Primary care providers' preferences for pay-for-performance programs: a discrete choice experiment study in Shandong China.

BACKGROUND: Pay-for-performance (P4P) schemes are commonly used to incentivize primary healthcare (PHC) providers to improve the quality of care they deliver. However, the effectiveness of P4P schemes can vary depending on their design. In this study, we aimed to investigate the preferences of PHC providers for participating in P4P programs in a city in Shandong province, China. METHOD: We conducted a discrete choice experiment (DCE) with 882 PHC providers, using six attributes: type of incentive, whom to incentivize, frequency of incentive, size of incentive, the domain of performance measurement, and release of performance results. Mixed logit models and latent class models were used for the statistical analyses. RESULTS: Our results showed that PHC providers had a strong negative preference for fines compared to bonuses (- 1.91; 95%CI - 2.13 to - 1.69) and for annual incentive payments compared to monthly (- 1.37; 95%CI - 1.59 to - 1.14). Providers also showed negative preferences for incentive size of 60% of monthly income, group incentives, and non-release of performance results. On the other hand, an incentive size of 20% of monthly income and including quality of care in performance measures were preferred. We identified four distinct classes of providers with different preferences for P4P schemes. Class 2 and Class 3 valued most of the attributes differently, while Class 1 and Class 4 had a relatively small influence from most attributes. CONCLUSION: P4P schemes that offer bonuses rather than fines, monthly rather than annual payments, incentive size of 20% of monthly income, paid to individuals, including quality of care in performance measures, and release of performance results are likely to be more effective in improving PHC performance. Our findings also highlight the importance of considering preference heterogeneity when designing P4P schemes.

Job satisfaction of the primary healthcare providers with expanded roles in the context of health service integration in rural China: a cross-sectional mixed methods study.

OBJECTIVE: Against the backdrop of integrating public health services and clinical services at primary healthcare (PHC) institutions, primary healthcare providers (PCPs) have taken on expanded roles. This posed a potential challenge to China as it may directly impact PCPs' workload, income, and perceived work autonomy, thus affecting their job satisfaction. This study aimed to explore the association between the expanded roles and job satisfaction of the PCPs in township healthcare centers (THCs), the rural PHC institutions in China. METHODS: A cross-sectional study using mixed methods was conducted in 47 THCs in China's Shandong province. Based on a sample of 1146 PCPs, the association between the proportion of PCPs' working time spent on public health services and PCPs' self-reported job satisfaction was estimated using the logistic regression. Qualitative data were also collected and analyzed to explore the mechanism of how the expanded roles impacted PCPs' job satisfaction. RESULTS: One hundred eighty-four physicians and 146 nurses undertook increased work responsibilities, accounting for 15.91% and 12.61% of the total sample. For those spending 40-60%, 60-80%, and more than 80% of the working time providing public health services, the time spent on public health was negatively associated with job satisfaction, with the odds ratio being 0.199 [0.067-0.587], 0.083 [0.025-0.276], and 0.030 [0.007-0.130], respectively. Qualitative analysis illustrated that a majority of the PCPs with expanded roles were dissatisfied with their jobs due to the heavy workload, the mismatch between the income and the workload, and the low level of work autonomy. PCPs' heavier work burden was mainly caused by the current public health service delivery policy and the separation of public health service delivery and regular clinical services delivery, a significant challenge undermining the efforts to better integrate public health services and clinical services at PHC institutions. CONCLUSION: The current policies of adding public health service delivery to the PHC system have negative impacts on PCPs' job satisfaction through increased work responsibilities for PCPs, which have led to low work autonomy and the mismatch between the income and the workload. The fundamental reason lies in the fragmented incentives and external supervision for public health service delivery and clinical service delivery. Policy-makers should balance the development of clinic and public health departments at the institutional level and integrate their financing and supervision at the system level so as to strengthen the synergy of public health service provision and routine clinical service provision.

Analysis of context factors in compulsory and incentive strategies for improving attraction and retention of health workers in rural and remote areas: a systematic review.

BACKGROUND: Current literature systematically reports that interventions to attract and retain health workers in underserved areas need to be context specific but rarely defines what that means. In this systematic review, we try to summarize and analyse context factors influencing the implementation of interventions to attract and retain rural health workers. METHODS: We searched online databases, relevant websites and reference lists of selected literature to identify studies on compulsory rural service programmes and financial incentives. Forty studies were selected. Information regarding context factors at macro, meso and micro levels was extracted and synthesized. RESULTS: Macro-level context factors include political, economic and social factors. Meso-level factors include health system factors such as maldistribution of health workers, growing private sector, decentralization and health financing. Micro-level factors refer to the policy implementation process including funding sources, administrative agency, legislation process, monitoring and evaluation. CONCLUSIONS: Macro-, meso- and micro-level context factors can play different roles in agenda setting, policy formulation and implementation of health interventions to attract and retain rural health workers. These factors should be systematically considered in the different stages of policy process and evaluation.

Work Motivation of Primary Health Workers in China: The Translation of a Measurement Scale and Its Correlation with Turnover Intention.

Background: High turnover intention, as a manifestation of low work motivation, is a crucial barrier to strengthening primary health systems worldwide, including in China. Targeting those being less motivated will be a realistic choice to retain primary health workers. This study translate, adapt, and validate the Work Motivation Scale for Health Workers (WMSHW) scale to directly measure and rate health workers' motivation composition based on Self-Determination Theory, and assessed how health workers with different levels of motivation being associated with the turnover intention. Methods: The process of translation and cross-cultural adaptation followed the recommendations of international guidelines. Participants include 1341 health workers within 75 primary health institutions from 6 provinces in China. The reliability and validity of the scale was analyzed. Cluster analysis in a person-centered approach and logistic regression analysis was used to understand how different combinations of motivations related to intention to leave. Results: Confirmatory factor analysis indicated that the modified five-factor model had a better fit than the other models in accordance with the original English version. The factor loads were high and ranged from 0.70 to 0.9. Cronbach's alpha coefficients for five dimensions of the Chinese WMSHW ranged from 0.81 to 0.94, indicating the scale's high internal consistency. Four distinct clusters of work motivation were found in this study, representing low motivated, highly controlled, highly autonomous and highly motivated primary health workers. Compared with low motivation group, both controlled and autonomous motivation groups were more likely to have lower turnover intention. The negative relationship between motivation and intention to leave became stronger with the level of motivation increasing: highly controlled cluster (OR: 0.47; 95% CI: 0.35-0.63), highly autonomous (OR: 0.27; 95% CI: 0.18-0.41) and highly motivated (OR: 0.20; 95% CI: 0.15-0.27). Conclusion: The Chinese version of WMSHW showed satisfactory reliability and validity and can be used as an instrument for measuring and rating the work motivation of Chinese health workers. The primary health workers were grouped into four motivation levels based on this scale. Both controlled and autonomous motivation could work in reduce the turnover intention, and the influence of autonomous motivation on retaining was stronger.

Precision targeting for more equitable distribution of health professionals in rural China.

A strong health workforce is widely recognized as a prerequisite for health care and a crucial determinant of health system performance. The number of health professionals in China increased following the 2009 health system reform, which, in part, aimed to address the shortage and unequal distribution of health professionals. We examined whether the distribution of health professionals was more equitable following the reform and whether the reform had targeted impacts in terms of the quantity of health professionals. We interacted economic (poor and non-poor counties) and geographic (eastern, central and western regions) dimensions to more precisely target vulnerable areas, focussing on the quantity and distribution of health professionals in rural China. We used a county-level longitudinal dataset from the National Health and Family Planning Commission consisting of 1978 counties in all 31 provinces in rural China, with measurements taken every other year from 2008 to 2014. The distribution of health professionals was summarized using descriptive and interaction analyses. We found a constant improvement in the number of health professionals per 1000 population co-existing with a worsening of the distribution across rural China following the health system reform. Most of the non-poor counties improved faster compared with poor counties across all geographic regions, especially in the western and eastern regions. The growth of the number of health professionals per 1000 population was greatest and fastest in western-non-poor counties and least and slowest in eastern-poor counties. As an example of the 'Central Region Downfall' phenomenon, the central counties (both poor and non-poor) performed poorly in terms of the quantity and distribution of health professionals. Based on an analysis of multiple dimensions, targeted and differential measures should be taken to reduce inequalities, and the central region should not be ignored in efforts to improve the distribution of health professionals in rural China.