This presentation was made by Dr. Sunil Babu (CARE) in the session on ‘Taking it to the frontline: Improving frontline worker motivation, performance and convergence in health and nutrition’ at the POSHAN Conference "Delivering for Nutrition in India Learnings from Implementation Research", November 9–10, 2016, New Delhi. For more information about the conference visit our website: www.poshan.ifpri.info

1. CARE India
(Member of CARE International)
Team Based Goals and Incentives
(TBGI) – Performance of Front Line Workers
(FLW)

2. 2
Some monetary incentive schemes that FLWs (mainly ASHAs) are
entitled to
Part A
 JBSY
 PPIUCD
 Post Partum Sterilization
 TL
 NSV
 Vitamin A Supplementation
 MDR
The incentives fall under the following categories of NRHM programming
Part B
 ASHA Diwas
 HBNC
 Aadarsh Dampati
Part C
 Routine Immunization
• Full immunization
• Booster Dose
 Pulse Polio
Part D (National Programmes)
 Filaria
 NLEP
• Leprosy- MB
• Leprosy- TB
 DOTS (TB)
 Kala Azar Elimination Program (NVBDCP)
A2

3. 3
However, the use of monetary incentives alone to drive performance
has its drawbacks
A2
The performance of FLWs tends to get skewed towards
• Schemes that have maximum payout
• Schemes that require minimum effort, and
• Schemes where content is easier to communicate to families
1
While FLWs remain motivated by monetary benefits they only fulfil the quantity criteria for
Home visits, the lack of linkage to output/ outcome indicators affects the quality
2
This also drives FLWs to work in silos, with each FLW looking only at means of maximizing
the amount they can make off these schemes
3
The risk of delayed payout (which keeps happening) might end up acting as a demotivator,
thereby driving down FLW performance
4

4. 4
To keep FLWs motivated to deliver high quality output, it is necessary
to create a strong focus on output/ outcomes
FLW effort has been limited to meeting the bare
minimum targets of quantity of home visits that give
maximum payout
While FLWs remain motivated to only fulfil the
quantity criteria, there is no real linkage to
output/outcome indicators
To ensure quality of visits there is a need to bring to the understanding of FLWs that it is the quality of
interactions that will lead to sustainable achievement of long term goals
The aim is to create a strong result oriented focus by tying up some portion of FLW incentives to
crucial output/ outcome indicators impacted by the quality of interactions of FLWs
Illustration
Women report high contact with FLWs but only
some of them are through home visits. The quality
and content of these interactions are not known
HBNC is one such scheme where
FLWs make minimum 6 visits to claim
their incentives but often don’t use all
tools provided for conducting proper
home visits
Counseling for proper diet
through visits
Behavioral change Healthy pregnancy
Maternal
Health
Impact on indicatos

5. 5
In addition to result-orientation, other elements of FLW work
environment could also be addressed to build motivation
Key elements of working environment Method to address these elements
Result-orientation of FLWsClear objectives and goals
Creating opportunities to problem-solveQuality/ Nature of work
Making FLWs accountable for delivering
results
Level of responsibility
Growth and advancement
Building teamwork component for FLWsRelationship with supervisors, subordinates, peers
Rewards and recognition initiativesSense of achievement
Addressing these non-monetary aspects of FLW work environment will increase their levels of
engagement in outreach activities, thereby driving up the quality of service they provide

6. 6
Team Based Goals and Incentives served the purpose of creating a
facilitative work environment to keep FLWs motivated and engaged
A2
The program aims to make teams of FLWs who work with the same catchment area population
jointly responsible for delivering results
Aim
Key features Envisaged upside
Non-monetary incentives have not been used in Bihar earlier to drive quality of service delivery
Promotes teamwork, leading to joint problem solving and joint accountabilityTeam Incentives
Integrated approaches to counseling and delivering care across the continuum is promoted and
FLWs may be more likely to work in mutually supportive ways with common goals
Incentives for multiple
interventions
Easier to implement (easy accounting, avoid frauds) and high impact (e.g: coverage of multiple areas
across the continuum of care)
Non-monetary
incentives

7.  FLWs in each sub-center identified goals around key behaviors
– In the initial stage, 7 key health indicators were chosen against which the
teams were expected to reach specific targets
– Later, a more comprehensive list of indicators and targets were set for
17 indicators across 5 intervention areas
 All FLWs in the sub-center get a non-monetary incentive on
completion of targets at the sub-center level
 Implemented in 5 blocks (about 35 subcenters)
 Evaluation included an impact study with an RCT design with
randomization of sub-centers (~70 sub-centers) and a process study
– Data collected from households and frontline workers
Team-based Goals & Incentives (TBGI) in Begusarai
7

8. 8
TBGI– Mechanism of the pilot
Undertake independent quarterly assessment of
each team against their numeric target
3
Provide incentives to sub center teams reaching
the target.
4
A3
Define quarterly numeric targets and annual
numeric targets for each sub-center team (ANMs,
ASHAs, and AWWs)
2
Form sub center teams comprising of ANMs,
AWWs, and ASHAs ( ~20 individuals)
1

9. 9
Incentive structure
Annual Incentive:
If an HSC team achieves the annual target in minimum of 14 out of 17 indicators, then every member of
the team qualifies for a non financial incentive (household and utility items along with recognition
certificates from District and Sate Officials at annual events
Quarterly Incentive:
Every quarter if the HSC team achieves the target in minimum 14 out of 17 indicators, then every
member of the team qualifies for a non financial incentive (household and utility items)
A4

10. Quantitative data from households and FLWs
 Baseline surveys conducted in May/June 2012;
endline surveys conducted August/September 2013
 Interviews with women who gave birth in the past year
– 2 villages and 30 eligible women per subcenter
– 1,607 young mothers surveyed at endline
 Surveys with FLWs
– 4 ASHAs and 4 AWWs per subcenter, all ANMs
– 275 ASHAs, 271 AWWs, 92 ANMs surveyed at endline
10

11. Findings from Household Surveys
11

12. Impact on FLW-Household Interactions
Baseline
(Percentage Points)
Endline
(Percentage Points)
Treatment
Mean
Control
Mean
Treatment
Mean
Control
Mean
Adjusted
Difference
(p-value)
FLW Gave Advice on IFA 58.8 55.3 67.3 63.1 4.0
(p=0.235)
Visit by FLW in Final
Trimester
42.5 44.4 80.8 73.9 6.7+
(p=0.014)
Visit by FLW in First 24
Hours After Delivery
-- -- 45.3 40.6 5.3*
(p=0.078)
Visit by FLW on Child
Feeding (Child 5-11 mos)
-- -- 40.3 26.2 14.5**
(p=0.001)
Visit by FLW on Family
Planning
--
--
29.4 18.9 10.7**
(p<0.001)
Joint ASHA and AWW Visit -- -- 36.8 28.1 9.0**
(p=0.007)
N=1,607. **p<0.05, *p<0.10.

13. Impact on ANC and Delivery preparation
Baseline
(Percentage Points)
Endline
(Percentage Points)
Treatment
Mean
Control
Mean
Treatment
Mean
Control
Mean
Adjusted
Difference
(p-value)
Transport – Had Correct
Number of Ambulance
-- -- 9.5 10.9 -0.9
(p=0.668)
Transport – Had Number of
Private Vehicle
-- -- 9.8 13.2 -2.7
(p=0.246)
Transport – Had Number of
FLW
-- -- 47.2 48.4 -0.9
(p=0.835)
Received 90 IFA Tablets 23.1 25.0 21.5 19.2 1.5
(p=0.657)
Consumed 90 IFA Tablets 10.3 12.6 15.0 13.8 1.2
(p=0.661)
N=1,607. **p<0.05, *p<0.10.

14. Impact on Delivery and Postnatal Care
Baseline
(Percentage Points)
Endline
(Percentage Points)
Treatment
Mean
Control
Mean
Treatment
Mean
Control
Mean
Adjusted
Difference
(p-value)
Delivered at Facility 70.1 66.5 81.8 79.4 2.6
(p=0.301)
Nothing Applied to Cord 41.8 40.0 55.2 54.6 0.3
(p=0.944)
Breastfed Within 1 Hour of
Delivery
50.6 50.9 58.8 54.8 4.4
(p=0.218)
Exclusively Breastfed in
Past 24 Hours (Child <6
Months)
44.9 51.9 72.0 61.1 9.0**
(p=0.029)
N=769-1,607. **p<0.05, *p<0.10.

15. Impact on Infant Feeding
Baseline
(Percentage Points)
Endline
(Percentage Points)
Treatment
Mean
Control
Mean
Treatment
Mean
Control
Mean
Adjusted
Difference
(p-value)
Fed Cereal-Based Meal
Yesterday (Child 6-11 Mo.)
46.9 42.0 58.7 49.8 9.1**
(p=0.025)
Fed Meal from Own Bowl
(Child 6-11 Mo.)
-- -- 40.6 37.6 3.7
(p=0.435)
Times Fed Yesterday
(Child 6-11 Mo.)
1.1 1.0 1.5 1.2 0.3**
(p=0.022)
Amount Fed Yesterday –
Karoris (Child 6-11 Mo.)
-- -- 0.50 0.40 0.08
(p=0.210)
N=755. **p<0.05, *p<0.10.

16. Impact on Family Planning and Immunization
Baseline
(Percentage Points)
Endline
(Percentage Points)
Treatment
Mean
Control
Mean
Treatment
Mean
Control
Mean
Adjusted
Difference
(p-value)
Using Permanent Method
of FP (Birth in Last 12 Mo.)
7.1 11.2 10.0 11.1 -1.9
(p=0.410)
Using Modern Method of
FP (Birth in Last 12 Mo.)
19.3 21.7 17.8 13.9 3.9
(p=0.231)
Using Modern Method of
FP (Birth in Last 6 Mo.)
20.4 18.5 8.6 11.5 -1.5
(p=0.615)
DPT 3 Received (Child 6-11
Mo.)
57.4 46.7 73.9 67.5 7.0
(p=0.140)
N=755-1,607. **p<0.05, *p<0.10.

17. 17
Key learnings
High motivation and enthusiasm in FLWs was seen due to their involvement in reaching a consensus on
each component of the innovation
A6
Annual ceremony where achievers were awarded by high authority figures like the DM instilled a feeling of
recognition in ANMs, who otherwise lacked ownership as they are indifferent towards small incentives
- Low ownership of tasks among ANMs as such incentive had little value for ANMs
- Transfer of group heads (ANMs) from ‘intervention’ blocks to ‘control blocks’
TBGI led to higher coordination between ICDS and health department which helped to achieve all round
success in the innovation
TBGI is a promising solution to increase quantity of interactions through home visits by FLWs
Moving together in teams made it easier to cover hard to reach areas
Lack of ownership of senior officials at district and block reduced emphasis on team based work
overtime