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The Impact of Performance Based Incentives and Biometric Devices on Improving Tuberculosis Treatment through Community Based Counselors in India
Last registered on August 18, 2014

Pre-Trial

Trial Information
General Information
Title
The Impact of Performance Based Incentives and Biometric Devices on Improving Tuberculosis Treatment through Community Based Counselors in India
RCT ID
AEARCTR-0000038
Initial registration date
August 18, 2014
Last updated
August 18, 2014 1:52 PM EDT
Location(s)
Region
Primary Investigator
Affiliation
IFPRI
Other Primary Investigator(s)
Additional Trial Information
Status
On going
Start date
2009-09-01
End date
2015-12-31
Secondary IDs
Abstract
This experiment assesses whether financial incentives can increase healthcare counselors’ motivation, and therefore their detection and treatment of TB. Ninety-six counselors from Operation ASHA and 51 field extension workers from CARE India were randomly assigned to either the treatment group—which received financial rewards for each new patient enrolled in the DOTS system—or the comparison group—which received a fixed salary. After six months, the health workers were re-assigned at random to either a new treatment group, in which they were financially penalized for each patient that defaulted on their treatment, or the comparison group, in which they received a fixed salary. We are evaluating the impact of the incentives—both positive and negative—on counselors’ motivation and commitment to their job, and on the detection of and treatment compliance for TB.

In another arm of the project, we are testing the impact of improving monitoring of health worker’s efforts and patient compliance through the introduction of biometric technology in TB control centers. Operation ASHA has developed a biometric system based on a fingerprint scanner connected to a low-end computer and cellphone. Health workers as well as patients identify themselves when they come to the center. The data is then sent by SMS several times per day to a server located in Delhi, and alerts and reminders are sent to health workers when noncompliance is detected.
We are evaluating the impact of these two strategies (performance-based incentives and the biometric monitoring tool) on the number of TB patients detected, the number of defaults, and a range of intermediary outcomes such as health workers’ motivation, provider absenteeism, and the quality of service delivery perceived by patients.
External Link(s)
Registration Citation
Citation
Delavallade, Clara. 2014. "The Impact of Performance Based Incentives and Biometric Devices on Improving Tuberculosis Treatment through Community Based Counselors in India." AEA RCT Registry. August 18. https://doi.org/10.1257/rct.38-1.0.
Former Citation
Delavallade, Clara. 2014. "The Impact of Performance Based Incentives and Biometric Devices on Improving Tuberculosis Treatment through Community Based Counselors in India." AEA RCT Registry. August 18. https://www.socialscienceregistry.org/trials/38/history/2501.
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Experimental Details
Interventions
Intervention(s)
The program- Incentives
Operation ASHA hires community-based health workers, who are each responsible for operating two DOTS centers. During the first three months, CHWs all receive a fixed salary. Indeed, centers often take a slow start, irrespective of the involvement of the CHW. This initial 3-month period also enables the CHWs to get their bearings in a new place and for the center to be identified by the population. The experiment starts after the initial three months of a center lifespan. Between 3 and approximately 9 months, CHWs have to grow their center until they have reached the optimal size (not more than 50 patients), where they are cost-effective and where patients can be effectively followed-up. Half of the CHWs, randomly chosen, receive a fixed component and a variable amount based on their performance regarding detection of new patients, while the other half receives a fixed salary.

After nine months of work, CHWs should focus on preventing defaults. The CHW's compensation scheme is randomized again. Half of them receive a fixed salary for the following 6 months of their contract while the other half receive an incentivized scheme where the variable component no longer depends on the number of detections, but on the number of defaults they prevent. If the number of patients keeps growing, Operation ASHA opens a new center and the detection work is taken over by another CHW operating that newly open center.
These incentives (for detection) or penalties (for default) come in addition to a base salary, that guarantees the health workers that they will get a minimum amount for their work, whatever happens, and thereby contains the amount of risk and stress they are facing. The introduction of financial incentives explicitly linked to the outcome of their counselling work is aimed at increasing their motivation, effort, and performance, and in turn their impact on TB treatment in slums.

The Program- Biometrics
Additionally, there is a second intervention designed to enhance treatment compliance: biometric devices enabling to monitor the absenteeism of Operation ASHA’s health workers, as well as the pills intake by the patients, patient satisfaction, and patient health outcomes.Operation Asha (OA), developed a biometric identification system, eCompliance, based on a fingerprint scanner connected to a low-end computer and cellphone, which were randomly assigned to each counselor.

Intervention Start Date
2009-09-01
Intervention End Date
2015-06-30
Primary Outcomes
Primary Outcomes (end points)

Incentives Study
The main outcomes of interest are new patient detection as well as the number of defaults. Some of the other outcomes of interest are counselor absenteeism, treatment compliance, interaction between counselor and patients which will be determined through patient surveys as well as counselor job commitment and satisfaction, which will be captured through counselor surveys.

Biometrics Study
Our main outcomes of interest will be counselors’ absenteeism, patients’ compliance with the treatment and number of defaults.
In addition to the data also collected for the first experiment, we will conduct frequent random checks in centers operated both by treatment and control counselors. Indeed, while the biometric devices will give us data of great quality about counselors' absenteeism and the number of pills missed by the patients, our evaluation should be based on data of comparable quality across treatment and control counselors.The richness of the patient and counselor surveys will enable us to disentangle the role of various channels (including for instance more intensive follow-up with patients who missed their pill) through which the biometric devices might affect our outcomes of interest.
Primary Outcomes (explanation)
Secondary Outcomes
Secondary Outcomes (end points)
Secondary Outcomes (explanation)
Experimental Design
Experimental Design
Incentives Study
The randomization
After their first three months, counselors hired by Operation ASHA are offered one of the two types of contract 1 described below between three and nine months, and one of the two types of contract 2 after nine months.
Contracts 1: months 3-9
• Contract 1a: Fixed salary
• Contract 1b: Fixed salary (75% of contract 1a) + incentives based on detection
Contracts 2: months 9 – onwards
• Contract 2a: Fixed salary
• Contract 2b: Fixed salary (75% of contract 2a) + incentives based on default

At the end of three months, a counselor, who agrees to participate, can either be on a fixed salary scheme or a fixed plus detection based incentive salary scheme. Similarly, at the end of nine months, the counselors are re-randomized and they can either be on the fixed scheme or a fixed plus default based incentive salary scheme. Therefore, assignments to contracts 1 and 2 are cross-randomized, which gives a total of 4 different cases (1a – 2a; 1a – 2b; 1b – 2a; 1b – 2b).

Biometrics:
This intervention will also be evaluated using the randomized controlled trial methodology: once they have gone through the first intervention, Operation ASHA counselors will be once again randomly allocated to two groups- counselors that receive a Biometric device at their center (treatment) and counselors that do not(control).

Since most counselors will have been included in the evaluation of both the first and the second interventions, our estimates of their impacts, obtained for identical workers and under very similar contexts, will be very comparable. This will make our cost-effectiveness calculations particularly informative, to decide which of the two traditional alternatives available to increase performance at work – incentives or monitoring – is most efficient in the context of TB eradication.
Experimental Design Details
Randomization Method
Randomization done in office by a computer,
Randomization Unit
Individual level randomization: Health Provider (Counselor)
Was the treatment clustered?
No
Experiment Characteristics
Sample size: planned number of clusters
Incentives Experiment:
Operation ASHA - 104 Counselors
CARE - 29 Counselors

Biometrics Experiment:
Operation ASHA - 66 Counselors
Sample size: planned number of observations
6000 TB patients
Sample size (or number of clusters) by treatment arms
Incentives: Total number of counselors enrolled: 104;
Phase 1 detection: 45 Incentives; 39 Fixed
Phase 2 default: 30 Incentives 30 Fixed
Biometrics: Total number of counselors randomized: 66

Biometrics: Total enrolled 73
Control: 40 Treatment 33.
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
IRB
INSTITUTIONAL REVIEW BOARDS (IRBs)
IRB Name
Massachusetts Institute of Technology (MIT), Institutional Review Board (IRB)
IRB Approval Date
2013-05-09
IRB Approval Number
1103004410
IRB Name
Institute of Financial Management and Research (IFMR), Institutional Review Board (IRB)
IRB Approval Date
2011-08-08
IRB Approval Number
IRB00007107
Post-Trial
Post Trial Information
Study Withdrawal
Intervention
Is the intervention completed?
No
Is data collection complete?
Data Publication
Data Publication
Is public data available?
No
Program Files
Program Files
Reports and Papers
Preliminary Reports
Relevant Papers