Does public service motivation matter in Moroccan public hospitals? A multiple embedded case study

International Journal for Equity in Health, Volume 18, No. 1, Year 2019

Ukuhunyushwa

Background: The motivation of health workers is a key concern of policy makers, practitioners and researchers. Public Service Motivation (PSM), defined as the altruistic desire to serve the common interest, to serve others and to help patients and their families regardless of financial or external rewards, has been shown to be key to the performance of public servants. Yet, limited attention has been paid to this kind of motivation in health care settings in low- A nd middle-income countries. Little is known about PSM and its contextual specificity in the Moroccan health system. We set out to qualitatively explore the meaning of PSM and its expression among health workers in four public hospitals. Methods: We adopted a multiple embedded case study design to explore PSM in two well-performing and two poor-performing hospitals. We carried out 68 individual interviews, eight focus group discussions and 11 group discussions with different cadres (doctors, administrators and nurses). We carried out thematic analysis using NVivo 10. Results: Our analysis shows that public service motivation is a notion that seems natural to the health workers we interviewed. Daily interactions with patients catalysed health providers’ affective motives (compassion and self-sacrifice), a central element of PSM. It also provided them with job satisfaction aligned with their intrinsic motivation. Managers and administrative personnel express other PSM components: Attraction to public policy making and commitment to public values. A striking result is that health workers expressed strong religious beliefs about expected rewards from God when properly serving patients. Conclusion: This study highlights the presence of PSM as a driver of motivation among health workers in four Moroccon hospitals, and the prominence of intrinsic motivation and compassion in the motivation of frontline health workers. Religious beliefs were found to shape the expression of PSM in Morocco. This study is part of a larger research project that adopted the realist evaluation approach [53] to examine the links between leadership, staff motivation and performance. This study is exploratory in nature [54] in a sense that it explores the motivation of health workers using insights from PSM theory in the context of Morocco. Morocco is a lower middle-income country with a population of 35.6 millions [55]. Islam is the religion of most Moroccans and this has an impact on daily life and work place practices [56–58]. The Moroccan society is multi-cultural, collectivistic and strongly attached to family relationships and filial piety [56, 57]. In health, there has been a significant progress in many health indicators (e.g. 35% reduction of the maternal mortality rate between 2010 and 2016), the extension of the coverage to the poor and vulnerable populations, the decentralisation and the introduction of public private partnerships [59, 60]. However, the Moroccan health system remains weak, ranked 134th out 195 countries in terms of health access and quality of care [61] with an inequitable access to care and a poorly regulated private sector [62, 63]. The Moroccan health system is constrained by an acute health workforce shortage, for instance having 0.7 doctors per 1.000 inhabitants and 0.92 nurses and midwives per 1.000 inhabitants) [64, 65]. Studies indicated a lack of staff commitment, poor motivation, low job satisfaction and poor working conditions [58, 66] that have hampered the implementation of many health system reforms, for instance quality assurance programmes [67, 68], fee exemption policies [69]. Other studies found that these health workforce issues affected the quality of patient-provider interactions [70, 71]. In this study, we adopted the case study design. The case here is PSM as experienced by health personnel in hospitals. The multiple embedded case study design is appropriate to the exploration of complex phenomena, such as PSM in real world settings and allows for comparison between sites [72]. We purposefully selected two high-performing and two low-performing hospitals. We used the results of the national quality assurance programme called concours qualité to select hospitals as our study sites. This programme assessed hospital performance in eight dimensions: (1) accessibility/availability/continuity; (2) patient security and responsiveness; (3) satisfaction; (4) ethics; (5) quality assurance; (6) resource utilisation; (7) technical competencies and (8) leadership. The overall performance score index is measured by the ratio between the actual score assessed by the external audit and the maximum obtainable score. We refer to [67, 68] for an overview of the programme. Using data from the quality assurance report 2011 [73] and 2016 [74], we identified hospitals with a significant increase or decrease of performance between 2011 and 2016. In the field of public management, the definition of PSM has evolved since 1990, broadening from ‘individual predisposition’ to a more detailed description (Table 1). Definitions of PSM In the last two decades, most PSM research focused on developing measurement scales. These studies were carried out in the USA, Europe, Asia and South America [78]. Wright noted a high degree of variability in operational definitions and a diversity of PSM scales [79]. To overcome this diversity, Kim and colleagues [80] refined the multidimensional scale developed by Perry and Wise [35] and validated it across 12 industrialised countries [81–83]. It comprises: In this study, we consider individual motivation as mix of motives including a continuum that ranges from extrinsic motivation to more autonomous forms of motivation (intrinsic motivation and PSM). We mean by intrinsic motivation ‘the doing of an activity for its inherent satisfaction rather than for some separable consequences’ [84]. We adopt Ryan and Deci’s definition of extrinsic motivation: “a construct that pertains whenever an activity is done in order to attain some separable outcome” (e.g. tangible and verbal rewards) [84]. We adopted the definition of Vandenabeele of PSM. As explained below, we used the 4 components of PSM as defined by Kim et al. [83] and the concepts of intrinsic and extrinsic motivation as defined by Ryan and Deci [84] to analyse the data. We started with interviews and then conducted group discussions. A document review was carried out all along the study. All data were collected during the period January–June 2018 (see Tables Tables22 and and33). Data collection Respondents characteristics We started the data collection by interviewing hospital staff. In total, we carried out 68 in-depth interviews (IDI) with senior-, middle-, operational-level managers and health professionals [85, 86]. We explored the views of respondents on public service motivation, its definition and its expression, as well as the factors that may influence PSM. We used adapted open-ended interview guides for each category of respondents (Additional file 1). These were tested in a pilot study with professionals. We carried out the interviews until saturation was attained. In a second stage, we carried out eight focus group discussions and 11 group discussions with different cadres (administrators, nurses and doctors) to further explore the key constructs mentioned by interviewees in relation to motivation. This allowed us to deepen the analysis across different categories of health workers (Table 3). The FGD and group discussions were conducted by the first author, who used a facilitator guide (Additional file 2). We conducted the FGD following standardised procedures described by Krueger and Morgan and used probes, asked follow up questions, summarised key themes and sought verification from participants [87, 88]. We used qualitative purposive sampling [86] in order to identify respondents for the in-depth interviews and the focus group discussions. Interviews were carried out in Moroccan dialect. All interviews, FGDs and group discussions were audio-recorded with the exception of two interviews. In these specific cases, we took notes and transcribed the unrecorded interviews using memory recall [85]. All transcripts were checked for accuracy by two co-authors (ZB and BM). Table 2 presents the breakdown per hospital. We used codes to identify respondents anonymously, referring to the hospital EJMH, NHMH, RKMH, SMBA. At the end of each contact with research participants, we wrote a brief contact summary that included major themes and ideas arising from the interaction following guidance provided by Miles and Huberman, and Krueger [87, 89]. Table 3 represents the summary of data collection tools and respondents’ profiles (Additional files 3, 4, 5 and 6 provide detailed descriptions of the respondent characteristics). In order to identify key elements in the broader health policy context and to describe the general context, we collected documents all along the study. Key informants at the four hospitals and at the Ministry of Health contributed to identifiying relevant documents. We focused on human resources availability and skill mix data, strategic plans, audit documents and quality assurance reports. We structured the qualitative data analysis along the analytic phases of compiling data, interpreting data, discussion and drawing conclusions [90]. During the initial coding cycle, we coded all data sources (transcripts, contact summaries and field notes) using different coding techniques (concept, hypothesis and “in vivo” coding) [91] and used NVivo 10 v11. 4.3 software to manage the data [92]. During the second coding cycle or pattern coding, [89], we used the four PSM components (attraction to public service, commitment to public values, compassion, self-sacrifice) described by Kim and colleagues [83] and the intrinsic/extrinsic types of motivation defined by Ryan and Deci [84]. As we will present below, we also identified other categories of motives that emerged from the inductive analysis of data (religious based motives). The coding was discussed during research team meetings. These meetings were conducted at different moments during the analysis, focusing on the initial coding, the second coding cycle, the in-case analysis and the cross-case analysis. The research protocol was approved by the Moroccan Institutional Review Board in Rabat (n°90/16) and the Institutional Review Board of the Institute of Tropical Medicine, Antwerp (N° 1204/17). All interviewees were informed before the start of data collection about the study objectives, the topics, the type of questions and their right to refuse being interviewed or interrupt the interview at any time. The same information was included in an information sheet that was given to candidate interviewees and reiterated when the written consent form was discussed before the start of the interview. The informed consent forms were signed by the participants and co-signed by the researcher. A copy of the signed consent form was given to research participants.

I-AI Digest

Study Justification:

– The motivation of health workers is a key concern for policy makers, practitioners, and researchers.
– Public Service Motivation (PSM), defined as the altruistic desire to serve the common interest, has been shown to be key to the performance of public servants.
– Limited attention has been paid to PSM in health care settings in low- and middle-income countries.
– Little is known about PSM and its contextual specificity in the Moroccan health system.

Study Highlights:

– The study explored the meaning of PSM and its expression among health workers in four public hospitals in Morocco.
– Daily interactions with patients catalyzed health providers’ affective motives, such as compassion and self-sacrifice, which are central elements of PSM.
– Health workers expressed strong religious beliefs about expected rewards from God when properly serving patients.
– The study highlights the presence of PSM as a driver of motivation among health workers in Moroccan hospitals, with intrinsic motivation and compassion being prominent.

Study Recommendations:

– Policy makers should consider the importance of PSM in motivating health workers and improving performance in public hospitals.
– Efforts should be made to understand and support the affective motives, such as compassion and self-sacrifice, of health workers.
– Religious beliefs should be taken into account when designing strategies to enhance PSM among health workers.

Key Role Players:

– Policy makers
– Health administrators
– Doctors
– Nurses
– Researchers

Cost Items for Planning Recommendations:

– Training programs to enhance PSM among health workers
– Support for religious practices and beliefs in the workplace
– Research and evaluation activities to monitor the impact of PSM on health worker motivation and performance
– Implementation of strategies to improve working conditions and job satisfaction for health workers

Amandla Obufakazi

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides a detailed description of the study design, data collection methods, and analysis techniques. However, it does not provide specific findings or results from the study. To improve the evidence, the abstract could include a summary of the key findings and their implications for policy makers, practitioners, and researchers.

Abstract

This study is part of a larger research project that adopted the realist evaluation approach [53] to examine the links between leadership, staff motivation and performance. This study is exploratory in nature [54] in a sense that it explores the motivation of health workers using insights from PSM theory in the context of Morocco. Morocco is a lower middle-income country with a population of 35.6 millions [55]. Islam is the religion of most Moroccans and this has an impact on daily life and work place practices [56–58]. The Moroccan society is multi-cultural, collectivistic and strongly attached to family relationships and filial piety [56, 57]. In health, there has been a significant progress in many health indicators (e.g. 35% reduction of the maternal mortality rate between 2010 and 2016), the extension of the coverage to the poor and vulnerable populations, the decentralisation and the introduction of public private partnerships [59, 60]. However, the Moroccan health system remains weak, ranked 134th out 195 countries in terms of health access and quality of care [61] with an inequitable access to care and a poorly regulated private sector [62, 63]. The Moroccan health system is constrained by an acute health workforce shortage, for instance having 0.7 doctors per 1.000 inhabitants and 0.92 nurses and midwives per 1.000 inhabitants) [64, 65]. Studies indicated a lack of staff commitment, poor motivation, low job satisfaction and poor working conditions [58, 66] that have hampered the implementation of many health system reforms, for instance quality assurance programmes [67, 68], fee exemption policies [69]. Other studies found that these health workforce issues affected the quality of patient-provider interactions [70, 71]. In this study, we adopted the case study design. The case here is PSM as experienced by health personnel in hospitals. The multiple embedded case study design is appropriate to the exploration of complex phenomena, such as PSM in real world settings and allows for comparison between sites [72]. We purposefully selected two high-performing and two low-performing hospitals. We used the results of the national quality assurance programme called concours qualité to select hospitals as our study sites. This programme assessed hospital performance in eight dimensions: (1) accessibility/availability/continuity; (2) patient security and responsiveness; (3) satisfaction; (4) ethics; (5) quality assurance; (6) resource utilisation; (7) technical competencies and (8) leadership. The overall performance score index is measured by the ratio between the actual score assessed by the external audit and the maximum obtainable score. We refer to [67, 68] for an overview of the programme. Using data from the quality assurance report 2011 [73] and 2016 [74], we identified hospitals with a significant increase or decrease of performance between 2011 and 2016. In the field of public management, the definition of PSM has evolved since 1990, broadening from ‘individual predisposition’ to a more detailed description (Table 1). Definitions of PSM In the last two decades, most PSM research focused on developing measurement scales. These studies were carried out in the USA, Europe, Asia and South America [78]. Wright noted a high degree of variability in operational definitions and a diversity of PSM scales [79]. To overcome this diversity, Kim and colleagues [80] refined the multidimensional scale developed by Perry and Wise [35] and validated it across 12 industrialised countries [81–83]. It comprises: In this study, we consider individual motivation as mix of motives including a continuum that ranges from extrinsic motivation to more autonomous forms of motivation (intrinsic motivation and PSM). We mean by intrinsic motivation ‘the doing of an activity for its inherent satisfaction rather than for some separable consequences’ [84]. We adopt Ryan and Deci’s definition of extrinsic motivation: “a construct that pertains whenever an activity is done in order to attain some separable outcome” (e.g. tangible and verbal rewards) [84]. We adopted the definition of Vandenabeele of PSM. As explained below, we used the 4 components of PSM as defined by Kim et al. [83] and the concepts of intrinsic and extrinsic motivation as defined by Ryan and Deci [84] to analyse the data. We started with interviews and then conducted group discussions. A document review was carried out all along the study. All data were collected during the period January–June 2018 (see Tables Tables22 and and33). Data collection Respondents characteristics We started the data collection by interviewing hospital staff. In total, we carried out 68 in-depth interviews (IDI) with senior-, middle-, operational-level managers and health professionals [85, 86]. We explored the views of respondents on public service motivation, its definition and its expression, as well as the factors that may influence PSM. We used adapted open-ended interview guides for each category of respondents (Additional file 1). These were tested in a pilot study with professionals. We carried out the interviews until saturation was attained. In a second stage, we carried out eight focus group discussions and 11 group discussions with different cadres (administrators, nurses and doctors) to further explore the key constructs mentioned by interviewees in relation to motivation. This allowed us to deepen the analysis across different categories of health workers (Table 3). The FGD and group discussions were conducted by the first author, who used a facilitator guide (Additional file 2). We conducted the FGD following standardised procedures described by Krueger and Morgan and used probes, asked follow up questions, summarised key themes and sought verification from participants [87, 88]. We used qualitative purposive sampling [86] in order to identify respondents for the in-depth interviews and the focus group discussions. Interviews were carried out in Moroccan dialect. All interviews, FGDs and group discussions were audio-recorded with the exception of two interviews. In these specific cases, we took notes and transcribed the unrecorded interviews using memory recall [85]. All transcripts were checked for accuracy by two co-authors (ZB and BM). Table 2 presents the breakdown per hospital. We used codes to identify respondents anonymously, referring to the hospital EJMH, NHMH, RKMH, SMBA. At the end of each contact with research participants, we wrote a brief contact summary that included major themes and ideas arising from the interaction following guidance provided by Miles and Huberman, and Krueger [87, 89]. Table 3 represents the summary of data collection tools and respondents’ profiles (Additional files 3, 4, 5 and 6 provide detailed descriptions of the respondent characteristics). In order to identify key elements in the broader health policy context and to describe the general context, we collected documents all along the study. Key informants at the four hospitals and at the Ministry of Health contributed to identifiying relevant documents. We focused on human resources availability and skill mix data, strategic plans, audit documents and quality assurance reports. We structured the qualitative data analysis along the analytic phases of compiling data, interpreting data, discussion and drawing conclusions [90]. During the initial coding cycle, we coded all data sources (transcripts, contact summaries and field notes) using different coding techniques (concept, hypothesis and “in vivo” coding) [91] and used NVivo 10 v11. 4.3 software to manage the data [92]. During the second coding cycle or pattern coding, [89], we used the four PSM components (attraction to public service, commitment to public values, compassion, self-sacrifice) described by Kim and colleagues [83] and the intrinsic/extrinsic types of motivation defined by Ryan and Deci [84]. As we will present below, we also identified other categories of motives that emerged from the inductive analysis of data (religious based motives). The coding was discussed during research team meetings. These meetings were conducted at different moments during the analysis, focusing on the initial coding, the second coding cycle, the in-case analysis and the cross-case analysis. The research protocol was approved by the Moroccan Institutional Review Board in Rabat (n°90/16) and the Institutional Review Board of the Institute of Tropical Medicine, Antwerp (N° 1204/17). All interviewees were informed before the start of data collection about the study objectives, the topics, the type of questions and their right to refuse being interviewed or interrupt the interview at any time. The same information was included in an information sheet that was given to candidate interviewees and reiterated when the written consent form was discussed before the start of the interview. The informed consent forms were signed by the participants and co-signed by the researcher. A copy of the signed consent form was given to research participants.

Izinto zokwakha

Emisha

Based on the provided description, it appears that the study focuses on exploring the motivation of health workers in Moroccan public hospitals, specifically in relation to Public Service Motivation (PSM). The study aims to understand the meaning of PSM and its expression among health workers, as well as its impact on their performance. The study also highlights the presence of intrinsic motivation and compassion among frontline health workers, as well as the influence of religious beliefs on the expression of PSM in Morocco.

In terms of potential innovations to improve access to maternal health, based on the information provided, it is not directly related to the study’s focus on health worker motivation and PSM. However, some general innovations that could potentially improve access to maternal health include:

1. Telemedicine: Implementing telemedicine programs that allow pregnant women in remote or underserved areas to access prenatal care and consultations with healthcare providers remotely, reducing the need for travel and improving access to healthcare services.

2. Mobile health (mHealth) interventions: Developing mobile applications or text messaging services that provide pregnant women with information, reminders, and support throughout their pregnancy, including prenatal care appointments, nutrition advice, and emergency contact information.

3. Community health worker programs: Expanding and strengthening community health worker programs to provide maternal health education, support, and referrals in communities where access to healthcare facilities is limited.

4. Maternity waiting homes: Establishing maternity waiting homes near healthcare facilities to provide accommodation for pregnant women who live far away and need to travel to access maternal health services. This can help ensure timely access to care during labor and delivery.

5. Financial incentives: Implementing financial incentive programs, such as conditional cash transfers or vouchers, to encourage pregnant women to seek and utilize maternal health services, particularly in low-income populations.

It is important to note that these recommendations are general and may need to be adapted to the specific context and needs of the Moroccan health system. Additionally, further research and evaluation would be necessary to assess the effectiveness and feasibility of these innovations in improving access to maternal health in Morocco.

AI Innovations Description

The study mentioned in the description focuses on exploring the concept of Public Service Motivation (PSM) among health workers in Moroccan public hospitals. PSM refers to the altruistic desire to serve the common interest and help others, regardless of financial rewards. The study found that PSM is a natural notion among the health workers interviewed, with daily interactions with patients catalyzing affective motives such as compassion and self-sacrifice. It also highlighted the importance of intrinsic motivation and compassion in the motivation of frontline health workers. Additionally, religious beliefs were found to shape the expression of PSM in Morocco.

Based on the findings of this study, a recommendation to improve access to maternal health could be to leverage and enhance the existing PSM among health workers. This could be done through the following steps:

1. Raise awareness: Conduct training and awareness programs to educate health workers about the importance of maternal health and the impact they can have in improving access and outcomes.

2. Foster a supportive work environment: Create a work environment that values and supports health workers’ intrinsic motivation and compassion. This can be done by providing adequate resources, improving working conditions, and recognizing and rewarding their efforts.

3. Strengthen leadership: Develop strong leadership at all levels of the healthcare system that promotes and reinforces the values of PSM. Leaders should lead by example and demonstrate a commitment to public service and the well-being of patients.

4. Promote collaboration: Encourage collaboration and teamwork among health workers to enhance their ability to provide comprehensive and coordinated maternal health services. This can be achieved through interdisciplinary training programs and regular team meetings.

5. Address workforce shortages: Take steps to address the acute health workforce shortage in Morocco by increasing the number of doctors, nurses, and midwives. This can be done through targeted recruitment and retention strategies, such as offering incentives and career development opportunities.

By implementing these recommendations, the motivation and performance of health workers can be enhanced, leading to improved access to maternal health services and better health outcomes for mothers and their babies.

AI Innovations Methodology

The provided text describes a study that explores the motivation of health workers in Moroccan public hospitals, specifically focusing on Public Service Motivation (PSM). The study adopts a multiple embedded case study design, conducting interviews, focus group discussions, and group discussions with different cadres of health workers in four public hospitals.

To improve access to maternal health, the study could consider the following innovations as potential recommendations:

1. Strengthening training programs: Enhancing the skills and knowledge of health workers through comprehensive training programs can improve the quality of maternal health services. This could include training on emergency obstetric care, prenatal and postnatal care, and family planning.

2. Implementing mobile health solutions: Utilizing mobile health technologies, such as mobile apps or SMS-based systems, can help overcome geographical barriers and provide access to maternal health information and services to remote or underserved areas.

3. Promoting community engagement: Involving local communities in decision-making processes and raising awareness about maternal health can help create a supportive environment for pregnant women. This can be done through community health workers, community-based organizations, and outreach programs.

4. Strengthening referral systems: Developing efficient referral systems between primary healthcare facilities and higher-level hospitals can ensure timely access to specialized maternal health services for high-risk pregnancies or complications.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify key indicators that measure access to maternal health, such as the number of antenatal care visits, skilled birth attendance, and availability of emergency obstetric care.

2. Collect baseline data: Gather data on the current status of these indicators in the selected hospitals or regions. This can be done through surveys, interviews, or existing health information systems.

3. Introduce the recommendations: Implement the recommended innovations in selected hospitals or regions, ensuring proper training, infrastructure, and support systems are in place.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the selected indicators. This can be done through regular data collection, surveys, or interviews with health workers and patients.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on improving access to maternal health. Compare the baseline data with the post-implementation data to identify any changes or improvements.

6. Draw conclusions and make recommendations: Based on the analysis, draw conclusions about the effectiveness of the recommendations in improving access to maternal health. Identify any challenges or barriers that may have influenced the results. Make recommendations for further improvements or adjustments to the interventions.

By following this methodology, researchers can simulate the impact of the recommended innovations on improving access to maternal health and provide evidence-based insights for policy makers and practitioners.

Ababhali & Co-Ababhali

Statistics:

Citations: 11

Authors: 4

Identifiers:

DOI: 10.1186/s12939-019-1053-8

Research Areas:

Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Workforce

Study Countries:

Morocco

Study Design:

Case Study, Cross Sectional Study, Exploratory Study, Grounded Theory, Phenomenological Study

Study Approach:

Qualitative

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