Table of Contents
Chapters
- Overview
- Getting Started
- Define Desired Performance
- Describe Actual Performance
- Measure/Describe Performance Gaps
- Find the Root Causes
- Select Interventions
- Implement Interventions
- Monitor and Evaluate Performance
- Managing Change
Highlights
Published by the Population Information Program, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA
Volume XXX, Number 2,
Spring 2002
Series J, Number 52
Family Planninng Programs |
Common environmental problems in reproductive health programs are lack of private space for counseling, stockouts of contraceptives, and lack of equipment or supplies for disinfecting instruments. To solve these problems organizations:
- Improve their logistics system and provide training (35) (see Population Reports, Family Planning Logistics: Strengthening the Supply Chain, Series J, No. 51, Winter 2002).
- Work with local government and communities to improve the workspace and provide supplies. Municipalities in Brazil funded improvements in clinics that participated in the PROQUALI accreditation program carried out by the Secretariats of Health in Bahia and Ceará states. The funding paid for repairs and remodeling, a computer, a car, and an autoclave. One city dug a well to provide the water needed to carry out infection prevention procedures (69).
- Ask for help from donors to buy equipment and set up a sustainable supply system or encourage public-private partnerships to supply contraceptives (46). The IDSS, for example, received help from the USAID-funded Family Planning Logistics Management program, which conducted two-day logistics management workshops and negotiated donations of contraceptives from USAID and the National Council for Population and the Family (CONAPOFA) in the Dominican Republic. The IDSS then began to buy contraceptives from UNFPA (91, 134).
People work in health care programs for a variety of reasons. Some like to care for people and value clients’ appreciation, or they value the social status accorded health care providers and the respect of clients and communities (3, 23, 38, 92, 148). The equipment and training that come with a job and the opportunity to attend meetings are also attractions (10, 23, 111, 169). Some providers value their work enough that they stay on the job even when their pay is delayed (13). Of course, many providers work only because they need an income (5).
To encourage better performance, organizations have tried incentives such as more money, recognition for good work, and the opportunity to provide better care.
Monetary incentives. A base salary attracts people to jobs and keeps them coming to work, but it does not necessarily motivate them to perform well (47). Monetary incentives include increases in pay; allowances for clothing, housing, or training; time off with pay or extra vacation; free meals, or gifts, such as appliances or bicycles (9, 155). A community-based distribution program in Tanzania pays agents with income-generating equipment such as boats, tractors, or sewing machines (62).
Linking pay to performance can be controversial, however. In Zimbabwe, for example, civil servants went on strike in 1996 when the government proposed to tie salary increases, an annual bonus, and promotions to job performance. Health workers thought that it was unfair to set high performance objectives in the face of shortages of staff and resources. Already poorly paid, the health workers challenged any threat to their small salaries. The experience in Zimbabwe raised several other potential problems with such an incentive scheme: Linking pay to job performance can inspire mistrust or abuse of the appraisal process, some supervisors are reluctant to give poor reports, and supervisors may not know how to appraise employees or may be too busy (110).
Reproductive health organizations supported by USAID are not permitted to reward employees for meeting quotas or targets for the number of family planning acceptors (156, 158). They can reward them, however, for excelling in other ways that help organizations meet their goals.
Recognition. Organizations can recognize outstanding work by posting staff members’ pictures (163), by selecting an employee of the month (9), or by mentioning staff in a newsletter. They can also announce promotions and report them to the local news media, and they can declare special days for groups of employees, such as nurse-midwives’ day.
Recognition through positive feedback encourages employees by showing them how they are improving. For example, the self-assessment and peer review in the Indonesian counseling study motivated providers by allowing them to track their own improvement and recognize and work on their weaknesses (74). In the PROQUALI clinic accreditation project in Brazil, providers were motivated to improve performance by the feedback they received from state and city officials, supervisors, coworkers, and clients (69).
Accreditation programs, by recognizing good performance, have motivated staff members to work hard to meet standards. For example, a program in western Guatemala is improving maternal and neonatal health care by accrediting hospitals, health centers and health posts. In baseline surveys conducted between March and August 2001, seven hospitals met an average of 11% of accreditation criteria, and in a follow-up survey in December 2001 compliance had increased to 40% (113).
Providing better care. Giving staff members the opportunity to improve care is an incentive in itself. In the “Building Bridges for Quality” project in Peru, for example, MOH staff said that they had never considered improving relations between clients and providers to be part of their job. In their new role they learned facilitation skills such as asking open-ended questions, encouraging participation, and making summarizing statements. They felt that they were doing more to improve services and not just checking on providers, receiving reports, and arranging training (57).
When supervisors ask employees what motivates them, they avoid guesswork. In the IDSS project, for example, the PI facilitators conducted focus-group discussions with providers and interviews with hospital directors to explore incentives aside from salary increases that would motivate considerate treatment of clients. Asked what types of incentives they would like, employees listed rewards such as clean and well-ventilated offices, extra days off, travel for training, more sharing of information with staff, public recognition, and insurance for risks on the job. Providers who worked alone in clinics wanted the chance to work in teams (157). Offering a variety of incentives allows employees to choose the ones they like the best (12, 169).
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