Stephan brenner

1. Effects of the RBF4MNH on health
workers’ work environment
Stephan Brenner
Institute of Public Health, University of Heidelberg

2. Background:
Work environment and PBF
• Inputs as determinants of the work
environment
• Enabling work environment as
determinant of improved performance
Input Process Output
Financing a pre-
defined set of inputs
(Input-based contract)
Financing pre-defined
output targets
(Incentive contract)

3. Actual work
environment changes
Personal / interpersonal work
environment (organizational
elements)
• Supervision and support
• Training / career opportunities
• Income and benefits
• Performance expectations
Technical work environment
(physical elements)
• availabiltiy / functionality of
equipment & supplies
• Staffing levels and
qualifications
Perceived work
environment changes
Perception of and satisfaction
with work environment
• Availability of drugs /
supplies
• Workload
• Compensation
• Supervisor support /
feedback
• Recognition of work effort
• Team work
• Personal influence on work
situation
• Understanding of
performance expectations
Conceptual Approach:
Work Environment

4. Study Context:
RBF4MNH in Malawi
• Pilot RBF program in 4 districts
– Phase 1 (April 2013): 18 facilities
– Phase 2 (Oct. 2014): 23 facilities
• PBF component:
– Incentivizing clinical performance related to obstetric care
– Clinical service teams, DHMTs
– Quantity indicators:
• number of women tested for HIV, number of updated stock cards for
essential medicines & supplies
– Quality indicators:
• partograph documentation, management of AMTSL, management of
pre-eclampsia, equipment maintenance, infection prevention
– DHMT indicators:
• Supply of essential medicines & supplies to all facilities, maintenance
of essential equipment in enrolled facilities only

5. Methods:
Mixed Research Approach
External impact evaluation:
• Controlled before-and-after study with 3 time points
(baseline, midterm, endline)
• Comparison facilities within RBF4MNH pilot districts
• Structured checklists:
– All health facilities (clinics and hospitals)
• Structured interview surveys:
– Health clinics: all health workers
– Hospitals: only health workers in maternal care unit
• In-depth interviews (midterm, endline):
– selected health workers (nurses, clinical officers) at clinics
and hospitals enrolled in PBF program

6. Results:
Actual changes in physical work environment
Average proportion of service readiness criteria met for:
Staffing & training Basic equipment Essential medicines
Sample sizes: Baseline: intervention 17, comparison 14; Endline: intervention 23, comparison 10
overall effect: 23 % increase
p-value: 0.04
overall effect: 3 % increase
p-value: 0.72
overall effect: 12 % decrease
p-value: 0.13

7. Results:
Actual changes in interpersonal work environment
effect estimate: < 1% increase
p-value: 0.99
effect estimate: 25.7% decrease
p-value: 0.18
Average proportion of HCW reporting:
Obstetric care in-service training
received in past year
Service supervision received in past
6 months
Sample sizes: Baseline: intervention 52, comparison 25; Endline: intervention 101, comparison 33

8. Results:
Perceived changes in working conditions (1)

9. Performance
feedback
Supervisor
support
Encouragement to
do one’s best
Recognition for
one’s work
Perceived
change
within last
year:
.083 .409 .004 .203 .101 .135 .529 .100
Midterm Endline Midterm Endline Midterm Endline Midterm Endline
p values
chi2 test
interventio
n vs.
control
0%
20%
40%
60%
80%
100%
Int Ctrl Int Ctrl Int Ctrl Int Ctrl Int Ctrl Int Ctrl Int Ctrl Int Ctrl
No
change
Negative
change
Positive
change
BEmONC staff only: Midterm: Int: n=45, Ctrl: n=33; Endline: Int: n=54, Ctrl: n=27
Results:
Perceived changes in working conditions (2)

10. • Generally positively perceived changes in physical
working conditions
“It [RBF] motivates us. In an environment where we have no
things to use, it [this situation] demotivates. Even if I go [to
work], what can I use? So it [RBF] has really helped us.”
(Nurse, Ntcheu, endline)
• Mainly positively perceived improvements in
supervision and performance feedback
“We are told the way we are performing. If we are not doing
well, we are given information on what to do. Where there
are changes, we are taught.” (Nurse, Mchinji, midterm)
Results:
Perceived changes in working conditions (3)

11. • Reasons provided for large postive perception
during initial RBF phase, while decline in
perceived improvements during second phase
– High expectations on RBF program to overcome
existing challenges faced by HCW
– Large initial investments (infrastructure upgrade, start-
up inputs) in initial RBF implementation phase
– Overall macroeconomic situation in Malawi worsening
over course of study period
– Implementation challenges (delays in verification,
delays in completion of initially anticipated
infrastructure upgrade)
Results:
Perceived changes in working conditions (4)

12. Conclusion
• RBF4MNH intervention produced only modest
actual changes in respect to technical and
interpersonal work environment.
• HCW perceived substantial improvements of
larger magnitude in early compared to later
intervention phase.
• Qualitative findings indicate that increased
expectations on the RBF4MNH at intervention
begin were largely responsible for decline in
perceived changes over course of intervention.

13. Thank You.
Acknowledgement: This study was funded by the United States
Agency for International Development under Translating Research
into Action, Cooperative Agreement No. GHS-A-00-09-00015-00, as
well as by the Royal Norwegian Embassy-Malawi, Grant No. MWI-
12/0010.
Disclaimer: This study is made possible by the support of the
American People through the United States Agency for International
Development (USAID). The findings of this study are the sole
responsibility of the University of Heidelberg and the College of
Medicine and do not necessarily reflect the views of USAID or the
United States Government.”