The Impact of Performance Based Incentives and Biometric Devices on Improving Tuberculosis Treatment through Community Based Counselors in India

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.

2009-09-01

2015-06-30

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.

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.

Randomization done in office by a computer,

Individual level randomization: Health Provider (Counselor)

No

Incentives Experiment:
Operation ASHA - 104 Counselors
CARE - 29 Counselors

Biometrics Experiment:
Operation ASHA - 66 Counselors

6000 TB patients

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.