Crowding out or no crowding out? A Self-Determination Theory approach to health worker motivation in performance-based financing
Crowding out or no crowding out? A Self-Determination Theory approach to health worker motivation in performance-based financing
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DOI：
10.1016/j.socscimed.2016.09.006
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发表时间：
2016-11-01
影响因子：
5.4
通讯作者：
De Allegri, Manuela
中科院分区：
文献类型：
--
作者：
Lohmann, Julia;Houlfort, Nathalie;De Allegri, Manuela
绩效融资（PBF）是目前中低收入国家卫生系统改革的一种常见方式。尽管越来越多的证据表明PBF的有效性和良好设计原则的知识是可用的，但在其他方面的研究仍然缺乏。其中包括对卫生工作者动机在PBF中的复杂作用以及潜在副作用（例如内在动机）的理解有限。我们的文章旨在通过推进围绕卫生工作者动机和PBF的理论讨论来支持有意义的未来研究。我们认为，在卫生工作者层面深入了解PBF的动机机制和后果具有高度的实际意义，应该成为PBF研究议程的核心，并且主要的卫生工作者动机的一维概念化和描述性而不是解释性研究方法不足以充分理解PBF计划是否、如何以及为什么改变卫生工作者的动机结构、心态、影响和行为。我们将自我决定理论引入并应用于PBF的背景下，作为未来实证探索的有价值的理论框架。由此，我们得出结论，PBF干预不太可能像部分PBF社区所担心的那样，对内在动机产生普遍的不利影响。相反，我们假设PBF可以对内在和外在动机产生积极和消极的影响，其程度取决于特定干预措施的具体设计、实施和结果，以及卫生工作者对其的看法和评价。(C) 2016 Elsevier Ltd.版权所有。
Performance-based financing (PBF) is a common health system reform approach in Low and middle income countries at, present. Although increasing evidence on the effectiveness of PBF and knowledge of principles of good design are available, research is still lacking in regards to other aspects. Among these are a yet limited understanding of the complex role of health worker motivation in PBF and of potential side effects, for instance on intrinsic motivation. Our article aims to support meaningful future research by advancing the theoretical discussion around health worker motivation and PBF. We argue that an in-depth understanding of the motivational mechanisms and consequences of PBF at health worker level are of high practical relevance and should be at the heart of the PBF research agenda, and that predominant unidimensional conceptualizations of health worker motivation and descriptive rather than explanatory research approaches are insufficient to fully understand whether, how, and why PBF schemes alter health workers' motivational structures, mindsets, affect, and behavior. We introduce and apply Self-Determination Theory to the context of PBF as a valuable theoretical framework for future empirical exploration. From this, we conclude that PBF interventions are unlikely to have a generally adverse effect on intrinsic motivation as feared by parts of the PBF community. Rather, we posit that PBF can have positive and negative effects on both intrinsic and extrinsic motivation, to varying degrees depending on the specific design, implementation, and results of a particular intervention and on health workers' perceptions and evaluations of it. (C) 2016 Elsevier Ltd. All rights reserved.