Can non-financial incentives improve the performance of health care workers in countries with cash-strapped health systems? In this study, researchers evaluated the impact of two types of non-financial incentives aimed at improving the quality of healthcare and the utilization of services at health clinics in Sierra Leone. A bottom-up community monitoring intervention had large, positive impacts: children under five saw a 44 percent reduction in wasting one year after the intervention began; pregnant women in the catchment area were 10 percent more likely to have delivered their babies at a government clinic; and households were 27 percent less likely to have paid illegal fees to the clinics. Top-down non-financial awards, however, did not have a significant impact on service provision or health outcomes. In response to the positive findings, the government of Sierra Leone is planning to scale-up community monitoring nationwide.

Policy Issue 

Governments are responsible for the provision of key public services, but budget constraints, limited accountability, and weak incentive structures contribute to the weak provision of public services in many low-income countries. To improve the performance of government workers, and the quality of services in turn, many policymakers have turned to performance-based financial incentives. The evidence is mixed, however, on whether this approach is effective in the health sector, and these programs can be very expensive. Some recent evidence suggests that, for health care workers, non-financial incentives like recognition and status-based incentives can be more motivational, less expensive, and less likely to erode intrinsic motivation than financial incentives.1 Another approach that has proven effective before is community monitoring, in which community members and health workers jointly address obstacles to adequate healthcare provision.2 This research investigated if either of these non-financial incentives were effective in the context of Sierra Leone’s health sector. 

Context of the Evaluation 

Over the past decade, the government of Sierra Leone has made a concerted effort to improve health care services throughout the country, including an ambitious free health care initiative launched in 2010. Key to the success of the initiative was strengthening the weak incentives faced by frontline health providers. The government increased worker salaries and the flow of resources to clinics nationwide, and sought to introduce non-financial incentive schemes, which recent studies have shown to be highly effective in improving worker performance in a range of environments.

In 2014, Sierra Leone was struck with the worse Ebola outbreak ever recorded, which revealed the limitations of the health care system. The outbreak highlighted a chronic lack of trust in the health authorities and more broadly in the public sector. In this respect, initiatives aiming at reinforcing accountability at the local level and improving relationships between the community and health care providers are likely to play a central role in the rebuilding of the health care system in the post-Ebola landscape.

Details of the Intervention 

Researchers worked with the World Bank and the Centre for the Study of African Economies to evaluate the impact of two non-financial incentive programs—community monitoring and non-financial awards—on the quality and quantity of health services at government clinics, and on the health outcomes of patients. They also examined the cost-effectiveness of the programs, both individually and in relation to each other. 

The researchers randomly assigned 254 clinics in four districts to one of two intervention groups or a comparison group, with a third of study clinics allocated to each group. The two intervention groups were as follows:

The community monitoring intervention introduced health scorecards that provided information regarding the state of health care in each community, and facilitated interface meetings between community members and health facility staff. During these meetings, information about the state of healthcare was disseminated via a community scorecard. Members of the community and clinic staff also made mutual commitments to improve services by addressing areas such as staff absenteeism, maternal mortality, and vaccination rates. This framework aimed to ensure participatory decision-making and to hold both health care workers and the community mutually accountable. 

The second intervention, non-financial incentives, facilitated a yardstick competition among groups of maternal and child health clinics, and rewarded workers at the most improved facilities. The relative rankings of clinics on key measures such as worker absenteeism, staff attitude and charging of illegal fees will be advertised publicly, and staff at winning clinics will receive letters of commendation from high-ranking politicians, and an award at a public ceremony.

The project was being conducted in partnership with the Government of Sierra Leone and the interventions have been designed for scale-up through the Ministry of Health and Sanitation. 

Results and Policy Lessons 

Community monitoring: Community monitoring significantly increased the quality and quantity of health services delivered by the clinics. Households in the catchment area of the clinics were 11 percent more likely to have used the clinic in the previous month and pregnant women in the catchment area were 10 percent more likely to have delivered their babies at a government clinic. Households were also 27 percent less likely to have paid illegal fees to the clinics. 

In terms of health outcomes, community monitoring resulted in a 44 percent reduction in wasting among children one year after the intervention began (4.2 percent compared to 7.5 percent in the comparison clinics). The intervention did not impact vaccination rates, nurse absenteeism, stunting, or mortality rates. The lack of impact on stunting was to be expected, however, since height-for-age is a long-term measure of chronic malnutrition, unlikely to change quickly (the final data collection was conducted around a year after the launch of the intervention).

Results also revealed a significant increase in trust in Western medicine relative to the comparison group, and households were more optimistic about the evolution of public health in the previous year. On the other hand, satisfaction with the performance of the health workers in general and state of the health and sanitation facilities were not affected.

Non-financial awards: The non-financial awards did not significantly impact quality of health care, the utilization of services, or health outcomes. In fact, this intervention had a significant negative impact, increasing nurse absenteeism by 69 percent (9.9 percent vs. 5.8 percent in the comparison group). 

Overall, these results suggest that initiatives focused on reinforcing the accountability and monitoring structures at the community level can play an essential role in improving not only the quality and the quantity of health service delivery but also health outcomes, like acute malnutrition. Community monitoring could be a relevant and effective approach to rebuild and strengthen the health care system in post-Ebola Sierra Leone.


[1]Ashraf, Nava, Oriana Bandiera, and Kelsey Jack. "No Margin, No Mission? A Field Experiment on Incentives for Pro-Social Tasks." Harvard Business School Working Paper, No. 12-008, August 2011.