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

Objectives1.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

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?

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

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

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 P4P districts4 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

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 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

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

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**

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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) -0.02I am punctual 2.9 (0.3) 2.9 (0.2) -0.05Important 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*

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

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

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 ?

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

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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