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How does performance-based financing affect health workers' intrinsic motivation? A Self-Determination Theory-based mixed-methods study in Malawi

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  • Lohmann, Julia
  • Muula, Adamson S.
  • Houlfort, Nathalie
  • De Allegri, Manuela

Abstract

“Intrinsic motivation crowding out”, the erosion of high-quality, sustainable motivation through the introduction of financial incentives, is one of the most frequently discussed but yet little researched potential unfavorable consequence of Performance-based Financing (PBF). We used the opportunity of the introduction of PBF in Malawi to investigate whether and how PBF affected intrinsic motivation, using a mixed-methods research design theoretically grounded in Self-Determination Theory (SDT). The quantitative component served to estimate the impact of PBF on intrinsic motivation, relying on a controlled pre- and post-test design, with data collected from health workers in 23 intervention and 10 comparison facilities before (March/April 2013; n = 70) and approximately two years after (June/July 2015; n = 71) the start of the intervention. The qualitative component, relying on in-depth interviews with health workers in selected intervention facilities one (April 2014; n = 21) and two (September 2015; n = 20) years after the start of PBF, served to understand how PBF did or did not bring about change in intrinsic motivation. Specifically, it allowed us to examine how the various motivation-relevant elements and consequences of PBF impacted health workers' basic psychological needs for autonomy, competence, and relatedness, which SDT postulates as central to intrinsic motivation. Our results suggest that PBF did not affect health workers’ overall intrinsic motivation levels, with the intervention having had both positive and negative effects on psychological needs satisfaction. To maximize positive PBF effects on intrinsic motivation, our results underline the potential value of explicit strategies to mitigate unintended negative impact of unavoidable design, implementation, and contextual challenges, for instance by building autonomy support activities into PBF designs.

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  • Lohmann, Julia & Muula, Adamson S. & Houlfort, Nathalie & De Allegri, Manuela, 2018. "How does performance-based financing affect health workers' intrinsic motivation? A Self-Determination Theory-based mixed-methods study in Malawi," Social Science & Medicine, Elsevier, vol. 208(C), pages 1-8.
    • Handle: RePEc:eee:socmed:v:208:y:2018:i:c:p:1-8
    DOI: 10.1016/j.socscimed.2018.04.053
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    References listed on IDEAS

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    1. Elise Huillery & Juliette Seban, 2014. "Performance-Based Financing, Motivation and Final Output in the Health Sector: Experimental Evidence from the Democratic Republic of Congo," Working Papers hal-01071880, HAL.
    2. Romaniuc, Rustam, 2017. "Intrinsic motivation in economics: A history," Journal of Behavioral and Experimental Economics (formerly The Journal of Socio-Economics), Elsevier, vol. 67(C), pages 56-64.
    3. Valéry Ridde & Maurice Yaogo & Sylvie Zongo & Paul‐André Somé & Anne‐Marie Turcotte‐Tremblay, 2018. "Twelve months of implementation of health care performance‐based financing in Burkina Faso: A qualitative multiple case study," International Journal of Health Planning and Management, Wiley Blackwell, vol. 33(1), pages 153-167, January.
    4. repec:hal:wpspec:info:hdl:2441/4pmvo3bm7m9claao2gl0337ip4 is not listed on IDEAS
    5. repec:hal:spmain:info:hdl:2441/4pmvo3bm7m9claao2gl0337ip4 is not listed on IDEAS
    6. Lohmann, Julia & Houlfort, Nathalie & De Allegri, Manuela, 2016. "Crowding out or no crowding out? A Self-Determination Theory approach to health worker motivation in performance-based financing," Social Science & Medicine, Elsevier, vol. 169(C), pages 1-8.
    7. György Bèla Fritsche & Robert Soeters & Bruno Meessen, 2014. "Performance-Based Financing Toolkit [Boîte à outils : Financement basé sur la performance]," World Bank Publications - Books, The World Bank Group, number 17194.
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    2. Galárraga, Omar & Kuo, Caroline & Mtukushe, Bulelwa & Maughan-Brown, Brendan & Harrison, Abigail & Hoare, Jackie, 2020. "iSAY (incentives for South African youth): Stated preferences of young people living with HIV," Social Science & Medicine, Elsevier, vol. 265(C).

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