individual subsidies. In Mali, the modalities for sharing PBF subsidies varied by setting and among DHs. Several studies (in Benin [12], Tanzania [18], and Burkina Faso [17; 39]) show that the methods of distribution of PBF subsidies in health centers are heterogeneous. Interestingly, in these studies suggesting that whatever the modalities chosen, there was sometimes tension among providers within the health centers. In Tanzania, for example, the methods for distributing PBF incentives varied among health units in health centers (60% to be shared among reproductive health staff, 30% among other staff, and 10% at the health centers) [18], which led to tension. In addition, in Mali since the PBF intervention is performance-based, the failure to choose this performance criterion for the calculation of subsidies was perceived as unfair by health workers. Similar feelings of inequity with regard to the distribution process and the criteria chosen for calculating individual PBF subsidies was observed in Burkina Faso [17;39], Benin [12], and Tanzania [18]. In Tanzania, perceived unfairness by health workers has negatively affected work motivation and undermined teamwork between services [18]. In Burkina Faso, in some health centres, managers disregarded the planned performance criteria, which was unfair to health workers [17;39].

In Mali, the lack of feedback for health workers on their performance evaluation under PBF meant that the program missed out on this opportunity to improve internal motivation, i.e., recognition of the tasks they perform in their work. In Burkina Faso, health workers appreciated the feedback during the implementation of the PBF because it enabled them to improve recognition of their work, and they made an effort to change following negative feedback [17]. However, in Tanzania, health workers reported insufficient feedback on their performance evaluation [40]. This resonates with the psychological literature on motivation, which stresses that the implementation of an effective performance evaluation system is essential to promoting internal motivation at work [41]. In particular, the literature shows that perceived fairness in the performance appraisal process can affect workers' relationship with managers, their performance, their job satisfaction, and their well-being [42;43;44].

The delay of PBF subsidies within hospitals led to rumors circulating among some health workers, accusing officials of embezzling the subsidies. This circulation of rumors about PBF subsidies shows the importance that health workers attach to subsidies issues, specifically to their timely payment to avoid unfavorable incidents [45] or if persisting, obstacles to the successful delivery of health interventions [46].

Recourse to a logic of financial profitability is increasingly used to finance public health policies [47]. By using performance criteria, the PBF mechanism illustrates a contractual approach based on a logic of financial profitability. PBF is a form of financialization of public health policies, in other words “the penetration of financialized logics and forms of evaluation in the formulation and implementation of policies, even when these do not concern the financial sector” [48]. In addition, the financialisation of public policies leads to the creation of new financial circuits [48]. The implementation of the PBF has brought additional money into hospitals, on top of the money usually invested. The implementation of PBF brings a new flow of money into the health care system. This new financial circuit completely changes the financing architecture that existed, where funds were injected by donors into the health system via the central level through different levels before landing in the health centres at the local level. This new financial circuit brought about by the PBF changed and structured the relationship between the beneficiaries (hospitals and health workers) and the health financing circuit. This new financial circuit allows for a market relationship (signing contracts, exchanging money, and setting the conditions for distributing the money) between a buyer (PBF's specialized agency in our case) and suppliers (hospitals and health workers). The process of distributing PBF subsidies to hospitals in Mali shows us how PBF as a new health financing mechanism has changed the financing circuit of hospitals.

Discrepancy between expectations and reality: are health workers' expectations of the PBF too high?

During the implementation of a health project, there is always a gap between what is planned and what is achieved [51]. A systematic review showed that the implementation of health initiatives requiring change in the health systems of LMICs is often complex and difficult [52]. Moreover, public health policies are sometimes more incoherent and ineffective in the context of Sub-Saharan African [53]. Our study shows that the expectations of healthcare professionals regarding the individual subsidies have not been met. When health workers saw how things worked in reality, and that their expectations were not met, it led to frustration and disappointment. It is important to differentiate relative frustration, as in our study (ie frustration in relation to expectations) from absolute frustration. Corcuff defines relative frustration as: "a state of tension between expected and denied satisfaction, resulting in dissatisfaction, feeding a potential for dissatisfaction and collective action" [27]. The frustration of the health workers in our study, therefore, stems from their comparison of what they have achieved in terms of earnings and socially constructed expectations. We believe that in Mali, health workers' expectations of the PBF were raised too high during the pilot project; the majority of them expected at least the same amount that they obtained during the pre-pilot PBF project. They did not account for the fact that the PBF pilot project had fewer paid indicators compared to the pre-pilot project, and that the indicator purchasing scales were higher during the pre-pilot project compared to the pilot project. It is unclear whether their expectations were unreasonable, or rather grounded in lack of information about differences between the two schemes. Interestingly, in Tanzania, health workers were reporting positive – but in retrospect slightly unrealistic – expectations of the intervention even without “precedent” as in Mali. They felt that the possibility of future financial incentives should strengthen their motivation [42].

With respect to motivational and behavioural effects, we observed enthusiasm at the beginning of the implementation of the PBF intervention. We believe that the motivational and behavioural effects of the early days may have an impact on the long-term motivation of the actors. Motivation is a dynamic process, it is important to understand the changes in this dynamic process and their causes. Actors adjust their motivational expectations and reactions, both positive and negative, over time. Even if some problems persist when implementing complex initiatives such as PBF, positive and/or negative motivational reactions normalize or diminish over time. Unfortunately, in Mali, this normalization was not possible given the short duration of the project. Seppey and al. further demonstrated the lack of sustainability of the PBF in Mali [13]. The same observation was made by Antony and al. who, in their study in Benin, noted the lack of sustainability and institutional anchoring of the PBF pilot projects [12]. Several studies show that the vast majority of development projects initiated by NGOs and donors in African countries are unsustainable or low [13;53]. However, short-term interventions are increasingly prioritized by donors at the expense of medium- and long-term interventions in LMICs [10]. In Mali, PBF certainly was one of those interventions that ended quickly without being able to rectify some of the negative effects due to its initial implementation challenges. When implementing development projects in the context of LMICs, it is therefore necessary to analyze the frustrations that may arise in the first days of interventions in order to readjust the projects. Moreover, it is essential to ensure the sustainability of these projects from the design stage to facilitate the overall strengthening of health systems. In practical terms, policies should : (i) prioritize long-term projects where implementing actors will have more time to identify, correct implementation errors and better adapt them to local contexts, (ii) in the implementation of a project that aims to improve the quality of care through the motivation of health workers, it is essential to reduce the negative effects (delay in the payment of subsidies, lack of transparency in the subsidies sharing process and the feeling of inadequacy between the work provided and the amount of subsidies obtained) that can demotivate health workers instead of motivating them, (iii) in baseline studies of a project aimed at motivating health workers, it is necessary to identify their expectations with regard to motivational subsidies. It is necessary to better adapt the project as well as the communication of the project so that the actors' expectations are not too unrealistic.

Limitation of the study

Our research has certain limitations. First, the experience in hospitals during the implementation of the PBF and the opinions of the sampled health workers are not necessarily representative of all ten health districts in Koulikoro Region. Second, the data collection was carried out in a cross-sectional and retrospective manner. Some of the frustrations observed during data collection may have overshadowed the initial positive experiences with the intervention. Third, the subsidies were distributed several months after the PBF pilot project was terminated. As a result, some of the deviations observed during the subsidies sharing process may have been different if the implementation continued. Fourth, PBF was a donor-funded development project, even if the study was conducted independently. Thus, the interviews may have included a social desirability bias or prompted respondents to have a normative discourse. Response bias could include strategic responses from respondents who thought that their answers might influence the possible return of PBF. To reduce response bias, we have insisted on our independence from the PBF implementing agency in Mali.

Our study showed that the PBF pilot project had both positive and negative effects on health worker motivation. Because there was not enough time for the actors to adjust their initial motivational expectations and reactions, PBF ended in frustration of many health workers built up during the first days of the intervention. It is reasonable to assume that the motivational and behavioural effects of the first few days can have an impact on the long-term motivation of the actors.

CV, Community verification; DHs, District hospitals; LMICs, Low- and middle-income countries; PBF, Performance-based financing.

Ethics approval and consent to participate

The research protocol has been validated by the ethics committee of the National Institute of Public Health Research (INRSP) of Mali (N°24/2015/CEINRSP). All participants were informed in detail about the objectives of our research. We obtained the free and informed consent from all the participants.

Consent for publication

Not applicable.

Availability of data and materials

The data sets used and analyzed in this study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was funded by three Canadian agencies: World Agency Canada (WAC), the Canadian Institutes of Health Research (CIHR), and the International Development Research Centre (IDRC). Our study is part of a larger research program on “Results based financing for equitable access to maternal and child health care in Mali and Burkina Faso”. This seven-year program is part of the "Innovation for Maternal and Child Health in Africa" initiative. This research program is implemented by two research NGOs based in the two countries, and researchers from the University of Montreal. In Mali, the team is composed of researchers and research assistants from the NGO MISELI led by Laurence Touré, who is the principal investigator of the program.

Authors’ contributions

The research protocol was developed by VR with the contribution of AC. The collection tools were developed by TZ and AC with the contribution of AF, JL, and VR. TZ organized the data collection in the district hospitals. Analyses were done by TZ with input from VR, JL, and AC. TZ wrote the first draft of the article. All authors read, improved, and approved the final version of the article.

Acknowledgements

Special thanks to Laurence Touré for her advice and support during the conduct of this research. We would also like to thank all the actors and organizations at the national, regional, and local levels that participated in and/or facilitated the completion of this research. Finally, we would like to thank Heather Hickey for her help in translating the article from French into English.

OMS, éditeur. Travailler ensemble pour la santé. Genève: Organisation Mondiale de la Santé; 2006. 213 p. (Rapport sur la santé dans la monde).
OMS. Accroître l’accès aux personnels de santé dans les zones rurales ou reculées grâce à une meilleure fidélisation recommandations pour une politique mondiale. Genève: Organisation Mondiale de la Santé; 2010.
Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D, Ditlopo P. Motivation and retention of health workers in developing countries: a systematic review. BMC Health Serv Res [Internet]. déc 2008 [cité 16 nov 2019];8(1):247. Disponible sur: http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-8-247
Roussel P. La motivation au travail - concept et théories. oct 2000;20.
Maugeri S. Théories de la motivation au travail. Paris: Dunod; 2013.
Ryan RM, Deci EL. Intrinsic and Extrinsic Motivations: Classic Definitions and New Directions. Contemporary Educational Psychology [Internet]. janv 2000 [cité 24 août 2019];25(1):54‑67. Disponible sur: https://linkinghub.elsevier.com/retrieve/pii/S0361476X99910202
Ministère de la sante du Mali. Plan de développement des ressources humaines 2009-2015. 2009.
Van Dormael M, Dugas S, Kone Y, Coulibaly S, Sy M, Marchal B, et al. Appropriate training and retention of community doctors in rural areas: a case study from Mali. Hum Resour Health [Internet]. déc 2008 [cité 23 nov 2019];6(1):25. Disponible sur: https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-6-25
Fritsche GB, Soeters R, Meessen B. Performance-based financing toolkit. Washington, D.C: The World Bank; 2014. 331 p.
Richard F, Hercot D, Ouédraogo C, Delvaux T, Samaké S, van Olmen J, et al. Sub-Saharan Africa and the health MDGs: the need to move beyond the “quick impact” model. Reproductive Health Matters [Internet]. janv 2011 [cité 25 avr 2020];19(38):42‑55. Disponible sur: https://www.tandfonline.com/doi/full/10.1016/S0968-8080%2811%2938579-5
Mwisongo A, Nabyonga-Orem J. Global health initiatives in Africa – governance, priorities, harmonisation and alignment. BMC Health Serv Res [Internet]. juill 2016 [cité 25 avr 2020];16(S4):212. Disponible sur: http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1448-9
Antony M, Bertone MP, Barthes O. Exploring implementation practices in results-based financing: the case of the verification in Benin. BMC Health Services Research [Internet]. déc 2017 [cité 26 févr 2018];17(1). Disponible sur: http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2148-9
Seppey M, Ridde V, Touré L, Coulibaly A. Donor-funded project’s sustainability assessment: a qualitative case study of a results-based financing pilot in Koulikoro region, Mali. Globalization and Health [Internet]. déc 2017 [cité 1 oct 2018];13(1). Disponible sur: https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-017-0307-8
NATIONS UNIES. PROJETS À EFFET RAPIDE POUR LES COMMUNAUTÉS [Internet]. [cité 26 mai 2020]. Disponible sur: https://peacekeeping.un.org/fr/quick-impact-projects-communities
MINUSMA. PROJETS À IMPACT RAPIDE (QIPS) [Internet]. [cité 26 mai 2020]. Disponible sur: https://minusma.unmissions.org/projets-%C3%A0-impact-rapide-qips
Kane S, Gandidzanwa C, Mutasa R. Coming full circle: how health worker motivation and performance in results-based financing arrangements hinges on strong and adaptive health systems. Int J Health Policy Manag. 2018;
Ridde V, Yaogo M, Zongo S, Somé P-A, Turcotte-Tremblay A-M. Twelve months of implementation of health care performance-based financing in Burkina Faso: A qualitative multiple case study. The International Journal of Health Planning and Management [Internet]. 3 juill 2017 [cité 26 févr 2018]; Disponible sur: http://doi.wiley.com/10.1002/hpm.2439
Chimhutu V, Songstad NG, Tjomsland M, Mrisho M, Moland KM. The inescapable question of fairness in Pay-for-performance bonus distribution: a qualitative study of health workers’ experiences in Tanzania. Globalization and Health [Internet]. déc 2016 [cité 27 févr 2018];12(1). Disponible sur: http://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-016-0213-5
Bertone MP, Lagarde M, Witter S. Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone. BMC Health Services Research [Internet]. déc 2016 [cité 26 févr 2018];16(1). Disponible sur: http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1546-8
Lohmann J, Wilhelm D, Kambala C, Brenner S, Muula AS, De Allegri M. ‘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. Health Policy and Planning [Internet]. 1 mars 2018 [cité 26 févr 2018];33(2):183‑91. Disponible sur: https://academic.oup.com/heapol/article/33/2/183/4641880
Aninanya GA, Howard N, Williams JE, Apam B, Prytherch H, Loukanova S, et al. Can performance-based incentives improve motivation of nurses and midwives in primary facilities in northern Ghana? A quasi-experimental study. Global Health Action [Internet]. déc 2016 [cité 2 nov 2019];9(1):32404. Disponible sur: https://www.tandfonline.com/doi/full/10.3402/gha.v9.32404
Fillol A, Lohmann J, Turcotte-Tremblay A-M, Somé P-A, Ridde V. The Importance of Leadership and Organizational Capacity in Shaping Health Workers’ Motivational Reactions to Performance-Based Financing: A Multiple Case Study in Burkina Faso. Int J Health Policy Manag [Internet]. 26 janv 2019 [cité 26 oct 2019];8(5):272‑9. Disponible sur: http://www.ijhpm.com/article_3593.html
Lohmann J, Souares A, Tiendrebéogo J, Houlfort N, Robyn PJ, Somda SM, et al. Measuring health workers’ motivation composition: validation of a scale based on self-determination theory in Burkina Faso. Human resources for health. 2017;15(1):33.
Lohmann J, Houlfort N, De Allegri M. Crowding out or no crowding out? A Self-Determination Theory approach to health worker motivation in performance-based financing. Social Science & Medicine [Internet]. nov 2016 [cité 26 oct 2019];169:1‑8. Disponible sur: https://linkinghub.elsevier.com/retrieve/pii/S0277953616305044
Renmans D, Holvoet N, Criel B, Meessen B. Performance-based financing: the same is different. Health Policy and Planning [Internet]. juill 2017 [cité 26 févr 2018];32(6):860‑8. Disponible sur: https://academic.oup.com/heapol/article-lookup/doi/10.1093/heapol/czx030
Ogundeji YK, Jackson C, Sheldon T, Olubajo O, Ihebuzor N. Pay for performance in Nigeria: the influence of context and implementation on results. Health Policy and Planning [Internet]. oct 2016 [cité 26 févr 2018];31(8):955‑63. Disponible sur: https://academic.oup.com/heapol/article-lookup/doi/10.1093/heapol/czw016
World Bank. Population, total | Data - BANQUE MONDIALE : Données [Internet]. [cité 30 juill 2020]. Disponible sur: https://donnees.banquemondiale.org/indicator/SP.POP.TOTL?end=2019&start=2019&view=map
FMI. Cadre de stratégie pour la croissance et la réduction de la pauvreté du Mali. Washington, D.C.: Fonds monétaire international; 2013 mai p. 386. Report No.: No. 13/111.
Cissouma L, Sioro A, Koné O, Traoré K, Bulthuis S, Mommers P, et al. Rapport de Capitalisation FBR à la Malienne. 2017 mars p. 45.
World Bank. Mali - Strengthening Reproductive Health Project [Internet]. Washington, D.C.: World Bank Group; 2017 août [cité 7 mai 2019] p. 81. Report No.: ICR4095. Disponible sur: http://documents.worldbank.org/curated/en/542131502720462868/Mali-Strengthening-Reproductive-Health-Project
KIT, Clinique de gestion et d’innovation des connaissances, Cordaid. RAPPORT FINAL DU PROJET PILOTE « PRSR/FBR » FBR-Financement Basé sur les Résultats – Approche pour accélérer les résultats en Santé de la Reproduction. 2017 avr.
Ministère de la Santé et de l’Hygiène Publique. Manuel Opérationnel du Financement basé sur les résultats du projet PRSR-FBR. 2016.
Yin RK. Case study research: design and methods. 4th ed. Los Angeles, Calif: Sage Publications; 2009. 219 p. (Applied social research methods).
Devaux-Spatarakis A, Gregot A. Les défis de l’emploi de l’étude de cas en évaluation. caf [Internet]. 2012 [cité 27 mai 2020];110(1):33‑44. Disponible sur: https://www.persee.fr/doc/caf_2101-8081_2012_num_110_1_2732
Paul E, Robinson M. Performance Budgeting, Motivation, and Incentives. In: Robinson M, éditeur. Performance Budgeting: Linking Funding and Results [Internet]. London: Palgrave Macmillan UK; 2007. p. 330‑75. Disponible sur: https://doi.org/10.1057/9781137001528_18
Ridde V. Building trust or buying results? The Lancet. 2005;366(9498):1692.
Gilson L. Editorial: building trust and value in health systems in low- and middle-income countries. Social Science & Medicine [Internet]. 1 oct 2005;61(7):1381‑4. Disponible sur: http://www.sciencedirect.com/science/article/pii/S0277953604006458
Gilson L, Palmer N, Schneider H. Trust and health worker performance: exploring a conceptual framework using South African evidence. Social Science & Medicine [Internet]. 1 oct 2005;61(7):1418‑29. Disponible sur: http://www.sciencedirect.com/science/article/pii/S027795360400646X
Lohmann J, Koulidiati J-L, Somda SM, De Allegri M. « It Depends on What They Experience in Each Health Facility. Some Are Satisfied, Others Are Not. » A MixedMethods Exploration of Health Workers’ Attitudes Towards Performance-Based Financing in Burkina Faso. Int J Health Policy Manag [Internet]. 4 mai 2020 [cité 30 juill 2020];1. Disponible sur: https://www.ijhpm.com/article_3803.html
Songstad N, Lindkvist I, Moland K, Chimhutu V, Blystad A. Assessing performance enhancing tools: experiences with the open performance review and appraisal system (OPRAS) and expectations towards payment for performance (P4P) in the public health sector in Tanzania. Globalization and Health [Internet]. 2012 [cité 27 févr 2018];8(1):33. Disponible sur: http://globalizationandhealth.biomedcentral.com/articles/10.1186/1744-8603-8-33
Gagné M, Forest J. The study of compensation systems through the lens of self-determination theory: Reconciling 35 years of debate. Canadian Psychology/Psychologie canadienne [Internet]. août 2008 [cité 28 déc 2019];49(3):225‑32. Disponible sur: http://doi.apa.org/getdoi.cfm?doi=10.1037/a0012757
Blader S L, Tyler T R. How can theories of organizational justice explain the effects of fairness ? In: Handbook of organizational justice. 2005. p. 329‑54.
Sparr JL, Sonnentag S. Fairness perceptions of supervisor feedback, LMX, and employee well-being at work. European Journal of Work and Organizational Psychology [Internet]. juin 2008 [cité 29 déc 2019];17(2):198‑225. Disponible sur: http://www.tandfonline.com/doi/abs/10.1080/13594320701743590
Grenier S, Chiocchio F, Beaulieu G. Évaluation du rendement et motivation au travail : propositions de recherche pour une rétroaction sur le rendement qui favorise la satisfaction des besoins psychologiques fondamentaux. mi [Internet]. 15 nov 2012 [cité 28 déc 2019];16(4):169‑79. Disponible sur: http://id.erudit.org/iderudit/1013156ar
Bonhomme J, Bondaz J. L’offrande de la mort: une rumeur au Sénégal. Paris: CNRS éditions; 2017. 286 p.
Kaler A. Health interventions and the persistence of rumour: The circulation of sterility stories in African public health campaigns. Social Science & Medicine [Internet]. 1 mai 2009;68(9):1711‑9. Disponible sur: http://www.sciencedirect.com/science/article/pii/S0277953609000495
Gabas J-J, Ribier V, Vernières M. Présentation. Financement ou financiarisation du développement ? Une question en débat. Mondes en développement [Internet]. 2017;178(2):7‑22. Disponible sur: https://www.cairn.info/revue-mondes-en-developpement-2017-2-page-7.htm
Chiapello È. La financiarisation des politiques publiques. Mondes en développement [Internet]. 2017;178(2):23‑40. Disponible sur: https://www.cairn.info/revue-mondes-en-developpement-2017-2-page-23.htm
Ridde V, Olivier de Sardan J-P. The implementation of public health interventions in Africa: a neglected strategic theme. Médecine et Santé Tropicales [Internet]. janv 2017 [cité 27 déc 2019];27(1):6‑9. Disponible sur: http://www.john-libbey-eurotext.fr/medline.md?doi=10.1684/mst.2016.0605
Pantoja T, Opiyo N, Lewin S, Paulsen E, Ciapponi A, Wiysonge CS, et al. Implementation strategies for health systems in low-income countries: an overview of systematic reviews. Cochrane Effective Practice and Organisation of Care Group, éditeur. Cochrane Database of Systematic Reviews [Internet]. 12 sept 2017 [cité 27 déc 2019]; Disponible sur: http://doi.wiley.com/10.1002/14651858.CD011086.pub2
Olivier de Sardan J-P, Ridde V, éditeurs. Les spécificités des politiques publiques et des systèmes de santé en Afrique sahélienne. In: Une politique publique de santé et ses contradictions: la gratuité des soins au Burkina Faso, au Mali et au Niger. Paris: Éditions Karthala; 2014. p. 15‑30. (Hommes et sociétés).
Corcuff P. Frustrations relatives. In: Dictionnaire des mouvements sociaux [Internet]. Paris: Presses de Sciences Po; 2009. p. 242‑8. (Références). Disponible sur: https://www.cairn.info/dictionnaire-des-mouvements-sociaux--9782724611267-p-242.htm
Mallé Samb O, Ridde V, Queuille L. Quelle pérennité pour les interventions pilotes de gratuité des soins au Burkina Faso ? Revue Tiers Monde [Internet]. 2013 [cité 23 mai 2017];215(3):73. Disponible sur: http://www.cairn.info/revue-tiers-monde-2013-3-page-73.htm

Download PDF

Journal Publication

published 02 Feb, 2021

Read the published version in Global Health Research and Policy →

Editorial decision: Revise before peer review
12 Jan, 2021
Editor assigned by journal
02 Jan, 2021
Submission checks completed at journal
02 Jan, 2021
Editor invited by journal
02 Jan, 2021

You are reading this older preprint version

Read the latest preprint version →

Does the gap between health workers’ expectations and the realities of implementing a Performance-Based Financing project in Mali create frustration?

Status:

Journal Publication

Version 3

Abstract

Background

Methods

Results

Discussion

Conclusion

List Of Abbreviations

Declarations

References

Status:

Journal Publication

Version 3