The Feasibility and Effectiveness of Digital Enabled Performance-based Incentives in Ethiopia’s Community Health Program

Ethiopia is among the countries with a well-established community health program also known as a health extension program (HEP) aiming at improving access to basic healthcare services at the community level. The program has achieved remarkable success, significantly improving healthcare access, reproductive, maternal, newborn, and child health (RMNCH) outcomes, and advancing Ethiopia’s progress toward meeting national and global health targets. Despite its success, a national HEP assessment conducted in 2020 showed a decline in health extension workers’ performance, low motivation, and gaps in performance management have challenged the program. To enhance motivation, performance, and accountability, and improve service quality, the Ministry of Health integrated Performance-Based Incentive (PBI) intervention into the Electronic Community Health Information System (eCHIS). This implementation research (IR) explored the feasibility, acceptability, and adoption of digitally enabled Performance-Based incentives (PBI).

Implementation research (IR), which employed a mixed method design guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework [1]was conducted in three implementations and four control Woredas. The qualitative data collection utilized a semi-structured interview and discussion guides to collect data using focus group discussion, key informant interviews, and small group discussions. Content analysis was used to underpin the qualitative components of the study, and was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Thematic analysis was used to analyze the qualitative data. Quantitative data was obtained from eCHIS and DHIS2 dashboards and interrupted time-series analysis and paired t-tests to evaluate changes in maternal and child health services and describe performance of HEWs.

The PBI intervention was fully adopted across the intervention Woredas. The HEWs extensively utilized eCHIS for service provision, tracking their performances, reporting, and referrals. Supervisors on the other hand used the enhanced focal person application to set HEWs performance targets, provide supervisory and mentorship support, and monitor the progress of HEWs towards set targets. Adoption of the PBI was facilitated by its alignment with the existing workflow, and intergradation into the routine HEP operations. High acceptability of the intervention was reported due to its transparency, efficiency, and ability to streamline workflows. Digital tools minimized manual tasks and enhanced trust in performance evaluations and efforts to incentivize the best performers. The intervention fostered motivation among HEWs, witnessed by significantly improved KPI scores between the first and second incentive rounds (from 66 to 82, p<0.05). Supervisors and Woreda managers emphasized the intervention’s capacity to drive data-driven decision-making and performance monitoring. Feasibility was demonstrated by availing of essential digital tools (tablets, Wi-Fi routers, power banks, and fingerprint scanners), eCHIS capacity-building training, and alignment of strategies with routine health system practices. HEWs reported that the intervention simplified the tracking of performances and target-setting. However, infrastructure limitations, inconsistent mentorship, and high staff turnover were identified barriers to optimal implementation.

The digitally enabled PBI intervention proved to be feasible, acceptable, and effective in improving the health extension workers’ performance and improving RMNCH outcomes. Addressing the issue of infrastructure limitations, availing resources needed for consistently implementing PBI, and institutionalizing the intervention within the routine HEP activities remained crucial.