Background
Theoretical framework
Pay-for-performance (P4P) in Tanzania
Methods
Study setting
Study design and data collection
Research participants
Category of informant | Number of interviews |
---|---|
Medical Officers (MO) | 2 |
Assistant Medical Officers (AMO) | 2 |
Clinical Officers (CO) | 3 |
Nursing staff | 11 |
Medical attendants (MA) | 11 |
Laboratory staff | 2 |
Official from the district health office | 1 |
FGD number | Category of staff | Location | Participants | Men | Women |
---|---|---|---|---|---|
FGD 1 | RCH | Hospital K | 5 | 1 | 4 |
FGD 2 | RCH | Health Centre D | 5 | 1 | 4 |
FGD 3 | RCH | Dispensary B | 4 | 0 | 4 |
FGD 4 | non-RCH | Hospital K | 6 | 3 | 3 |
FGD 5 | non- RCH | Health Centre E | 5 | 3 | 2 |
FGD 6 | non- medical | Hospital H | 5 | 4 | 1 |
Data analysis
Category: bonus distribution concerns in OpenCode 3.6 | ||||
---|---|---|---|---|
Meaning unit | Condensed meaning unit | Interpretation underlying meaning | Sub-theme | Theme |
Description close to the text | ||||
The report for RBF comes from RCH every end of the month, but when the bonus come it is shared equally, even with ecurity guards | RCH staff do more work | RBF indicators are from RCH | Negative perceptions towards RBF bonus distribution and their influence on social and work relations | Perceived unfairness over RBF bonus |
I think it is a normal problem for human to fight for money. Sometimes you see someone who doesn’t even put an effort at work claiming that they need more bonus share | Money always cause problems | Sharing money is a problem | ||
RCH’s work is important but they cannot accomplish this task alone, why then do they need more bonus than anyone else. Everyone deserves the same RBF bonus. | Flat rates are fair ‘everyone toils’ | A flat rate need to be used for RBF bonuses | ||
When we sit and try to solve our problems here concerning RBF bonus, the RCH staff do not support me because RBF favors them. I see this program has some negative impacts. Just imagine you have a family and you give food to one of your child while the others are looking | RBF encouraging conflicts among workers | RBF bonus distribution causing conflicts | ||
We normally get our bonuses too late. Sometimes, some people can get their money early while others get it late and we wonder how this is possible | The need for RBF bonus to be distributed timeously | Bonus is delayed | RBF management concerns/problems | |
Sometimes we do good work and report good data, but during the verification process, somehow we always end up with lower figures. This affects our RBF bonus money. We don’t know what they take into consideration | Data is not captured properly | RBF data is not captured properly | ||
The thing I don’t like about RBF is that it doesn’t consider the workload. As you can see we are a dispensary here but we do a lot and serve many people, …sometimes more than a health centre but when RBF bonus money come they don’t consider that workload or the number of people we serve | Target setting not fair | The criteria for setting RBF targets not fair |
Results
Interpersonal and inter-departmental relations
We do a lot here in RCH
“You see P4P indicators are from RCH, we do a lot here to meet P4P targets, a person from the laboratory doesn’t even touch the P4P report, and even our doctor here doesn’t know how to fill that report. Yes, we work with them but it is only us who prepare the P4P report and because of this RCH need to get more bonus money. You know during the first round we even got the same amount as security guards, how is this possible?” (Nurse-RCH staff, Dispensary A, IDI)
“When P4P came we thought it was for all. But later we discovered it wasn’t even for me, a doctor or other staff, it is only for RCH. We don’t know why it is for some people only while we all work here. How come only some are benefitting? We were all happy in the beginning, but we came to know that there was a special group chosen. During the last distribution, I was given as little as TZS 18,000, (RCH staff at this facility got TZS 120,000) just the same as a security guard and a laundry man” (Assistant medical officer- non-RCH staff, Dispensary B, IDI)
P4P bonus distribution discourages us
“When the program started we were motivating each other to work hard and together. But later we heard that some staff will not be paid and we became discouraged. There are a lot of things we do to assist the RCH department, like encouraging pregnant mothers and or encouraging them to come with their children for check-ups, including even treating them. But when the P4P bonus started to create these groups we became automatically discouraged because even if you make an effort, you will not be paid as others. Why work in order for others to get money?” (Non-RCH staff, Health Centre E, FGD 5)
“The problem is that an element of selfishness is present when people think of money, especially when a person works in a section getting less P4P bonus knowing that someone is getting more money in another section. In the end you find that everyone wants to work in one section, the RCH” (Medical officer-non-RCH staff, Hospital H, IDI)
“The program is good, but the problem starts when the money is distributed. My opinion is that the money should be shared equally to all because all workers have their own responsibilities. The RCH does more on P4P records but we have to keep in mind that it is their duty. For example a driver does a lot, taking RCH people to outreach and assisting them with their work. P4P is the only motivation we have; other high ranked staff can go for trainings and seminars [where they have opportunities to get per diems], what about a security guard?” (Non-medical staff, Hospital H, FGD 6)
P4P is causing segregation and tensions
“P4P segregates other workers and to me that is the problem. For example, the security guards are not involved in treatments but they are an important part of the dispensary. As a supervisor of the dispensary I see them all as important in meeting our objectives. If a security guard doesn’t perform his duty well and some damage or theft happen at the RCH, how will they deliver their patients? Is it fair to give him less P4P money? Can you give food to one of your child while the others are just looking?” (Clinical officer-non-RCH staff, Dispensary A, IDI)
A flat rate is better
“This P4P money to us is just like an asante (thank you). You can’t divide an asante and say this one will get a bigger portion because they have a higher training or because they do more work. Every worker here has a salary and we know and agree that a salary need to consider the level of education and training but not an asante . However, people are selfish when it comes to money, you start to hear many staff categories and this destroys the motivation they intend to build. Personally I think a flat rate is fair.” (Non-RCH, Hospital K, FGD 4)
“Bonus distribution is a problem, in one way the RCH plays a big role and P4P’s main focus is to reduce maternal- and infant mortality. On the other hand, non-RCH also plays an important role in this since RCH staff cannot do their tasks independently of others. When it comes to payment we are facing this problem and non-RCH a staff is threatening to leave all the tasks related to P4P bonuses to the RCH staff. If this happens, the RCH staff cannot manage these tasks alone. Therefore my opinion is to make the rates flat so that everyone can participate effectively knowing that we are going to get the same bonuses. This also helps in reducing the tensions we face since the introduction of P4P. (Official from district health offices, Utete, IDI)
P4P management and target setting concerns
“The thing I don’t like about P4P is that it doesn’t consider the workload. As you can see we are a dispensary here but we do a lot and serve many people. For example our vaccination target is of 60 children per month, and yet other dispensaries can have a target of as little as five but in the end we are all paid an equal P4P bonus. And let’s say if we don’t reach 40 children, which is 80% of the target, we get nothing despite the hard work. Yet someone with five children, which is their 100%, are paid fully. So you see. It is not ok.” (Nurse- RCH staff, Dispensary A, IDI)
“Sometimes we do good work and report good data, but during the verification process, somehow we always end up with lower figures. This affects our P4P bonus money. We don’t know what they take into consideration.” (RCH staff, Dispensary B, FGD 3)
“We normally get our bonuses too late. We have had a situation where people nearly fought in order to get their bonuses. At this facility, sometimes, some people can get their money early while others get it late and we wonder how this is possible. We need to get the money in our bank accounts just like our salaries”. (Non-RCH staff, Health Centre E, FGD 5)
“Generally we think P4P is a good thing, but of course there are concerns like that bonuses have to be increased or that they are delayed or concerning the distribution modalities at facilities. On the delays we have to admit that it is also our internal problems and we are partially responsible for the delays.” (Official from district health office, Utete, IDI).