Abstract:
Background: In high-resource settings, ‘pay-for-performance’ (P4P) programs have generated interest as a potential
mechanism to improve health service delivery and accountability. However, there has been little or no experimental
evidence to guide the development or assess the effectiveness of P4P incentive programs in developing countries.
In the developing world, P4P programs are likely to rely, at least initially, on external funding from donors. Under
these circumstances, the sustainability of such programs is in doubt and needs assessment.
Methods/design: We describe a cluster-randomized controlled trial underway in 18 health centers in western
Kenya that is testing an innovative incentive strategy to improve management of an epidemiologically and
economically important problem—diagnosis and treatment of malaria. The incentive scheme in this trial
promotes adherence to Ministry of Health guidelines for laboratory confirmation of malaria before treatment, a
priority area for the Ministry of Health. There are three important innovations that are unique to this study
among those from other resource-constrained settings: the behavior being incentivized is quality of care rather
than volume of service delivery; the incentives are applied at the facility-level rather than the individual level,
thus benefiting facility infrastructure and performance overall; and the incentives are designed to be budget neutral if effective.
Discussion: Linking appropriate case management for malaria to financial incentives has the potential to
improve patient care and reduce wastage of expensive antimalarials. In our study facilities, on average only
25% of reported malaria cases were confirmed by laboratory diagnosis prior to the intervention, and the total
treatment courses of antimalarials dispensed did not correspond to the number of cases reported. This study
will demonstrate whether facility rather than individual incentives are compelling enough to improve case
management, and whether these incentives lead to offsetting cost-savings as a result of reduced drug
consumption.
