1.
Do financial incentives
undermine health workers
intrinsic motivation?
Evidence from a pay-for-performance
scheme in one region of Tanzania
Contributors: E Patouillard, J Borghi, P Binyaruka, T Powell-Jackson, G Greco, G Torsvik

2.
Objectives
1. Explore the impact of P4P on health
workers’ intrinsic motivation
2. Explore the differential impact of P4P on
institutional delivery rates in facilities
with different staff motivation levels

3.
P4P Objectives
• Improve coverage of quality health services
• By increasing health workers’ motivation
• Health workers are assumed to be intrinsically
motivated
• Could P4P crowd -out intrinsic motivation?
–Money competes with the self concept of
working hard; altruism and moral
contentment
• Are P4P effects higher/lower among workers
who are more intrinsically motivated?

4.
P4P in Tanzania
• Pilot in Pwani region, 7
districts
• To improve MCH
intervention coverage
• Start Jan 2011
• Implemented by MOHSW
and Clinton Health Access
Initiative
• Intervention package:
bonus, HMIS, supervision,
financial autonomy
PWANI

5.
P4P Scheme
• Targets MCH services
• Payouts every 6 months
• 70% to health workers, remainder to the facility
• Represents about 10% of health worker monthly
salary

6.
Study Design
• Design: Controlled before and after study design
– 7 intervention districts
– 4 neighbouring control districts
– Comparable poverty, literacy, rate of
institutional deliveries, IMR, pop. per health
facility, no. of children < 1 yr
• Timing:
-Baseline in January-February 2012
-Endline in March-April 2013 (13 months)

7.
7 P4P districts 4 districts with no P4P
150 health facilities, 75 in each
arm incl.
6 hospitals
16 health centres
53 dispensaries
1 facility survey at
each facility
20 interviews with
women who delivered
in past 12 months, from
the catchment area of
each facility
Only include
facilities
eligible for
first cycle
payment
1-2 health
workers at each
facility

8.
Intrinsic motivation measure
• Adapted a World Bank questionnaire
• Collected data on health workers’ feeling and
attitudes towards work
• 9 questions using Likert scale 3 point answers
• Created a mean score / index
8

9.
9 questions on motivation
Scale reliability: 0.7
Never/rarely Sometimes Often
My job makes me feel good about myself 1 2 3
I am proud of the work I am doing at the
facility
1 2 3
I am proud to be working for the facility 1 2 3
I am inspired to do my best at work by this
facility
1 2 3
I complete tasks efficiently 1 2 3
I am a hard worker 1 2 3
I am punctual 1 2 3
It is important for me that peers recognize
me as a professional
1 2 3
It is important for me that the community
recognize me as a professional
1 2 3

10.
Does P4P impact on our measure of
intrinsic motivation?
• Used a OLS regression analysis with a DiD approach
• Estimated the effect of P4P 𝛽1 on individual motivation
• Controlling for facility 𝛾𝑗 and year 𝛿𝑡 fixed effects
• And health workers characteristics 𝑋𝑖𝑗𝑡 (sex, age,
education, place of work,…)
𝑌𝑖𝑗𝑡 = 𝛽0 + 𝛽1(𝑃4𝑃𝑗 × 𝛿𝑡) + 𝛽2 𝛿𝑡 + 𝛽3 𝑋𝑖𝑗𝑡 + 𝛾𝑗 + 𝜀𝑖𝑗𝑡

11.
Has P4P had the same impact in facilities
with different staff motivation levels?
• Binyaruka (2015) found a significant 8.2% (95% ci 3.6-
12.8) increase in delivery rates following P4P intro
• Generated two samples of facilities at the median staff
motivation score
• Estimated the differential effect of P4P on delivery rates in
facilities with low/high motivation
• With 𝑆𝑀 𝑗, the facility staff motivation level
𝑌𝑖𝑗𝑡 = 𝛽0 + 𝛽1(𝑃4𝑃𝑗 × 𝛿𝑡 × 𝑆𝑀𝑗) + 𝛽2 𝛿𝑡 + 𝛽3 𝑋𝑖𝑗𝑡 + 𝛾𝑗 + 𝜀𝑖𝑗𝑡

12.
Health Workers’ socio-
demographic
characteristics
Baseline, N=209 Follow-up , N=180
P4P
n=101
No P4P
n=108
Diff P4P
n=94
No P4P
n=86
Diff
Female, % 71.3 63.9 7.4 60.6 68.6 -8.0
Age, mean years 41.9 42.9 -1.0 42.5 41.9 0.6
Married, % 65.3 73.1 -7.8 75.5 59.3 16.2**
Born in facility district, % 16.8 31.5 -14.7** 25.5 23.3 2.2
Primary education, % 22.8 15.7 7.1 14.9 10.5 4.4
Secondary education, % 46.5 43.5 3.0 31.9 53.5 -21.6***
College or above educ, % 30.7 40.7 -10.0 53.0 36.0 17.0**
Facility in charge, % 38.6 47.2 -8.6 46.8 47.7 -0.9
Clinical cadre, % 43.6 39.8 3.8 46.8 46.5 0.3
Nursing cadre, % 44.6 48.1 -3.5 48.9 51.2 -2.3
Paramedical cadre, % 11.9 12.0 -0.1 4.3 2.3 2.0

13.
13
Health Workers’ intrinsic motivation Baseline, N=209
P4P
n=101
No P4P
n=108
Diff.
Intrinsic motivation score, Mean score (sd) 25.1 (2.8) 25.6 (1.7) -0.50
My job makes me feel good about myself, 2.8 (0.5) 2.8 (0.4) -0.00
I am proud of the work I am doing at the facility 2.7 (0.6) 2.7 (0.5) -0.07
I am proud to be working for the facility 2.8(0.4) 2.8(0 .5) 0.06
I am inspired to do my best at work by this facility 2.4 (0.8) 2.6 (0.6) -0.17*
I complete tasks efficiently and effectively 2.8 (0.5) 2.9 (0.3) -0.05
I am a hard worker 2.9 (0.3) 2.9 (0.2) -0.02
I am punctual 2.9 (0.3) 2.9 (0.2) -0.05
Important for me that peers recognize me as a
professional
2.9 (0.3) 3.0 (0.2) -0.05
Important for me that the community recognize me as a
professional
2.9 (0.3) 3.0 (0.0) -0.08*

14.
Has P4P had an impact on
health workers intrinsic
motivation?
• No evidence of a significant effect
(0.5, 95% ci -0-5, 1.6)
• No evidence of crowding – out on our measure
of intrinsic motivation

15.
Has P4P the same impact on delivery
rates in facilities with different staff
motivation levels?
• A significantly greater effect on delivery rates in facilities with
lower (baseline) staff motivation
Delivery rate at facilities with staff
motivation at or below median
Delivery rate at facilities with staff
motivation above median
N Beta
(95% ci)
P-value N Beta
(95% ci)
P-value
ID% 2846 0.12 ***
(0.06-0.19)
0.000 2901 0.04
(-0.02-0.10)
0.171

16.
Limitations
• Motivation reported to be high by health workers
– Social bias of responses about HW attitudes
towards work?
• Did the measure of motivation really capture intrinsic
motivation ?

17.
Conclusion
• P4P does not (negatively) effect
intrinsic motivation
• Results suggest that extrinsic
incentives may work better in
settings where health workers are
less intrinsically motivated
17

18.
Acknowledgments
• MOHSW and Pwani regional health authorities and
Clinton Health Access Initiative
• Funding support : Government of Norway
• Ifakara health Institute, LSHTM and CMI
• The P4P evaluation team
• Health workers for their precious time, and
women and household heads