J U N E 1 1 , 2 0 1 5

P A B L O C E L H A YP A U L G E R T L E R

P A U L A G I O V A G N O L IC 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

T E M P O R A R Y I N C E N T I V E S H A D A L O N G -R U N I M P A C T O N M E D I C A L C A R E

P R O D U C T I V I T Y

T E M P O R A R Y I N C E N T I V E S H E L P E D O V E R C O M E T H E I N I T I A L C O S T O F

I M P R O V I N G M E D I C A L C A R E R O U T I N E S

Main findings

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

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

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).

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.

The Misiones experiment

Misiones Province

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%

Arg. Pesos

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

Timeline

Jan

2009

May

2010

Dec

2010

Mar

2012

Dec

2012

Pre-intervention Intervention Post intervention I

Post intervention II

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

Results

Weeks pregnant at first prenatal visit

PRE POST

-1.47

Proportion of mothers with prenatal visit before week 13

PRE POST

+0.11

Density of birth weight

Pre-intervention Intervention

We do not find an impact on birth weight.

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

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

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

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

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

Martin Sabignoso, National Coordinator of Plan Nacer and Humberto Silva, National Head of Strategic Planning ofPlan 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 thepilot facilitated access to provincial data, supported the authors in interpreting datasets and the provincial legalframework and in carrying out the in-depth interviews.

Fernando Bazán Torres, Ramiro Florez Cruz, Santiago Garriga, Alfredo Palacios, Rafael Ramirez, Silvestre RiosCenteno, 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 inidentifying sources of data.

Sebastian Martinez, Luis Perez Campoy, Vanina Camporeale and Daniela Romero contributed to the initial designof the pilot.

The Health Results Innovation Trust Fund (HRITF) and the Strategic Impact Evaluation Fund (SIEF) of the WorldBank generously funded the evaluation.

The opinions in the paper are of the authors alone and do not necessarily represent the opinions of the funder ortheir affiliated institutions.

Acknowledgements