Investigating the determinants of health worker performance in Senegal

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.

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.

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.