Bonuses were given at a flat rate, yet health workers were satisfied with the payments
The P4P bonuses in Mvomero were paid in February 2011. The District Medical Officer (DMO) and the District Treasurer turned up at each facility and distributed the money in cash. Even though health workers had been told that payments were contingent on performance beforehand, this turned out not to be the case. In contrast to the way that the P4P programme was designed (presented above), the bonus was given at a flat rate and was unrelated to the actual results. Nevertheless, we observed that although payments failed to be contingent on performance, we can still expect the scheme to have worked as performance pay, as long as health workers thought payments would be contingent on performance. However, future effects are another matter entirely. The district administration gave the following reason for paying the bonuses at a flat rate:
In 2009–10 we paid all facilities, they all qualified. We saw how many vaccinations they had given, if they had brought the reports timely, etc. We also looked at deliveries. Some people qualified in some respects and not in others, and since this was like a motivation for the employees, we just paid all the facilities the same amount (…). For the case of last year, we were not able to pay P4P because it was not in the budget (a new ambulance was prioritized). If we had continued with P4P we would have been stricter, we would have put more efforts to check whether they had really improved or not. (District Administrator, 2011)
Each dispensary was given T.Shs 500,000, while each health centre was given T.Shs 700,000 to be equally distributed to all staff members at the facility regardless of rank. These bonuses were approximately 50% of the maximum bonuses stated in the P4P planning documents. Depending on the number of staff who shared the bonus at each facility, the actual sums that individual health workers received varied considerably between the facilities we visited, from T.Shs 18,000 to T.Shs 169,000, with the vast majority receiving more than T.Shs 100,000. In comparison, interviewees had a take home monthly salary varying between T.Shs 380,000 to 450,000. The bonus thus constituted 5-40% of what health workers would usually receive per month. Nonetheless, it should be noted that many of our informants had taken loans to finance their children’s education, and after the deductions of these loans the performance bonuses were even more significant. The majority of the health workers used the bonus for their daily requirements, while three had used the money to move one of their children to a school that was either of higher quality and/or closer to where they worked.
Informants expressed gratitude for having received the payments. While many said that it was “like a dream”, something that they had hoped for but not fully trusted that they would receive (due to a prior experience of nonpayment of allowances), others expressed that they had been quite confident that they would get the bonus:
I wasn’t surprised, as we were told that if we do well this would follow. (Nurse 3, Dispensary C, 2011, received 60,000)
Some respondents brought in the question of unpaid overtime, saying that P4P showed that the government actually cares about them after all:
I think P4P is good because it motivates the workers and makes them realize that the government cares about them. (CO, Dispensary C, 2011, received 169,000)
While some informants hinted that the bonus should preferably have been a bit higher, others emphasized that the bonus was a gift (zawadi) and not part of their regular salary, and therefore not something that they could demand:
I was so glad to see that our superiors considered us, the people at the bottom. (…) And whatever a father decides to give to his son – that is something that cannot be forced. Personally, therefore, I am so happy to have received that reward and I saw the sum as large and satisfactory because I did not expect it to happen. (Nurse 2, Dispensary B, 2011, received 100,000)
None of the interviewed health workers had been informed about the discontinuation of P4P, and many said that they expected new bonus payments to be made. The district administration confirmed that they had not sent out any written information about the discontinuation of the scheme, but that they had attempted to orally inform health workers during supervisions.
Attitudes toward alternative usage of the funds changed after payments were made
In 2010, before the bonus payments had been made, a good number of our informants expressed scepticism towards the idea of P4P. Some informants warned against rewarding health workers in isolation:
P4P is just addressing health workers, but we do not work alone or with no assistance. For example, we are assisted by traditional birth attendants and traditional healers. But if the government had said, OK, we have some incentives for these traditional health workers…ohh surely we would not miss these targets. (Nurse 1, Dispensary D, 2010)
In 2011, a number of our informants said that they had approached Traditional Birth Attendants (TBA) to encourage them to bring women in labour to a health facility, though none argued that TBAs or healers should be given P4P. Another area where the tone has changed is the question of equipment. A number of studies have shown that dispensaries in Tanzania often lack equipment and medicines, and health workers often identify a lack of laboratories as a major hindrance for offering quality care [23]. In 2010, some informants argued that the resources that were to be spent on P4P would have little effect if the equipment situation was not improved as well:
I think P4P will help, but first of all the equipment situation at the facilities has to improve. You know, so that P4P can be successful. But if there is no equipment, we will not be able to give the proper treatment and care needed, and then you can’t reach the target. (Nurse 1, Dispensary C, 2010)
After the bonus payments had been made, however, all but one of our informants were in favour of this way of spending health funds. When asked whether some of the money should instead be used for equipment, the respondent quoted above had this to say:
The fact is that it (P4P) is a good approach. It’s an encouragement since working in a village is tedious. Therefore, when they decided to encourage us ….that was really motivating. It should be continued and it shouldn’t be stopped (in favour of buying equipment). (Nurse 1, Dispensary C, 2011, received T.Shs 38,000)
Other informants were more outspoken when arguing that P4P was a good investment compared to spending money on equipment:
Equipment…? For what? We’re really not in need of equipment. (Nurse 1, Dispensary A, 2011, received T.Shs 125,000)
In 2010, some informants expressed concerns that P4P could lead to unethical behaviour in health care. These health workers felt that P4P was aiming at making them more result-oriented, thereby forcing them to prioritize results over quality care. One nurse expressed this reservation in the following way:
It is not good to use targets. For example, if you are told to treat 100 patients per day, I don’t think you will treat them accordingly, you will just rush them to reach the right number. I don’t think it’s a good idea to put targets in health care. (Lab Assistant, faith based Health Centre, 2010)
When asked whether the forging of data was another possible pitfall of P4P, several informants agreed that this could be a real danger:
They have to think of something that can motivate us and not the P4P-way which says 'when you produce this, then we will give you a bonus’. I think it creates problems where people will forge data at health facilities to meet the target. (Nurse 1, Dispensary A, 2010)
In 2011, the tone had changed considerably. While the above informant said that there may be a chance of forgery since “people need money and some aren’t trust worthy”, the great majority argued strongly that for practical reasons forging data is impossible. Similarly, while many informants agreed in 2010 that P4P might make health workers concentrate on tasks that are rewarded at the expense of other tasks (crowding out), no informants saw this as a problem in 2011.
Informants claim that P4P has improved services, enhanced cooperation and fostered a spirit of competition
Many informants view P4P as a competition between health facilities. They feel that in order to attract clients, they need to offer better services than other primary health facilities in the same area. In the words of one clinical officer:
P4P is part of a competition and every person wants to be a winner. (…) We have several health facilities and we have the same design and the same indicators, and most health workers will say 'why not here’? Every health facility will want to score better than the other. Due to that spirit, some changes will happen in health service provision. (CO, Dispensary A, 2010)
In 2011, when asked whether P4P had entailed competition between facilities, several informants argued that P4P had indeed improved services and that their facility now attracted patients from outside of their catchment area:
P4P has made people be more thorough in the work that they do. Patients decide to go where they find the best treatment. For example, we get patients who aren’t happy with the services elsewhere and they come to our facility for better treatment. We get expecting mothers who were supposed to be treated at Mkindo, but we can’t tell them to go back. (Nurse 1, Dispensary A, 2011)
Poor staff attitudes have been noted in the literature as one of the reasons why expectant mothers prefer to deliver at home without assistance from qualified personnel as opposed to facility delivery. In 2010, nurses explained that they sometimes had to “be a bit hard” on women who were delivering or to raise their voice:
You know patients are so different and difficult. A mother may come in the labour room at the stage of contractions. Some of them get confused, so when you try to tell her something and she doesn’t understand or refuse […] then sometimes you have to be a little bit hard on her. This is to avoid infections and to help her deliver the baby safely. (Assistant Nurse 1, Dispensary B, 2010)
In 2011, nurses still argued that they often needed to be strict with women who come to give birth, that women could not choose birthing position but had to lie down on the delivery bed, and that they would generally not allow relatives to enter the delivery room. At the same time, positive staff attitudes were seen by health workers as one of the strategies to increase service utilization, which would again enable them to meet P4P targets. As one medical attendant puts it:
If you are being given incentives you need to realize that you must have good attitudes towards work and desist from bad behavior, like using bad language to clients. If you do not change you will let your workmates down. (Medical Attendant 1, Dispensary C, 2011, received T.Shs 18,000)
P4P then, appears to have encouraged unity of purpose at the health facility level since the programme was designed to offer incentives to individuals as a result of team performance.
Strategies to make women deliver at facilities
An important aim of the second round of interviews was to find out what measures, if any, health workers had taken to make more women deliver at their facilities. Some informants say that they have increased outreach activities and sensitized women on the dangers of giving birth at home:
They (women) come here because we sensitize expecting mothers (…) We tell them that here the equipment is sterilized well compared to that used at home, which is not sterilized. They just hang the gloves to dry which is very risky, it can lead to AIDS transmission. Once they hear that they can get AIDS, they come in large numbers. (Registered Nurse 3, Dispensary C, 2011, received T.Shs 60,000)
One informant said that such health education made some women decide to deliver at a health facility, even if her husband or relatives did not see the importance and wanted her to deliver at home. However, the need to attract more clients in order to reach P4P targets has entailed that many health facilities in the district have developed negative strategies to attract and/or force clients to utilize their services. In fact, the staff at all of the five facilities we visited in 2011 admitted that women had either been told that they would be fined if they delivered at home, or that they would be denied a live birth card and/or vaccination for their newborn.
As for fining, focus group participants in the catchment areas of dispensaries E and F told us that health workers had announced that women who delivered at home would be fined T.Shs 10,000. The health workers we interviewed confirmed that this had been announced, but that it was only a threat, and not something that was actually carried out:
Last year there was a clinical officer who used to tell women that if they give birth at home they will be charged a fine, and that they should come to give birth at the dispensary because it is free of charge. He was just saying that to scare them. (…) If you tell them that, they are afraid to get the fine. So up till this day there is no one who gives birth at home. (Assistant Nurse 2, Dispensary F, 2011)
The reason why the fining had not been carried out was that in order to actually fine someone, one would need to involve the Village Government, which had not yet been done. The health workers got the idea to criminalize home birth from colleagues from a neighbouring district, Morogoro Rural, where fines for home birth had been passed as a by-law by local authorities:
When we go for seminars we sometimes ask what others do to sensitize the people. So whatever you hear from others, if you haven’t tried it yet, then you should also attempt it to see how it works, (…) but only after involving the village leaders. There are some things - even if it hasn’t been decided at the district level – that we can make a decision about and then involve the village leadership. (Registered Nurse 1, Dispensary E, 2011)
Other health workers argued against fining, but were positive towards other forms of sanctions:
I don’t think fining the mother is a good approach. We should rather educate women by telling them the consequences of delivering at home. There are many ways to mobilize them like telling them that they won’t be given a birth card at the dispensary (…). Instead they will have to get it from the Ward Executive Officer, a more tasking process. If she doesn’t do that, she will end up not getting a clinic card for the baby. We can manage to mobilize them to a large extent using these threats. (Nurse 3, Dispensary C, 2011)
Also in this case, the strategy was something the health workers had learned from others:
We heard that at “Dispensary B” they have more deliveries these days, so we asked ourselves how are they doing it? How come they are getting safe deliveries, how are they doing it? We investigated how they succeed to have safe deliveries. How come there are fewer midwives, but they perform better? (…) After inquiring about their successes we are now educating our colleagues. (…) If she won’t deliver here, then she won’t get a clinical card for the baby. So it is just an educational competition. But there is no forcing of the mothers. (Nurse 2, Dispensary C, 2011)
At dispensary A, the same approach had been adopted, but the informant felt that it hadn’t had the expected outcome:
We said that for those who deliver at home - their babies won’t be vaccinated and the babies won’t get clinical cards, but they still continued to deliver at home. Maybe we should look for other means, like fining them. We should tell them that those who deliver at home will be fined. (Nurse 1, Dispensary A, 2011)
Health workers, particularly those with a low level of education, appeared to have little scruples about sanctioning women who deliver at home. The various methods were weighted against each other on the basis of the degree to which they were feasible in practice. A medical attendant had the following response to whether fining would be a good way to make women deliver at a facility or not:
The community here is different from that one (where they fine patients). Here, people are quite tricky - just a minor thing and he/she will go to the village administration or to the Councillor to report! You ask yourself why you should cause all that? (…) But fining is good (…), since to be fined - when even money for food is a problem - they will just decide to do what they are told. (Medical Attendant 1, Dispensary C, 2011)
When we asked the district health authorities what they thought about strategies such as fining, their response revealed that they were ambivalent and undecided, and that they did not appear to do anything about these practices:
I don’t know much about it. It is not according to the government guidelines, we don’t have any regulations on that. But people say it helps (…). On the other hand, if the woman doesn’t have the 10,000 shillings she will not take her child to the clinic (for vaccinations, in fear of the fine). (Official from district health office, 2011)
The fact that the council health management team (CHMT) also benefits from health facilities’ good performance may be one reason why the monitoring and follow-up of such practices is limited.