Physicians’ and nurses’ attitudes towards performance-based financial incentives in Burundi: a qualitative study in the province of Gitega

BACKGROUND Performance-based financing (PBF) was first implemented in Burundi in 2006 as a pilot programme in three provinces and was rolled out nationwide in 2010. PBF is a reform approach to improve the quality, quantity, and equity of health services and aims at achieving universal health coverage. It focuses on how to best motivate health practitioners. OBJECTIVE To elicit physicians' and nurses' experiences and views on how PBF influenced and helped them in healthcare delivery. METHODS A qualitative cross-sectional study was carried out among frontline health workers such as physicians and nurses. The data was gathered through individual face-to-face, in-depth, semi-structured interviews with 6 physicians and 30 nurses from February to March 2011 in three hospitals in Gitega Province. A simple framework approach and thematic analysis using a combination of manual technique and MAXQDA software guided the analysis of the interview data. RESULTS Overall, the interviewees felt that the PBF scheme had provided positive motivation to improve the quality of care, mainly in the structures and process of care. The utilization of health services and the relationship between health practitioners and patients also improved. The salary top-ups were recognized as the most significant impetus to increase effort in improving the quality of care. The small and sometimes delayed financial incentives paid to physicians and nurses were criticized. The findings of this study also indicate that the positive interaction between performance-based incentive schemes and other health policies is crucial in achieving comprehensive improvement in healthcare delivery. CONCLUSIONS PBF has the potential to motivate medical staff to improve healthcare provision. The views of medical staff and the context of the area of implementation have to be taken into consideration when designing and implementing PBF schemes.