title: Establishing sustainable performance-based incentive schemes: views of rural health workers from qualitative research in three sub-Saharan African countries.
abstract: BACKGROUND
  Performance-based incentives (PBIs) are currently receiving attention as a strategy for improving the quality of care that health providers deliver. Experiences from several African countries have shown that PBIs can trigger improvements, particularly in the area of maternal and neonatal health. The involvement of health workers in deciding how their performance should be measured is recommended. Only limited information is available about how such schemes can be made sustainable. This study explored the types of PBIs that rural health workers suggested, their ideas regarding the management and sustainability of such schemes, and their views on which indicators best lend themselves to the monitoring of performance. In this article the authors reported the findings from a cross-country survey conducted in Burkina Faso, Ghana and Tanzania.
  
  
  METHODS
  The study was exploratory with qualitative methodology. In-depth interviews were conducted with 29 maternal and neonatal healthcare providers, four district health managers and two policy makers (total 35 respondents) from one district in each of the three countries. The respondents were purposively selected from six peripheral health facilities. Care was taken to include providers who had a management role. By also including respondents from district and policy level a comparison of perspectives from different levels of the health system was facilitated. The data that was collected was coded and analysed with support of NVivo v8 software.
  
  
  RESULTS
  The most frequently suggested PBIs amongst the respondents in Burkina Faso were training with per-diems, bonuses and recognition of work done. The respondents in Tanzania favoured training with per-diems, as well as payment of overtime, and timely promotion. The respondents in Ghana also called for training, including paid study leave, payment of overtime and recognition schemes for health workers or facilities. Respondents in the three countries supported the mobilisation of local resources to make incentive schemes more sustainable. There was a general view that it was easier to integrate the cost of non-financial incentives in local budgets. There were concerns about the fairness of such schemes from the provider level in all three countries. District managers were worried about the workload that would be required to manage the schemes. The providers themselves were less clear about which indicators best lent themselves to the purpose of performance monitoring. District managers and policy makers most commonly suggested indicators that were in line with national maternal and neonatal healthcare indicators.
  
  
  CONCLUSIONS
  The study showed that health workers have considerable interest in performance-based incentive schemes and are concerned about their sustainability. There is a need to further explore the use of non-financial incentives in PBI schemes, as such incentives were considered to stand a greater chance of being integrated into local budgets. Ensuring participation of healthcare providers in the design of such schemes is likely to achieve buy-in and endorsement from the health workers involved. However, input from managers and policy makers is essential to keep expectations realistic and to ensure the indicators selected fit the purpose and are part of routine reporting systems.
authors.affiliation: Department of Research, Training and Communication, Nouna Health Research Centre, Nouna, Burkina Faso. yemaure@yahoo.fr.
authors.forename: M
authors.initials: M
authors.lastname: Yé
authors.affiliation: QUALMAT Project, Navrongo Health Research Centre, Navrongo, Ghana. gapiung@gmail.com.
authors.forename: G A
authors.initials: GA
authors.lastname: Aninanya
authors.affiliation: Nouna Health Research Centre, Nouna, Burkina Faso. alisie.crsn@fasonet.bf.
authors.forename: A
authors.initials: A
authors.lastname: Sié
authors.affiliation: Department of Medical Anthropology, Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar-Es-Salaam, Tanzania. knkuru@yahoo.com.
authors.forename: D C V
authors.initials: DC
authors.lastname: Kakoko
authors.affiliation: Navrongo Health Research Centre, Navrongo, Ghana. schatio@yahoo.co.uk.
authors.forename: S
authors.initials: S
authors.lastname: Chatio
authors.affiliation: Nouna Health Research Centre, Nouna, Burkina Faso. kmoubache@yahoo.fr.
authors.forename: M
authors.initials: M
authors.lastname: Kagoné
authors.affiliation: Institute of Public Health, University of Heidelberg, Heidelberg, Germany. helen.prytherch@yahoo.com.
authors.forename: H
authors.initials: H
authors.lastname: Prytherch
authors.affiliation: QUALMAT Project, Institute of Public Health, University of Heidelberg, Heidelberg, Germany. svetla.loukanova@urz.uni-heidelberg.de.
authors.forename: S
authors.initials: S
authors.lastname: Loukanova
authors.affiliation: Navrongo Health Research Centre, Navrongo, Ghana. williamsjeo@hotmail.com.
authors.forename: J E
authors.initials: JE
authors.lastname: Williams
authors.affiliation: Institute of Public Health, University of Heidelberg, Heidelberg, Germany. rainer.sauerborn@urz.uni-heidelberg.de.
authors.forename: R
authors.initials: R
authors.lastname: Sauerborn
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D001291:Attitude of Health Personnel; D005260:Female; D006282:Health Personnel / Q000523:psychology*; D006801:Humans; D007318:Inservice Training; D008297:Male; D008427:Maternal Health Services / Q000458:organization & administration*; D008875:Middle Aged; D009042:Motivation; D036301:Qualitative Research; D011787:Quality of Health Care / Q000458:organization & administration*; D012456:Salaries and Fringe Benefits
keywords: Health Service reform; Public Health; Qualitative Research; Workforce