Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.




Do financial incentives undermine health workers intrinsic motivation? 



Evidence from a pay-for-performance scheme ...
Objectives
1.Explore the impact of P4P on health
workers’ intrinsic motivation
2.Explore the differential impact of P4P
on...
P4P Objectives
• Improve coverage of quality health services
• By increasing health workers’ motivation
• Health workers a...
P4P in Tanzania
• Pilot in Pwani region, 7
districts
• To improve MCH
intervention coverage
• Start Jan 2011
• Implemented...
P4P Scheme
• Targets MCH services
• Payouts every 6 months
• 70% to health workers, remainder to the facility
• Represents...
Study Design
• Design: Controlled before and after study design
– 7 intervention districts
– 4 neighbouring control distri...
7 P4P districts
4 districts with no
P4P
150 health facilities, 75 in
each arm incl.
6 hospitals
16 health centres
53 dispe...
Intrinsic motivation measure
• Adapted a World Bank questionnaire
• Collected data on health workers’ feeling
and attitude...
9 questions on motivation
Scale reliability: 0.7
Never/rarely Sometimes Often
My job makes me feel good about myself 1 2 3...
Does P4P impact on our measure of
intrinsic motivation?
•  
Has P4P had the same impact in facilities with different staff
motivation levels? 

•  
Health Workers’ socio-
demographic
characteristics
Baseline, N=209 Follow-up , N=180
P4P
n=101
No P4P
n=108
Diff P4P
n=94
...
13
Health Workers’ intrinsic
motivation
Baseline, N=209
P4P
n=101
No P4P
n=108
Diff.
Intrinsic motivation score, Mean scor...
Has P4P had an impact on health
workers intrinsic motivation?
• No evidence of a significant effect
(0.5, 95% ci -0-5, 1.6...
Has P4P the same impact on delivery rates in
facilities with different staff motivation levels?
• A significantly greater ...
Limitations
• Motivation reported to be high by health workers
– Social bias of responses about HW attitudes
towards work?...
Conclusion
• P4P does not (negatively)
effect intrinsic motivation
• Results suggest that extrinsic
incentives may work be...
Acknowledgments
• MOHSW and Pwani regional health authorities
and Clinton Health Access Initiative
• Funding support : Gov...
Upcoming SlideShare
Loading in …5
×

Do financial incentives undermine health workers intrinisic motivation? - Josephine Borghi et al

This presentation was given at the pay-for-performance workshop in Tanzania, November 2015

Related Books

Free with a 30 day trial from Scribd

See all

Related Audiobooks

Free with a 30 day trial from Scribd

See all
  • Be the first to comment

  • Be the first to like this

Do financial incentives undermine health workers intrinisic motivation? - Josephine Borghi et al

  1. 1. 
 
 Do financial incentives undermine health workers intrinsic motivation? 
 
 Evidence from a pay-for-performance scheme in one region of Tanzania Contributors: E Patouillard, J Borghi, P Binyaruka, T Powell-Jackson, G Greco, G Torsvik
  2. 2. Objectives 1.Explore the impact of P4P on health workers’ intrinsic motivation 2.Explore the differential impact of P4P on institutional delivery rates in facilities with different staff motivation levels
  3. 3. P4P Objectives • Improve coverage of quality health services • By increasing health workers’ motivation • Health workers are assumed to be intrinsically motivated • Could P4P crowd -out intrinsic motivation? – Money competes with the self concept of working hard; altruism and moral contentment • Are P4P effects higher/lower among workers who are more intrinsically motivated?
  4. 4. P4P in Tanzania • Pilot in Pwani region, 7 districts • To improve MCH intervention coverage • Start Jan 2011 • Implemented by MOHSW and Clinton Health Access Initiative • Intervention package: bonus, HMIS, supervision, financial autonomy PWANI
  5. 5. P4P Scheme • Targets MCH services • Payouts every 6 months • 70% to health workers, remainder to the facility • Represents about 10% of health worker monthly salary
  6. 6. Study Design • Design: Controlled before and after study design – 7 intervention districts – 4 neighbouring control districts – Comparable poverty, literacy, rate of institutional deliveries, IMR, pop. per health facility, no. of children < 1 yr • Timing: -Baseline in January-February 2012 -Endline in March-April 2013 (13 months)
  7. 7. 7 P4P districts 4 districts with no P4P 150 health facilities, 75 in each arm incl. 6 hospitals 16 health centres 53 dispensaries 1 facility survey at each facility 20 interviews with women who delivered in past 12 months, from the catchment area of each facility Only include facilities eligible for first cycle payment 1-2 health workers at each facility
  8. 8. Intrinsic motivation measure • Adapted a World Bank questionnaire • Collected data on health workers’ feeling and attitudes towards work • 9 questions using Likert scale 3 point answers • Created a mean score / index 8
  9. 9. 9 questions on motivation Scale reliability: 0.7 Never/rarely Sometimes Often My job makes me feel good about myself 1 2 3 I am proud of the work I am doing at the facility 1 2 3 I am proud to be working for the facility 1 2 3 I am inspired to do my best at work by this facility 1 2 3 I complete tasks efficiently 1 2 3 I am a hard worker 1 2 3 I am punctual 1 2 3 It is important for me that peers recognize me as a professional 1 2 3 It is important for me that the community recognize me as a professional 1 2 3
  10. 10. Does P4P impact on our measure of intrinsic motivation? •  
  11. 11. Has P4P had the same impact in facilities with different staff motivation levels? 
 •  
  12. 12. Health Workers’ socio- demographic characteristics Baseline, N=209 Follow-up , N=180 P4P n=101 No P4P n=108 Diff P4P n=94 No P4P n=86 Diff Female, % 71.3 63.9 7.4 60.6 68.6 -8.0 Age, mean years 41.9 42.9 -1.0 42.5 41.9 0.6 Married, % 65.3 73.1 -7.8 75.5 59.3 16.2** Born in facility district, % 16.8 31.5 -14.7* * 25.5 23.3 2.2 Primary education, % 22.8 15.7 7.1 14.9 10.5 4.4 Secondary education, % 46.5 43.5 3.0 31.9 53.5 -21.6** * College or above educ, % 30.7 40.7 -10.0 53.0 36.0 17.0** Facility in charge, % 38.6 47.2 -8.6 46.8 47.7 -0.9 Clinical cadre, % 43.6 39.8 3.8 46.8 46.5 0.3 Nursing cadre, % 44.6 48.1 -3.5 48.9 51.2 -2.3 Paramedical cadre, % 11.9 12.0 -0.1 4.3 2.3 2.0 Prior health sector post, % 41.6 56.5 -14.9* * 42.6 59.3 -16.7**
  13. 13. 13 Health Workers’ intrinsic motivation Baseline, N=209 P4P n=101 No P4P n=108 Diff. Intrinsic motivation score, Mean score (sd) 25.1 (2.8) 25.6 (1.7) -0.50 My job makes me feel good about myself, 2.8 (0.5) 2.8 (0.4) -0.00 I am proud of the work I am doing at the facility 2.7 (0.6) 2.7 (0.5) -0.07 I am proud to be working for the facility 2.8(0.4) 2.8(0 .5) 0.06 I am inspired to do my best at work by this facility 2.4 (0.8) 2.6 (0.6) -0.17* I complete tasks efficiently and effectively 2.8 (0.5) 2.9 (0.3) -0.05 I am a hard worker 2.9 (0.3) 2.9 (0.2) -0.02 I am punctual 2.9 (0.3) 2.9 (0.2) -0.05 Important for me that peers recognize me as a professional 2.9 (0.3) 3.0 (0.2) -0.05 Important for me that the community recognize me as a professional 2.9 (0.3) 3.0 (0.0) -0.08*
  14. 14. Has P4P had an impact on health workers intrinsic motivation? • No evidence of a significant effect (0.5, 95% ci -0-5, 1.6) • No evidence of crowding – out on our measure of intrinsic motivation
  15. 15. Has P4P the same impact on delivery rates in facilities with different staff motivation levels? • A significantly greater effect on delivery rates in facilities with lower (baseline) staff motivation Delivery rate at facilities with staff motivation at or below median Delivery rate at facilities with staff motivation above median N Beta (95% ci) P-value N Beta (95% ci) P-value ID% 2846 0.12 *** (0.06-0.19) 0.000 2901 0.04 (-0.02-0.10) 0.171
  16. 16. Limitations • Motivation reported to be high by health workers – Social bias of responses about HW attitudes towards work? • Did the measure of motivation really capture intrinsic motivation ?
  17. 17. Conclusion • P4P does not (negatively) effect intrinsic motivation • Results suggest that extrinsic incentives may work better in settings where health workers are less intrinsically motivated 17
  18. 18. Acknowledgments • MOHSW and Pwani regional health authorities and Clinton Health Access Initiative • Funding support : Government of Norway • Ifakara health Institute, LSHTM and CMI • The P4P evaluation team • Health workers for their precious time, and women and household heads

    Be the first to comment

    Login to see the comments

This presentation was given at the pay-for-performance workshop in Tanzania, November 2015

Views

Total views

632

On Slideshare

0

From embeds

0

Number of embeds

12

Actions

Downloads

21

Shares

0

Comments

0

Likes

0

×