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What is the effect of RbF on the work environment, mixed methods results from Malawi

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Stephan brenner

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What is the effect of RbF on the work environment, mixed methods results from Malawi

  1. 1. Effects of the RBF4MNH on health workers’ work environment Stephan Brenner Institute of Public Health, University of Heidelberg
  2. 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. 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. 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. 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. 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. 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. 8. Results: Perceived changes in working conditions (1)
  9. 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. 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. 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. 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. 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.”