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Kenneth Leonard University of Maryland. “Motivation, in the work context, can be defined as an individual’s degree of willingness to exert and maintain.

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Presentation on theme: "Kenneth Leonard University of Maryland. “Motivation, in the work context, can be defined as an individual’s degree of willingness to exert and maintain."— Presentation transcript:

1 Kenneth Leonard University of Maryland

2 “Motivation, in the work context, can be defined as an individual’s degree of willingness to exert and maintain an effort towards organizational goals.” This effort is costly.

3  Paying for outcomes or outputs can help to align individual goals with organizational goals  Salary can compensate individuals who pursue organizational goals, but it generally does not align individual and organizational objectives  Does extrinsic motivation augment or diminish other sources of motivation?

4  Individuals have many sources of motivation  They exert effort until marginal benefit equals marginal cost  Maybe, if they have more sources of motivation, they have greater marginal benefits and will therefore exert more effort.  Maybe, if the returns to effort are high enough (the “wage”) they will provide more effort.

5 From the management, non-health, literature:  Intrinsic: Associated with the job itself: ◦ Chance to learn new skills ◦ Chance to accomplish things  Extrinsic: Earned for doing the job. ◦ Promotion ◦ Salary ◦ Praise for work well done.

6 Motivator (improves satisfaction)Hygiene (avoids dissatisfaction: necessary but not sufficient) AchievementSupervision AdvancementInterpersonal relations RecognitionPhysical working conditions ResponsibilitySalary

7  Satisfied workers exhibit ◦ positive organizational citizenship behaviors, ◦ tend to perform better ◦ are more likely to receive pay increases and promotions  Dissatisfied workers tend to ◦ quit, ◦ engage in destructive behavior (theft, sabotage, drug use) ◦ exhibit work-related fatigue ◦ and have higher illness

8 “It can be hypothesized that job satisfaction could function as a buffer against conditions favoring a higher turnover.”

9  Multiple sources of motivation, including intrinsic and extrinsic motivation makes worker more satisfied with their job.  Job satisfaction makes better employees (in the non-health labor force world wide)  Job satisfaction makes health workers less likely to quit (in developed countries).

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11  Health care processes cannot be fully specified and therefore cannot be enforced.  Health care has sector-wide norms and goals and is a service industry.  Health workers must be at least partially motivated by intrinsic factors to meet organizational goals.  Turnover is not the main problem.  We are interested in the process of change.

12  In developing countries, the problem is not turnover: ◦ Never showing up for a posting (refusing a posting) ◦ Not coming to work even if you show up  If people don’t go to the posting, how do we study them? (we have to get them in medical school)

13  The goal is performance, not job satisfaction  Improved satisfaction is not necessarily the route to improved performance.  Hygiene factors are not sufficient, we must have motivators  We need to study the process by which changes in motivators leads to changes in performance.  Key motivators should come from the service and professional aspects of health care.

14  “not maximizing own monetary payoffs when those actions affect others’ payoffs” Charness and Rabin (2002)  People are both self-interested and concerned with the payoff of others.  Pro-social behavior is when individuals voluntarily engage in activities that are costly to themselves but benefit others  “to help others” is a common response to the question: “why did you choose the health care field?”

15  We know performance is low ◦ We are not very likely to make it worse  However, is RBF sustainable?  Is there an easier way (intrinsic motivation)?  Can performance based pay damage the potential for intrinsically motivated health workers?  Does performance based pay increase intrinsic motivation?

16  Health workers seek the esteem of their supervisors and peers in the hierarchy.  By paying them to provide effort, we signal that the esteem of their peers is not a worthy goal.  They provide effort to earn the money, but are no longer intrinsically motivated.

17  Two types of “others” ◦ Patients ◦ Peers  Two directions: ◦ Caring about the welfare of others ◦ Caring what others think of you.  Of these four combinations, two important ones are likely to be:  Patient-Based social preferences: Caring about the welfare of patients.  Peer-Based social preferences: Caring what your peers think of you.

18  Mayo noticed that assembly line workers changed their productivity for reasons that had nothing to do with the process of assembly.  Thus, psychology becomes important in understanding performance.  However, if they change their behavior for odd reasons, do they not also change their attitudes and the way they report them?

19  Qualitative  Questionnaires on preferences (what motivates you, are you motivated?)  Discrete choice (do you prefer A over B?)  Laboratory Experiments (what do you do in our controlled setting?)  Field experiments (alter something exogenously in the real world)  Performance measurement (measure what you want to produce more of)  RCTs

20  Reliability ◦ Internal consistency (does it represent one underlying factor?) ◦ Test-retest validity  Construct validity (does theory or data suggest we are measuring something meaningful?)  Content Validity (is it sufficiently broad?)  Discriminant Validity or Responsiveness (does it change if it should change?)

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22  Intrinsic incentives are necessary to do the job, but can extrinsic incentives increase the motivation of individuals to conform to organizational norms?  Preliminaries: ◦ What is the source of intrinsic incentives? ◦ How much are they currently motivating health workers?

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24  Give each clinician 100 tokens (worth 15,000 TSH)  Tell him he is paired with an unknown stranger in the next room.  Ask how much he wants to divide the money between himself and the stranger.  No extrinsic benefits from sharing, only extrinsic costs.  Some people may experience intrinsic benefits from giving to strangers.

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33 4 groups (randomized) 1. Control 2. Immediate Gift 3. Delayed Gift 4. Prize for better adherence

34  Enroll (team leader)  Measure Baseline (secret enumerator)  Peer effect (secret enumerator and visible peer)  Encouragement (Local MD)  Data visits (secret enumerator)  Follow-up (Local MD)  Post study visits (secret enumerator)

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36  Large Hawthorne effect shows that basic “hygiene” conditions are not met. ◦ Failure of supervision or social interactions  Thus, patient-focused social preferences are not playing a sufficient role in increasing quality  Hard to crowd out what isn’t there.

37  Health workers care what their peers think of them ◦ We have always known this ◦ The data supports this  A profession is supposed to self-regulate and then sell the collective quality of its services to the public.  Calling it a profession and creating a professional society does not make this happen.  In Tanzania, NGOs have created an environment that appears to have produced same result within the organization. ◦ No dependence on generosity ◦ High levels of peer motivation (in the baseline) ◦ High levels of quality

38  Although generosity does not mean health workers conform to organizational norms, it is possible that being a professional does:  Is professionalism: ◦ Type? ◦ Learned?  How would we identify a professional?  Would extrinsic incentives damage the activities of this kind of health worker?

39  Any program that increases the contact with health workers, provides guidance and notices improvements in quality is likely to improve quality  Extra funds can make improvements easier  There may be very little extrinsic motivation in a pay for performance scheme.

40  Performance by itself does not indicate the type of motivation  Motivation is difficult to measure because of the Hawthorne effect  Linking motivation and performance is not a causal story  We don’t know which instruments are responsive and valid.  Changes in motivation and changes in behavior are better ways to investigate.

41  Qualitative  Questionnaires on preferences (what motivates you, are you motivated?)  Discrete choice (do you prefer A over B?)  Laboratory Experiments (what do you do in our controlled setting?)  Field experiments (alter something exogenously in the real world)  Performance measurement (measure what you want to produce more of)  RCTs


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