Pay-for-performance, Motivation and final output in the health sector in DRC
Last registered on May 17, 2014

Pre-Trial

Trial Information
General Information
Title
Pay-for-performance, Motivation and final output in the health sector in DRC
RCT ID
AEARCTR-0000386
Initial registration date
May 17, 2014
Last updated
May 17, 2014 4:41 PM EDT
Location(s)
Primary Investigator
Affiliation
Sciences Po
Other Primary Investigator(s)
PI Affiliation
International Rescue Committee
Additional Trial Information
Status
Completed
Start date
2009-09-01
End date
2013-03-01
Secondary IDs
Abstract
The experiment studies the effects of a financing mechanism for the health sector in which governmental payment to health facilities is contingent upon the number of patients for some pre-determined health services, as opposed to a fixed payment. Even though performance-based financing models have been implemented in developed and developing countries in various settings and forms, the scientific evidence on its impact on health worker effort and consequent health outcomes remains thin. From 2009 to 2013, a research project was conducted in the Haut-Katanga district of DRC to study the effect of the PBF approach compared to a fixed payment approach. The 96 health areas present in the Haut-Katanga district were randomly assigned to performance-based or fixed payments, while ensuring that the same amount of governmental resources was allocated to each group to neutralize the ressource effect. The two mechanisms have been in place from June 2010 to September 2012. Administrative data was collected throughout the project, spotchecks of health workers' attendance were performed in July, August and September 2012, and a final independent survey was administered from December 2012 to Feburary 2013 -after the incentives have been withdrawn. We give evidence that pay-for-performance led to more effort from health workers with respect to rewarded services. Equally important, health workers did not substitute effort put in non-rewarded activities. However, the increase in overall staff motivation happened at the expense of its intrinsic component. Finally, the increased effort put in by the health workers proved unsuccessful at attracting more patients, suggesting that health workers lacked means or inventiveness to meet their objective. There are key policy implications of our findings for governments considering PBF as a way to allocate public ressources to the health sector. First, pay-for-performance increases health worker overall motivation without deterring service quality or non-rewarded services, meaning that health workers are strategic but not cynical; However, two types of precaution should be considered. First, contingent rewards reduce the intrinsic component of health worker motivation so incentives should be used as a permanent instrument otherwise it would backfire. Second, our results suggest that contingent rewards are not appropriate when the task is difficult and requires sophisticated strategies, because agents focus on the reward and do not develop novel ideas to reach complicated goals. The translation of motivation into performance may thus be better in contexts where the rewarded task is easy.
External Link(s)
Registration Citation
Citation
Huillery, Elise and Juliette Seban. 2014. "Pay-for-performance, Motivation and final output in the health sector in DRC." AEA RCT Registry. May 17. https://www.socialscienceregistry.org/trials/386/history/1776
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Experimental Details
Interventions
Intervention(s)
In Haut-Katanga district, the 96 health areas (totalizing 152 health facilities and a catchment population close to two millions) were randomly assigned to one of two payment systems.
- In the fixed payment group, the amount allocated to each facility was calculated based on the staff in the facility: a list of eligible workers was established at the beginning of the pilot conjointly by Ministry of Health; each worker received a given payment depending on his/her grade and experience.
- In contrast, payments to the PBF health facilities were to be made after verification of declared service volumes by facilities. The targeted services included seven services at the primary care level (outpatient first curative consultations, prenatal consultations, deliveries, obstetric referral, children completely vaccinated, tetanus toxoid vaccination, and family planning consultations) and three additional services at the secondary care level (C-section, blood transfusion, and obstetric referrals to hospitals).
In order to ensure neutrality in the level of financing between the two groups and isolate the incentive effect from the resource effect, the total budget allocated to health facilities in the PBF group was the same as the total budget allocated to health facilities in the fixed payment group. The relative prices attached to the targeted services were constant, but absolute prices and facility payments were determined by the quantity of services provided by the facility relative to the quantity of services provided by the other incentivized health facilities in order to keep the total enveloppe constant. The budget used in this experiment estimated at $0.43 per capita per year.
Service volumes were measured by use of monthly reports submitted by facilities, in which the number of patients for each targeted service was reported. Subsequently verification of declared service volumes was conducted by verification agents through (i) comparing reported volumes with those found in health facility registers, and (ii) verifying that the information noted in the registers was true by conducting community verification: a random sample of 30 patients in registers were selected and visited by independent associations to check the accuracy of the information reported in the facility register. Community verifications were meant to take place only in the PBF group as part of the financing mechanism. However, we conducted community verifications in the fixed payment health facilities for impact evaluation purposes (1 community verification by facility in the comparison group). The fixed payment health facilities had no incentive to cheat on service volumes so the comparison of discrepancy rates between the PBF and the fixed payment groups allow for differentiating cheating from natural -unavoidable- discrepancies due to the fact that some patients moved or were absent at the time of the verification. A system of financial sanctions was integrated in order to reduce providers’ incentives to submit fraudulent reports and over-reporting of phantom patients.
Intervention Start Date
2010-06-01
Intervention End Date
2012-12-01
Primary Outcomes
Primary Outcomes (end points)
User Fees

Accessibility of Health Services : opening hours, worker attendance, on-the-job effort, number and qualification of workers, number of service varieties offered, number of preventive sessions organized at the facility and number of outreach activities in the community in the last 12 months, waiting time before the consultation.

Service Quality: consultation time, compliance with standard medical procedures, proportion of patients who understand the diagnosis and prescriptions, proportion of patients and household members who are satisfied with the visit.

Service Utilization in the last 12 months: proportion of individuals who visited a health facility, who got sick but did not visit, proportion of children aged 0-5 who took at least one immunization shot, the number of immunization shots reported in the immunization card, and the proportion of children who have a scar from TB immunization on the shoulder, proportion of attended deliveries among mothers who gave birth in the last 12 months, proportion of C-sections, number of prenatal and postnatal visits at the facility, proportion of mothers supplemented with iron and taking malaria preventives, number of months mothers breastfeed their newborn, proportion of women and partners who are in favor of the use of family planning, proportion of women actually using family planning, number of patients in the last month as reported by the facility head.

Population Health Status: under-5 weight-for-height z-score, number of persons who died in the last 12 months in the household, and among them the number of women who died for perinatal reasons and the number of children under 5, proportion of new-born in the last 12 months that are still alive.

Health Facility Revenue

Health workers’ satisfaction, anxiety and motivation
Primary Outcomes (explanation)
Secondary Outcomes
Secondary Outcomes (end points)
Secondary Outcomes (explanation)
Experimental Design
Experimental Design
96 health areas were randomly assigned to one of two payment systems.
Experimental Design Details
Randomization Method
Public lottery
Randomization Unit
Health area.
Was the treatment clustered?
Yes
Experiment Characteristics
Sample size: planned number of clusters
96 health areas
Sample size: planned number of observations
152 health facilities, 331 health workers, 1014 patients and 1704 households
Sample size (or number of clusters) by treatment arms
48 health area control, 48 health area treatment
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
IRB
INSTITUTIONAL REVIEW BOARDS (IRBs)
IRB Name
IRB Approval Date
IRB Approval Number
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