The inescapable question of fairness in Pay-for-performance bonus distribution: a qualitative study of health workers' experiences in Tanzania
The inescapable question of fairness in Pay-for-performance bonus distribution: a qualitative study of health workers' experiences in Tanzania
复制标题
DOI：
10.1186/s12992-016-0213-5
复制
发表时间：
2016-11-25
影响因子：
10.8
通讯作者：
Moland, Karen Marie
中科院分区：
文献类型：
--
作者：
Chimhutu, Victor;Songstad, Nils Gunnar;Moland, Karen Marie
背景：在过去十年中，人们越来越关注许多低收入国家的卫生部门缺乏成果。妇幼保健方面的进展尤其缓慢。由于认识到需要加快实现这些保健成果的进度，一些国家启动了按业绩计薪计划。本文探讨的看法和经验的卫生工作者与P4P奖金分配在卫生系统的农村context of rural Tanzania.Methods：这项定性研究的基础上P4P试点在坦桑尼亚的Pwani地区。这项研究在鲁菲吉区的11个卫生保健设施进行。研究的被调查者和参与者是分配到卫生机构不同门诊和住院部的不同卫生工作者干部，以及P4P奖金分配的当地管理人员。与行政人员和卫生保健工作者进行了32次深入访谈（IDI），并与生殖和儿童健康（RCH）工作人员、非RCH工作人员和非医务人员进行了6次焦点小组讨论（FGD）。收集的数据进行了分析，通过定性内容analysis.Results：研究发现，在P4P程序中采用的奖金分配方式是从根本上不公平的经验。奖金是根据卫生工作者在达到生殖和儿童健康部分的目标指标方面的核心地位计算的。RCH工作人员和非RCH人员都认为P4P奖金不公平。非RCH反对获得比RCH工作人员更少的奖金，而RCH工作人员则反对不获得更多的P4P奖金。非RCH工作人员和卫生管理人员建议将统一费率作为分配P4P奖金的最公平方式。感知的不公平影响了工作动机，破坏了跨部门的团队合作，并在卫生设施的社会关系中造成紧张局势。结论：我们的研究结果表明，在卫生设施一级的奖金分配和管理的方式不公平的经验破坏了P4P计划的合法性。更重要的是，工作场所的长期紧张局势和冲突可能会对P4P旨在改善的护理质量产生负面影响。我们认为，公平是一个P4P计划的成功的关键因素，并应特别注意在P4P奖金结构的设计工作场所的正义方面。
Background: During the last decade there has been a growing concern about the lack of results in the health sectors of many low income countries. Progress has been particularly slow in maternal- and child health. Prompted by the need to accelerate progress towards these health outcomes, pay-for-performance (P4P) schemes have been initiated in a number of countries. This paper explores the perceptions and experiences of health workers with P4P bonus distribution in the health system context of rural Tanzania.Methods: This qualitative study was based on the P4P pilot in Pwani Region of Tanzania. The study took place in 11 health care facilities in Rufiji District. The study informants and participants were different cadres of health workers assigned to different outpatient and inpatient departments at the health facilities, and local administrators of the P4P bonus distribution. Thirty two in-depth interviews (IDIs) with administrators and health care workers, and six focus group discussions (FGDs with Reproductive and Child Health (RCH) staff, non-RCH staff and non-medical staff were conducted. Collected data was analyzed through qualitative content analysis.Results: The study found that the bonus distribution modality employed in the P4P programme was experienced as fundamentally unjust. The bonuses were calculated according to the centrality of the health worker position in meeting targeted indicators, drawn from the reproductive and child health (RCH) section. Both RCH staff and non-RCH perceived the P4P bonus as unfair. Non-RCH objected to getting less bonus than RCH staff, and RCH staff running the targeted RCH services, objected to not getting more P4P bonus. Non-RCH staff and health administrators suggested a flat-rate across board as the fairest way of distributing P4P bonuses. The perceived unfairness affected work motivation, undermined teamwork across departments and created tensions in the social relations at health facilities.Conclusion: Our results suggest that the experience of unfairness in the way bonuses are distributed and administered at the health facility level undermines the legitimacy of the P4P scheme. More importantly, long term tensions and conflicts at the workplace may impact negatively on the quality of care which P4P was intended to improve. We argue that fairness is a critical factor to the success of a P4P scheme and that particular attention should be paid to aspects of workplace justice in the design of P4P bonus structures.