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Carrots or sticks? Health workers’ perspectives on performance-based incentives – Findings from a mixed-methods study in Malawi

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Julia Lohmann

This document summarizes findings from a mixed-methods study in Malawi on health workers' perspectives on performance-based incentives (PBI). The study found that while PBI improved health worker motivation and quality of care by addressing resource constraints, it also risked negative consequences if not implemented fairly with participatory decision-making, adequate staffing and resources, realistic expectations, and transparency. PBI was more likely to function as a "carrot" rather than a "stick" when these conditions were met and when feedback focused on learning rather than punishment. However, PBI also sometimes led to conflicts over incentive sharing, cheating to meet targets despite capacity limitations, and feelings of psychological burden.

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Carrots or sticks? Health workers’ perspectives on performance-based incentives – Findings from a mixed-methods study in Malawi Julia Lohmann1, Christabel Kambala12, Adamson S. Muula2, Manuela De Allegri1 1 Institute of Public Health, University of Heidelberg, Germany 2 School of Public Health and Family Medicine, College of Medicine, University of Malawi Global Maternal Newborn Health Conference, Mexico City, October 21st, 2015
Research questions How do performance- based incentives affect health workers? Which factors determine whether health workers react positively or negatively to PBI? Source: Queuille et al., 2014
The Malawian RBF4MNH Initiative Implementers Financial support Germany Norway Ministry of Health Technical support Implementation (start April 2013) Aim: reduce maternal and neonatal mortality • Increase the quantity of institutional deliveries • Improve the quality of delivery care
The Malawian RBF4MNH Initiative RBF4MNH components 1.Investment in infrastructure & equipment 2.Quality & performance contracts (PBI) 3.Conditional cash transfers Indicator example Completely and appropriately filled partographs according to national standards for all deliveries. PBI elements • Quarterly performance verification (1st year: biannual) • Incentive use – 30%: reinvestment in facility – 70%: disbursement to staff
• Structured provider survey in intervention facilities before (n=52), one year (n=103), and two years (n=106) after the start of the intervention • In-depth interviews with selected nurses, medical assistants, and clinical officers in intervention facilities one (n=24) and two years (n=20) after the start of the intervention Methods
Results
Many respondents feel that the PBI have improved the quality of care they deliver. Satisfaction with quality of care being provided “It has helped us to assist the patients the way they are supposed to be assisted according to the standards.” Nurse, Balaka, endline Midterm (n=103) Endline (n=106) High level Low level Baseline (n=52) “We usually had patients coming back from the communities with sepsis, but now, it’s one patient maybe in a week.” Maternity in-charge, Dedza, endline
Changes are attributed to the improved resource situation, which permits better patient care and is a major motivator, … Satisfaction with changes at the workplace Midterm (n=67) Endline (n=78) High level Low level “That’s the excellent part. Before RBF it was very tiresome to work because the consumables were not available so it was like we were coming here to play and chat with the patients, but now it’s better.” Clinical officer, Balaka, midterm “It motivates us. In an environment where we have no things to use, it demotivates. Even if I go [to work], what can I use? So it has really helped us.” Nurse, Ntcheu, endline
… as well as to the fact that there is something to gain if the facility does well, … “It felt very good to have that money to take home. It actually motivated me to work extra hard.” Nurse, Balaka, midterm “Everybody is trying hard so that you win. This time you came number three, you want to be number two, the next time you want to be number one.” Nurse, Mchinji, midterm
… as well as to the performance targets and feedback inherent in PBI, particularly when it’s timely and delivered in a learning-oriented way. Perceived changes in performance feedback in last year 0% 20% 40% 60% 80% 100% No change Decrease Increase Midterm (n=74) Endline (n=80) “It acts like a reminder to us. […] You see, oh, I’m supposed to be doing this, this, this.” Nurse, Dedza, endline We are told the way we are performing. If we are not doing well, we are given information on what to do. Where there are changes, we are taught. Nurse, Mchinji, midterm
So it seems that performance-based incentives do have a certain “carrot potential”. However, our study shows the importance of …
… adequate staff numbers, skills, infrastructure, and essential equipment, … Source: Nyasa Times 15.12.14 “Patients are not getting the care that they are supposed to get because of the workload. […] We are failing here and there.” Nurse, Dedza, endline “The mothers after delivery, they are supposed to be monitored for 48 hours […] We don’t usually achieve that indicator because we don’t have much space, and so we discharge them […] after 24 hours.” Maternity in-charge, Dedza, endline
… and that decisions, actions, and communication are participatory and transparent, so that they are perceived as fair, and expectations are realistic. “Ideally, […] we should sit down and discuss what we should buy […], but this hasn’t been done. It’s just the in-charge that will come and say we have bought this. […] We complained.” “It’s unfair, because we work hard to achieve those things, and then they come and say, you didn’t do this, yet the things are there, it’s unfair.” Nurse, Dedza, endline Nurse, Dedza, endline
Otherwise, PBI might be more stick than carrot. “Some of the labor graphs are not filled because of shortage of staff. [...] Seeing it clearly that you are losing some money because you did not fill all the partographs, you feel like you could have had that money, but you have lost it. […] We feel bad, but we also feel that there is nothing we could do.” Nurse, Mchinji, endline “It is psychological torture to be told to work extra hard for something and that something is almost nothing.” Clinical officer, Dedza, midterm “Honestly, I feel like the project is there to bring a burden on us. They are just trying to get more customers in, but the staff and resources to attend to those customers are few. ” Nurse, Mchinji, endline
“This RBF, it is bringing us together, but it is also driving us apart.” Nurse, Balaka, endline Our findings also indicate that decision-making autonomy in sharing incentives amongst individuals can lead to serious conflict, ... “I think the project should decide. They should just calculate and give us the figures, that this one should take such, such amount, because this money is creating a lot of enmity at this hospital.” Nurse, Balaka, midterm
... and that there will likely be cheating, possibly with negative consequences for the patients. “What is documented is not what has been done. [In the records,] you see that patient was monitored on the blood pressure, the blood pressure was good, then one hour later, the patient starts fitting. […] One starts to wonder how did it happen. You just know that […] the BP was not checked […]. So instead of just leaving the area blank [in the records], for the sake of the RBF to get the incentives, [the nurse] decides to put the fake BP.” Nurse, Dedza, endline
Acknowledgement: This study was funded by the United States Agency for International Development under Translating Research into Action, Cooperative Agreement No. GHS-A-00-09-00015-00, as well as by the Royal Norwegian Embassy-Malawi, Grant No. MWI-12/0010. Disclaimer: This study is made possible by the support of the American People through the United States Agency for International Development (USAID). The findings of this study are the sole responsibility of the University of Heidelberg and the College of Medicine and do not necessarily reflect the views of USAID or the United States Government.

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Carrots or sticks? Health workers’ perspectives on performance-based incentives – Findings from a mixed-methods study in Malawi

  • 1. Carrots or sticks? Health workers’ perspectives on performance-based incentives – Findings from a mixed-methods study in Malawi Julia Lohmann1, Christabel Kambala12, Adamson S. Muula2, Manuela De Allegri1 1 Institute of Public Health, University of Heidelberg, Germany 2 School of Public Health and Family Medicine, College of Medicine, University of Malawi Global Maternal Newborn Health Conference, Mexico City, October 21st, 2015
  • 2. Research questions How do performance- based incentives affect health workers? Which factors determine whether health workers react positively or negatively to PBI? Source: Queuille et al., 2014
  • 3. The Malawian RBF4MNH Initiative Implementers Financial support Germany Norway Ministry of Health Technical support Implementation (start April 2013) Aim: reduce maternal and neonatal mortality • Increase the quantity of institutional deliveries • Improve the quality of delivery care
  • 4. The Malawian RBF4MNH Initiative RBF4MNH components 1.Investment in infrastructure & equipment 2.Quality & performance contracts (PBI) 3.Conditional cash transfers Indicator example Completely and appropriately filled partographs according to national standards for all deliveries. PBI elements • Quarterly performance verification (1st year: biannual) • Incentive use – 30%: reinvestment in facility – 70%: disbursement to staff
  • 5. • Structured provider survey in intervention facilities before (n=52), one year (n=103), and two years (n=106) after the start of the intervention • In-depth interviews with selected nurses, medical assistants, and clinical officers in intervention facilities one (n=24) and two years (n=20) after the start of the intervention Methods
  • 7. Many respondents feel that the PBI have improved the quality of care they deliver. Satisfaction with quality of care being provided “It has helped us to assist the patients the way they are supposed to be assisted according to the standards.” Nurse, Balaka, endline Midterm (n=103) Endline (n=106) High level Low level Baseline (n=52) “We usually had patients coming back from the communities with sepsis, but now, it’s one patient maybe in a week.” Maternity in-charge, Dedza, endline
  • 8. Changes are attributed to the improved resource situation, which permits better patient care and is a major motivator, … Satisfaction with changes at the workplace Midterm (n=67) Endline (n=78) High level Low level “That’s the excellent part. Before RBF it was very tiresome to work because the consumables were not available so it was like we were coming here to play and chat with the patients, but now it’s better.” Clinical officer, Balaka, midterm “It motivates us. In an environment where we have no things to use, it demotivates. Even if I go [to work], what can I use? So it has really helped us.” Nurse, Ntcheu, endline
  • 9. … as well as to the fact that there is something to gain if the facility does well, … “It felt very good to have that money to take home. It actually motivated me to work extra hard.” Nurse, Balaka, midterm “Everybody is trying hard so that you win. This time you came number three, you want to be number two, the next time you want to be number one.” Nurse, Mchinji, midterm
  • 10. … as well as to the performance targets and feedback inherent in PBI, particularly when it’s timely and delivered in a learning-oriented way. Perceived changes in performance feedback in last year 0% 20% 40% 60% 80% 100% No change Decrease Increase Midterm (n=74) Endline (n=80) “It acts like a reminder to us. […] You see, oh, I’m supposed to be doing this, this, this.” Nurse, Dedza, endline We are told the way we are performing. If we are not doing well, we are given information on what to do. Where there are changes, we are taught. Nurse, Mchinji, midterm
  • 11. So it seems that performance-based incentives do have a certain “carrot potential”. However, our study shows the importance of …
  • 12. … adequate staff numbers, skills, infrastructure, and essential equipment, … Source: Nyasa Times 15.12.14 “Patients are not getting the care that they are supposed to get because of the workload. […] We are failing here and there.” Nurse, Dedza, endline “The mothers after delivery, they are supposed to be monitored for 48 hours […] We don’t usually achieve that indicator because we don’t have much space, and so we discharge them […] after 24 hours.” Maternity in-charge, Dedza, endline
  • 13. … and that decisions, actions, and communication are participatory and transparent, so that they are perceived as fair, and expectations are realistic. “Ideally, […] we should sit down and discuss what we should buy […], but this hasn’t been done. It’s just the in-charge that will come and say we have bought this. […] We complained.” “It’s unfair, because we work hard to achieve those things, and then they come and say, you didn’t do this, yet the things are there, it’s unfair.” Nurse, Dedza, endline Nurse, Dedza, endline
  • 14. Otherwise, PBI might be more stick than carrot. “Some of the labor graphs are not filled because of shortage of staff. [...] Seeing it clearly that you are losing some money because you did not fill all the partographs, you feel like you could have had that money, but you have lost it. […] We feel bad, but we also feel that there is nothing we could do.” Nurse, Mchinji, endline “It is psychological torture to be told to work extra hard for something and that something is almost nothing.” Clinical officer, Dedza, midterm “Honestly, I feel like the project is there to bring a burden on us. They are just trying to get more customers in, but the staff and resources to attend to those customers are few. ” Nurse, Mchinji, endline
  • 15. “This RBF, it is bringing us together, but it is also driving us apart.” Nurse, Balaka, endline Our findings also indicate that decision-making autonomy in sharing incentives amongst individuals can lead to serious conflict, ... “I think the project should decide. They should just calculate and give us the figures, that this one should take such, such amount, because this money is creating a lot of enmity at this hospital.” Nurse, Balaka, midterm
  • 16. ... and that there will likely be cheating, possibly with negative consequences for the patients. “What is documented is not what has been done. [In the records,] you see that patient was monitored on the blood pressure, the blood pressure was good, then one hour later, the patient starts fitting. […] One starts to wonder how did it happen. You just know that […] the BP was not checked […]. So instead of just leaving the area blank [in the records], for the sake of the RBF to get the incentives, [the nurse] decides to put the fake BP.” Nurse, Dedza, endline
  • 17. Acknowledgement: This study was funded by the United States Agency for International Development under Translating Research into Action, Cooperative Agreement No. GHS-A-00-09-00015-00, as well as by the Royal Norwegian Embassy-Malawi, Grant No. MWI-12/0010. Disclaimer: This study is made possible by the support of the American People through the United States Agency for International Development (USAID). The findings of this study are the sole responsibility of the University of Heidelberg and the College of Medicine and do not necessarily reflect the views of USAID or the United States Government.