To provide context, we first describe informants’ perspectives on the integration of TB services in the designated hospitals before presenting emerging themes related to health worker motivation in the context of integrated TB service delivery in the designated hospitals. These are organized under three key areas: (1) professional status and identity; (2) working conditions and (3) the work environment in TB clinics of the designated hospitals.
Integration of TB services within the designated hospitals
Informants had different perspectives on the rationale for integrating TB services within the hospital, and the associated advantages and disadvantages. In both counties, health authorities from the upper administrative levels (provincial and prefecture) had significant influence on the process. There was strong consensus between the CDC and Health Bureau that TB services should be integrated into the general hospital, given the CDC limited space and clinical capacity to manage complicated cases of TB patients.
However, views of the hospital management in both sites were somewhat more ambivalent. Hospital leaders in County A were initially hesitant about the prospect of integrating TB services due to concerns about limited resources and the impact of additional service provision on an already busy routine workload. Gradually, given the pressures towards integrating TB services at the provincial level, the hospital management became more receptive towards the idea of the integrated model which combined strengths of the hospital and CDC in TB control.
In County B, there was similar strong initial resistance from the hospital managers, due to the perceived pressures of dealing with an infectious disease and complicated public health procedures. Hospital management made the case that their infrastructure and staff were not ready to take up the new service. After considerable pressure to accept responsibility for TB treatment services and numerous communications between the health bureau, CDC and hospital, the TB clinic was set up in the infectious disease control department.
This ambivalence around integrating TB services within the hospitals in both County A and County B was reflected in the views of the health workers tasked with providing TB care under the new model.
Professional status and identity
In County A, staff to deliver TB services were either recruited from other health facilities or shifted from other departments of the hospital and placed in a relatively independent outpatient clinic. In County B, doctors were sent by the infectious disease control department of the hospital, with regular staff rotation from various departments of the hospital.
The doctors allocated to TB care perceived their professional status as being compromised through working in the TB clinic, which was considered to be ‘second-rate’ as compared with other clinical settings. TB, a stigmatized condition associated with poverty, is associated with public health work, and therefore potentially disempowering for a clinician, as is hinted in the comments of Dr. F1 (Vice Director, County A hospital):
‘You say you are a TB doctor, but actually, you do not have any power. For other doctors, if patients ask for treatment, doctors will have good faces. But for TB patients, most are poor, vulnerable, have little education.’ [‘Face’ is a common colloquial expression in China, to indicate identity, dignity, pride].
Placing this comment in context is important: working in TB is also associated with lower income for doctors, as TB falls under the ‘free care’ directives, and infectious disease control doctors have limited capacity to generate income. Treatment of infectious diseases requires extensive use of antibiotics and antiviral medicines, however, the drug prescription control and zero-price mark-up policies that aim to counteract potential perverse incentives have reduced income generating opportunities. In contrast, in other clinical departments, income was generated from revenues gained from high-tech diagnostic tests and examinations.
Health workers working in the integrated TB clinics generally expressed a sense of professional discrimination. They felt they had been ‘misplaced’ in the TB clinic, as the hospital could not find a more ‘suitable’ post for them. Further, TB-related stigma was perceived to affect their social connections and family lives. A male TB clinic laboratory worker, in County A Hospital, commented:
‘If I say we are working in infectious disease, nobody will be happy to marry me...I feel depressed about working here.[…] it is not good for a man to keep working on TB. You just dare not tell your friends what you are doing.’
In County B, similarly, the Head of the TB Control Department of the CDC complained that: ‘Compared to doctors from other departments, TB doctors are discriminated against for treating TB. […] after all, TB is an infectious disease.’
Many felt that TB staff working in the smaller designated hospitals had limited promotion opportunities compared to those working in the higher-level hospitals. TB doctors in both hospitals could receive updated training on TB diagnosis and treatment. However, interviews with public health officials suggested that TB treatment was seen as mundane, requiring rigid adherence to simple and repetitive clinical knowledge and skills, and preventing the development of advanced medical knowledge in routine practice. Dr. A1 (health official, County A Health Bureau) shared his views:
‘Working in the TB clinic will not help to improve their medical knowledge, but will decrease their capacity as they are not exposed to the treatment of other diseases. TB is just such a small thing. If they see TB every day, it is too monotonous for them.’
The perceived low status of TB health workers was underpinned by their experiences of working conditions and relationships.
Staff shortage and workload
The allocation of doctors to the TB clinic was dependent on the local prioritization of TB control and resources available in the designated hospitals. TB clinics were commonly only staffed with one or two doctors. In County A, two doctors shared the workload and saw approximately 40 to 50 patients per day. According to them, employing two doctors was ‘wasting resources’, in view of the current TB burden, since most of the patients just came back for routine checks and to renew their prescriptions. In County B, where the TB clinic was integrated with the infectious disease control department, the interviewees reported a serious shortage of health staff. In the infectious disease control department, there were eight doctors and eight nurses. These health workers were mainly based in the wards, but also provided consultations in a number of infectious disease clinics, including the TB clinic. There was only one doctor based in the ‘rotational’ TB clinic, Dr. M2, who complained, ‘I am exhausted, and do not have enough of a break throughout the year.’ Dr. E2, Head of TB Control Department, County B CDC agreed that ‘TB doctors are too few, and the TB clinic is very busy’.
Others confirmed that working in the TB clinic was not desirable, but that in some cases preferable in terms of the timing of work:
‘To be honest, nobody is willing to work here. I have no choice because I don’t want to take the night duties…Here in the TB clinic (generally opening from 8 a.m. to 7 p.m. during the weekdays), it is busy but not necessary to take the night duty … at least I can have a comfortable sleep at home.’ (Dr. M2, TB doctor, TB clinic, County B hospital).
Dissatisfaction with payment
Hospital staff are paid a basic salary based on the professional titles as specified by the government, as well as the performance-based payment, which is based on the number of patients treated and income generated from the services. Performance payment could thus vary significantly and cause a sense of inequity in staff. In County A, the TB staff were dissatisfied to receive the same bonus as the logistical staff. The bonus given to staff in other clinical departments could be several times higher than that of the TB staff since they could generate more income from treating other diseases.
In County B, similarly, staff of the infectious disease control department resented the fact that their salaries did not reflect the high workload of TB service provision, or the perceived high infectious risk. As Q2 (Director of Infectious Disease Control Department, County B hospital) noted, ‘Before TB was integrated here, we had this number of staff, but since integration, our workload has increased, but income not. Why?’.
In County B, the TB clinic, as part of the infectious disease control department, could not escape the influences and practices of ‘independent accounting’, where the department should be responsible for the income generation and general expenses of the department. Subsequently, TB doctors’ income was related to their performance with respect to income generation. In general, the unified implementation of performance-based payment and ‘economic assessment’ among all the clinical departments was regarded as putting the infectious disease control department in an unfair position, with the potential loss of income, infection risks and increasing public health tasks and emergencies. Health workers particularly noted the discrepancy between payment and compensation for working in an environment perceived to put them at high exposure to infection risks.
In both hospitals, the potentially high infectious disease risk and other health concerns were important factors discouraging health workers from working in the TB clinics. For example, one of the doctors in the TB clinic in County A hospital recounted how his prospective father-in-law was reluctant for him to marry his daughter due to the perceived risk of TB infection. Some health workers thought that their immune systems could be weakened if they continued to work in the TB clinic. In County B, a number of interviewees saw TB doctors or laboratory staff who had face-to-face contact with patients or sputum samples as being significantly at risk of contracting TB.
In both hospitals, however, not all health workers were concerned with the risk of infection. As a nurse in County B pointed out, working in TB clinics helped to improve their awareness of the potential risk, due to the physical existence of the TB clinic and patients wearing facemasks, as compared to working in the non-TB clinics where the infection risk was hidden. Nonetheless, the lack of risk assessment and protective measures remained a concern for TB control in both hospitals. For instance, professional facemasks like N95 were reported to have limited availability due to the high cost at the time of study.
Retaining staff to work in the integrated TB clinics was challenging, due to the perceived losses in professional identity and payment, and heightened risk of infection. As Dr. D1 (Head of TB Department of the CDC, County A) summarized: ‘It is a common problem in China. Health workers are generally unwilling to work for TB control.’