Qualitative Study of In-kind Incentives to Improve Healthcare Quality in Belize: Is Quality Work Better Than Wealth?

Overview

Journal PLoS One

Specialties General Medicine
Science

Date 2023 Aug 18

PMID 37594970

Authors

Diego Rios-Zertuche

Angel Eugenio Benitez Collante

Ana Mylena Aguilar Rivera

Armelle Gillett

Natalia Largaespada Beer

Julio Sabido

Karla Schwarzbauer

Affiliations

Soon will be listed here.

Abstract

Background: There is a sparsity of knowledge of the specific mechanisms through which financial and non-financial incentives impact the performance of health teams. This study aims to address this knowledge gap by examining an in-kind incentives program for healthcare teams implemented in three districts in Belize (2012-2022) as part of the Salud Mesoamerica Initiative, which aimed to improve healthcare quality.

Methods: We performed a qualitative study to understand the mechanisms through which the in-kind incentive program supported quality improvement in Belize. We conducted key informant interviews (April-June 2021) remotely on a sample of former and current healthcare workers from Belize's Ministry of Health and Wellness familiar with the program. We analyzed responses using qualitative content analysis. We used open coding to identify patterns and themes.

Results: We conducted eight key informant interviews from a pool of thirty potential informants. Our analysis of the interviews yielded a total of 11 major themes with 27 subthemes. Most informants reported that in-kind incentives were not the primary motivation for improving their performance, though they did acknowledge that incentives had increased their attention on the quality of care provided. Conversely, we found that quarterly measurements and supportive supervision by national level authorities offered an external validation mechanism and instilled frontline staff with a sense of shared responsibility towards improving their performance. The majority of informants conveyed positive opinions about the in-kind incentives program.

Conclusions: Our study contributes to the understanding of how in-kind incentives can enhance performance. We found that in-kind incentives created extrinsic motivation, leading to an increased focus on quality. Standardized measurements and supportive supervision improved intrinsic motivation and formed a stronger commitment to quality of care. Rather than focusing on tangible incentives, explicitly incorporating standardized measurements and supportive supervision in the routine work of the Ministry of Health could have longer lasting effects on quality improvement.

References

Doran T, Kontopantelis E, Valderas J, Campbell S, Roland M, Salisbury C . Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework. BMJ. 2011; 342:d3590. PMC: 3125475. DOI: 10.1136/bmj.d3590. View

Rios-Zertuche D, Zuniga-Brenes P, Palmisano E, Hernandez B, Schaefer A, Johanns C . Methods to measure quality of care and quality indicators through health facility surveys in low- and middle-income countries. Int J Qual Health Care. 2018; 31(3):183-190. PMC: 6464097. DOI: 10.1093/intqhc/mzy136. View

Tong A, Sainsbury P, Craig J . Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007; 19(6):349-57. DOI: 10.1093/intqhc/mzm042. View

Diaconu K, Falconer J, Verbel A, Fretheim A, Witter S . Paying for performance to improve the delivery of health interventions in low- and middle-income countries. Cochrane Database Syst Rev. 2021; 5:CD007899. PMC: 8099148. DOI: 10.1002/14651858.CD007899.pub3. View

Kruk M, Gage A, Joseph N, Danaei G, Garcia-Saiso S, Salomon J . Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018; 392(10160):2203-2212. PMC: 6238021. DOI: 10.1016/S0140-6736(18)31668-4. View

Leatherman S, Ferris T, Berwick D, Omaswa F, Crisp N . The role of quality improvement in strengthening health systems in developing countries. Int J Qual Health Care. 2010; 22(4):237-43. DOI: 10.1093/intqhc/mzq028. View

Perreira T, Innis J, Berta W . Work motivation in health care: a scoping literature review. Int J Evid Based Healthc. 2016; 14(4):175-182. DOI: 10.1097/XEB.0000000000000093. View

Aninanya G, Howard N, Williams J, Apam B, Prytherch H, Loukanova S . Can performance-based incentives improve motivation of nurses and midwives in primary facilities in northern Ghana? A quasi-experimental study. Glob Health Action. 2016; 9:32404. PMC: 5065697. DOI: 10.3402/gha.v9.32404. View

Tan S, Melendez-Torres G . Do prospective payment systems (PPSs) lead to desirable providers' incentives and patients' outcomes? A systematic review of evidence from developing countries. Health Policy Plan. 2017; 33(1):137-153. DOI: 10.1093/heapol/czx151. View

10.

Matsuoka S, Obara H, Nagai M, Murakami H, Chan Lon R . Performance-based financing with GAVI health system strengthening funding in rural Cambodia: a brief assessment of the impact. Health Policy Plan. 2013; 29(4):456-65. DOI: 10.1093/heapol/czt030. View

11.

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. Soc Sci Med. 2016; 169:1-8. DOI: 10.1016/j.socscimed.2016.09.006. View

12.

Tyllinen M, Kaipio J, Laaveri T, Nieminen M . End-Users' Voice in EHR Selection: Development of a Usability Questionnaire for Demonstrations in Procurement (DPUQ). Stud Health Technol Inform. 2017; 234:346-351. View

13.

van Dorssen-Boog P, De Jong J, Veld M, van Vuuren T . Self-Leadership Among Healthcare Workers: A Mediator for the Effects of Job Autonomy on Work Engagement and Health. Front Psychol. 2020; 11:1420. PMC: 7381118. DOI: 10.3389/fpsyg.2020.01420. View

14.

Millar R, Chen Y, Wang M, Fang L, Liu J, Xuan Z . It's all about the money? A qualitative study of healthcare worker motivation in urban China. Int J Equity Health. 2017; 16(1):120. PMC: 5501304. DOI: 10.1186/s12939-017-0616-9. View

15.

Paul E, Albert L, Bisala B, Bodson O, Bonnet E, Bossyns P . Performance-based financing in low-income and middle-income countries: isn't it time for a rethink?. BMJ Glob Health. 2018; 3(1):e000664. PMC: 5859812. DOI: 10.1136/bmjgh-2017-000664. View

16.

Bailey C, Blake C, Schriver M, Cubaka V, Thomas T, Martin Hilber A . A systematic review of supportive supervision as a strategy to improve primary healthcare services in Sub-Saharan Africa. Int J Gynaecol Obstet. 2015; 132(1):117-25. DOI: 10.1016/j.ijgo.2015.10.004. View