This study explored the impact of a pay-for-performance (P4P) scheme in Tanzania on health workers' intrinsic motivation and institutional delivery rates. The study found no evidence that P4P undermined intrinsic motivation. It did find that P4P had a greater positive effect on delivery rates in facilities whose staff had lower baseline intrinsic motivation levels. This suggests that extrinsic incentives like P4P may work better in settings where health workers are less intrinsically motivated to begin with. The study was limited by potential social desirability bias in health workers' self-reported motivation levels and questions around how well the motivation measure captured intrinsic motivation.

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. 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. 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. 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. 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. 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 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. 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 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. Does P4P impact on our measure of
intrinsic motivation?
•

11. Has P4P had the same impact in facilities with different staff
motivation levels?
•

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
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. 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. 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. 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. 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. 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