Measuring Motivation for Health Care in Low Income Countries

1. Measuring Motivation for Health Care in Low Income Countries Kenneth Leonard University of Maryland

2. Franco et al (2002) “Motivation, in the work context, can be defined as an individual’s degree of willingness to exert and maintain an effort towards organizational goals.” This effort is costly.

3. Extrinsic Motivation • Paying for outcomes or outputs can help to align individual goals with organizational goals • Salary can compensate individuals who pursue organizational goals, but it generally does not align individual and organizational objectives • Does extrinsic motivation augment or diminish other sources of motivation?

4. Sources of Motivation • Individuals have many sources of motivation • They exert effort until marginal benefit equals marginal cost • Maybe, if they have more sources of motivation, they have greater marginal benefits and will therefore exert more effort. • Maybe, if the returns to effort are high enough (the “wage”) they will provide more effort.

5. Intrinsic versus Extrinsic sources of motivation From the management, non-health, literature: • Intrinsic: Associated with the job itself: • Chance to learn new skills • Chance to accomplish things • Extrinsic: Earned for doing the job. • Promotion • Salary • Praise for work well done.

6. Herzberg (1959) two factor model of work place characteristics

7. Do we need satisfied workers? • Satisfied workers exhibit • positive organizational citizenship behaviors, • tend to perform better • are more likely to receive pay increases and promotions • Dissatisfied workers tend to • quit, • engage in destructive behavior (theft, sabotage, drug use) • exhibit work-related fatigue • and have higher illness

8. From a review of Job Satisfaction Instruments (van Saane et al.) “It can be hypothesized that job satisfaction could function as a buffer against conditions favoring a higher turnover.”

9. Ideas in this literature • Multiple sources of motivation, including intrinsic and extrinsic motivation makes worker more satisfied with their job. • Job satisfaction makes better employees (in the non-health labor force world wide) • Job satisfaction makes health workers less likely to quit (in developed countries).

10. “Relative motivational factors” from a discrete choice survey

11. Health Care in Low Income Countries • Health care processes cannot be fully specified and therefore cannot be enforced. • Health care has sector-wide norms and goals and is a service industry. • Health workers must be at least partially motivated by intrinsic factors to meet organizational goals. • Turnover is not the main problem. • We are interested in the process of change.

12. Turnover, absenteeism? • In developing countries, the problem is not turnover: • Never showing up for a posting (refusing a posting) • Not coming to work even if you show up • If people don’t go to the posting, how do we study them? (we have to get them in medical school)

13. Our objectives are different • The goal is performance, not job satisfaction • Improved satisfaction is not necessarily the route to improved performance. • Hygiene factors are not sufficient, we must have motivators • We need to study the process by which changes in motivators leads to changes in performance. • Key motivators should come from the service and professional aspects of health care.

14. Social Preferences and Pro-Social Behavior • “not maximizing own monetary payoffs when those actions affect others’ payoffs” Charness and Rabin (2002) • People are bothself-interested and concerned with the payoff of others. • Pro-social behavior is when individuals voluntarily engage in activities that are costly to themselves but benefit others • “to help others” is a common response to the question: “why did you choose the health care field?”

15. What do we want to know for RBF? • We know performance is low • We are not very likely to make it worse • However, is RBF sustainable? • Is there an easier way (intrinsic motivation)? • Can performance based pay damage the potential for intrinsically motivated health workers? • Does performance based pay increase intrinsic motivation?

16. Pride and Prejudice Model • Health workers seek the esteem of their supervisors and peers in the hierarchy. • By paying them to provide effort, we signal that the esteem of their peers is not a worthy goal. • They provide effort to earn the money, but are no longer intrinsically motivated.

17. Potential sources of intrinsic motivation • Two types of “others” • Patients • Peers • Two directions: • Caring about the welfare of others • Caring what others think of you. • Of these four combinations, two important ones are likely to be: • Patient-Based social preferences: Caring about the welfare of patients. • Peer-Based social preferences: Caring what your peers think of you.

18. The Hawthorne Effect: • Mayo noticed that assembly line workers changed their productivity for reasons that had nothing to do with the process of assembly. • Thus, psychology becomes important in understanding performance. • However, if they change their behavior for odd reasons, do they not also change their attitudes and the way they report them?

19. Let’s look at some common ways to collect data. • Qualitative • Questionnaires on preferences (what motivates you, are you motivated?) • Discrete choice (do you prefer A over B?) • Laboratory Experiments (what do you do in our controlled setting?) • Field experiments (alter something exogenously in the real world) • Performance measurement (measure what you want to produce more of) • RCTs

20. Job Satisfaction Questionnaires • Reliability • Internal consistency (does it represent one underlying factor?) • Test-retest validity • Construct validity (does theory or data suggest we are measuring something meaningful?) • Content Validity (is it sufficiently broad?) • Discriminant Validity or Responsiveness (does it change if it should change?)

22. Question: Does increasing extrinsic incentives crowd out intrinsic incentives? • Intrinsic incentives are necessary to do the job, but can extrinsic incentives increase the motivation of individuals to conform to organizational norms? • Preliminaries: • What is the source of intrinsic incentives? • How much are they currently motivating health workers?

23. Do health workers exert effort to meet organizational goals?

24. How generous are you to strangers? • Give each clinician 100 tokens (worth 15,000 TSH) • Tell him he is paired with an unknown stranger in the next room. • Ask how much he wants to divide the money between himself and the stranger. • No extrinsic benefits from sharing, only extrinsic costs. • Some people may experience intrinsic benefits from giving to strangers.

25. Laboratory Results

26. Proportion Generous by Sector

27. Changes within the Lab Setting

28. Lab and the Field

29. Protocol Adherence by sector and type

30. Changes in Protocol Adherence when observed by a peer and Changes in Lab Behavior

31. Change in Adherence when observed by a peer

32. Change in Adherence when encouraged by a peer

33. A Token 4 groups (randomized) • Control • Immediate Gift • Delayed Gift • Prize for better adherence

34. Timing • Enroll (team leader) • Measure Baseline (secret enumerator) • Peer effect (secret enumerator and visible peer) • Encouragement (Local MD) • Data visits (secret enumerator) • Follow-up (Local MD) • Post study visits (secret enumerator)

35. Response to Gifts and Prizes

36. Results • Large Hawthorne effect shows that basic “hygiene” conditions are not met. • Failure of supervision or social interactions • Thus, patient-focused social preferences are not playing a sufficient role in increasing quality • Hard to crowd out what isn’t there.

37. Peer-Based social preferences • Health workers care what their peers think of them • We have always known this • The data supports this • A profession is supposed to self-regulate and then sell the collective quality of its services to the public. • Calling it a profession and creating a professional society does not make this happen. • In Tanzania, NGOs have created an environment that appears to have produced same result within the organization. • No dependence on generosity • High levels of peer motivation (in the baseline) • High levels of quality

38. Professional Health Workers • Although generosity does not mean health workers conform to organizational norms, it is possible that being a professional does: • Is professionalism: • Type? • Learned? • How would we identify a professional? • Would extrinsic incentives damage the activities of this kind of health worker?

39. What does this mean for RBF? • Any program that increases the contact with health workers, provides guidance and notices improvements in quality is likely to improve quality • Extra funds can make improvements easier • There may be very little extrinsic motivation in a pay for performance scheme.

40. Conclusion • Performance by itself does not indicate the type of motivation • Motivation is difficult to measure because of the Hawthorne effect • Linking motivation and performance is not a causal story • We don’t know which instruments are responsive and valid. • Changes in motivation and changes in behavior are better ways to investigate.

41. Instruments • Qualitative • Questionnaires on preferences (what motivates you, are you motivated?) • Discrete choice (do you prefer A over B?) • Laboratory Experiments (what do you do in our controlled setting?) • Field experiments (alter something exogenously in the real world) • Performance measurement (measure what you want to produce more of) • RCTs