Physicians’ responses to financial and social incentives: a medically framed real effort experiment

Because compensation policies have critical implications for the provision of health care, and evidence of their effects is limited and difficult to study in the real world, laboratory experiments may be a valuable methodology to study the behavioural responses of health care providers. With this experiment undertaken in 2013, we add to this new literature by designing a new medically framed real effort task to test the effects of different remuneration schemes in a multi-tasking context. We assess the impact of different incentives on the quantity (productivity) and quality of outputs of 132 participants. We also test whether the existence of benefits to patients influences effort. The results show that salary produces the lowest quantity of output, and fee-for-service the highest productivity. By contrast, we find that the highest quality is achieved when participants are paid by salary, followed by capitation. We also find a lot of heterogeneity in behaviour, with intrinsically motivated individuals hardly sensitive to financial incentives. Finally, we find that when work quality benefits patients directly, subjects improve the quality of their output, while maintaining the same levels of productivity. This paper adds to a nascent literature by providing a new approach to studying remuneration schemes and modelling the medical decision making environment

Can the private education sector help overcome nursing shortages? A synthesis of evidence from Thailand, Kenya and India

Nursing shortages are a critical health workforce challenge and are likely to be exacerbated in coming years by changing population demographics and healthcare needs. As pressures grow, shortages will intensify the unequal distribution of nurses both within and between countries. Currently, many countries are experiencing a rapid expansion of private nurse training institutions. These institutions have the potential to contribute positively to local and national health systems by increasing the supply of nurses, possibly even in rural areas where shortages are most severe. However, little is known about private training institutions (e.g. their syllabus, the quality of training, how they are regulated), or about the job choices of their graduates. RESYST Consortium has conducted research in Thailand, Kenya and India to compare public and private nurse training institutions, and investigate the extent to which the type of training institution influences their job choices. In March 2016, a meeting was held in Bangkok, Thailand, bringing together researchers and policymakers to share new evidence and exchange experiences on the topic. This report synthesises the research findings that were shared during the workshop, and outlines recommendations that were jointly developed by researchers and policymakers. Key cross-country findings: - In recent years there has been a rapid expansion of private training institutions. - Private institutions are unlikely to reduce nurse shortages in under-served areas. - There are variations in the quality of private training institutions and in the quality of the graduates produced. In some countries there is poor absorption of nurses into the public health sector

Effects of incentive framing on performance and effort: evidence from a medically framed experiment

We study the effects on performance of incentives framed as gains or losses, as well as the effort channels through which individuals increase performance. We also explore potential spill-over effects on a non-incentivised activity. Subjects participated in a medically framed real-effort task under one of the three contracts, varying the type of performance incentive received: (1) no incentive; (2) incentive framed as a gain; or (3) incentive framed as a loss. We find that performance improved similarly with incentives framed as losses or gains. However, individuals increase performance differently under the two frames: potential losses increase participants’ performance through a greater attention (fewer mistakes), while bonuses increase the time spent on the rewarded activity. There is no spill-over effect, either negative or positive, on the non-incentivised activity. We discuss the meaning and implications of our results for the design of performance contracts

A review of the application and contribution of discrete choice experiments to inform human resources policy interventions

Although the factors influencing the shortage and maldistribution of health workers have been well-documented by cross-sectional surveys, there is less evidence on the relative determinants of health workers' job choices, or on the effects of policies designed to address these human resources problems. Recently, a few studies have adopted an innovative approach to studying the determinants of health workers' job preferences. In the absence of longitudinal datasets to analyse the decisions that health workers have actually made, authors have drawn on methods from marketing research and transport economics and used Discrete Choice Experiments to analyse stated preferences of health care providers for different job characteristics

Overtreatment and benevolent provider moral hazard: evidence from South African doctors

Overtreatment is widespread in health, with potentially dire consequences for patients, health systems and public health. It may be fueled by providers when they do not bear the cost of treatment (moral hazard), even they do not profit financially from it (i.e. benevolent providers). We test this hypothesis by creating an exogeneous change in the incentives faced by private doctors in South Africa. We find that provider moral hazard has no effect on overtreatment in volume but fuels overtreatment in cost. By contrast, when they bear the marginal treatment cost, doctors choose cheaper drug. While these results suggest that provider moral hazard contributes to overtreatment in primary care, we consider other plausible channels, such as responses to a perceived demand for high-quality drugs or market segmentation. We discuss the potential scope for supply-side cost-sharing incentives to reduce inefficiency in future health system reforms in South Africa

A rapid appraisal of maternal health services in South Africa

This report is a rapid appraisal of maternal health services in South Africa. It reflects the first activity in a five-year research programme, funded by DFID. The research project is a multi-country project involving researchers from the London School of Hygiene and Tropical Medicine, (UK) Manchester University (UK) and research institutions in Uganda, Bangladesh, Russia as well as South Africa. The programme aims to develop theoretical frameworks and methodologies to better understand health system functioning in developing countries, and to apply these insights to strengthening health system development. As part of this project maternal health has been identified as a possible probe or tracer to illuminate particular features of health system functioning and performance.Funded by DFI

Aligning vertical interventions to health systems: a case study of the HIV monitoring and evaluation system in South Africa

<p>Abstract</p> <p>Background</p> <p>Like many low- and middle-income countries, South Africa established a dedicated HIV monitoring and evaluation (M&E) system to track the national response to HIV/AIDS. Its implementation in the public health sector has however not been assessed. Since responsibility for health services management lies at the district (sub-national) level, this study aimed to assess the extent to which the HIV M&E system is integrated with the overall health system M&E function at district level. This study describes implementation of the HIV M&E system, determines the extent to which it is integrated with the district health information system (DHIS), and evaluates factors influencing HIV M&E integration.</p> <p>Methods</p> <p>The study was conducted in one health district in South Africa. Data were collected through key informant interviews with programme and health facility managers and review of M&E records at health facilities providing HIV services. Data analysis assessed the extent to which processes for HIV data collection, collation, analysis and reporting were integrated with the DHIS.</p> <p>Results</p> <p>The HIV M&E system is top-down, over-sized, and captures a significant amount of energy and resources to primarily generate antiretroviral treatment (ART) indicators. Processes for producing HIV prevention indicators are integrated with the DHIS. However processes for the production of HIV treatment indicators by-pass the DHIS and ART indicators are not disseminated to district health managers. Specific reporting requirements linked to ear-marked funding, politically-driven imperatives, and mistrust of DHIS capacity are key drivers of this silo approach.</p> <p>Conclusions</p> <p>Parallel systems that bypass the DHIS represent a missed opportunity to strengthen system-wide M&E capacity. Integrating HIV M&E (staff, systems and process) into the health system M&E function would mobilise ear-marked HIV funding towards improving DHIS capacity to produce quality and timely HIV indicators that would benefit both programme and health system M&E functions. This offers a practical way of maximising programme-system synergies and translating the health system strengthening intents of existing HIV policies into tangible action.</p

Equity in maternal health in South Africa: analysis of health service access and health status in a national household survey

Background: South Africa is increasingly focused on reducing maternal mortality. Documenting variation in access to maternal health services across one of the most inequitable nations could assist in re-direction of resources. Methods: Analysis draws on a population-based household survey that used multistage-stratified sampling. Women, who in the past two years were pregnant (1113) or had a child (1304), completed questionnaires and HIV testing. Distribution of access to maternal health services and health status across socio-economic, education and other population groups was assessed using weighted data. Findings: Poorest women had near universal antenatal care coverage (ANC), but only 39.6% attended before 20 weeks gestation; this figure was 2.7-fold higher in the wealthiest quartile (95%CI adjusted odds ratio = 1.2-6.1). Women in rural-formal areas had lowest ANC coverage (89.7%), percentage completing four ANC visits (79.7%) and only 84.0% were offered HIV testing. Testing levels were highest among the poorest quartile (90.1% in past two years), but 10% of women above 40 or with low education had never tested. Skilled birth attendant coverage (overall 95.3%) was lowest in the poorest quartile (91.4%) and rural formal areas (85.6%). Around two thirds of the wealthiest quartile, of white and of formally-employed women had a doctor at childbirth, 11-fold higher than the poorest quartile. Overall, only 44.4% of pregnancies were planned, 31.7% of HIV-infected women and 68.1% of the wealthiest quartile. Self-reported health status also declined considerably with each drop in quartile, education level or age group. Conclusions: Aside from early ANC attendance and deficiencies in care in rural-formal areas, inequalities in utilisation of services were mostly small, with some measures even highest among the poorest. Considerably larger differences were noted in maternal health status across population groups. This may reflect differences between these groups in quality of care received, HIV infection and in social determinants of health

Job preferences among clinical officers in public sector facilities in rural Kenya: a discrete choice experiment

Background: Clinical officers (COs), a mid-level cadre of health worker, are the backbone of healthcare provision in rural Kenya. However, the vacancy rate for COs in rural primary healthcare facilities is high. Little is known about factors motivating COs' preferences for rural postings. Methods: A discrete choice experiment (DCE) questionnaire was used with 57 COs at public health facilities in nine districts of Nyanza Province, Kenya. The questionnaire was developed on the basis of formative qualitative interviews with COs (n = 5) and examined how five selected job attributes influenced COs' preferences for working in rural areas. Conditional logit models were employed to examine the relative importance of different job attributes. Results: Analysis of the qualitative data revealed five important job attributes influencing COs' preferences: quality of the facility, educational opportunities, housing, monthly salary and promotion. Analysis of the DCE indicated that a 1-year guaranteed study leave after 3 years of service would have the greatest impact on retention, followed by good quality health facility infrastructure and equipment and a 30% salary increase. Sub-group analysis shows that younger COs demonstrated a significantly stronger preference for study leave than older COs. Female COs placed significantly higher value on promotion than male COs. Conclusions: Although both financial incentives and non-financial incentives were effective in motivating COs to stay in post, the study leave intervention was shown to have the strongest impact on COs' retention in our study. Further research is required to examine appropriate interventions at each career stage that might boost COs' professional identity and status but without leading to larger deficits in the availability of generalist COs. 2016 Takemura et al.sch_iih14pub4260pub

Nursing staff dynamics and implications for maternal health provision in public health facilities in the context of HIV/AIDS

This study, carried out in Limpopo, KwaZulu-Natal, and Mpumalanga provinces in South Africa, aimed to document nursing staff dynamics in maternal health services, and to explore the factors associated with these dynamics. The study found that a high percentage of nursing staff working in public facilities were demotivated, burnt out, and were considering leaving the facility where they were working. A range of factors, both financial and nonfinancial, were associated with nurses considering going overseas: inadequate pay, poor promotion, feeling unsupported by management, and having bad relationships at work were all associated with lack of organizational commitment. As a result of high numbers of nurses feeling demoralized, there is not a conducive environment for policy interventions. Policymakers need to pay more attention to how policies are implemented and the impact of policies on the relationships between nurses, and nurses and managers in facilities