In this section we will explore what health workers in the study district held as important for motivation, their experiences with OPRAS and expectations towards P4P.
Perceptions of motivation
The interviewed health workers used two Swahili terms for motivation. The most frequently used term was motisha, denoting the employer’s effort to motivate staff through offering incentives. The other term used to describe motivation was hamasa, a term that can be translated as ‘determination for work’. One Nursing Officer made a clear distinction between being motivated because of working conditions with reference to motisha and being motivated as a calling, or hamasa:
This work requires a calling. If one bases the work on the salary alone, then one would say ‘why worry with such little pay?’ But if the person is committed whole-heartedly to the serve the patients, then he/she can perform the work well even though the payment is poor. (Nursing Officer, district hospital, IDI)
Health workers readily acknowledged that work effort varies and they pointed out a number of issues they consider motivating for effort at the workplace.
Salary and allowances
All the interviewed health workers emphasized that a decent salary is very important for their motivation. It was consistently argued that the basic salary is too low to make ends meet. One Assistant Medical Officer (AMO) explained that:
If people really want us to provide good health services, the health workers should be paid a reasonable salary, enough to meet the basic important requirements, at least enough to be able to send children to school and have decent clothing. (AMO, district hospital, IDI)
The role of financial incentives was also explained:
If you get something in addition to the salary you will maintain a high level of performance and have more zeal. (AMO, district hospital, IDI)
The general experience of receiving a low salary generated discontent and demands for additions to the salary. A recurring comment was that a low salary and a high workload make staff demotivated. A nurse commented on the importance of additional payment for working morale:
When one gets an extra income then certainly one becomes motivated and performs work better. Working continuously without any improvement of the income and with an increasing workload, one becomes demotivated, and the working morale is lost or reduced. (Nurse, district hospital, FGD)
In addition to the concern about the salary, substantial emphasis was placed on the allowances, in particular the entitled allowance when attending seminars, short courses or workshops. One Clinical Officer (CO) explained:
When we are being trained in seminars we get good allowances. Such an income could not be achieved in a whole month of work, but it can be obtained in, say, one week of seminar. (CO, district hospital, IDI)
The emphasis placed on the financial aspects of working conditions, for example the salary level and the extra allowances attest to the importance of motisha as vital for motivation. Health workers however also emphasized non-financial aspects of working conditions as vital for motivation.
Recognition of good performance
Recognition of good performance was pointed out as important for motivation. One AMO explained:
If a leader stands up in a general meeting of all staff and announces that a certain group of people have done very well, the people praised will become motivated. (AMO, district hospital, IDI)
A similar argument was put forward by one nurse:
Even a simple letter showing that you have done well, or even an expression of congratulations for the good work would really give a person encouragement to work. (Nurse, district hospital, FGD)
Health workers claimed that they do not receive regular feedback on the work they perform and held this out as a serious shortcoming of the workplace management. Health workers however pointed out a few exceptions, one being the annual 1st May, Workers’ Day, celebration with the announcement of Mfanyakazi Bora, - the ‘worker of the year’. In addition to the public recognition of having performed well, the awardees receive a gift in cash or in kind. Several of the interviewed health workers had previous experience of being selected as the worker of the year. One CO explained:
If one of the staff is selected here, his colleagues will work very hard so that they can become selected the next time. (CO, dispensary, IDI)
A Council Health Management Team (CHMT) member who explained that he had received a letter from the District Executive Director (DED) thanking him for his effort and that this encouraged him to perform better and how it gave him the determination to work better than before. Receiving recognition from the patients was also held out as a motivating factor. One nurse explained:
The gratitude from patients is also giving me determination because it is an indicator that my performance at work is good and helpful to the patients. (Nurse, district hospital, FGD).
The interviewed health workers consistently pointed out the importance of receiving feedback on performance and also pointed out the importance of supervision. The examples above attest to the importance health workers place of being recognised for the work they perform.
Perceptions of OPRAS
The interviewed health workers had gained experience over several years of filling in the OPRAS form. The overall picture emerging from the data was a high degree of skepticism towards OPRAS. The perceptions of OPRAS however ranged from seeing it as being of little value to perceiving it as a positive development. The interviewed health workers, regardless of their stance towards OPRAS, referred to it as a system in which individual goals are set and performance measured. However, the interviewed health workers raised a series of concerns about whether OPRAS is reaching its aim, and to what extent it is appropriate in the health sector.
Number of patients vs. quality care
Many health workers expressed concerns about measuring performance through OPRAS in a setting of shortage of resources. A recurring argument was that the shortage of resources at the workplace makes it very difficult for health workers to reach their targets. It was also argued that the measurements of performance in OPRAS are of little relevance and help in the health sector.
The one who has attended 10 patients and correctly diagnosed and treated them well has performed better than the one who has seen 20 patients and made mistakes or prescribed the wrong medication. The important issue is not attending many patients but providing correct treatment. (CO, district hospital, IDI).
One Assistant Medical Officer expressed clear skepticism towards setting targets in terms of number of patients in OPRAS stated:
I am supposed to see or attend 300 patients. What if people in the communities hear that this is my target? I don’t know how they would feel. It could mean that we are praying for them to get sick so that we can achieve our targets. I don’t get the logic behind that. Should we go to the churches and mosques praying to get more patients? (AMO, district hospital, IDI).
A Clinical Officer raised a similar concern:
On the side of a clinician it is difficult to aim at treating a certain number of patients. We don’t want people to become sick. (CO, district hospital, IDI).
The principle of using numbers of patients as an indicator for performing well was hence met with skepticism. Health workers repeatedly pointed out that the optimal situation should be a low number of patients receiving proper treatment.
OPRAS is intended to evaluate performance and to provide feedback to the employee. In practice, however, OPRAS appeared not be used for providing feedback.
We would request that feedback is given to us, because it is a difficult process to fill in the OPRAS form. You do this work and you don’t get any feedback. It becomes tiresome and meaningless, wasting our time and effort almost for nothing, feedback is very much needed! (Nurse, district hospital, FGD).
A Clinical Officer brought up the challenge of verifying whether targets in OPRAS are achieved:
At the end of the day I don’t think that there is any person coming to inspect or to verify that you attend the 200 children you said you would treat. (CO, district hospital, IDI).
Experiences with OPRAS indicate that many of the interviewed health workers do not see the benefits of the system. One AMO explained:
Up to now there is nothing coming out of filling in the OPRAS form. It is just like an order. After every six months they tell us to fill it in and again. It is just a routine but it has no meaning. (AMO, district hospital, IDI).
The large majority of health workers interviewed expressed great skepticism towards OPRAS and furthermore explained that they have little knowledge about the use of the information collected through OPRAS. The degree of reluctance towards complying with OPRAS indicates that dissemination of information on the performance appraisal and providing feedback to health workers has been insufficient.
Openness and opportunities
Some health workers did mention benefits of OPRAS and it was repeatedly pointed out that OPRAS is a better system than the earlier confidential assessment. One nurse explained:
I think OPRAS is better because it is a more open system. You can express or defend yourself, or if you find that you may have been badly treated you have the chance to complain. (Nurse, district hospital, FGD).
Other health workers expressed that OPRAS was an important tool guiding them at work.
It is possible for me to adjust myself at work. Where I have been reluctant or where I have been negligent, the in-charge may warn me before things get worse. (Nurse, district hospital, FGD).
The most concrete examples of employees’ positive evaluation of OPRAS related to promotions. In the latter part of the data collection for this study some of the interviewed health workers reported to have received the expected promotions. One nurse expressed her experiences with OPRAS in relation to promotions as follows:
We were told that a worker cannot be promoted without OPRAS, and that only when one has properly filled in the OPRAS form can promotion be considered. (Nurse, district hospital, FGD).
Members of the Council Health Management Team (CHMT) and the Human Resource Officer in the district generally praised OPRAS, and explained that it provides an opportunity to evaluate the performance of staff, but remained vague as to its relation to promotions.
Mid-level managers’ experiences with OPRAS
Managers at sections or departments in the health facilities are responsible for working with staff members in order to set and evaluate the individual goals in OPRAS. Health workers reported to have job descriptions but these descriptions appeared not to be actively used to guide the work or to direct effort to tasks important for the quality of health services. OPRAS was perceived by the managers as an attempt to operationalise the job descriptions but a manager in the district administration noted that there was a paucity of knowledge about the ways in which OPRAS is expected to operate:
The employees do not yet understand OPRAS, therefore it is giving them problems in filling in the forms properly. Or you may find that a person is unable to estimate the targets. Thus they may fill in the forms with inaccuracy, while others simply evade it. (Manager in district administration, IDI).
Also the managers brought up the challenges of measuring performance:
The weakness of OPRAS is that you find that an employee has a job description in which its target cannot be measure or evaluated. (Manager in district administration, IDI).
The mid-level managers reflected well on the dynamics of OPRAS on OPRAS, on both its weaknesses and opportunities. They recognized health workers reluctance towards OPRAS as well as the structural problems of resource shortages and the challenges this may cause in implementing OPRAS.
Expectations towards P4P and its link to OPRAS
The planned P4P in Tanzania is based on measuring performance through assessing whether quantifiable targets have been met at the health facility level. As explained above P4P was not yet implemented in the study area at the time of the data collection. The informants nonetheless had substantial expectations towards P4P due to the information that had been disseminated on the possibilities of additional payment. Health workers expressed positive expectations towards P4P, and perceived that the forthcoming financial incentives would enhance their motivation for work. One nurse explained:
It is encouraging because it is something extra, an extra income on top of the salary. It gives hope to workers that one may get an extra income that can help the family, for example to pay for school fees. (Nurse, district hospital, FGD).
The interviewed health workers however expressed varying degrees of knowledge about the background and rationale for P4P. They generally saw OPRAS and P4P to be two connected systems.
When they introduced P4P they emphasized that we should properly fill in OPRAS so that we could be given the P4P payments. (Nurse, district hospital, FGD).
The initial plans for P4P were however halted, much to the disappointment of the health workers who clearly expected to receive additional payment when meeting their targets. The high expectations coupled with limited information created much confusion about the aims of both OPRAS and P4P, and the possible connections between the two.