Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Globalization and Health
Published in: Globalization and Health 1/2012

Open Access 01-12-2012 | Research

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

Authors: Nils Gunnar Songstad, Ida Lindkvist, Karen Marie Moland, Victor Chimhutu, Astrid Blystad

Published in: Globalization and Health | Issue 1/2012

Login to get access

Abstract

Background

Health workers’ motivation is a key determinant of the quality of health services, and poor motivation has been found to be an obstacle to service delivery in many low-income countries. In order to increase the quality of service delivery in the public sector in Tanzania, the Open Performance Review and Appraisal System (OPRAS) has been implemented, and a new results-based payment system, Payment for performance (P4P) is introduced in the health sector. This article addresses health workers’ experiences with OPRAS, expectations towards P4P and how lessons learned from OPRAS can assist in the implementation of P4P. The broader aim is to generate knowledge on health workers’ motivation in low-income contexts.

Methods

A qualitative study design has been employed to elicit data on health worker motivation at a general level and in relation to OPRAS and P4P in particular. Focus group discussions (FGDs) and in-depth interviews (IDIs) have been conducted with nursing staff, clinicians and administrators in the public health sector in a rural district in Tanzania. The study has an ethnographic backdrop based on earlier long-term fieldwork in Tanzania.

Results

Health workers evaluated OPRAS and P4P in terms of the benefits experienced or expected from complying with the tools. The study found a general reluctance towards OPRAS as health workers did not see OPRAS as leading to financial gains nor did it provide feedback on performance. Great expectations were expressed towards P4P due to its prospects of topping up salaries, but the links between the two performance enhancing tools were unclear.

Conclusions

Health workers respond to performance enhancing tools based on whether the tools are found appropriate or yield any tangible benefits. The importance placed on salary and allowances forms the setting in which OPRAS operates. The expected addition to the salary through P4P has created a vigorous discourse among health workers attesting to the importance of the salary for motivation. Lessons learned from OPRAS can be utilized in the implementation of P4P and can enhance our knowledge on motivation and performance in the health services in low-income contexts such as Tanzania.
Appendix
Available only for authorised users
Literature
1.
World Health Organization: The World Health Report 2006: Working together for health. 2006, Geneva: World Health OrganizationCrossRef
2.
Ryan RM, Deci EL: Intrinsic and extrinsic motivations: Classic definitions and new directions. Contemp Educ Psychol. 2000, 25: 54-67. 10.1006/ceps.1999.1020.CrossRefPubMed
3.
Franco LM, Bennett S, Kanfer R: Health sector reform and public sector health worker motivation: A conceptual framework. Soc Sci Med. 2002, 54 (8): 1255-1266. 10.1016/S0277-9536(01)00094-6.CrossRefPubMed
4.
Eisenhardt KM: Agency theory: an assessment and review. Acad Manage Rev. 1989, 14 (1): 57-74.
5.
Dieleman M, Toonen J, Touré H, Martineau T: The match between motivation and performance management of health sector workers in Mali. Hum Resour Health. 2006, 4: 2-10.1186/1478-4491-4-2.CrossRefPubMedPubMedCentral
6.
Dieleman M, Harnmeijer JW: Improving health worker performance: in search of promising practices. 2006, Geneva: WHO Department of Human Resources for Health
7.
McAuliffe E, Bowie C, Manafa O, Maseko F, Maclachlan M, Hevey D, Normand C, Chirwa M: Measuring and managing the work environment of the mid-level provider - the neglected human resource. Hum Resour Health. 2009, 7: 13-10.1186/1478-4491-7-13.CrossRefPubMedPubMedCentral
8.
McAuliffe E, Manafa O, Maseko F, Bowie C, White E: Understanding job satisfaction amongst mid-level cadres in Malawi: The contribution of organizational justice. Reprod Health Matter. 2009, 17 (33): 80-90. 10.1016/S0968-8080(09)33443-6.CrossRef
9.
Häggström E, Mbusa E, Wadensten B: Nurses' workplace distress and ethical dilemmas in Tanzanian health care. Nurs Ethics. 2008, 15 (4): 478-491. 10.1177/0969733008090519.CrossRefPubMed
10.
Manongi RN, Marchant TC, Bygbjerg IC: Improving motivation among primary health care workers in Tanzania: A health worker perspective. Hum Resour Health. 2006, 4: 6-10.1186/1478-4491-4-6.CrossRefPubMedPubMedCentral
11.
Stringhini S, Thomas S, Bidwell P, Mtui T, Mwisongo A: Understanding informal payments in health care: motivation of health workers in Tanzania. Hum Resour Health. 2009, 7: 53-10.1186/1478-4491-7-53.CrossRefPubMedPubMedCentral
12.
Gilson L, Magomi M, Mkangaa E: The structural quality of Tanzanian primary health facilities. B World Health Organ. 1995, 73 (1): 105-114.
13.
Leonard KL, Masatu MC: Professionalism and the know-do gap: Exploring intrinsic motivation among health workers in Tanzania. Health Econ. 2009, 19 (12): 1461-1477.CrossRef
14.
Mæstad O, Torsvik G, Aakvik A: Overworked? On the relationship between workload and health worker performance. J Health Econ. 2010, 29 (5): 686-698. 10.1016/j.jhealeco.2010.05.006.CrossRefPubMed
15.
Lindkvist I: Health worker motivation and effort in a low-income context: quantitative and qualitative research from Tanzania. 2011, PhD thesis. Bergen, Norway: University of Bergen, Department of Economics, Faculty of Social Sciences
16.
Das J, Hammer J, Leonard K: The quality of medical advice in low-income countries. J Econ Perspect. 2008, 22 (2): 93-114. 10.1257/jep.22.2.93.CrossRefPubMed
17.
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. 2008, 8: 247-10.1186/1472-6963-8-247.CrossRefPubMedPubMedCentral
18.
Gilson L, Hanson K, Sheikh K, Agyepong IA, Ssengooba F, Bennett S: Building the field of health policy and systems research: social science matters. PLoS Med. 2011, 8 (8): e1001079-10.1371/journal.pmed.1001079.CrossRefPubMedPubMedCentral
19.
The United Republic of Tanzania: National Health Policy. 2003, Dar es Salaam: Ministry of Health
20.
The United Republic of Tanzania: Primary health services development programme 2007–2017. 2007, Dar es Salaam: Ministry of Health and Social Welfare
21.
The United Republic of Tanzania: Human resource for health strategic plan 2008–2013. 2008, Dar es Salaam: Ministry of Health and Social Welfare
22.
The United Republic of Tanzania: PSRP II Annual report 2008–09. 2009, Dar es Salaam: President's Office - Public Service Management
23.
The United Republic of Tanzania: Public Service Reform Programme - Phase Two (PSRP II). 2008, Dar es Salaam: President's Office - Public Service Management
24.
The United Republic of Tanzania: The staff circulars 1996–2005. 2005, Dar es Salaam: Tanzania Government Printer
25.
McCourt W: Public Management in Developing Countries. Public Manag Rev. 2008, 10 (4): 467-479. 10.1080/14719030802263897.CrossRef
26.
Oxman AD, Fretheim A: An overview of research on the effects of results-based financing. 2008, Oslo: The Norwegian Knowledge Centre for the Health Services
27.
Trisolini MG: Theoretical perspectives on pay for performance. Pay for performance in health care: methods and approaches. Edited by: Cromwell J, Trisolini MG, Gregory C Pope, Mitchell JB, Greenwald LM. 2011, Research Triangle Park, NC: RTI Press, 77-98.
28.
Smithson P, Iteba N, Mukasa O, Mzige A, Mapunda M, Minja G: Performance-based financing. Report on feasibility and implementation options. 2007, Ifakara: Ifakara Health Research and Development Centre
29.
Morgan L, Eichler R: Pay for performance in Tanzania. 2009, Bethesda, Maryland: Health systems 20/20 project, Abt. Associates Inc
30.
The United Republic of Tanzania: Payment for performance - strategy 2008–2015. 2008, Dar es Salaam: Ministry of Health and Social Welfare
31.
The United Republic of Tanzania: Implementation guideline - payment for performance. 2008, Dar es Salaam: Ministry of Health and Social Welfare
32.
The United Republic of Tanzania: Health sector strategic plan III July 2009 - June 2015. Partnership for delivering the MDGs. 2009, Dar es Salaam: Ministry of Health and Social Welfare
33.
Lauglo M, Swai GBR: Payment for performance appraisal - report to Norad and the Royal Norwegian Embassy, Tanzania. 2009, Oslo: Centre for Health and Social Development (HeSo)
34.
Smithson P, Eichler R, Winani S, Msuya A, Olsen IT, Musch E: Results-based bonus. Design, implementation & budget. 2008, Ifakara: Ifakara Health Research and Development Centre
35.
Chimhutu V: Pay for performance in maternal health in Tanzania: Perceptions, expectations and experiences in Mvomero District. 2011, Master thesis. Bergen, Norway: University of Bergen, Department of Health Promotion and Development, Faculty of Psychology
36.
The United Republic of Tanzania: The Coast Region Pay-for-performance (P4P) pilot programme. Design document. 2010, Dar es Salaam: Ministry of Health and Social Welfare
37.
Malterud K: Kvalitative metoder i medisinsk forskning: en innføring. 2011, Oslo: Universitetsforlaget
38.
Tanzania National Health Research Forum: Guidelines on ethics for health research in Tanzania. 2009, Dar es Salaam: Tanzania National Health Research Forum
39.
Joint Learning Initiative: Human resources for health: Overcoming the crisis. 2004, Cambridge: Mass.: Global Equity Initiative, Harvard University Press
40.
Deci EL, Ryan RM: Intrinsic motivation and self-determination in human behavior. 1985, New York: PlenumCrossRef
41.
Ryan RM, Deci EL: Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000, 55 (1): 68-78.CrossRefPubMed
42.
Justice J: Neglect of cultural knowledge in health planning: Nepal's assistant nurse-midwife program. Anthropology in public health bridging differences in culture and society. Edited by: Hahn RA. 1999, New York: Oxford University Press, 327-344.
43.
Levy PE, Williams JR: The social context of performance appraisal: A review and framework for the future. J Manage. 2004, 30 (6): 881-905.
44.
Songstad NG, Rekdal OB, Massay DA, Blystad A: Perceived unfairness in working conditions: The case of public health services in Tanzania. BMC Health Serv Res. 2011, 11: 34-10.1186/1472-6963-11-34.CrossRefPubMedPubMedCentral
45.
Songstad NG, Moland KM, Massay DA, Blystad A: Why do health workers in Tanzania prefer public sector employment?. BMC Health Serv Res. 2012, 12: 92-10.1186/1472-6963-12-92.CrossRefPubMedPubMedCentral
46.
Ridde V: Per diems undermine health interventions, systems and research in Africa: Burying our heads in the sand. 2010, Tropical Medicine and International Health, Epub ahead of print
47.
Ryan RM: Psychological needs and the facilitation of integrative processes. J Pers. 1995, 63 (3): 397-427. 10.1111/j.1467-6494.1995.tb00501.x.CrossRefPubMed
48.
Issa FHH: Reforming human resource development in Tanzania: Issues, challenges and lessons. Afr J Public Adm Manag. 2007, 18 (1): 39-50.
49.
COWI, Goss Gilroy Inc., EPOS Health Consultants: Joint external evaluation of the health sector in Tanzania 1999–2006. 2007, Copenhagen: COWI
50.
The United Republic of Tanzania: Management of public servants. 2011, Dar es Salaam: President's Office - Public Service Management
51.
The United Republic of Tanzania: Training strategy for local government authorities. 2010, Dar es Salaam: Prime Minister’s Office - Regional Administration and Local Government
52.
Deci EL: Effects of externally mediated rewards on intrinsic motivation. J Pers Soc Psychol. 1971, 18 (1): 105-115.CrossRef
53.
Rosenthal MB, Frank RG: What is the empirical basis for paying for quality in health care?. Med Care Res Rev. 2006, 63 (2): 135-157. 10.1177/1077558705285291.CrossRefPubMed
54.
Golden B, Sloan F: Physician pay for performance: Alternative perspectives. Incentives and choice in health care. Edited by: Sloan FA, Kasper H. 2008, Cambridge, MA: MIT Press, 289-318.CrossRef
55.
Holmstrom B, Milgrom P: Multitask principal-agent analyses: Incentive contracts, asset ownership, and job design. J Law Econ Organ. 1991, 7: 24-52.CrossRef
56.
Basinga P, Gertler PJ, Binagwaho A, Soucat AL, Sturdy J, Vermeersch CM: Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet. 2011, 377 (9775): 1421-1428. 10.1016/S0140-6736(11)60177-3.CrossRefPubMed
57.
Van Herck P, De Smedt D, Annemans L, Remmen R, Rosenthal MB, Sermeus W: Systematic review: Effects, design choices, and context of pay-for-performance in health care. BMC Health Serv Res. 2010, 10: 247-10.1186/1472-6963-10-247.CrossRefPubMedPubMedCentral
Metadata
Title
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
Authors
Nils Gunnar Songstad
Ida Lindkvist
Karen Marie Moland
Victor Chimhutu
Astrid Blystad
Publication date
01-12-2012
Publisher
BioMed Central
Published in
Globalization and Health / Issue 1/2012
Electronic ISSN: 1744-8603
DOI
https://doi.org/10.1186/1744-8603-8-33

Other articles of this Issue 1/2012

Globalization and Health 1/2012 Go to the issue

Review

Crossing the quality chasm in resource-limited settings

Review

A profile and approach to chronic disease in Abu Dhabi

Research

Prevalence of overweight, obesity and thinness in 9–10 year old children in Mauritius

Research

Availability, prices and affordability of the World Health Organization’s essential medicines for children in Guatemala

Debate

Conceptualising global health: theoretical issues and their relevance for teaching

Research

Descriptive review and evaluation of the functioning of the International Health Regulations (IHR) Annex 2