1. J U N E 1 1 , 2 0 1 5
P A B L O C E L H A Y
P A U L G E R T L E R
P A U L A G I O V A G N O L I
C H R I S T E L V E R M E E R S C H
Long Run Effects of Temporary Incentives
on Medical Care Productivity

2. TEMPORARY INCENTIVES HAD A LONG -
RUN IMPACT ON MEDICAL CARE
PRODUCTIVITY
TEMPORARY INCENTIVES HELPED
OVERCOME THE INITIAL COST OF
IMPROVING MEDICAL CARE ROUTINES
Main findings

3. Routines in medical care
 Medical care is a
complex technology
 Coordination of
team activities is
key
 Routines =
“Established rules”,
“standard operating
procedures” that
become habits

4. Institutions have a hard
time changing their
routines.
.. It takes effort
.. It takes time
.. It might be costly

5. Medical care routines can be suboptimal
E.g.: Adherence to clinical practice guidelines (best-
practice) is low.
18%
24%
45%
46%
50%
60%
67%
75%
81%
84%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
India - Diahrrea
Tanzania - Malaria
Rwanda - Prenatal Care
Indonesia - Tuberculosis
USA - Preventive Care
USA - Chronic Conditions
Netherlands - Family
Mexico - Prenatal Care
UK - Diabetes
UK - Asthma
Adherence to CPG
Source: Authors’ elaboration based on Schuster et al. (1998); Grol (2001); Campbell et al. (2007); Das and Gertler (2007); and Gertler and
Vermeersch (2012).

6. Role of incentives – causal chain
 Initial/Upfront cost inhibits change of routines
 Financial incentives may help overcome this initial
cost
 Once the institution adopts new routines, it will
continue them as long as recurrent costs are covered.

7. The Misiones experiment
Misiones Province

8. The Misiones experiment
 Aim: Increase the probability that 1st prenatal visits take place in first
trimester
 In primary care setting
 Intervention: Temporary (8 months) increase in fees
40
120
40 40
0
20
40
60
80
100
120
140
Pre & post periods Intervention period
Fee-for-service payment for 1st prenatal visit before week 13
Treatment Control
+200%
A
r
g
.
P
e
s
o
s

9. The Misiones experiment
 Identification strategy:
 Randomized assignment of 37 primary care clinics to
treatment and control
 Assignment not fully respected (but close enough)  use IV
estimator
Treated Not treated
Assigned to
treatment
14 4
Assigned to
control
1 18

10. Timeline
Jan
2009
May
2010
Dec
2010
Mar
2012
Dec
2012
Pre-intervention Intervention Post
intervention I
Post
intervention II

11. Data
 Clinic records
 services delivered
 Registry of Plan Nacer
beneficiaries
 beneficiary status of the
mother
 Hospital medical records
 birth outcomes
link using the
mother’s national
identity number

12. Results

13. Weeks pregnant at first prenatal visit
PRE POST
-1.47

14. Proportion of mothers
with prenatal visit before week 13
PRE POST
+0.11

15. Density of birth weight
Pre-intervention Intervention
We do not find an impact on birth weight.

16. C H A N G E S I N R O U T I N E S
E V I D E N C E F R O M I N - D E P T H I N T E R V I E W S
Mechanisms

17. What did treatment clinics do?
 Change in assignment of incentives to personnel
 Conditioned on number of women brought in
 Change in routines to improve efficiency of outreach
by community health workers
 Offer pregnancy tests to mothers when picking up milk for
their children
 Visit adolescents when parents aren’t home
 Visit women who abandoned birth control pills
 Organize the Ob/Gyn schedule to ensure predictability of
service

18. Increase in maternal-child “hits” due to outreach
 Treatment and
comparison clinics
equally paid for outreach
activities that result in
actual maternal-child
service at the clinic

19. Why no impact on birth outcomes?
 Hypothesis: Impact of early prenatal care is uneven
in the population
 Need to be able to reach very high risk women
 Impacts are washed out in a population average

20. I n c e n t i v e s i n c r e a s e d i n i t i a t i o n o f p r e n a t a l c a r e
b e f o r e w e e k 1 3 b y 3 5 % .
E f f e c t p e r s i s t e d f o r a t l e a s t o n e y e a r a f t e r t h e
i n c e n t i v e s e n d e d .
T e m p o r a r y i n c e n t i v e s h e l p p r o v i d e r s t o
o v e r c o m e i n e r t i a a n d c h a n g e c l i n i c a l p r a c t i c e
r o u t i n e s .
N e e d t o t a i l o r i n c e n t i v e s t o t a r g e t h i g h - r i s k
p o p u l a t i o n s .
Conclusions

21. Martin Sabignoso, National Coordinator of Plan Nacer and Humberto Silva, National Head of Strategic Planning of
Plan Nacer led the development and implementation of the experiment.
Luis Lopez Torres and Bettina Petrella from the Misiones Office of Plan Nacer oversaw the implementation of the
pilot facilitated access to provincial data, supported the authors in interpreting datasets and the provincial legal
framework and in carrying out the in-depth interviews.
Fernando Bazán Torres, Ramiro Florez Cruz, Santiago Garriga, Alfredo Palacios, Rafael Ramirez, Silvestre Rios
Centeno, and Adam Ross provided excellent assistance and project management support.
Alvaro Ocariz, Javier Minsky and the staff of the Information Technology unit at UEC provided valuable support in
identifying sources of data.
Sebastian Martinez, Luis Perez Campoy, Vanina Camporeale and Daniela Romero contributed to the initial design
of the pilot.
The Health Results Innovation Trust Fund (HRITF) and the Strategic Impact Evaluation Fund (SIEF) of the World
Bank generously funded the evaluation.
The opinions in the paper are of the authors alone and do not necessarily represent the opinions of the funder or
their affiliated institutions.
Acknowledgements