Team- and individual-level motivation in complex primary care system change: A realist evaluation of the Salud Mesoamerica Initiative in El Salvador

• Published in: Gates open research 2018, Vol.2, p.55
• Main Authors: Munar, Wolfgang, Wahid, Syed S., Mookherji, Sangeeta, Innocenti, Cinzia, Curry, Leslie
• Format: Article
• Language: English
• ISSN: 2572-4754; 2572-4754
• DOI: 10.12688/gatesopenres.12878.1

Background: We study the role of individual and team-level motivation in explaining large-scale primary care performance improvements in El Salvador, one of the top-performing countries in the Salud Mesoamerica Initiative. Methods: Case study with outlier sampling of high-performing, community health teams in El Salvador. Design includes scoping review of literature, document review, non-participant observation, and qualitative analysis of in-depth interviews following a realist case study protocol. Results: The interplay between program interventions and organizational, community and policy contexts trigger multi-level motivational mechanisms that operate in complex, dynamic fashion. Interventions like performance measurement and team-based, in-kind incentives foster motivation among individual members of high-performing teams, which may be moderated by working conditions, supervision practices, and by the stress exerted by the interventions themselves. Individuals report a strong sense of public service motivation and an overarching sense of commitment to the community they serve. At the interpersonal level, the linkage between performance measurement and in-kind incentives triggers a sense of collective efficacy and increases team motivation and improvement behaviors. The convening of learning forums and performance dialogue increases the stakes for high-performing teams, helps them make sense of performance data, and leads to performance information utilization for healthcare improvements. Closeness to communities creates strong emotional linkages among team members that further increases collective efficacy and social identity. Such changes in individuals, team, and organizational behaviors can contribute to improved delivery of primary care services and explain the gains in performance demonstrated by the program. Conclusions: This case suggests that primary care systems that rely on multi-disciplinary teams for the provision of care can benefit from performance measurement and management interventions that leverage individual and team-level motivation. Realist evaluation can help prioritize policy-relevant research and enhance the design and evaluation of large-scale performance reforms in primary care systems in low- and middle-income settings.