Discussion
Health sector performance hinges on a competent, motivated, and well-supported workforce. If performance gains are to be realized when transitioning from vertical disease-based health programs to integrated primary care systems, HCW satisfaction must be considered as a desired outcome measure. Technical training and enhanced incentives are necessary for improving HCW satisfaction [
32]. However, the existing curricula of health-related professions in the Philippines have limited content and training on primary care. An appraisal conducted on HCW job motivation underscores a systemic approach in improving satisfaction scores and workforce retention [
33]. According to existing literature, insufficient performance incentives and compensation have resulted in poor health outcomes and HCW maldistribution across challenging environments such as the Philippines [
34‐
37]. Non-financial incentives also play a role in attracting physicians to practice in rural health systems, which includes supervision and being near to their families. To address maldistribution, this study initiated several interventions to encourage system integration and HCW capacity-building [
38]. Primary care training workshops and access to UpToDate were provided to HCWs throughout the study period. Additional pharmacies and laboratories were incorporated into existing networks in the rural and remote sites to expand drug supply and services. A unified EHR system was also introduced to all sites to ease patient intake, diagnosis, referral, and monitoring.
In the study’s rural and remote sites, clinical care is delivered across a multitude of facilities. These range from central health units that house a limited number of physicians, to smaller community health stations that primarily operate through the services rendered by nurses, midwives, and CHWs. The introduction of the EHR enhanced system integration across these facilities through a unified patient database. In effect, the EHR enabled previously underutilized community health stations to refer patients to the central health unit and to likewise produce laboratory requests or prescriptions with the remote approval of the patient’s attending primary care physician. Rural HCWs were less dissatisfied with their ability to prescribe medical drugs post-intervention. As supported by post-intervention studies conducted in rural terrains, this likely resulted from the expansion of these services alongside the remote referral/approval capabilities provided by the EHR [
39,
40]. The central health unit of the rural site experienced the highest number of consultations year-round. As such, the referral/approval capabilities aided in distributing patients across the network of available community health stations. While most rural satisfaction scores have remained consistent, majority of rural HCWs (> 90%) were already highly satisfied with all motivational factors during the baseline period. Considerable institutional support and tight integration pre-intervention may have contributed to the high confidence level demonstrated by rural HCWs at baseline [
41]. Their overall satisfaction was mirrored in their greater intention to stay after the implementation of primary care system interventions.
Dissatisfaction towards perceived compensation fairness was consistently high pre-intervention. To address possible gaps in remuneration, performance-based financial incentives were provided to all primary care providers across the three sites during the intervention period. These incentives were calculated based on completed consultations by the involved HCWs per consult. When a patient is initially assessed by a nurse and referred to an attending physician, both HCWs would merit financial incentives in the implemented payment scheme. As indicated in research evaluating the impact of HCWs income, adequate wage provisions are vital to system-incentivized performance improvements [
42,
43] and coordinated care among HCWs within the primary care network [
25]. The results of this study reveal that perceptions towards compensation fairness significantly improved among urban and rural HCWs post-intervention. This may largely be due to the provision of the aforementioned incentives as wages and other fringe benefits across all sites remained the same.
Job hygiene at the remote site showed a conservative decline. Remote HCWs were more dissatisfied with supply accessibility and job security post-intervention. Although urban and rural job hygiene improved with the introduction of financial incentives, the remote site reported no significant difference in HCW perceptions towards perceived compensation fairness post-intervention. A slight decline in the level of satisfaction and the proportion of generally satisfied HCWs were also noted towards several motivation factors. Four underlying contexts can be examined to qualify these results: 1) delayed incentivization [
36]; 2) HCW maldistribution [
42]; 3) weak infrastructure [
44]; and 4) the impact of COVID-19 [
45]. Irregular payments and delayed remuneration contribute to HCW dissatisfaction and ultimately poor retention [
46]. Resulting from administrative delays in the disbursement of additional financial incentives, most remote HCWs received these incentives several months after their services were rendered. This may have significantly mitigated the intended positive impact of incentivization. Although delays in incentive payouts occurred in other sites, the impact of delayed remuneration may have been more difficult to ignore in the remote site given the abundance of other challenges shouldered by its workforce.
Apart from administrative challenges, the demographic composition of remote-based staff likely had some impact on the reported dissatisfaction towards several hygiene factors. CHWs comprised the vast majority of the remote-based workforce surveyed in this study. CHWs are part-time volunteer workers, rendering them ineligible for receiving a regular wage, unlike other primary care providers. Non-urban CHWs typically receive a marginal monthly allowance of Php 1150 (estimated at $24.00 per month) alongside other benefits such as free groceries or medical care depending on the local government unit [
47]. While intrinsic job factors such as perceived social prestige and acquired technical skills have been shown to be critical motivators for CHWs in existing literature [
47], heightened dissatisfaction towards the inadequacy of job hygiene factors relative to the work expected may increase turnover intention as Herzberg’s theory and the findings of this study present.
The sporadic distribution of HCWs, particularly physicians, in remote areas proves potentially hazardous for providers—threatening to overload both staff and infrastructure. Expanding primary care providers’ responsibilities to include public health service delivery may cause low job satisfaction due to inadequate work autonomy and high dissatisfaction due to income mismatch [
48]. HCWs are expected to deliver quality clinical services to individual patients while assuming population health roles for specific health programs (i.e., vaccination, sanitation). Despite the range of tasks HCWs are expected to fulfill, infrastructural gaps in the remote site vastly surpass those of other sites. Intermittent internet connectivity, unreliable transportation, poor maintenance of select health stations, and frequent electrical outages are additional challenges to an already understaffed workforce. These challenges potentially diminish health outcomes, rendering clinical efforts futile or frustrating, and may reinforce low regard for the primary care system—amongst providers and patients [
44,
49]. With infrastructural lacunae and the regular onslaught of natural disasters in this Pacific-facing site, seemingly minor inconveniences have resulted in adverse delays. This is evident in hours of back-encoding patient data, longer patient queues, difficulties in servicing remote communities, and challenges in referring patients throughout the primary care network.
Enhanced retention necessitates providing basic resources required for the job—including improved infrastructure, a unified EHR, supply accessibility, and fair compensation. Furthermore, experiences from the remote site suggest that financial incentives prove more effective once other infrastructural hurdles have already been addressed. System interventions must indeed provide enabling environments to prevent dissatisfaction and reduce workforce attrition. However, as Herzberg’s theory posits, job satisfaction is primarily achieved with a motivated workforce. In the urban site, most HCWs were not dissatisfied with hygiene factors such as workload and overall job security. However, satisfaction with motivational factors was still lower compared to rural and remote scores. Despite being in a well-supported job environment that retained its workforce the longest compared to other sites, urban data shows that good job hygiene alone does not ascertain HCW satisfaction. Providing non-monetary incentives such as training opportunities, pathways for career advancement, and involvement in clinical decision-making proves foremost essential in improving job satisfaction.
Scope and limitations
This study employed a diachronic approach in evaluating HCW satisfaction across three sites, with varying baseline and endline periods per site due to funding and infrastructural constraints. The endline responses from the rural and remote sites were obtained shortly after the onset of the COVID-19 pandemic. As such, the shifting social and economic climate may have affected responses at the time of the survey. Other factors such as survivor bias may have had some impact on the reported results. Only respondents with matched scores (i.e., HCWs present in both baseline and endline periods) were included for analysis. Other factors influencing satisfaction were not controlled. As such, the magnitude of each factor and its corresponding effect on satisfaction and intent to stay was outside the scope of the present study. Attempts to further contextualize satisfaction scores have been undertaken to grasp a holistic understanding of HCW experience. These were done through informal interviews with HCWs, and long-term participant observation of field teams deployed to each site. However, we were unable to measure the role of corruption in this study and we suggest that future studies collect data on this to better qualify and quantify its effect. With these limitations outlined, this research places greater focus on the possible impact of specific interventions undertaken in strengthening primary care networks in each area.
Conclusion
This study presents the observed impact of strengthening urban, rural, and remote primary care system interventions on primary care providers. Using Herzberg’s two-factor classification, overall job satisfaction and turnover intention were examined through motivational and hygiene factors experienced in each site before and after the implementation of study interventions. Perceptions towards job hygiene factors improved post-intervention at urban and rural sites—likely because of performance-based financial incentives provided to all HCWs during the study. Alongside the provision of monetary incentives, the expansion of service delivery networks to include additional pharmacies in the rural site showed a positive impact among HCWs in their regard for medical supply.
Despite attempts to strengthen the existing primary care system and potentially exacerbated by the effects of the COVID-19 pandemic, infrastructural deficits have contributed to lower motivation and higher dissatisfaction among remote HCWs during the endline period. Reducing dissatisfaction by addressing hygiene factors at the workplace proves vital in retaining HCWs in remote and disadvantaged areas. This may be done by providing adequate remuneration and ensuring work environments support the demands of person-centered integrated care. However, targeting system interventions aimed at improving motivational factors may render beneficial in retaining a satisfied workforce in the long term. Strengthening primary care systems must, therefore, consider interventions that address motivational and job hygiene needs to improve healthcare worker satisfaction and intention to stay. This includes addressing HCW needs, strengthening infrastructural support, and enhancing primary care training across all HCW cadres. In doing so, patient-centered primary care can ultimately be better sustained by the very workforce it is founded upon.
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