Based on the expectation theory, in this study we hypothesizes that a satisfying PBS design should strengthen the link between rewards and outputs, increase the awareness of health workers on their work outputs, and set an appropriate proportion of performance-linked rewards in the total income. The analysis on data from three counties in Shandong Province of China found that the health workers being aware of assessment methods and having knowledge on personal performance were linked to the satisfaction with PBS, and the increase in floating income proportion was linked with decreased possibility of feeling satisfaction. The analysis also found that the influences of being awareness on assessment and performance on satisfaction were only significant in those health workers with strong preference on financial rewards, and the negative influence of increasing proportion of floating income was only found in those health workers with lower preference on financial rewards.
Being aware of assessment methods was found to be positively related to satisfaction of health workers in THCs in this study. Theoretically, being clear on the performance assessment criteria can build the perceived link between different levels of their performance and different levels of income they can get, which helps health workers set clear performance and income targets and is the basis for satisfying their preference on the monetary rewards. International evidences have shown that financial incentive to reward the better performance is one of most effective measures to improve the morale and change the behaviour of health workers [7]. But the empirical studies on the feeling of workers with this aspect of PBS design is limited. Fu’s study collecting data from three provinces in China also found that self-reported link between income and performance assessment was related to satisfaction of health workers with the payment methods[8]. Some findings support that the linkage between promotion and performance can also increase the work satisfaction in China, and the promotion in professional title in PHIs directly brought the income increase[9].
This study also found that having knowledge on personal performance was linked to the satisfaction of health workers with PBS. Job feedback through different ways, including the feedback of manager, patients and public performance reporting, has been proved as an important motivator for health workers[10–12]. Knowing the performance level can help health workers understand the gap to target and make the judgement on fairness, and then help to improve the performance if the feedback is combined with the supportive suggestions. Studies in China also have the same findings, the performance feedback and public reporting were both correlated with satisfaction of health workers [8].
Analysis on this survey data shows that the percentage of floating income in total income was negatively associated with the satisfaction. One possible reason is the data of this study being from Shandong province, where the Confucius cultural was born and relatively follows traditional Chinese cultural strongly, so collectivism, doctrine of the mean, preference on stability are more dominate in the culture of work place[13], and then the health workers are more likely to have positive feeling on less floating and competitive payment methods. Existing studies mainly analyzed the relationship between proportion of performance-based income and the behaviors of health workers, and have varied findings under different settings, and several systematic reviews have confirmed that it was hard to get conclusion on it because the heterogeneity in specific payment design and contexts[14, 15]. Some studies concluded that low proportion of income being linked to performance was not enough to motivate the behavior of health workers and improve the performance [16, 17], and little gap in income levels of health workers with difference performance could not incentivate the performance improvement[18]. One study used data in PHIs health workers in China found that higher level of performance-based rewards was related to better control of blood pressure for the contracted patients[19]. The influence of floating income on feelings of health workers seems be in opposite direction of it on behaviour of health workers, even few empirical studies tested the relationship between the proportion of floating income and feelings of health workers. Theoretical analysis based on self-determinant theory explains that too much financial incentives would destroy the intrinsic motivation, and reduce the the enjoy of health workers on the tasks in the long term[20, 21]. Some qualitative studies found that pay-for-performance directly using financial incentive to guide the behavior directions of health workers were detrimental to autonomy and professionalism of health professionals[22, 23]. Though bonding income with performance could push health workers to work harder on the incentivated targets as earning more income being a driver of health workers to make efforts, the fatigue of efforts and pressure also decrease the utility of health workers at the same time[24]. So each individual health workers would determine the direction of their behavior and efforts level to balance the utility increase from expected income and utility deacrease from fatigue of efforts[25], and in the balance process those with less value on income will have lower willingness to make efforts for performance target. As what we found in this study, the relationship between higher proportion of performance-based income and lower satisfaction was more significant in those health workers with lower preference on monetary rewards, which meant linking too much proportion of income with performance was not welcome by health workers with less value in monetary income.
In this study, it was also found that work role was related to the satisfaction with PBS, especially the public health workers being more satisfied with PBS design compared with doctors. In China Equalization of Basic Public Health Services (EBPHS) policy defines a basic public health services package, which are provided by PHIs (THs and Community Health Centers) to their covered residents. In THs, public health workers are mainly in charge of EBPHS tasks, with doctors coordinating in some works related to clinical technologies, like physical check-up for the elderly. Policy EBPHS strongly emphasizes the need to track performance and has designed explicit performance targets to ensure the uniform enforcement of the service packages[2]. Accordingly in the facility level, the performance assessment criteria for individual public health workers is also designed according to the requirement of policy on EBPHS package, and the performance criteria usually is the rewards for each instance of public health service provision, like 15 Yuan RMB for each diabete patients follow-up management[26]. In addition to clear performance assessment methods, EBPHS funds are all from government subsidies and are more stable and predictable once the performance targets are achieved. In contrast, the revenues from providing medical services, the main resources to pay doctors and nurses, are more dependent on medical insurance fund and out-of-pocket payment of patients. Together with the performance criteria of doctors being quantity of clinical services provided, so the income of doctors is closely related to the volume of patients, all of which implies higher level of instability in doctors’ income level. In summary, the higher level of satisfaction of public health workers on PBS is due to clear performance assessment methods and less floating income level, which are both in according with the above findings on relationship between several PBS design characteristics with the satisfaction of PHWs on PBS.
Several limitations of our study should be mentioned. First, this study used the cross-sectional data and could only find the correlation between PBS design characteristics and satisfaction of health workers, and we can not draw any causal inference from our findings. The results should not be interpreted as the effect of the PBS design characteristics on satisfaction of health workers. Second, the measurements on perception of health workers on design of PBS were designed by research team because there are no validated scale on evaluation of performance-based payment design. Lastly, this study only explore the relationship between PBS design and feeling of health workers, and we did not look at the possible influence of payment design on behavior. Satisfaction, as an important emotional state and feeling health workers receive from the work, is one of the most predictor of mobility, productivity and service quality of health workers[6]. In addition, only analysis on feeling of health workers on payment design is also crucial for the welfare of health workers and sustainability of payment methods on performance. Rather, the association found in this study also reminded that the different direction of influences on feelings and performance, and even linking more income with performance may stimulate the behaviour change in certain time period, this impact may not be sustainable if this design cannot improve the satisfaction of health workers in work place.