Effects of team-based goals and non-monetary incentives on front-line health worker performance and maternal health behaviours: a cluster randomised controlled trial in Bihar, India

Suzan L Carmichael, Kala Mehta, Hina Raheel, Sridhar Srikantiah, Indrajit Chaudhuri, Shamik Trehan, Sunil Mohanty, Evan Borkum, Tanmay Mahapatra, Yingjie Weng, Rajani Kaimal, Anita Sivasankaran, Swetha Sridharan, Dana Rotz, Usha Kiran Tarigopula, Debarshi Bhattacharya, Yamini Atmavilas, Wolfgang Munar, Anu Rangarajan, Gary L Darmstadt, Ananya Study Group, Y Atmavilas, D Bhattacharya, E Borkum, S L Carmichael, I Chaudhuri, A Creanga, G L Darmstadt, P Dutt, L Irani, R Kaimal, T Mahapatra, K M Mehta, R Mitra, W Munar, K Pepper, H Raheel, A Rangarajan, N Saggurti, P Sastry, J Schooley, H Shah, S Srikantiah, U Kiran Tarigopula, V Ward, Y Weng, S Wahid, J Wilhelm, Suzan L Carmichael, Kala Mehta, Hina Raheel, Sridhar Srikantiah, Indrajit Chaudhuri, Shamik Trehan, Sunil Mohanty, Evan Borkum, Tanmay Mahapatra, Yingjie Weng, Rajani Kaimal, Anita Sivasankaran, Swetha Sridharan, Dana Rotz, Usha Kiran Tarigopula, Debarshi Bhattacharya, Yamini Atmavilas, Wolfgang Munar, Anu Rangarajan, Gary L Darmstadt, Ananya Study Group, Y Atmavilas, D Bhattacharya, E Borkum, S L Carmichael, I Chaudhuri, A Creanga, G L Darmstadt, P Dutt, L Irani, R Kaimal, T Mahapatra, K M Mehta, R Mitra, W Munar, K Pepper, H Raheel, A Rangarajan, N Saggurti, P Sastry, J Schooley, H Shah, S Srikantiah, U Kiran Tarigopula, V Ward, Y Weng, S Wahid, J Wilhelm

Abstract

Introduction: We evaluated the impact of a 'Team-Based Goals and Incentives' (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition.

Methods: This study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention's team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year.

Results: The TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid (IFA) tablets (7 PP, p=0.02), but non-significant changes in other health behaviours related to the trial's goals. Improvements were seen in selected attitudes related to coordination and teamwork among FLWs, and in the provision of advice to beneficiaries (ranging from 8 to 14 PP) related to IFA, cord care, breast feeding, complementary feeding and family planning.

Conclusion: Results suggest that combining an integrated set of team-based coverage goals and targets, small non-cash incentives for teams who meet targets and team building to motivate FLWs resulted in improvements in FLW coordination and teamwork, and in the quality and quantity of FLW-beneficiary interactions. These improvements represent programmatically meaningful steps towards improving health behaviours and outcomes.

Trial registration number: NCT03406221.

Keywords: community health worker; coordination; performance-based incentives; primary healthcare; teamwork.

Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Description of the design and sample selection for the Team-Based Goals and Incentives (TBGI) intervention trail in Begusarai, Bihar, 2012–2014. (A) If a large village (population ≥150, as identified by CARE) was selected, the village was organised into approximately equal segments (75–150 households per segment) and one segment was randomly selected for surveying. ANM, auxiliary nurse midwives; ASHA, accredited social health activists; AWW, Anganwadi workers.

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