Should performance-based incentives be used to motivate health care providers? Views of health sector managers in Cambodia, China and Pakistan

Abstract

This study qualitatively investigates what factors apart from or in addition to financial incentives can encourage better performance of frontline health care providers. We interviewed health sector managers in Pakistan, Cambodia and China, and they highlighted many potential limitations in the applicability of financial incentives in their contexts. There was a consistent view that providers are not always primarily driven by monetary rewards and that non-monetary rewards – such as recognition from direct supervisors and career development – could have a greater influence on performance. Managers also highlighted several challenges related to the design and implementation of performance management schemes: supervisors may not have performance information necessary to determine which agents to reward; when performance information is available, organisational culture may value other attributes such as social ties or years of experience; finally, concentration of power at higher levels of the health system can reduce supervisors’ ability to manage performance, rewards and accountability. Although health sector managers were enthusiastic about measures to improve performance of providers, our study indicated that specific social, cultural and health system factors may mean that non-monetary rewards and structural changes to support a more transparent and meritocratic working environment should also be considered.

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

“…For example, addressing unethical marketing practices that pharmaceutical companies use to incentivise HCPs is required in addition to a greater emphasis on professional ethics in HCP education [57]. It is also crucial to acknowledge that HCPs often seek additional income or rely on other sources of job motivation because public sector salaries in LMIC are low, and income during clinical training years is typically minimal [58][59][60][61][62]. Finally, low access to affordable diagnostics, and the need for many poor patients earning a daily wage to return to work quickly, will continue to play a role in HCP's decision-making [17].…”

Labour remuneration in the healthcare sector of Ukraine in terms of decent work concept

“…Based on the results of interviewing health sector managers in Pakistan, Cambodia, and China, the scientists (Khan et al , 2020) obtain somewhat different outcomes: health-care providers are not always primarily driven by monetary rewards, and non-monetary rewards (recognition from direct supervisors and career development) could have a greater influence on performance. It means that financial reward is not the only motivation, and the motivational mechanism should include both tangible and intangible incentives.…”

Impact of a multifaceted intervention on physicians’ knowledge, attitudes and practices in relation to pharmaceutical incentivisation: protocol for a randomised control trial

“…Training interventions focusing on increasing technical knowledge and skills are the most common approach used to improve the quality of care 22 23. Our previous research also suggests that an intervention that can enhance GPs’ understanding of COI in medical practice might be useful to enable them to recognise potential actions that threaten professional ethics in their medical practice while interacting with PSRs 13 15. It is clear, however, from consistent evidence on the ‘know-do’ gap that COI related to profit generation from medicine sales plays a critical role in prescribing decisions, as do values associated with professional ethics and altruism 24 25.…”

“… 12–16 First, insufficient income generation from patient consultations alone—as patients are unwilling to spend substantial sums on medical advice without a prescription—resulted in a reliance on other sources of income. 15 Second, limited opportunities for continuing medical education (CME) other than from pharmaceutical companies may lead to a close relationship with pharmaceutical sales representatives (PSRs). 13 Third, inadequate access to diagnostic tools to establish the clinical need for antibiotics, making it easier for doctors to justify defensive overprescribing.…”

“…Our previous research in Pakistan helped us identify three interlinked health system constraints that shape private GPs’ decisions on receiving personal benefits from prescribing antibiotics 12–16. First, insufficient income generation from patient consultations alone—as patients are unwilling to spend substantial sums on medical advice without a prescription—resulted in a reliance on other sources of income 15. Second, limited opportunities for continuing medical education (CME) other than from pharmaceutical companies may lead to a close relationship with pharmaceutical sales representatives (PSRs) 13.…”