Investigating the determinants of health worker performance in Senegal

Lead Research Organisation: London School of Economics & Pol Sci
Department Name: LSE Health

Abstract

Training, motivating and retaining professional health workers is crucial for the improvement of health outcomes, especially in low and middle-income countries where poor health worker performance has been recognised as one of the key obstacles to achieving better health outcomes. To improve staff motivation and performance, many donors and governments have recently supported the introduction of Performance-Based Financing (PBF) mechanisms, which link part of the health workers' remuneration to performance targets. While promising results have shown that these programmes can improve utilisation of health services and some health outcomes, it is still unclear what specific effects they have on the motivation and behaviours of health workers. Yet it is key to understand better how PBF works for health workers, and in particular whether all aspects of health workers' performance have improved or whether PBF can induce some undesired effects, e.g. a reduction in time spent with each patient.

The aim of the proposed research is to generate new knowledge and understanding of how PBF programmes work and influence health workers' performance. The proposed research takes advantage of a quasi-experimental study introduced by the World Bank in four of the poorest and most rural regions of Senegal in 2014. The project will collect a rich set of primary data in control and PBF facilities to answer several critical questions.

The research will first undertake some interviews to assess whether the extent to which what was planned in the PBF scheme is actually what is happening in practice. This will help understand exactly the nature of the intervention being implemented. The research will then undertake a large survey, collecting information in control and PBF facilities on the working environment and characteristics, behaviours and performance of health care workers. The aim is to determine the effects of PBF, by comparing the performance and behaviours of health workers with and without PBF incentives. Specifically, the survey will explore whether PBF improves the productivity, quality of care provided and attitude towards patients. The data collected will also help determine whether the time and effort spent on each patient increase and on non-incentivised activities decrease as a result of the PBF. Finally, with the information collected, we will be able to identify mechanisms through which the performance of health workers changes.

Technical Summary

In many Low- and Middle-Income Countries were the performance of health workers is low, governments are increasingly seeking to make sure that the way in which health workers are paid encourages them to work more efficiently and effectively. To that aim, interest in payment mechanisms linking part of the remuneration to achieving certain performance targets (often termed Performance-Based Financing or PBF) has recently grown. Many are hopeful that these schemes will improve health outcomes in places where, despite huge investments, they remain low. Despite this enthusiasm, there is limited evidence on the effects of PBF, and no understanding of whether and how financial incentives improve the performance of health care workers.

The research aims to evaluate whether and how PBF contributes to improved health worker performance in Senegal, where it will take advantage of the introduction of a PBF programme in a quasi-experimental manner. Following a process evaluation that will help determine the degree of implementation of the programme, a large cross-sectional survey will be carried out to collect a broad range of health workers' performance outcomes in control and PBF facilities. Comparing these outcomes between health workers working in facilities with and without PBF, we will be able to determine the causal impact of PBF on health workers' performance. As the survey will also collect information on health workers' motivation and working conditions, we will be able to understand some of the causal pathways through which any changes occur.

Findings from the project will not only inform the national discussions around the scale-up of PBF in Senegal, but they will also feed into the policy debates on human resources performance in other countries and on the global health scene. This will be achieved through an active research uptake plan that will include the production of policy briefs, the organisation of workshops and a number of networking activities.

Planned Impact

We anticipate that this research will lead to three types of impact. We highlight below the beneficiaries, explain how they might benefit from this research and provide some details about the activities to be undertaken to ensure they benefit from this research.

1. Contribute to the effectiveness of health care policies in Low- and Middle-Income Countries (LMICs) by feeding into the debates around payment mechanisms of health care workers

Given current interest in PBF, this research should directly feed into the reflections of policy-makers involved in the design of financial incentives and other interventions that aim to shape the behaviours of health workers, in Senegal, in other LMICs, as well as on the global health scene (donors, international organisations, etc.). Several activities are planned to ensure that policy-makers will benefit from this research:
- engagement with key leaders and decision makers in Senegal and other LMICs, facilitated by existing networks of the members of the research teams, for example at through the DfID-funded RESYST Consortium.
- Seminars presenting interim findings to policy-makers to discuss interpretations of results, additional analyses and potential lessons drawn: such seminars will be easy to organise at DfID or with regular interactions with donors the research team has; in Senegal, they will take place during specifically organised workshops.
- Findings will be disseminated through working papers and in a non-technical language through policy briefs and other online resources (e.g. blogs, webinars, etc.) that will be sent to policy makers.

2. Improve the quality and efficiency of health care delivery by enabling a greater understanding amongst managers of the ways in which their services can be rearranged to achieve better outcomes and higher performance
The research offers real potential to affect health outcomes by informing how health care providers work with, adapt to and react to incentives. We will make sure that research participants in Senegal, and in general health workers and managers involved in the delivery of health care in LMICs will benefit from findings of this research through the following activities:
- Workshops presenting interim and final findings to health workers and district managers in Senegal to discuss the results and potential lessons drawn.
- Written briefing material highlighting key findings and their implications for policy and practice to demonstrate the various ways in which teams and organisations are likely to react to incentives. This material will seek to draw lessons for and with health care providers on the ways in which they could change the organisation of care to improve their performance.

3. Build the capacity of future public health professionals and decision makers, especially from LMICs, by promoting a greater understanding of the ways in which health care providers' behaviours can be affected by incentives

The last group of beneficiaries will be future public health professionals and decision-makers in health policy.
The three UK-based members of the research teams contribute to the LSHTM teaching programme on topics of health economics and health services through seminars or lectures provided for different taught modules, online and in London. Teaching material will be developed and used for LSHTM in-house and online courses (case studies, role-play situations) in health economics and health services.

The material developed will then be translated in French and shared with the Senegalese partner to be used in their taught courses. Other African universities will also be able to use the material developed through the Consortium for Health Policy and Systems Analysis in Africa, a partnership of African and European universities, whose purpose is to increase African capacity in the area of high-quality Health Policy and Systems research through the development of teaching material for African educators.

Publications

10 25 50
 
Description Health Systems Research Initiative
Amount £765,082 (GBP)
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 04/2020 
End 04/2023
 
Description Dissemination event (Dakar, Senegal) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact We organised a one-day dissemination workshop in Dakar (Senegal) to present and discuss the findings of the study with local stakeholders. The event was attended by approximately 40 policy-makers from the national, regional and district levels as well as members of international organisations working in health care in Senegal. The research team first briefly presented the findings. Then, group activities were organised to discuss the findings, consider their impact on policy and potential interventions to address quality issues in health care, and discuss what areas still needed to be explored by the study or related research.
Year(s) Of Engagement Activity 2018
 
Description Health Economics Study Group meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact The health economics study group (HESG) is a formal study group for health economists based in the UK. It provides researchers - particularly young researchers and PhD student, with the opportunity to have their paper discussed by a senior researcher in the field and receive valuable advice. The RA attended the HESG meeting at london city university in January 2018. A senior member of staff presented the RA's research paper on patient trust - which is based on data collected through this grant. The talk was followed by a discussion and questions. The RA received several excellent comments, which allowed her to improve their research strategy.
Year(s) Of Engagement Activity 2017
URL https://www.city.ac.uk/arts-social-sciences/health-economists-microsite/health-economists-study-grou...
 
Description Kyoto Global - presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The RA attended the Kyoto Global conference which took place at the university of kyoto in december 2017. The conference provided the opportunity for young researchers and PhD students to interact with senior colleagues but also policymakers in the public health field. The RA presented research findings on the effect of information provided by patients on the quality of healthcare - which were generated by making use of data collected through this grant. The talk was attended by approximately 50 people, many of which were policymakers, students and practitioners in the public health field.
Year(s) Of Engagement Activity 2017
 
Description Newspaper article about study findings 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact An article about the findings of the study was published in two prominent Senegalese newspapers (Walf Fadjri and Le Quotidien)
Year(s) Of Engagement Activity 2018
 
Description PhD upgrading 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact The RA was given the opportunity to use data generated by the project to pursue a part-time PhD in health economics at the london school of hygiene and tropical medicine (LSHTM). To ensure that the RA's PhD and the project output are sufficiently distinct, the RA added several data collection tools to the initial study design, to be able to pursue separate research questions. This not only allowed the RA to develop academically but also prolongs and broadens the impact of the project. Every research degree student at LSHTM has to hold an upgrading seminar, in which a general outline of the PhD is presented an appraised by fellow students and faculty. During the upgrading seminar, the RA provided a general overview of the research project (research questions, study design). Questions and discussion took place afterwards. The talk was attended by approximately 30 research degree students as well as university faculty.
Year(s) Of Engagement Activity 2016
 
Description Policy Brief 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact To ensure that the findings of the study can be communicated to a broader audience, we created a policy brief which provides an overview of main results. We distributed the policy brief during our dissemination event in dakar, senegal - which was attended by most regional and district health managers in Senegal. To ensure that healthcare professionals working in study areas (many of which took part in the study) could also engage with the results, additional copies were given to regional and district health managers - to be distributed to healthcare professionals directly.
Year(s) Of Engagement Activity 2018
 
Description TV report about study findings 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Members of the research team gave two interviews to TV journalists about the findings of the study on Senegalese national television (RTS and TFM). The interviews were shown in the main evening news, along with a summary of the study findings (TV report from RTS can be seen on YOUTube 16mn30s into the news)
Year(s) Of Engagement Activity 2018
URL https://www.youtube.com/watch?v=Ada4_hceBqs