Table 3 Illustrative quotations by motivational domains

Work environment

“We had a more organized work environment, because of the [new] chairs, lockers, the fans ... the environment became more comfortable and safer for my patients.” IDI55_Nampula

“I was not satisfied working in a place that is not clean. [Implementing] PBF brought hygiene supplies and cleaning. [Now] my work environment is beautiful and well organized. I’m happy with the environment, so I’m satisfied with my work too, because I work well when I’m in a good place.” IDI34_Nampula

“I will say that the more organized the work environment, the better our activities comply with our business and management plans and our work environment goals. Because of PBF, we made plans to ensure our workplace focuses on patient care. We planned what equipment was needed. All this contributes to a healthy work environment. Before, we did not have a fan to at least reduce the heat in our office, but now allocating [for equipment] through the PBF means a positive work environment where the professionals and patients do not feel suffocated from the heat.” IDI25_Gaza

Equipment and infrastructure

“It would take 15 years for each facility [to upgrade] if we did not have the PBF [to supply] the porch, these comfortable chairs, upgraded bathrooms, and electrification. We know a district budget is never enough to meet all our needs. The PBF therefore has great impact … because it improves working conditions for health professionals.” IDI35_Nampula

“For example, we have improved chairs; before we were not comfortable. Now I will not tire so easily [because] I am well seated and can continue with my work without discomfort. Also they have given us fans [for the heat] and the ventilation helps me spend more time in a small office and meet the patients without discomfort, [improving] my performance.” IDI18_Gaza

Bonuses

“It all depends on the patients that meet (come) to our health facility because the amount is determined by the data, if the number of patients is greater than we gain more ... the biggest piece of the cake is the payment that EGPAF provides, so I feel like we have improved because we try to achieve more to earn more...we make ourselves available of those patients who feel the suffering, and we treat them as our friends, so that they never want to leave to go to another health facility. If patients left that would be at the expense of the bonus we receive from EGPAF, and would also not help us achieve our health goals.” IDI31_Nampula

“Only some providers contribute to the performance that is counted toward the payment. We do not perform the same jobs [even if] we have the same [level of] performance, only some of that performance counts to increase the payment. So this is a challenge. Because those who are involved with PBF services have their performance measured and have to watch over the situation. All of us always tend to work hard for the bonus because it ends up benefiting the overall performance of the health facility and helps the others who count to perform better.” IDI31_Nampula

“We are worried; why this difference [in bonuses] if the payment is based on performance? It [should not be] based on the career or the position that the person has. That is why there were personal contracts with the PBF ... that each individual had to sign. So the only thing I personally criticize is [the inequity] in bonuses because it should be the same for everyone.” IDI43_Nampula

“We have so many employees and only cover some of the PBF services so the bonuses are very small for me. Sometimes I do not notice them as being different from my regular salary.” IDI07_Gaza

Teamwork

“I think yes, there was a change, because [now] we always talk about the instruments and indicators and other PBF matters... [showing] our strong commitment.” IDI04_Gaza

“We say to colleagues that the PBF is for everyone. So all of us have to make every effort together to achieve those goals or to have those indicators to avail ourselves of [the benefits of] PBF. So there is a concerted effort to achieve these goals.” IDI21_Gaza

“I think the individual [perspective] ends up being part of a collective. We are earn more as a collective so we work together to improve. Because first comes motivation, and then when people are motivated [they] end up doing things to improve the quality of care. And when we improve the quality of care [we] also improve … the achievement level [of staff in working toward] the objectives of each health sector to improve indicators.” IDI14_Nampula

Regular consultations with supervisors

“Before PBF, if we did not do our job, accountability was not in place, so no one said whether it was done correctly or done at all.” IDI055_Nampula

“It has been pretty positive to work with the verification team because there is always interaction between the evaluator and the employee … to show how much we have accomplished, how much we should have done, and why we did not reach our goals. And then we try to work to overcome what we failed in before over the next few months.” IDI15_Gaza

“The [new approach to] evaluation is positive because before PBF we worked to produce information to report to the provincial directors and then to the Ministry. And this information somehow was charged as we achieved certain goals, and we worked accordingly. But with PBF…we make more effort to reach the goals we are given because at the end of a certain period we will receive a bonus for that [extra] effort and it will be acknowledged. With the start of PBF we felt like, efforts were duplicated because in some ways our efforts were to improve our performance both for government goals and PBF goals- sometimes the same. Then after some time in PBF, it was really positive because we doubled [our efforts] knowing we were going to receive something in return.” IDI21_Gaza (Manager)

Application of knowledge and skills to deliver a good job

“In terms of quality, especially in the provision of services ... we did our duty ... to see the patients and deliver treatment. But when PBF began it provided an incentive to succeed. The more important outcome of the incentives is the quality of service provision, so we look at the standards and ask for instructions, and we are committed to doing a good job. This is a significant change, because before we came to do our duties and then went home. But now my unit is doing a better job and I stay my whole shift time or even past my shift time make sure each patient is seen and provided care.” IDI51_Nampula

“We applied the knowledge from verifiers. When they come to present to us PBF and how to get more for our work. PBF taught us some of the things to increases on time with patients. But no, we have not looked at any new clinical trainings from the DPS (district health manager).” IDI06_Gaza

Competition among my colleagues

“We compare our performance among ourselves. We track activities and so does the medical chief. No my colleagues will show up to say I will do some tests (HIV) because you did your part. This ends up influencing the indicators and our performance, and we do it together but comparing with each other. Staff more clearly know what they need to do ... to improve performance, and then together we share the incentive.” IDI60_Nampula

“We all share a goal now, which will be reached this quarter. If the goal is high, the bonus is also high, and then it helps a lot to motivate the whole team, or the institution, as well as their own health officials to seek more, run more, go go go. And we encourage each other when we see one person not doing their part.” IDI17_Gaza

Feeling satisfied with the work I complete

“I am satisfied with my work for the moment because I know what work I have to do, and at the end of the quarter there will be bonuses. I have more motivation because the PBF [has helped] my work to be fully organized in my office, and my colleagues are also organized for their patients. So PBF really makes me very satisfied with my own work.” IDI35_Nampula

“We had to achieve the goals, and to achieve those goals and be noticed within the Health Unit, we had to work hard, we had to follow up with the patients. This drive is satisfying for me in this job.” IDI25_Gaza

“Patients will notice the changes at the facility, the fresh paint and less trash … and are also happy to have reduced wait times. They tell me we are doing a better job and that is why PBF has improved my satisfaction.” IDI04_Gaza

Prestige within the community

“I think EGPAF wants to improve the indicators as a way to help us as employees, the community, the hospital, and the Directorate, because they offer a bonus depending on how well we work. That bonus helps us help the community and the hospital. To us, it means kind, humanized care … encouraging us to work more for the Health Center to improve infrastructure and everything else. For the community, we see that the more people are coming and feel comfortable during their wait” IDI36_Nampula

“People were aware that we have to be paid decently for services (provided) because if we do not, we cannot provide as much service, and patients will abandon us. And if we abandon our indicators in vain, then we cannot succeed. It is true that it is not right either to come (to the health facility) with a bad mood, but this is normal happens to everyone, but in terms of performance and delay with the wait time- we are all now aware, if we do not offer high-quality services ... to our users, they abandon us. What will happened to us with PBF indicators if we do not provide good service is no increased performance.” IDI51_Nampula

Feeling proud as a professional

“Improving services ... is a way of motivating employees. If the employee feels motivated soon he or she will ... work with more desire for achieving quality. ... if yesterday had two patient and motivated professional can make even greater efforts to have MORE patient because it has something that motivates you ... she has benefit, yes, then it is in this context that I was saying that ... improves the quality of work and not only ... the very PBF as I was saying ... quality work also with the same value that we have at the clinic we can buy some equipment that before we did not have the facility, then more so the work equipment and also improves ... is quality work ... yes.” IDI34_Nampula

“As a health professional, I feel proud … of the work that I do. For example, I can follow a mother from the ANC visit until delivery, then follow the same mother and child. This leaves me satisfied that I gave a good follow-up and it was worth it.” IDI24_Gaza