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We reviewed the published and unpublished international literature to determine the influence of salaried payment on doctor behaviour. We systematically searched Medline, BIDS Embase, Econlit and BIDS ISI and the reference lists of located papers to identify relevant empirical studies comparing salaried doctors with those paid by alternative methods. Only studies which reported objective outcomes and measures of the behaviour of doctors paid by salary compared to an alternative method were included in the review. Twenty-three papers were identified as meeting the selectioncriteria. Only one of the studies in this review reported aproxy for health status, but none examined whether salarieddoctors differentiated between patients on the basis of health needs. Therefore, we were unable to draw conclusions on the likely impact of salaried payment on efficiency and equity. However, the limited evidence in our review does suggest that payment by salaries is associated with the lowest use of tests, and referrals compared with FFS and capitation. Salary payment is also associated with lower numbers of procedures per patient, lower throughput of patients per doctor, longer consultations, more preventive care and different patterns of consultation compared with FFS payment.
Address correspondence to T. Gosden, National Primary Care Research and Development Centre, 5th Floor Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL
Impact of payment method on behaviour of primary care physicians: a systematic review
Toby Gosden, Frode Forland, Ivar Sonbo Kristiansen, Matthew Sutton,Brenda Leese, Antonio Giuffrida, Michelle Sergison, Lone Pedersen
National Primary Care Research and Development Centre, University of Manchester, UK; Department of Public Health and International Affairs, Norwegian Board of Health, Oslo, Norway; Institute of Public Health-Health Economics, University of Southern Denmark, Odense, Denmark; National Primary Care Research and Development Centre, York University, UK; National Primary Care Research and Development Centre, York University, UK; National Primary Care Research and Development Centre, York University, UK; R&D Department, Huddersfield Royal Infirmary, UK; Danish Institute for Health Services Research and Development, Copenhagen, Denmark
Objective: To review the impact of payment systems on the behaviour of primary care physicians.
Methods: All randomised trials, controlled before and after studies, and interrupted time series studies that compared capitation, salary, fee-for-service or target payments (mixed or separately) that were identified by computerised searches of the literature. Methodological quality assessment and data extraction were undertakenindependently by two reviewers using a data checklist. Study results were qualitatively analysed.
Results: Six studies met the inclusion criteria. There was considerable variation in the quality of reporting, study setting and the range of outcomes measured. Fee-for-service resulted in a higherquantity of primary care services provided compared with capitation but the evidence of the impact on the quantity of secondary care services was mixed. Fee-for-service resulted in more patient visits, greater continuity of care, higher compliance with a recommended number of visits, but lower patient satisfaction with access to a physician compared with salary payment. The evidence of the impact of target payment on immunisation rates was inconclusive.
Conclusions: There is some evidence to suggest that how a primary care physician is paid does affect his/her behaviour but the generalisability of these studies is unknown. Most policy changes in the area of payment systems are inadequately informed by research. Future changes to doctor payment systems need to be rigorously evaluated.
Pay for performance in healthcare sector is able to draw more and more attention these years. Since 2007, there are over 100 private and federal Medicare reward available in the United States. Other counties like Italy and New Zealand are both decided to re-form its healthcare system and applying financial reward to physicians to motivate them by increasing service quality, which provides to patient.
Pay for performance programme has been launched in the UK for many years, and in 2007 the amount of the quality and outcomes framework has been reached £1000m paying out to general practices. Also, the amount of financial reward as estimated would keep increasing during next couple of years. Hence, this pay for performance faces question whether it really helps increasing service quality to patients.
Financial reward could increase service quality in healthcare because financial incentive could motive physicians to perform better to
reduce operation cost in healthcare sector,
there is some evidence shown that better process of care could improve patient satisfaction.
If better performance cannot be reward, it might provide disincentives in healthcare.
Many psychology and organizational behavior theories have proved financial incentive could increase people's motivation.
Physicians has begun to agree that healthcare quality can be measured and financial incentive could secure better quality service.
Many prospective do not agree financial reward could increase service quality to patients.
Tunnel vision: physicians would focus on certain performances which are given reward, and neglect other unmeasured areas.
Adverse selection: physicians would tend to select patients. They would more like to treat those patients who are easy to cure and avoid those severely ill patients.
Erosion: Physicians are supposed to be motivated intrinsically by serving to communities. Financial rewards could actually cause the backfire to drive out physician's intrinsic motivation.
4). Some evidences have already shown that in order to get better financial reward, healthcare tend to misreport some factors.
Some health sector achieved good scores of quality and outcome measurement, but it could be fraud. In order to maximize their income, some healthcare clinics excludes large number of severer ill patients. (â€¦â€¦â€¦â€¦exception report ..in qof) These fraud could be very difficult to indentify. Especially in the Quality and outcomes framework, it is launched to systematically appraisal general practitioners performance. This framework allows GP to use "exception reporting" to protect their personal achievement, which makes GP have authority to decide it by himself to include or exclude some patients.
Recent evaluation of the quality and outcomes framework in Scotland suggests that practices delivered higher quality than that required to maximise their financial income.4 The behavioural drivers thus seem to go beyond the financial reward and may include, for example, professionalism, pride, or differentiating the practice from local peers.4
How to appraisal physician's performance.
Service quality, which provides to patients are subjective and difficult to measure, so some objective standards needs to be introduced into this performance appraisal process. It should be easy to measure and it should not be interfered by managers' subjective assessments of physician's characteristic.
The financial incentive scheme should be based on a management-by-objectives agreement, which should include
Key job responsibility and what result has to be achieved.
Clear standards of performance and target levels of competence.
Regular, objective reviews of performance and competence
How efficient financial reward could motivate physician's behavior change depend on the amount of financial reward. If there is only a little financial reward available, this might not be strong enough to change physician's motivation. This brings up another question, regarding to cost efficiency. What if use this amount of financial incentive to improve facilities in the healthcare sector, instead of giving to physicians, will this increase patient satisfaction even more?
Hence, by deciding how much financial incentive should be rewarded to physicians, managers should assess physicians as outstanding, superior, standard or developing. In addition, managers should consider
1). financial status of this healthcare organization
2). typical pay range in current health sector
3). the present position of the physician in the salary band and
4). Organization policy on speed of process through the salary band.
Health care system in the UK is nationalized, and centrally driven. In US, it is a concatenation of health care system, with different insurance benefits. However, both countries faced same challenges in improving healthcare. As recently medical care failure in Bristol and Newham in the UK, increased patients' concern of safety in healthcare. Patient safety concern has been rising in US as well, as report produced by Institute of Medicine stated that the incidence of morality relating to medical error to be 44,000 to 98,000 per year.
Supply -induce- demand problem?
If the payment system changes in one healthcare organization, how physicians would react to this change. Because some physicians might support this change and others do not, if so how does the final agreement would be reached. Lewin's Force-Field 3 step model is applied to analyze and explain it.
Kurt Lewin stated it usually takes three stages for a group to adapt to a change. These three stages are "unfreeze, change and Freeze (or Refreeze)".
In a healthcare organization, when the payment system are planned to change, it could create two forces. One force supports this change, the driving force, which is positive force for change. The other force is the restraining forces, which is the obstacles to change. Before financial incentive scheme was planned, two forces are equilibrium. Healthcare organization stayed at a stable environment. The change of payment system would only happen, after this equilibrium status has been broken. It could be either to add extra attractive condition to the change side, or reduce restraining forces.
Stage 1: unfreezing
This stage could be regarded as the most important stage to let physicians understand change is going to happen and allow them to be ready. The payment system changes from physicians paid standard salary each month to pay for performance scheme. Because of this financial incentive scheme, they might be paid more if their performance exceeds requirement, but if might be paid less. Hence, not all physicians would like this change.
In this stage, it needs to create an environment to let physicians understand this payment system change is necessary and they have to move out of their comfort zone. The more urgent physicians feel, the more motivation they will have to deliver this change. Setting a deadline to inform physicians when this change is going to happen, would help to create a sense of urgency to face this payment system change and this increases motivation.
Also, in this unfreezing stage, physicians would think about the advantage and disadvantage of this change. Before any action had take place, physicians would weight these advantages and disadvantages to evaluate which factor is outnumbered. Kurt Lewin addressed this process as 'Force Field Analysis'.
In this Force Field analysis, Kurt Lewin mentioned there were many forces would against change to happen in this payment system. If physicians consider there are more advantage than disadvantage in this payment system change, then this change could happen easily and physicians are readily happy to accept it. However, if physicians outweighed disadvantage to advantage factors, then there is low motivation to this change. If in this circumstance, financial incentive scheme is still pushed, then it might cause backfire and even resistance could happen. Therefore, this force field analysis explains how physicians react to payment system change and how they move through change and why they resist change.
Stage 2: Change or Transition
In the second stage, change is happening and is during the process. The positive driving force to change has been stronger than restraining forces. Kurt Lewin used Transition to describe this process. Physicians could be confused in this stage, as they do not really know this new financial incentive scheme, but standard monthly payment, which are familiar with had been replaced. This stage should be processed slow, as physicians should be given time to understand how does this scheme work. Managers in healthcare should be supportive to physicians and communicate with them by giving them a clear picture of the desired change and how this could benefit to them.
Stage 3: Freezing or Refreezing
In this stage, change has already been made and it reached stability again. Therefore, physicians have already accepted and comfortable about this financial incentive scheme and even it takes some time to achieve. â€¦â€¦â€¦two forces reached equilibrium again
â€¦â€¦â€¦â€¦â€¦â€¦â€¦.go force stronger.
Another factor which needs to be considered is physician's motivation.
Franco (20020 has defined motivation is one of the most important factors that will influence on physician's working performance in the health sector. As motivation is to describe how much is individual's willingness to put all his energy and effort to help organisation to achieve its goal. Health sector is a 100% service incentive organization, so physician's motivation is essential in terms of increasing service quality, reducing waiting list, managing hospital bed, allocating other resources efficiently and so on.
Maslow's hierarchy of needs theory could explain physicians' motivation working in the healthcare sector. Maslow divides people needs into 5 sections from lowest to highest are physiological needs, safety needs, love and belonging, esteem and self - actualization. The lowest needs is at bottom of the pyramid and highest is at the top. Only the bottom of the hierarchy needs have been satisfied, and then the needs could move forward to the next level and the movement is kept going on to the top one.
Physiological needs means people have to need food, clothing and some place to live to keep them alive. After people achieve this one, it moves to safety needs.
In the safety needs this stage people is looking for personal security, financial security, health security and safety net against accidents and ill. In the work place, people would like to have job security. After these are achieved, it moves to the third level love and belonging.
In this love and belonging stage, people would like to be recognized and accepted by others. People need emotional based relationships, such as friendship, Intimacy and family.
Esteem, in this stage people is looking for more than where they are belonged and they ask for respect from others. They need others to recognize their value to the orginisation to community or society. These recogonisations will give them self-respect.
The top level is self-actualization. This stage is regard to people's full potential and to realize what is his potential. Since everyone's ability is different, this stage could be various to each person. In addition, everyone has different specific goal to achieve.
Many researches have been conducted to study the motivation for the physicians working in the healthcare sector. There are unanimous results that almost all the physician would like to work in the healthcare sector, because they mentioned the job satisfaction. They believe their work have been highly recognized by patient and by community. They are able to gain both respect from others and themselves. Also, many physicians like the working environment in the hospital, and they feel they belong to it and fit in the team. Therefore, from the result from those researches, it clearly shows that most of physicians they are in the level 4 or 5 in Maslow's hierarchy of needs theory. Physicians are looking for self-esteem and self-actualization and the job satisfaction is their main motivation. However, financial inventiveness or the amount of monthly salary pay is categorized in stage two and Maslow stated that if the needs in stage two are not satisfied and people will not move for next level. Therefore, it is fair that most of physicians satisfy their month salary and increasing financial reward would not improve their job performance, as this is not what they are looking for. However, recogonising their work and their value to the community could actually motivate them better to improve their performance. In addition, this result shows that many people worry that financial rewards to physicians might cause the backfire to drive out physicians' intrinsic motivation.
Herzberg's two-factor theory (motivation-hygiene theory) could take a step further to explain physician's job satisfaction in the healthcare sector. Two factors are motivator factors and hygiene factors, respectively.
Motivator offers positive conditions to physicians. Those factors leads to job satisfaction, such as achievement, recognition, work itself, responsibility, advancement and growth. Managers in healthcare organisation should create a positive working environment and experience for physicians. It could motivate physicians to improve their performance by enriching and enlarging their daily job responsibility. Job rotation sometimes could also help physicians to understand other colleagues' responsibility and understand how is this healthcare organization operation from another perspective. Therefore, operation in the healthcare is going to be more efficient, when this physician co-ordinates with others next time and his contribution to the team would be recognized. Those positive experience could be regarded as achievement and advancement, which enhance physician's job satisfaction. Furthermore, what is worth mention here is salary or financial rewards does not include in the motivator factors.
Hygiene factors give negative working conditions for physicians. These factors leads to job dissatisfaction, such as organisation policy, supervision, relationship with others, work condition, salary, and security. These factors lower physicians motivation and make them not comfortable working with others, which affects their work performance and service quality providing to patient. Also, salary is included in the hygiene factors. It means if salary amount not meet physician's expectation, this could create job dissatisfaction during work.
Hence, if combines motivator and hygiene factors together, the analysis shows that if physicians salary is below physicians' expatiation, it would form negative working condition for physicians, which cause job dissatisfaction. But after physician's salary is up to their expectation, increasing their salary amount or giving them extra financial reward this would not become motivator factors to increasing their job satisfaction and results in improving service quality. However, job satisfaction is increasing by recognition of their work, achievement and others.
According to Herzberg's two-factor theory, increasing physician's job satisfaction is the most efficient way to improving service quality to patients. Herzberg stated job characteristics is directly related to what an individual does and have the capacity to gratify, which makes them satisfied. Nevertheless, less of satisfying job characteristics will not necessarily create dissatisfaction. The dissatisfaction is usually formed by other unfair assessments in job related factors. Herzberg also addressed that satisfaction and dissatisfaction are two separated and independent factors. Therefore, one factors increasing would not result the other factor decreasing. Furthermore, to those managers in healthcare organizations who would like to improve physicians' performance and increasing service quality should focus on the nature of physician's work by giving them more opportunity, responsibility, achievement, and growth space. If a physician is increasing his capability and increasing his service quality to patients, he should be given more responsibility by managers and this is able to utilize his full working ability. On the other hand, for these managers who would like to reduce dissatisfaction in the healthcare organisation, they should focus on the working environment, such as policies, procedures, supervision, and working conditions.
However, both Maslow's hierarchy of needs theory and Herzberg's two-factor theory have been criticized. Because both theories assume each individual are same and when they face same working environment, their motivation would be not different and this leads to their same reaction and job performance. This unlikely happens all the time. Second, both theories are like drive theory, which estimates physician's motivation and performance from pasting learning experience. It is going to be more accurate to estimate physicians performance by analyzing his current performance and to estimate for future.
These criticisms lead to victor Vroom's expectancy theory. Victor Vroom stated that physician's motivation to work in healthcare sector and their performance to their patients and for every decision they made from all kinds of alternatives is all trying to maximize their pleasure and minimize their pain. Physicians' performance depends on many factors such as characteristics, skills, knowledge, experience and abilities. Also victor Vroom stressed that physician's relation with his colleagues could largely influence his job performance as well. Victor Vroom believes that even physicians in one healthcare organisation have same job responsibility and provides same service to patients, but their achievements and their motivation in their conscious are different. In addition, their effort put into their job performance is highly related to the quality of their work. Victor also believes financial reward would help physicians to satisfy his needs, which is strong enough to make the effort worthwhile.
Victor Vroom takes three elements to measure this expectancy theory, which are expectancy [E], instrumentality [I] and valence [V].
Expectancy: is physician's belief whether he thought he had the ability to perform this task or not. Victor Vroom has given an objective view to measure this unit by giving a scale of 0 to 1 (scale 0 indicate a physician believes himself is not able to do this task, and 1 indicate that he has not any doubt and confident enough to solve this task). Managers in healthcare sector could help physicians to increase their expectancy by giving them supports, such as a clear instrument for each task, what kind of skill sets need for in this treatment, patient's information previous medical record. Also many evidences have shown that previous success in a similar task could help to increase physician's expectancy beliefs.
Instrumentality: is that good outcome of task should link to good rewards to employees (physicians). Therefore, financial reward could be the instrumentality, which links physician's job performance and encourage physicians to perform well. Instrumentality is also given a scale of 0 to 1 to measure this linkage between the outcome of task and rewards to physicians (scale 0 indicates that there is no any relationship between those two and scale 1 indicates those two have highly related). This shows that managers in healthcare organization must give physicians rewards to improve their service quality. However, there are various kinds of rewards, expect financial rewards. For example, extra holidays to best performed physician could also be a reward. Therefore, managers should have better communication with physicians to understand what rewards are most desired to them. As each individual working in the healthcare sector are different, each physician's desired reward shall be different too, and most of time it is not about increasing pay. If managers are able to reward physicians their most desired rewards, then it could be the strongest motivation force for physicians to performance their best of ability.
Valence: is still about the rewards what physicians are able to obtain if they achieved good outcome in their work, but the rewards here is different to the rewards mentioned in the instrumentality. Reward in the valence element is more about the respect which they are able to gain from other physicians if they perform this task well. It is more about their value to the team could be more recognized. It is more emotional orientated. However, if the outcome of the task is rather poor, physicians would try to avoid negative valence such as fatigue, stress and others. It is also given a scale of 0 to 1 to measure this element (0 indicates that there is no difference in valence reward for a physician no matter how good or bad service quality he delivers to patients, and 1 indicates there are significant difference). Therefore, valance is more related to the level of satisfaction physician would like to achieve rather than the actual physical satisfaction.
These three elements give physicians beliefs, which create a motivational force to perform the best of their ability to achieve organization goals. Therefore, when these physicians performing their treatment to patients with this certain beliefs and expectancy, it maximizes their pleasure and avoids pain. There is a formula: Motivation = Valance Ã- Expectancy (Instrumentality) to measure physician's motivation force. Victor Vroom stated that employees (physicians) would link their performance to the outcome of their tasks and look for a best reward to this achieved outcome. Hence, financial reward could be regarded as Instrumentality units to increasing physician levels of reward and maximizes their pleasure and strengthen their motivation force. Managers in healthcare organization should create a positive working environment, by giving physicians confidence, positive thinking and clear instruction as so on. Also, managers should reward to physicians no matter physically or emotionally or both, if they delivered a good performance to patients.
Avinash Dixit (2000) in his research report 'incentives and organization in the public sector', he mentioned that there are two kinds of payment schemes are usually used in public sector including healthcare organizations.
The first one is nature of standard incentive scheme: Y= w + mx.
X is observed output by physicians, m is strength of financial incentive scheme in healthcare sector, w is wage, which is fixed income to every physicians, and Y is total monthly monetary reward. Grossman and Hart (1983). Linera â€¦.and provides a simple intuitions
The other one is standard contract design model: m=1(1+rcv)
v= riskiness of the project, c=cost of agent's (physician's) effort, r is risk aversion of agent (physician).
This model shows, the larger risk aversion a physician has to face in the task, the higher financial reward would be given. This model is more insightful, because managers in healthcare organization are not able to diversify of bad outcome or performance, if it happens, and this makes them more risk-averse at outcome. Therefore, a more incentive pay scheme is used to reward physician's performance.
Those two incentive pay schemes are combined together in some healthcare organizations, standard contract deign model helps healthcare organization to define the strength of the reward scheme by determining the risk of tasks that a physician is going to manger. nature of standard incentive scheme is a linear reward or penalty if a physician did or did not deliver his performance well to patients.
National Health Service (NHS) is using Quality and outcomes framework (QOF) to monitor general practitioners' (GP) performance and decide their monthly remuneration. Quality and outcome framework financially rewards GP and makes a difference in their pay if they are able to deliver a good practice to patient. There actually a large portion of GPs monthly remuneration comes from financial reward. Before this framework launched, previously GP's income is influenced by a mixture of capitation, salary, fee for service and grant. In this new contract, GPs performance is evaluated by QOF points, and this performance appraisal has 146 indicators, which need to be considered, and GP could achieve 1050 points as maximum. These 146 indicators are categorized into 4 parts, which are clinical, organizational, patient experience and additional service. At the end of financial year, the more points a GP is able to achieve, the more financial reward he will get. Apparently, more patients a GP is able to provide service to, more points a GP will be able to generate before financial year, and this encourages all GPs to work more efficiently to reduce patient waiting list and make up the situation that NHS is short of GP currently. In the financial year 2004 to 2005, each point is worth £77.50 and this has been increasing to £124.60 a year later. Therefore, in an ideal situation, if a GP manage to achieve maximum 1050 points, his annual financial reward would be up to £130,830 and plus his basic pay on top. This QOF was slightly changed in 2006 and 2008 respectively, but its main purpose remains the same.
National Audit office produced an assessment report for this Quality and outcomes framework (QOF). This report stated in order to get more QOF points, GPs would more like to try to enlarge their responsibility in the practice and try to extend the range of patient service. This helps NHs increasing its productivity and improving GPs' mix of skills. More multi-skilled GPs benefits practice to manage demand changing problems, because they will be able to suit more positions and this help practice operate more efficiently and reduce operation cost too.
On the other hand, this new QOF contract cost £1.76 billion more than government expected, because government underestimated of GP's achievement levels, as it only expected GPs could achieve up to 75% of total points, however, they actually achieved about 90% even in the first year. Also, there is additional cost of providing out of hours care, which is more than government expected. This overspending problem has been caused, but improvement in NHS' productivity has not yet been demonstrated.
The strengths and risks of this QOF could be summarized:
1). Rewarding what matters (structure, process and outcome)
2). Balanced scorecard
3). Local GP freedom to decide on priorities
4). Real rewards
5). Consistent with national clinical guidelines
6). Developed by the profession
7). Commitment to review and update
1). High expenditure commitment
2). Reward structure distortive (some too easy, some too hard, and wrong balance)
3). Unmeasured activity ignored
4). Discourages practice in disadvantaged areas (cream skimming complaint patients, recruitment of GPs)
5). Misrepresentation (lack of effective audit)
6). Increasing managerial costs
7). Undermines professional morale
There are many researches of QOF and its impact on NHS and main comments are summarized below.
1). Service quality was improved rapid after QOF was introduced.
2). In order to improve quality, the QOF may have to lead to more small rewarding points and it should be more transparent too.
3). The rewards associated with QOF appear to have been excessive.
4). Only modest evidence that unmeasured quality is suffering relative to measured quality
5). Evidence of some small amount of 'gaming' to achieve improve scores
6). Only a small quantitative impact has so far been detected.
Scope of scheme
Power and size of incentives
Use of thresholds in QOF
Difficulty of targets
Too easy in QOF
Risk adjustment for disadvantaged populations
Avoidance of gaming and other adverse outcomes
Involve clinical professionals in design
Set a quantitative 'baseline' against which the impact of the P4P scheme can be measured
Seek out performance measures in 'hard to measure' domains
Evaluate the scheme carefully
Start with pilots, testing much lower rewards than used in the QOF
Undertake continuous monitoring and review of scheme.
Financial incentive scheme is used to motivate physicians to improve their work performance. When financial incentive scheme is applied to the healthcare organization, a systematic performance appraisal must be available. Good performance appraisal system is not only to help healthcare organizations to indentify good and bad physicians and also help to design health system reform. There are more and more diversify objectives addressed that physician's performance measurement is important. A standard performance management helps managers to have a better control of service provided to patients and even benefit physicians themselves to improve their performance.
This performance measurement circle is largely used in the healthcare organizations. It compares original input and output at the end to evaluate how much value has been added on. Physicians count responsibility for tasks or patients they are involved with. However, in this model physicians could be regarded as a group if they are performance some tasks together and this is not easy to identify each individual's effort and development in the group. Therefore, this performance measurement would not be able suitable for financial incentive scheme and also this appraisal should be more convincing.
300 degree feedback should be conducted to measure a physician's performance. In this appraisal method, a physician's performance measurement would be provided by all other employees around him. Feedback should be given by a physician's manager, other physicians working with him and his own assessment, and also in some circumstances his patients is better to be involved as well.
motivation choice what kind of quality service they provide to
How much payoff is there for me toward attaining a personal goal while expending so much effort toward the achievement of an assigned organizational objective?"  TheExpectancy theory by Victor Vroom also provides a framework for motivation based on expectations.
This approach to the study and understanding of motivation would appear to have certain conceptual advantages over other theories: First, unlike Maslow's and Herzberg's theories, it is capable of handling individual differences. Second, its focus is toward the present and the future, in contrast to drive theory, which emphasizes past learning. Third, it specifically correlates with behavior to a goal and thus eliminates the problem of assumed relationships, such as between motivation and performance. Fourth, it relates motivation to ability: Performance = Motivation*Ability.
changing currently working environment.
Worker motivation will be affected by health sector reforms which potentially affect organizational culture, reporting structures, human resource management, channels of accountability, types of interactions with clients and communities, etc.
Resource availability and worker competence are essential but not sufficient to ensure desired worker performance.